Monthly Archives: February 2016

Cost effectiveness, rights, and universal health coverage

As I’ve thought, read, and worked more on the social movement for the right to health, one inevitable tension that comes up is the aspiration for the highest attainable standard of health for all and the choices inherent in allocating scarce resources to the delivery of health care services. The tension between the right to health for all and the need to make choices about what to do (and what not to do) has led to the invention and widespread use of “cost-effectiveness analysis” to aid policy-makers in making these difficult choices. I have been meaning to read the book “Epic Measures“, about Chris Murray, but I know that it documents his work, with the Institute for Health Metrics and Evaluation to invent and codify analytic tools such as the Disability Adjusted Life Year (DALY) and the Quality Adjusted Life Year (QUALY) used in their efforts to quantify how, and of what, people die from around the world. This research has formed the basis of the Global Burden of Disease study, whose goal is to comprehensively measure epidemiological levels and trends worldwide.

These tools have been very useful to help “rationalize” budgets and allocate resources to ensure that needs are best met with the limited resources available. But, scholars, activists, and health care practitioners have routinely critiqued the blunt force use and uncritical application of narrowly defined cost effectiveness analysis to prescribe policy solutions challenges facing health care challenges, especially in settings of poverty. The challenge is that often these technocratic tools tend to scrub these policy decisions of their inherent political basis and can lead to deeply problematic policy decisions that apply a double (lower) standard to those living in poverty.

Historically, one of the most important examples what the cost-effectiveness analysis of HIV antiretroviral therapy (ART) in the early 2000’s: at nearly $10,000 per person per year, it was considered not cost-effective (and even unethical because of the cost) to provide access to ART to the majority of HIV positive people living in poor countries. Paul Farmer has a great analysis of this history in his 2013 NEJM Shattuck Lecture, showing the malleability of both cost and effectiveness in its narrow application to the question of whether or not to provide ART to poor communities. The cost of HIV meds dropped from $10K per person per year to less than $200. The effectiveness of building community-based programs through community health worker networks and social accompaniment (as demonstrated by the HIV Equity Initiative) could be proven. If both cost and effectiveness can change so rapidly, what is the epistemological basis for dogmatic deployment of cost-effectiveness analysis?

Eric Friedman and Larry Gostin of the O’Neill Institute at Georgetown Law School have a good blog post about reconciling cost-effectiveness in a rights-based approach to universal health coverage policy change.

“A traditional approach to answering this question is to focus on cost-effectiveness. Start with a given resource envelope. Then choose the set of health interventions that will buy the most health for the population. Under this approach, health is typically measured by disability-adjusted life years (DALYs). Run the numbers – the cost of different interventions, the expected benefits in DALYs – and include the most cost-effective interventions within the funds available. There is your universal health coverage benefit package.

A human rights approach differs dramatically. The first difference is the question we ask. It is no longer a straightforward matter of determining how to get the greatest health gain for the dollar based on straightforward formulas. “Coverage of what?” is only one question of many. The questions extend to the very process of answering this question, and include such questions as how are the benefits distributed across the population, how health systems can deliver on the chosen priorities, what are the resources available, and more.”

Friedman and Gostin expand upon how a rights-based approach could expand up and reconcile the use of cost-effectiveness tools, delineating the need for the approach to move beyond discrete interventions,  expand the resource envelope, acknowledge core obligations and a robust standard for all, move towards progressive realization, commit to equity and nondiscrimination, valuing local / people’s perspectives, and being accountable to those perspectives.

They conclude with a nod to the need for a robust social movement to ensure a rights-based approach to UHC and the potential utility of a Framework Convention on Global Health.

Social movements will determine whether the commitment to universal health coverage catalyzes incremental progress or a revolution in health, achieving a little more health for a few more people or, decades after the Declaration of Alma-Ata (1978), finally brings health for all. Committing to universal health coverage as a means towards the right to health is one of the surest steps we can take towards true transformation.

With this importance of the right to health, we must use the right to health platforms that we now have, even as we build upon them to construct even stronger ones – such as a new global treaty, a Framework Convention on Global Health, to reinforce the right to health, to clarify its standards, to provide for the pathways to towards this transformation – and in so doing, to further unleash the awesome power of human beings who will not be content until they succeed in claiming their rights.

Global health can never be boiled down to a technical math problem in which datasets deliver simple solutions. Advancing equity in global health is a challenge of reconciliation between what matters to people and how to allocate the resources within society to deliver those goods. It is fundamentally a matter of politics. Cost effectiveness is a valuable tool only insofar as it sharpens the political problems we face and helps us navigate these political challenges towards a more equitable allocation of health resources.

Koch bros and the neoliberal movement, cont.

Charles Koch

Charles Koch

Bill McKibbin has a great review of Jane Mayer’s new book, “Dark Money: The Hidden History of the Billionaires Behind the Rise of the Radical Right” in the New York Review of Books. I really want to read the full book, especially since I’ve been thinking more and more about the roots of neoliberalism and the global health equity movement. But, the review is great and I learned a lot from it.

Specifically, I didn’t know the deep familial roots of the Koch brother’s business, political, and economic ideology.

“The origin story of the Koch brothers, however, is like something out of a Robert Ludlum novel, connected to most of the darkest forces of the twentieth century. Their father, Fred Koch, had invented an improved process for refining crude oil into gasoline. The Russians sought his expertise as they set up their own refineries after the Bolshevik Revolution—at first he said he didn’t want to work for Communists, but since they were willing to pay in advance he overcame his scruples and helped Stalin meet his first five-year plan by building fifteen refineries and then advising on a hundred more, across the Soviet Union.”

