Summary Reimagining Global Health - Chapter 1,3,4 PDF

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Global Health and Disease Reimagining Global Health Chapter 1 – Biosocial Approach to Global Health  Biosocial Analysis o Global health is not yet a discipline, but rather a collection of problems o Changing global health into a coherent discipline requires an interdisciplinary approach  An Overview of Health Disparities: The Burden of Disease o 5 of the leading causes of death in poor countries are infectious diseases that do not kill in rich countries  Effective treatments remain unavailable in these areas  Most of the world’s AIDS’s deaths occur in a single area (sub-saharan Africa) even though the treatment is only $100 per person now  Diarrheal diseases can be treated with simple rehydration, which is very inexpensive, but it is the 3rd highest killer o When looking at DALY’s, bith asphyxia and bith trauma are disproportionally high o Average life expectancy in SSA is 49.2 years, 30.2 years lower than rich countries  Defining Terms o Health (WHO) – state of physical, mental, and social well-being  May not be how people in SSA view health? o Structural Violence – social, political, and economic forces that drive up the risk of ill health for some while sparing others o Differences between public health and medicine  Public health – focus on health of populations  Medicine – focus on health of individuals  “All fields have myopias” – all fields are blind to certain aspects of broader health and need to work together to become more broad – work together under the biosocial approach in order to properly build the field of global health o Global Health: encapsulates the role of non-state institutions in the health of the world  Pathogens pass borders, so one countries alone cannot worry about it all – must be combined efforts o Global Health Delivery – provisions of health interventions through laboratory research or clinical trials  Begins with the question: “How can a health system efficiently provide health services to all who need them?”  This alone will not be effective – we must seek a broad-based agenda of social changes Chapter 3 – Colonial Medicine and Its Legacies  Summary: account of colonial medicine and its legacies – creation of WHO; how eco and political priorities of wealthy nations informed assumptions about other populations and corresponding modalities of intervention; global fascination with power of biomedical intervention (abx, DDT) in context of two important global health compaigns – smallpox and malaria eradication campaigns – very different results  Many failures in global health can be attributed to a lack of historical reflection and biosocial analysis o Many people think that global health is a new thing, when it has really been going on for a long, long time o History can help us understand the intended and unintended consequences of global health interventions

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Global Health – coined to define health problems and intervention extending beyond national boundaries o Different from international health – used describe efforts to improve the health of populations transnationally o Also different from colonial medicine – used to describe medicine of imperial rule and colonization Global health is rooted in colonial medicine – many global health problems of today have patterns going back to the social forces of colonial times Global Health and Global Empire o Notions of global health have influenced imperial ambitions for a long time  Example: stop plagues that interrupted commerce o Redefinition of public health took place when European powers began to build empires o Sites of imperial occupation often served as laboratories for medical strategies later taken up by the colonizers o Global health was important for European nations because of the Colombian Exchange – many new pathogens were exchanged with the goods o Differences in disease susceptibility both helped and hurt imperial expansion  Sometimes diseases were spread on purpose in order to kill off the natives o Many people began to interpret the disparity in infectious disease mortality as a providential sign of the rightness of the European imperial project and evidence of the frailty of “savage” bodies compared to European ones - this over time hardened racial disparities o Colonial Medicine  Quinine for malaria in the tropics  Found from the bark of the cinchona tree – one of the first instances of isolating an active ingredient from a botanic source o Colonial medicine began to support the military and services were concentrated in ports and urban centers o After military assistance, colonial medicine began to protect health of the laboring people because the local labor was necessary to create economic value o Colonial medicine tended to focus heavily on particular epidemic diseases o Led to the first epidemiological studies  Led to the belief that the black body was better suited for outdoor labor than the white body – had a big thing to do with the justification for the trans-Atlantic slave trade  Black bodies were also seen as “vectors for diseases”  Found that diseases tended to come from urban centers The Birth of Tropical Medicine o Berlin Conference – split up Africa for colonization o Identification of vibrio cholera that caused cholera – seen as important because the diseases interfered with European trade in North Africa o Tropical medicine flourished in the 20th century  Discovery of the Anopheles mosquito as the vector for malaria o Since tropical medicine is associated with tropical regions and diseases that don’t really affect rich countries, it makes since that many US people see global health as treatment of “them” rather than “us” o Shift in logics of imperial governments  Joseph Chamberlain decided to start treating malaria as if treating the vector and not the people – made since to those that want to treat the population more than the individual  Shift in idea from the diseased native to the microorganism – HUGE!