Next, he turned to another autocrat with busy expansion plans, Adolf Hitler, traveling frequently to Germany where he “provided the engineering plans and began overseeing the construction of a massive oil refinery owned by a company on the Elbe River in Hamburg.” It turned into a crucial part of the Reich’s military might, “one of the few refineries in Germany” that could produce “the high-octane gasoline needed to fuel fighter planes.” And it turned the elder Koch into an admirer of the regime, who as late as 1938 was writing in a letter to a friend that “I am of the opinion that the only sound countries in the world are Germany, Italy, and Japan, simply because they are all working and working hard.” Comparing the scenes he saw in Hamburg to FDR’s New Deal, he said it gave him hope that “perhaps this course of idleness, feeding at the public trough, dependence on government, etc., with which we are afflicted is not permanent and can be overcome.”

Fred met his wife at a polo match in 1932, when his “work for Stalin had put him well on his way to becoming exceedingly wealthy.” They built a Gothic-style stone mansion on the outskirts of Wichita, with stables, a kennel for hunting dogs, and the other paraphernalia required for pretend gentry, and in the first eight years of their marriage they had four sons: Frederick, Charles, and a pair of twins, David and William. The first two were raised by a German governess who “enforced a rigid toilet-training regimen requiring the boys to produce morning bowel movements precisely on schedule or be force-fed castor oil and subjected to enemas.” Luckily for the twins, she left for home when they were born, apparently because “she was so overcome with joy when Hitler invaded France she felt she had to go back to the fatherland in order to join the führer in celebration.”

Of those four sons, Charles became the dominant force, and one of the twins—David—his close colleague. Eventually, by Mayer’s account, they essentially blackmailed the eldest brother, Frederick, out of his share of the family business by threatening to tell their father that he was gay. Bill, too, later parted ways with his brothers, parlaying his share of the inheritance into a lucrative oil business and then using the proceeds to, among other things, fund opposition to wind energy off Cape Cod. But Charles was always the crucial Koch. His father, despite or because of the original source of his fortune, became a fervent anti-Communist and one of the eleven founding members of the John Birch Society. One of the figures in its orbit, Robert LeFevre, became Charles’s original guru, opening a “Freedom School” in Colorado Springs in 1957, where he preached not just the Birchers’ anticommunism but also an adamant opposition to America’s government.”

Thinking back to the piece by Alex Hertel-Fernandez and Theda Skocpol and their analysis of how the Koch brothers’ network of think tanks, grassroots groups, philanthropy networks, etc have formed some kind of a black hole, sucking the Republican party to the radical right, it is easy to see how these efforts have shaped the insane political climate we see today.

And, now that the Koch brothers are gaining public notoriety (mostly negative), they have started an aggressive “rebranding campaign” targeted at reclaiming the “middle third” of voters who are neither conservative or liberal.

“Perhaps realizing that forty years of heavy spending had failed to make their ideas popular (though often successful nonetheless), the Kochs, Mayer reports, are undergoing a branding makeover, launching a PR campaign designed to appeal to the “middle third” of voters who are neither conservative or liberal. The effort to produce a “positive vision” resulted in, among other things, a “Well-Being Forum” sponsored by the Charles Koch Institute in Washington, where the founder quoted from Martin Luther King Jr. The most substantive part of this image-building has been a drive for criminal justice reform, in partnership with many progressive and minority leaders concerned about mass incarceration who advocate reform of sentencing. But late last fall the coalition began to falter, with many complaining that the Kochs were pushing changes to the criminal code that would make it even harder to prosecute corporate crimes—the very crimes that, as Mayer shows, most of the biggest players in their network have regularly engaged in.”


NGOs: In the service of imperialism?

Just re-stumbled upon an oldie but a goodie paper, “NGOs: In the service of imperialism,” that is purposefully provocative about the purpose and function of NGOs in the global development and economic landscape. James Petras is a somewhat eccentric Marxist and this paper is a scathing critique of NGO action, even purportedly “rights based,” liberal NGOs working to “mobilize civil society” in the name of democracy and rights.

Similar to Monika Krause’s view of “the good project” 1 and the commodification of projects and beneficiaries, Petras see’s NGOs as serving the function of preventing or co-opting true, locally-driven movements to apply political pressure to governments and the international actors to protect rights.

“NGOs emphasize projects not movements; they “mobilize” people to produce at the margins not to struggle to control the basic means of production and wealth; they focus on the technical financial assistance aspects of projects not on structural conditions that shape the everyday lives of people.”

He goes on:

“The formal claims used by NGO directors to justify their position  — that they
fight poverty, inequality, etc. are self-serving and specious. There is a direct relation between the growth of NGOs and the decline of living standards: the proliferation of NGOs has not reduced structural unemployment, massive displacements of peasants, nor provided liveable wage levels for the growing army of informal workers. What NGOs have done, is provided a thin stratum of professionals with income in hard currency to escape the ravages of the neo-liberal economy that affects their country, people and to climb in the existing social class structure.

“By talking about “civil society” NGOers obscure the profound class divisions, class exploitation and class struggle that polarizes contemporary “civil society.” While analytically useless and obfuscating, the concept, “civil society” facilitates NGO collaboration with capi- talist interests that finance their institutes and allows them to orient their projects and followers into subordinate relations with the big business interests that direct the rico- liberal economies… In addition, not infrequently the NGOers’ civil society rhetoric is a ploy to attack comprehensive public programs and state institutions delivering social services. The NGOers side with big business’ “anti-statist” rhetoric (one in the name of “civil society” the other in the name of the “market”) to reallocate state resources. The capitalists’ “anti-Statism” is used to increase public funds to subsidize exports and financial bailouts, the NGOers try to grab a junior share via “subcontracts” to deliver inferior services to fewer recipients.”

I tend to agree with him about the structure of power and forces that shape the NGO terrain and ultimately drive the practice of NGO managers and the programs they develop. I think (as I’ve written) that these forces are often, if not always, antagonistic to the political process necessary to demanding the protection of rights, especially the right to health. Private NGOs seem to lessen the pressure on the public sector to provide fundamental social services (such as education and health care) and can function as a tool of privatization. Linking back to the comments by Dr. Salmaan Keshavjee about his experience with developing a revolving drug fund Kazakhstan with the Aga Khan Foundation, its easy to see how NGOs can function “transplantation device” for neoliberal, “free market” ideas and the privatization of fundamental social services.

At the end of this piece, Petras calls for a more robust “theory of NGOs.” I think there is a major opportunity to build off Bourdieu, McAdam, and Krause to develop better theoretical constructs and case study examples to analyze the expansion of transnational nongovernmental organizations and the ways they alter the local political, economic, and cultural landscape in poor and marginalized communities around the world. It seems clear that the “field” of international development has set up the game that NGOs play, the rules of which are dominated by large-scale capital. This is the game of the construction of commodified “good projects” that then get sold to the international financiers on an “open market.

The question for me is: what’s to be done?

Though I’m sure you can level all sorts of critiques at Partners In Health as a fairly large transnational NGO, I do believe there is something unique and special about the way that we have tried to institutionalize a practice of “accompaniment.” I believe that PIH has a stated and deeply held set of values, internal logics, and defined purpose that in many ways runs perpendicular to the animating logics of the “Bourdieusian” field of international development. PIH’s core purpose is to work alongside ministries of health and marginalized communities to build the capacities to develop high-quality health care delivery systems that can be scaled into national systems of universal health coverage. We seek to accompany governments in the process of helping them meet the obligations of protecting the rights of their citizens, of which we consider health to be foundational.

I have seen how the field-defining “good project” drives the flow of capital through financing mechanisms (bilateral foreign aid, in particular), and makes PIH’s core mission (and a more broadly important function in the world if we want to advance rights-based work) very difficult to finance. At least, it makes it nearly impossible for an organization attempting to support governments in the task of being effective in their work to deliver packages of needed services (thus, protecting rights) at scale to gain access to the capital necessary to do this work effectively.

Questions we need to keep working on:

  • What type of social movement or political project is necessary to sufficiently disrupt and reorient the field of international development such that it can be less organized towards the narrow construction of tightly defined projects and more towards the goal of enabling governments to be effective in protecting rights?
  • What would it take to reform the large-scale financing mechanisms that reflexively define “the good project” and are reinforced by this definition?
  • Could we imagine the creation of new financing mechanisms that would direct capital towards the idea of a “third sector organization” type that we might call an “accompaniment” organization? An accompaniment organization could be thought of as one that would be focused on the specific work of embedding in and enabling a public sector (government ministry) to be effective in its work to protect social/economic rights of citizens (health in particular, or at least for us).
  1.  Krause, Monika. The Good Project: Humanitarian Relief NGOs and the Fragmentation of Reason. Print.

Theorizing on the emergence of university-based global health programs

A couple of years ago, some student volunteers and I embarked on a mini-research project to better understand the magnitude and time dynamics of the growth of university-based global health programs across the U.S.  You can find our posts and summary of our amateur findings here.

Personally, I’ve seen the remarkable growth and expansion of undergraduate-focused global health educational programs (new majors, minors, centers of interdisciplinary study, study abroad programs, etc) through my work with both GlobeMed and PIH Engage, and seeing the rapid expansion of the Global Health Corps and similar fellowship organizations over the past ten years. In fact, GlobeMed students and many others have been a catalyzing force urging administrators to develop new courses and programs of study.

Figure 5

Our attempt to measure the growth of undergraduate-focused global health program growth at U.S. universities.

Others have also commented and tried to characterize the fairly rapid and significant expansion of undergraduate-focused university-based global health training and educational programs. The Center for Strategic and International Studies has two solid reports, one from 2009 and another from 2014. A flurry of papers have also worked to characterize and have tried to understand the implications of this new focus in higher education. The Consortium of Universities for Global Health has emerged as a powerful force “sharing knowledge and best practices” across universities and colleges, especially between those in “resource rich and resource poor” countries. It seems clear that universities are important and powerful hubs of meaning-making, frame-setting, agenda developing, and training of powerful (or soon-to-be) actors in global health. The magnitude of U.S. universities’ role has grown significantly over the last decade and seems to be growing.

Despite all of this however, I have struggled to understand the drivers of these changes at the university level. Why are these programs being set up? Why are they growing in terms of students, faculty, and influence? What catalyzed this emergence and shift? I think that theorizing on and testing answers to those questions is an important step in understanding the “social movement” for the right to health. University-based global health programs are very important in understanding the full picture of the “field of practice” of global health that has emerged, especially since the emergence of the AIDS treatment movement.

Doing some google and database searching led me to the great dissertation and subsequent research of Karl Maton, a professor of sociology at The University of Syndey. Specifically, his dissertation titled, “The Field of Higher Education: A sociology of reproduction, transformation, change and the conditions of emergence for cultural studies” lays out a compelling theoretical construct that I think is very useful to understand the institutional practices of conservation and change within universities. His case is explores the structuring shifts that led to crises and realignments in English universities during the 1960’s that led to the emergence of “cultural studies” as a legitimized discipline.