Typhoid Mary – white woman responsible for spreading typhoid fever to 53 people – “health carrier” – she was incarcerated for the last 23 years of her life to keep her from infecting others – she did not show symptoms o Missionary Medicine  Medical missionaries had a different approach to the “diseased native”  Held up western Christianity as a solution to illness and a pathway to salvation  Missionary medicine focused more on the individual than colonial medicine – focus on the populations because missionaries were concerned with the reformation of individual souls and bodies  Prior to 20th century, medical missionaries were not required to be trained professionals o Therefore, mission doctors at the turn of the 20th century were much more effective than previously – because they actually had formal medical training  Traditional Medicine – Considered to be associated with backwards natives and heathen religions and medical missionaries hoped to change their methods of medicine and their religion  Mission medicine was not done only to spread health, but also to spread Christianity  Medical missions expanded the idea of the civilizing mission with the clinician at the center of civilizing natives Global Health, Global Commerce, and the Foundations of International Health Bureaucracies o Histories of global health are often tied closely with specific diseases o PAHO – Pan-American Health Organization – world’s first permanent institution of its kind and is now the world’s oldest international public health agency o Rockefeller Foundations has financially supported many global health efforts o Bureaucratic intervention was shown to increase efficiency  This efficiency came at the cost of comprehensiveness and  Example, Rockefeller Foundations purposefully ignored tuberculosis because it was seen to involve too many social factors and to be beyond the scope of the foundation o Many bureaucracies that help with global health view the population as opposed to the individual Health, Development, and the Legacies of Colonialism o WHO formed in 1948 – after requests for the formation of a single international agency responsible for international health cooperation  Representatives from over 70 nations o 2 primary aims of WHO:  1) engage states even before they became members of WHO  2) decentralized structure  Regional offices would carry out much of the work, with a central office in Geneva o 1st international health crisis – cholera – was a success and the WHO gained international legitimacy o WHO became the principal funder and implementer of international health programs in 1955 – did this after announcing that they wanted to eradicate malaria o The Malaria Eradication Programme  Malaria cannot be eradicated without proper drainage – water puddles allow for the creation of a mosquito breeding ground  There was general faith in technology in the post-WWII period 

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This also led to more support for an eradication campaign versus a comprehensive rural development plan that would lead to malaria control  This program was the direct result of the success of DDT and vector-control as well as the donor’s preference for narrow, top-down approaches to health  Decided to do a DDT spraying plan – spray all homes once per year  They felt like this was too personnel-intensive  Also, mosquitos began to show resistance to DDT and chloroquine  WHO abandoned this program in 1969  Ultimately, the campaign failed because of overwhelming belief in technological fixes  The Who eradication campaign underestimated the biosocial fact that malaria is a disease deeply embedded in social factors like ag traditions, labor migration patterns, etc. o McKeown Hypothesis  Declining mortality can be attributed mainly to improved standards of living, which lead to reduced exposure to disease and, more important, advancement in nutrition  Not only related to development of medical treatments  Forces you to think about the limitations of relying too heavily on targeted medical interventions  Treatment of HIV/AIDS is seen as an alternative to this – medical intervention dramatically decreased mortality rates o Smallpox Eradication  Focused on 2 main activities:  1) large-scale vaccination  2) surveillance and containment Chapter 4 – Health for All? – Competing Theories and Geopolitics  Summary: analyzes the 1970s and 1990s – very important for public health; 1978 International Conference on Primary Health Care where the world adopted the goal “health for all by the year 2000;” shift towards selective primary health in the 1980s; geopolitical shifts that led to the rise of the World Bank – one of most influential institutions in global health during the 1990s and considers the effects of its approach on the health of the global poor  Idea arose that all people deserve access to health care  Primary Health Care and Selective Primary Health Care o Health for all by 2000 – slogan o Roots of the Primary Health Care Movement – 1970s  Era of decolonialization  Arose after the eradication of smallpox and knowledge that not all diseases could be solved this way, even though they caused a ton of horrible symptoms for people  Chinese and Indian grassroots programs have been somewhat more effective than US top-down initiatives – shows that basic health care services are deliverable at low cost by encouraging community participation and integrating Western and local medical practices  Drawing on community interactions to implement care  Halfdan Mahler – father of the primary health care movement  Coined the slogan – health for all by the year 2000  Vocal champion for strengthening primary care systems o Alma-Ata International Conference on Primary Health Care  Here, representatives from 134 countries and 67 international organizations affirmed a commitment to strengthening primary acre by 2000  3 key themes of the declaration of Alma-Ata 