His theoretical construct uses Pierre Bourdieu’s field, capital, and habitus (as I’ve tried to sketch in application for global health) in combination with Basil Bernstein’s code theory to develop an explanatory mechanism for change and stability within the university, which he sees as an “emergent and irreducible social structure.” The combination of Bourdieu and Bernstein has led Maton to develop “Legitimation Code Theory“. In his study of the changing field of high education in England preceding the development of the new cultural studies discipline is what he describes as a struggle of control over the “legitimation device” — the “languages of legitimation” that dominant actors in the higher education field use to control what is allowed / not allowed. The legitimation device controls:

“the ways in which participants represent themselves and the field in their beliefs and practices are understood as embodying claims for knowledge, status, and resources. These languages of legitimation may be explicit (such as claims made when advocating a position) or tacit (routinised or institutionalised practices). All practices (or ‘position-takings’) thereby embody messages as to what should be considered legitimate. I conceptualise these messages as articulating principles of legitimation which set out ways of conceiving the field and thus propose both rulers for participation within its struggles and criteria by which achievement or success should be measured. The ‘settings’ or modalities of these principles of legitimation are regulated by the legitimation device.” 1

The principles governing the legitimation device are Autonomy (structuring of external relationships to the field), Density (relations within the field), Specialization (relations between the social and symbolic or cultural dimensions of the field), and Temporality (temporal aspects of these relations). Each principle can be ‘set’ (+/-) based on the preference of the dominant in field.

“To analyse change in higher education using these concepts is to view higher education as a dynamic field of possibilities. The legitimation device is the means of generating and distributing what is and is not possible within the field. Positions and position-takings are conceived of as representing possibilities, where some possibilities may be recognised, some realised, but others remain latent (unrecognised and unrealised). A possibility exists within a structured system or field of possibilities; conversely, a field is a structured space of possibilities. The structure of a field (and so the range and distribution of possibilities) is given by its legitimation code modality. Changes in legitimation code thereby represent changes in the structuring of the field and so the space of possibilities. To examine the emergence of new possibilities (such as cultural studies) is to analyse the effects of changes in legitimation code on the field.” 2

The legitimation device defines the dominant and dominated legitimation codes that set up the possible positions and their relative power / authority within the field of practice of higher education.

legitimation device and code

The legitimation device describes the set of possible positions in field. PA = positional autonomy; RA = relational autonomy MaD = material density; MoD = moral density SR = social relation; ER = epistemic relation C = classification; F = framing; i = internal; e= external; t = temporal +/- = relatively stronger/weaker

Ok, so lots of very abstract theory-talk here. But, I believe that the legitimation device as an analytic tool could be deployed to systematically study the changes in the field of higher education that have occurred over the past 15 to 20 years that led to the emergence of global health as a field of study. What have been the dominant legitimation principles in the most powerful universities in the U.S.? Who within these universities have controlled the legitimation device? Why? What shifts in the broader external political and economic and internal university (student, staff, faculty) environment have exerted pressures on those in control of the legitimation device?

How could those pressures (perhaps those akin to a social movement??) and the competition over the legitimation device create the space for a new domain of global health studies to emerge on college campuses across the U.S.?

  1.  Maton, Karl. “The Field of Higher Education: A Sociology of Reproduction, Transformation, Change and the Conditions of Emergence for Cultural Studies.” Diss. St. Johns College, U of Cambridge, 2004. p. 83.
  2.  Ibid. p. 84.

‘A Theory of Fields’ and the right to health movement

a theory of fieldsI think that Bourdieu’s concepts of field, capital, and habitus are very important to be able to understand the history and future of the movement for global health equity, as I’ve written about here.  The challenge I was trying to address in that piece was one of insurgent action and the dynamics of change within fields. Bourdieu’s account of fields of social action biases towards stasis — action is inhibited, or at least structured by the cumulative embodiment of history as habitus.

How does social change happen? This is something that Bourdieu is relatively quiet on in his work and is where McAdam and Fligstein have tried to build on the tradition of “field-based” social theory to account for social change in “meso-level social orders.” The result is their 2012 book, “A Theory of Fields” (TOF).

Doug McAdam is a scholar that I’ve drawn inspiration from for at least the last five years and is someone who has loomed large over the sociology of social movements for decades. His political process model serves as a way to conceptualize and study social movement emergence, growth, and decline is a standard for social movement sociology. He started his professional dialogue with Neil Fligstein, an organizational and political sociologist, decades ago and together they have been trying to understand why so many social scientists of different methodological and theoretical angles have come to a similar set of concepts and ways of interpreting social action. As they put it in the preface for TOF:

“We believe the reason that all of these scholars across so many disciplines, subfields, and methodological and theoretical persuasions have come to find one another is because we have all inadvertently discerned a set of foundational truths about social life. The problem of mesolevel social order and the creation of strategic action fields is the central problem of a social science interested in how people engage in collective action, how they construct the opportunity to do so, the skills they bring to the enterprise, how they sometimes succeed, and if they do succeed, how they seek to stabilize and maintain the resulting order. These issues are central to an understanding of how people make political change, build a new product to take to market, challenge existing laws by lobbying governments, as well as how actors maintain a stable hierarchical order in popular music, haute cuisine, or any other cultural field. It is this deep sociological problem that is at the core of what we are writing about. As such, we are happy to acknowledge our interest in and relation to the wide and voluminous literature that has developed on these topics in recent years. We have learned from these various literatures, borrowed from them, and tried to contribute to them. We have returned to this manuscript in order to clarify some of the literatures’ critical insights and to finally consolidate and elaborate the various strands of our own thinking.” 1

It’s kind of amazing to just be stumbling upon this book, especially after having written “Opportunities for research and practice in the social movement for the right to health” which was grappling with this same topic through the lens of global health. It’s also thrilling because I think that it provides an useful theoretical framework to study and actually engage in the social movement building work for the right to health; work that does, in fact, link ideas the ground Bourdieu (field, capital, habitus), McAdam (political process model), and Ganz (leadership and community organizing practice in social movements).

McAdam and Fligstein’s theory of fields rests on three clusters of ideas:

  1. Strategic action fields (SAFs): Meso-level social orders which serve as the basic structural building block of modern political / organizational life in the economy and civil society. This theoretical treatment allows sociologists to study stability and change dynamics at the field-level a la Bourdieu / Wacquant.2
  2. Embeddedness of fields: Fields are embedded within a broader environment of countless other strategic action fields and states (which themselves complex SAFs). Crises and shocks in proximate SAFs are often what create the space and opportunity for change within the SAF under study. SAFs can also be envisioned as if “Russian stacking dolls”: for instance the American economy could be broken down into specific industries, those industries into specific firms, those firms into regional offices / departments / functional units, and those departments into specific teams. Each of these SAF contain actors who make decisions about what to do in relationship to the other actors in the field.
  3. Social skill: Finally, M+F’s theory rests on the a microfoundation of an “existential function of the social.” Explaining social action within fields relies on a complex mix of material concerns (power, resources, constraints, opportunities) and also “existential” considerations: human emotions, meaning making, belonging, relationships. By understanding the essentially existential nature of human existence, M+F introduce the concept of “social skill” and “skilled social actors” who know how to bring people together, form relationships, shape meaning making of collective experience, and enable people to work together for shared social aims. Skilled social actors are necessary to create, maintain, and transform strategic action fields. “Put another way, the concept of social skill highlights the way in which individuals or collective actors possess a highly developed cognitive capacity for reading people and environments, framing lines of action, and mobilizing people in the service of broader conceptions of the world and of themselves.” 3

Overall, I think that this approach has much to offer students of institutions and change within global health. One can imagine the field of global health and international development as a somewhat distinct group of collective actors (NGOs, MOHs, foundations, financing organizations) all operating with a set of governing logics that are to some degree imposed by those dominant within the field of strategic action (aka, the financiers; think Gates, USAID, DFID, etc). More often than not, the logics that are imposed are rooted implicitly or explicitly in neoliberalism. This drives the logic of production of  “the good project” by international NGOs as described by Monika Krause. International NGOs, at the mercy of international financing bodies, must conform their work to producing short term, often vertically oriented global health programs that serve relatively easy to serve populations, outside of the public sector, in order to produce statistically significant outcomes / impact in order to appeal to donors’ grant evaluations and requirements.

This is how neoliberal logic is reproduced within well-meaning NGOs4 that have goals to advance human rights. More work should be done to extend Krause’s work more specifically from international development NGOs to more specifically global health organizations.

Finally, and this is the work that I hope to be able to do formally in graduate school, I believe there is a huge opportunity to study and understand how rights-based delivery organizations (PIH, Last Mile Health, Project Muso, Possible, etc) are making an insurgent response in the face of these orthogonal logics. How do they keep themselves from adopting the dominant logic and conforming with the resource and power flows within the field? What type of collective action, skilled social actors, meaning making processes, social movement organizing activities enable these organizations to insulate themselves from the broader field? How might these organizations continue to invent new modes of collective action that could actually alter the rules of the game and enable resources to flow in ways that support the public sector’s capacity to protect rights of citizens?

  1.  Fligstein, Neil; McAdam, Doug (2012-04-16). A Theory of Fields . Oxford University Press. Kindle Edition.
  2.  Bourdieu, Pierre, and Loi Wacquant. An Invitation to Reflexive Sociology. Chicago: University of Chicago Press, 1992. 36-46.
  3.  Fligstein 2001a; Jasper 2004, 2006; Snow and Benford 1988; Snow, et al. 1986). Fligstein, Neil; McAdam, Doug (2012-04-16). A Theory of Fields (p. 17). Oxford University Press.
  4.  Keshavjee, Salmaan. Blind Spot: How Neoliberalism Infiltrated Global Health. N.p.: n.p., n.d. Print.

Soft power, Arcade Fire

Can’t believe I’ve never heard this Arcade Fire song until just now… So good.

Soft power got them so upset.
They think it’s over.
But it’s not done yet.

Soft power in the underground
Gonna let the wind
Blow the shit all around.

Soft power gets into our brains
Soft power now it’s never going to be the same
All your voices in the streets tonight
Soft power
It’s alright

All your power makes the world go round
You can cut the speakers
You can cut all the sounds.
But can you hear us
Singing our song?
Soft power
Now it’s coming on strong

Soft power gets into our brains
Soft power now it’s never going to be the same
All your voices in the streets tonight
Soft power
It’s alright

Soft power
Look at them go
Soft power
They’re about to explode
Soft power
In the Underworld
Soft power
Every boy and girl

We were born
So it’s our right
You can cut all the power
You can cut all the lights
But we can see you even in the dark
Your words are fire
And we are the spark

Soft power gets into our brains
Soft power now it’s never, ever going to be the same
All your voices in the streets tonight
Soft power
It’s not alright

Soft power
Look at them go
Soft power
They’re about to explode
Soft power
In the Underworld
Soft power
Every boy and girl

Call a doctor
when it’s not alright

Call a doctor
Cause it’s not alright

Call a doctor
It’s not alright

Call a doctor
Cause it’s not alright


We’d love to help you
But we’re not home.
Leave a message:
It’s impossible now.