1) introduces the concept of “appropriate technology” to describe medical and public health tools that are readily deployable in resource-poor settings  2) critique of “medical elitism” – says that top-down is not always effective – calls for increased community participation in health care delivery as well as integration of Western and traditional medical practices  3) all-encompassing definition of primary care: “education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases appropriate treatment of common diseases and injuries; and provision of essential drugs.”  Reaffirmed the notion of healthcare as a universal right  Overall failure shows that ambitious plans can sometimes fail to be translated into action  Who would pay?  There was agreement about a plan, without agreement about who would pay for the plan  Also, the 1980s had a debt crisis that left many developing countries unable to provide comprehensive social services  Selective primary care then developed o Selective primary Health Care: An Interim Strategy  Group of policymakers from rich countries met at the Rockefeller Foundation’s office to discuss the future of world health  4 overall interventions: (GOBI) – low-cost, high-impact (less than $10/child)  Growth monitoring  Oral rehydration therapy  Breastfeeding  Immunizations  Easy to monitor and measure – brought lots of supports from donors  UNICEF became the greatest champion of GOBI o The Rise of Neoliberalism  Antecedents of Structural Adjustment  Ronald Reagan and Margaret Thatcher  conservatism in the West  Ideas from Hayek and Friedman – argued that free markets distribute society’s resources in an optimal way and to view with skepticism the efficiency of most forms of government intervention o Opposed Keynes – promoted a large roles for the state in macroeconomic stabilization, market failure, an social welfare  Reagan and Thather administrations argued that many components of social safety nets (public-sector health care and education) were preventing markets from achieving efficient social equilibria  Believed that health was a commodity delivered within a market context instead of a right for all people as proclaimed by Alma-Ata  Developing countries began to default on loans and western governments withdrew capital and tried to intervene to increase debt repayment  The “Washington Consensus” – “Stabilize, Liberalize, Privatize”  Mantra of IMF and World Bank Policy – required countries who received aid to do these things  Overall, the debt crisis allowed for cycles of loaning with punitive conditions 

Emphasized market-oriented policy reforms and a diminished role for the states as a direct service provider  The Commodification of Health  World Banks’s commodification and privatization of health sector charging fees for health care access – 3 aims o 1) generate revenues for health services o 2) increase the efficiency of health services by reducing “overconsumption” from patients and encouraging people to seek care at low-cost primary care facilities instead of expensive hospitals o 3) subsidize rural health acre with revenue collected from urban user fees  The fees did not increase these aims o Even small fees prevented poor populations from seeking health services; abolition of fees even led to increases in office visits o In some places, the cost of administrating the user fees exceeded the revenue received and defeated the purpose; in most cases the revenue was not a whole lot o User fees might have had appeal on multiple theoretical grounds, but their implementation in countries with limited administrative capacity proved difficult  1980s and 1990s were characterized by slow economic growth and deterioration of health systems o Selective Primary Healthcare and the Rise of UNICEF  Many policymakers viewed good health as a necessary precursor to economic growth  UNICEF Takes the Lead  UNICEF thought that decrease in child mortality rates and increase in maternal healthcare were priorities in healthcare policy  3 more interventions added to the GOBI interventions (together known as GOBI-FFF) o 1) family planning and birth spacing o 2) female literacy campaigns o 3) food supplementation  GOBI-FFF could allow for a major decrease in observed mortality, even though it didn’t address issues like malaria, etc. o Required minimal health care infrastructure and capitalized on existing cost-effective advancements in medical technology  Immunizations became the most important aspect of GOBI-FFF  Jim Grant o State immunization days – cease fire in war and allow children to be vaccinated for free (Days of Tranquility) o He was a large part of achieving the WHO’s goal of having 80% of the children immunized  Oral rehydration therapy (ORT) greatly decreased the number of deaths resulting from diarrhea  The Limits of GOBI-FFF o Minimal impact on health systems other than decreasing infant mortality o The successes, though significant, were not sustainable o Because UNICEF emphasized ORT and immunizations, the other interventions were not deployed as quickly and widespread 

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o Institutions that rely on the efforts of a charismatic leader often have difficulty being realized in the long-run (Jim Grant was that leader) o 2000 – the Global Alliance for Vaccines and Immunizations (GAVI) was launched with funding from the Bill and Melinda Gates Foundation o ORT – simply a band-aid when the real problem is lack of clean water and sanitations o More of a vertical solution – using technology – than a solution to improve the health systems of the world o A Growing Role for the World Bank in Health: Cost Effectiveness and Health-Sector Reform  Funded HIV prevention, family planning, and nutrition programs as well as microfinance for poverty reduction  Influence for World Bank grew as the power of the WHO waned  The 1993 World Development Report and Cost-Effectiveness  The World Development Report – road map for directing health funding toward cost-effective strategies and reforms based on the principles of efficiency and equity  Raised 2 major issues: o 1) bank criticized the high percentage of public funding that went to high-cost tertiary care and argued for a reallocation of resources to achieve a basic preventative and clinical care for all o 2) proposed cost-effectiveness as the appropriate tool for setting priorities  Created DALYs to determine which diseases should be tackled first  Calculated that the most cost-effective options would be:  Immunizations  Deworming drugs and micronutrients in schools  Information campaigns on family planning, nutrition, and household hygiene  Programs to reduce alcohol and tobacco use  HIV-prevention programs  Clinical services: family planning and maternal care, treatment of tuberculosis, control of STDs, care for common childhood illnesses – malaria, respiratory infections, and diarrheal disease  These options would require $12 per capita spent by the government o This was much more than the average of $6/capita spent by the government at the time o Bank lending increased a TON after this was released ^ Conclusion: o Primary health care for all was shelved and in some ways reversed o Declining public investment in health programs was triggered by the debt crisis and structural adjustment and widespread adoption of user feed undermined already limited access to health services among the world’s poorest...