We’d love to help you
But we’re not home.
Leave a message:
It’s impossible now.

We’d love to help you
But we’re not home.
Leave a message:
It’s impossible now.

(Here we go…)

CH188: Framework Convention on Global Health and its historical roots

This past Thursday, we had the third session for CH188: The Right to Health: Problems, Perspectives, and Progress and we focused on 1) readings that laid out the foundational texts that undergird the right to health (the Constitution of the WHO, Universal Declaration of Human Rights, Convention on the Rights of the Child, International Covenant on Economic, Social, and Cultural Rights, etc.), 2) we heard from guest lecturer Eric Friedman, JD who discussed the current work to more formally codify the right to health through the Framework Convention for Global Health (more here, too), and 3) we began a discussion about the ethical reasoning that underpins all of global health thinking and work and the notion of the right to health. It was a busy session and probably a bit too much to try to cover in a three hour seminar, but we powered through and I think it will provide, once again, a useful foundation as we begin to dive into some of the problems that delay our progress towards the right to health.

Eric Friedman skyped with CH188 and shared his view of the opportunity for renewed global governance for the right to health.

Eric Friedman skyped with CH188 and shared his view of the opportunity for renewed global governance for the right to health.

Linking to the last session’s discussion of the history of the global health project, we discussed the historically-rooted documents that to some extent define and provide the structure for arguments and action for the right to health. A couple things stand out to me upon re-reading these documents. First, it’s pretty clear from an international governance that a right to the “highest attainable standard of health” is to be protected across the board. The right to health exists. Second, its important to understand the the historical, cultural, and geopolitical context in which these documents were created. Finally, understanding that history, and the ethical roots of the documents could give us insights for ways to move forward collective work to enable their wider adoption and greater effectiveness.

The Right to Health in International Law

Summary of the right to health through the lens of the International Covenant on Economic, Social, and Cultural Rights. 1

What’s lacking is 1) accountability to these goals and mechanisms of holding individual states accountable for violations of protection for the right to health, 2) a commitment to progressive financing mechanisms to help poor countries move forwards progressive realization, and 3) the grassroots movement of people who acknowledge their right to health and who are organized enough to demand that right through their state actors and through broader international action.

I just finished reading Nitsan Chorev’s fantastic analysis of the World Health Organization2  and it’s strategic transformation during two distinct historical periods: the 1970s and 1980s, and the  1990’s and 2000’s. Her analysis, taken with Salmaan Keshavjee’s historical and ethnographic treatment of neoliberalism, construct a useful lens through which to see the changing power of human rights documents and language. Specifically, she looks at how the the WHO adapts strategically to exogenous pressures from states, private actors, and the changing geopolitical / and economic structures.

The 1970s-80s were largely shaped by the political power of the G77 — the block of the poorest countries in the world, many newly independent from their colonizers — and their ability to utilize the one-country, one-vote procedural process within the WHO to exert significant political power towards expansion of primary care and the push (led by Halfdan Mahler) of “health for all by the year 2000.” It was this balance of power within the WHO that allowed the primary care and health for all movements to gain traction and lead to the meeting at Alma Ata. It was during this period that many of the international human rights documents were drafted and when the right to health as an international legal principle gained the most ground.

But, the progressive political block of the G77 during the 1970s and 80s provoked a significant backlash from the wealthiest and most powerful countries in the world, whose action was shaped largely along the lines of the Cold War. As Keshavjee discussed, elite economists in the US and elsewhere were terrified about the potential for a re-emergence of totalitarianism and saw the expansion of Communism and Socialism throughout the G77 as a major threat to liberalism, liberty, and freedom. Hence, the rise of dogmatic neoliberal logic.

The political and financing environment of the 1990s and 00s for the WHO were very different. Understanding that the U.S. and the U.K. could apply other pressure than votes, they began withholding regularly scheduled dues and fees payments to the WHO. They gradually made more and more of the WHO budget focused on discretionary or dedicated budget line items, rather than general expenses. Additionally, the Gates Foundation and other large private philanthropies took a larger role in financing global health including funding the WHO. This precarious and narrow funding meant that the WHO was highly vulnerable to the pressures of states and organizations deeply entrenched in neoliberal logic. The WHO, which had lost stature due to the failure of malaria eradication efforts in the 1960s, had to adapt or grow increasingly marginalized in the global governance of health.

The WHO strategically adapted by transforming neoliberal logic to (to some extent) serve their purposes. Gro Harlem Brundtland, then Secretary-General of the WHO, sought to enlist economists in the effort to demonstrate how targeted, “cost effective” investments made in the health sector could be powerful drivers of economic growth for low and middle income countries. Cost effectiveness became a way of “rationalizing” spending on health services for the poor and created a technical framework by which the WHO could continue to serve as a powerful technical expert to countries around the world, thus staying relevant.

“The prominent role of the World Health Assembly, and therefore of member states, in the process of decision making has secured the dominance of geopolitical logic in the global health agenda. Especially in the first few decades of the WHO’s history, the Cold War division between East and West directly shaped international health priorities (Litsios 1997, Manela 2010). Following decolonization, the World Health Organization, along with the rest of the UN system, was greatly affected by the demands of the newly independent countries of the Global South for a New International Economic Order. In the mid-1980s, in turn, the NIEO logic was replaced with a U.S.-led neoliberal agenda, best expressed in what has become known as the “Washington Consensus” (Williamson 1990). For UN specialized agencies, including the WHO, each period was characterized by the emergence of a distinct global ideational regime and by exogenous pressures to follow that regime. An overview of the policies formulated by the WHO staff and leadership and adopted by the executive and the assembly illustrates, however, that these policies did not faithfully echo the call for a New International Order in the 1970s nor the neoliberal principles of the 1990s.”

  • Chorev, Nitsan (2012-05-01). The World Health Organization between North and South (p. 5). Cornell University Press. Kindle Edition.

The Framework Convention on Global Health (FCGH) is a modern attempt to once again move the balance of power towards the right to health. Eric Friedman gave a great presentation outlining the growing movement towards a convention, modeled after the Framework Convention on Tobacco Control.

See his slides here.

In hist view, the FCGH couple help address key gaps in financing, work to curb the power of non-health sectors, address problems with health worker migration and “brain drain”, and address health disparities within countries. It could accomplish this by leveraging the power of law (powerful norms, facilitation of collective action, and binding responsibilities to support local advocacy), taking advantage of a globalized world in which nation-states should not be sole unit of analysis, and learning from past experience (FCGTC).

There is much, much more to say on the topic of a Framework Convention for Global Health, but suffice it to say, there is stark opposition to such an idea. See the piece from the Health and Human Rights Journal on “the dark side of the FCGH.” I’m hoping to do another post soon diving in to the debate and potential future of global governance in global health.

Reading and Class Notes:

Grodin et al Chapter 2:
  • Direct human rights abuses continue: Abu-Ghraib, botched executions, torture, etc.
  • Subtle human rights abuses like lack of health systems, discrimination, etc
  • Brief history:
    • Nuremberg Trials — since then interest in health and human rights have grown.
    • Since HIV in the 1980s, health / human rights have had parallel but distinct tracks.
    • Jonathan Mann and the HIV treatment movement was the first global effort to link health and human rights explicitly.
    • Since the AIDS treatment movement, almost all development agencies and UN programs must acknowledge rights in their health work. Even some governments are building legislation / incorporating into their constitutions.
      • Yet, lots of work yet to do and many gaps to be filled.
    • WTHO constitution: one of the best sources of “the right to health.”
  • The idea of health as a human right as a subject is fairly new.
  • Advocacy and bearing witness:
    • Complacency of governments in their response to HIV: activists demanded and pushed for action. Result was dramatically reduced cost of HIV medications
    • A key dilemma: sustainable action, should it be connected to documentation and denouncements of human rights violations? How would that limit the ability to deliver the services that people need / jeopardize the safety of their workers?
  • Rights in Delivery of Care and Programming:
    • Examining laws and policies under which programs are being run
    • Systematically integrating core human rights principles such as participation
    • Focusing on key elements of the right to health.
  • Concerns for the future:
    • Government roles / responsibilities are increasingly being relegated to non-state actors (NGOs corporations, etc): accountability poorly defined inadequate monitoring.
    • Ways forward:
      • need to educate staff and engage them in conversations about right to health.
Lecture Notes:
–> Send class information on the TPP.
Consequentialist / Nonconsequentialist Logitcs + Ethics
  • Rightness / wrongness based on the consequences / outcomes of actions
    • Consequentialist: Utilitarianism is a function of this: action to take is to produce the greatest good for the greatest number. The end is more important than the means.
    • Nonconsequentialist: rightness / wrongness are due to the content of the actions. The means matter more than the ends. Actions can be right or wrong. Libertarianism, contractarianism: No policy that causes compensated harm is allowed.
  • FCGH: what are the values that are underlying this? What are the values and ethics?
    • What constraints will it place on non-state actors?
    • What effects will it have on the SDGs? 17 SDGs
  • Objective <–> Subjective
  • Radical Change <–> Status Quo
  2.  The World Health Organization Between North and South. Ithaca: Cornell University Press. (

The Iowa caucuses and the new neoliberal movement

As I have studied equity-oriented global health delivery, it’s become increasingly clear that the concerted effort to define liberty / freedom as equivalent to and inseparable from completely unregulated “free markets” is central to understand the contest at the center of a movement for the right to health. We learned last week from Dr. Salmaan Keshavjee and his book, “Blind Spot: How Neoliberalism Infiltrated Global Health” that a handful of intellectuals gathered after WWII to mount a concerted social strategy to “win the battle of ideas” in the global forum; to fight and reverse the notion of the welfare state, New Deal policies, the specter of Communism, and social and economic rights. The Mont Perelin Society set forth a radical intellectual, but also political, social, and moral project to reshape the foundation of Western liberal thought and underpinnings of the relationship between citizen and state.

In the wake of the Iowa caucuses last night it’s important to reflect on the historical roots of neoliberalism and the legitimate social movement that is driving the modern Republican party further and further to the radical right. In the recent New Yorker article, New Koch: The billionaire brothers are championing criminal-justice reform, Jane Mayer chronicles the work of the Koch brothers, their sprawling political network, and their recent re-branding effort. Once again we see a clash of ideas and a serious social / political strategy to decouple citizens and states and move forward the radical aim of completely unfettered markets.

Of specific interest to me was an article she cites from Harvard sociologists Theda Skocpol and Alexander Hertel-Fernandez: The Koch Effect: The Impact of a Cadre-Led Network on American Politics. In it they present an in-depth analysis of the evolution, organizational components, and effects that Koch-inspired and funded organizational network has had in driving polarization and shifting the GOP rightward over the past decade+. As opposed to just looking at the funding of political campaigns, ads, think tank and policy work, they take an organizational approach to try to understand the constellation of organizations, individuals/roles/positions, and institutional effects that these organizations have had on the two traditional political parties. As they put it:

“The Koch network is not just a congeries of big money donations from the two brothers themselves, or a loose, undisciplined array of advocacy groups and political action committees to which the principals send checks. Instead, the network has by now evolved into a nationally federated, full-service, ideologically focused parallel to the Republican Party. The Koch network operates on the scale of a national U.S. political party, pledging to spend in the 2016 cycle more than twice what the Republican national committee spent in the previous presidential election and employing more than three times as many staffers as the Republican committees had on their payrolls as of late 2015 (Vogel 2015a; Bump 2014)…

In a disciplined way, the Koch network operates as a force field to the right of the Republican Party, exerting a strong gravitational pull on many GOP candidates and officeholders.” 1

They demonstrate that the fraction of resources controlled by the formal GOP party committees has dropped significantly over the past 10 years, and so has the power of these institutionalized political party channels.

Skocpol and Hertel-Fernandez show a striking drop in resources controlled by the GOP party committees.

Skocpol and Hertel-Fernandez show a striking drop in resources controlled by the GOP party committees.

They also make the argument that the Koch brothers’ funding and institutional network touch all five of the most important types of political organizations that contribute to and influence party politics:

  • Political party committees: formal RNC / DNC
  • Non-party funders: organized groups of donors that fund campaigns and political activities
  • Constituency organizations: mobilize mass bases of people (think NRA / labor unions)
  • Issue advocacy organizations: pro-life / pro-choice groups, anti-tax groups, etc
  • Think tanks: produce policy research and concepts, like Heritage, Cato, Economic Policy Institute, etc

Since 1975, the Koch brothers have catalyzed the creation and coordination of organizations that contribute to each of those key areas of party politics. At the root of this strategy is that:

“the Kochs take ideas seriously and believe that politicians “reflect” rather than create “the prevalent ideology” (see Schulman 2014: 99). The Kochs were major backers of the nation’s leading libertarian think tank, the Cato Institute, founded in 1977. Starting soon after, in 1980, they began continuous sponsorship of the Mercatus Center at George Mason University, which runs educational programs in the humanities as well as policy studies and, these days, regularly issues research and policy recommendations on major issues such as global warming. Finally, perhaps the most prominent of several family foundations is the Charles G. Koch Foundation, which regularly disburses hundreds of grants to college and university-based scholars and programs, all meant to encourage free market and libertarian ideas and policy proposals (Levinthal 2015; Schulman 2014, 264- 66).”

The Koch's creation of political organizations spanning idea creators, policy advocacy, donor coordination, constituency mobilization, utilities.

The Koch’s creation of political organizations spanning idea creators, policy advocacy, donor coordination, constituency mobilization, utilities.

Especially striking is the more recent strategic investment in a rapidly growing grassroots constituency network of mobilizing organizations.

Growth of the Koch funded and coordinated grassroots network of activists.

Growth of the Koch funded and coordinated grassroots network of activists.

“But even though AFP is highly centralized like a corporation, it also has a federated structure with important state-level organizations, just like classic American voluntary associations and the U.S. governmental system as a whole (Skocpol et al. 2000). Directors and other paid staff members such as “grassroots directors” are installed in most of the states and given considerable room to monitor and influence state and local politics and weigh in locally with their state’s U.S. Senators and Representatives.

State-level AFP organizations are called “chapters,” but that is a misnomer because they are not really in any sense controlled from within the states themselves. Although AFP usually appoints directors who have experience and longstanding ties in their states, these pivotal players are not elected by in-state activists or selected through any internal decision-making process.”

Going back to Bourdieu, McAdam, and Ganz as useful theoretical underpinnings in understanding social movements, its difficult to dismiss that their description of the Koch’s sprawling political institutional network that links formal political party committees, non-party private funders, constituency/grassroots organizations, issue/policy advocacy organizations, and policy-creating think-tanks seems very Bourdieusian. It looks like an incredibly sophisticated strategy to not only play the electoral game of American politics, but a much more ambitious attempt to grow the political, social, symbolic, financial, and even cultural capital with the aim of re-writing the rules of American political game: one in which the state functionally ceases to exist.

McAdam’s political process model is also a useful analytical tool here: Hertel-Fernandez and Skocpol have identified the grassroots organizational strength of this network, shown the emerging political opportunities that the network is tapping into, demonstrated the effect of “cognitive liberation” created by think tanks and policy scholarship networks. Looking at broader political and economic trends–growing inequality, rising polarization and distrust of traditional political parties, the maintenance of Citizens United and unlimited private spending on political engagement– its hard to see how this movement might be challenged and stopped.

The victory of Ted Cruz over Donald Trump is one very practical indicator of this success. Trump, racist and deplorable as he is, is not an ideologue, but Cruz is. Ted Cruz is the kind of litmus-tested neoliberal candidate the Koch machine is designed to elect.

The American left, let alone a global movement for social and economic rights and the right to health, has nothing this robust. If Bourdieu calls for the irreplaceable role of the collective intellectual, “by helping to create the social conditions for the collective production of realist utopias… organize or orchestrate joint research on new forms of political action, on new ways of mobilizing and making mobilized people work together, on new ways of elaborating projects and bringing them to fruition”, 2 why is the right winning?

  1.  Skocpol, Theda, Hertel-Fernandez, Alexander. “The Koch Effect: The Impact of a Cadre-Led Network on American Politics” Inequality Mini-Conference, Southern Political Science Association. Jan. 28, 2016.
  2.  Bourdieu, Pierre. “A Scholarship with Committment.” Revueagone Agone 23 (2000): 205-11. Web.