Author Archives: Jon Shaffer

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.

Public intellectuals and social movements

The Chronicle of Higher Education has an interesting piece on public intellectuals1 and their role in “creating new publics” — groups that share a common interest, action, language, and purpose.

“The reason for this has less do with the elitism of the intellectual — mine is no brief for an avant garde or philosopher king — than with the existence, really, the nonexistence, of the public. Publics, as John Dewey argued, never simply exist; they are always created. Created out of groups of people who are made and mangled by the actions of other people. Capital acts upon labor, subjugating men and women at work, making them miserable at home. Those workers are not yet a public. But when someone says — someone writes — “Workers of the world, unite!,” they become a public that is willing and able to act upon its shared situation. It is in the writing of such words, the naming of such names — “Workers of the world” or “We, the People,” even “The Problem That Has No Name” — that a public is summoned into being. In the act of writing for a public, intellectuals create the public for which they write.” 2

This made me think about the work that has gone into forming the emerging discipline of global health equity and the “movement for the right to health” which is distinct from and actually in conflict with the broader field of global health and international development. In so many ways, the broader field of global health and international development has its roots in a history dominated by neoliberal economic dogma and powerful institutions that have shaped policies all the way down to local community clinics in poor and remote corners of the globe. How does an organization with a set of values and purpose that is perpendicular to the values of the broader field of power in which it is embedded continue to exist? How can it create a small pocket of space in the face of crushing pressure? A small platform on which to stand when powerful forces push in the opposite direction?

The notion of a public intellectual summoning a new language and therefor a new public into existence is crucial, I think, to understanding the nature of the right to health movement. Halfdan Mahler conjured “Health for All by the Year 2000”, Jim Kim called for “3×5”, or 3 million people on HIV treatment by the end of 2005, Larry Kramer and ACT UP mobilized powerful language and visual demonstration to politicize science and policy making around HIV in the U.S. Each confronted an unjust status quo, articulated a new vision for a possible future, and sought to mobilize the intellectual, political, cultural, and institutional capital in service of this alternative future.

“That’s also how public intellectuals work. By virtue of the demands they make upon the reader, they force a reckoning. They summon a public into being — if nothing else a public conjured out of opposition to their writing. Democratic publics are always formed in opposition and conflict: “to form itself,” wrote Dewey, “the public has to break existing political forms.” So are reading publics. Sometimes they are formed in opposition to the targets identified by the writer: Think of the readers of Rachel Carson’s Silent Spring or Michelle Alexander’s The New Jim Crow. Sometimes they are formed in opposition to the writer: Think of the readers of Hannah Arendt’s Eichmann in Jerusalem. Regardless of the fallout, the public intellectual forces a question, establishes a divide, and demands that her readers orient themselves around that divide.” 3

Few public intellectuals have created a broader organizational and intellectual foundation, new technical and moral language, than Paul Farmer. Chapter 5 of Pathologies of Power is a classic example of Farmer laying out an ethical, moral, political vision for the foundation of a rights-based global health agenda and forcing a choice.

“At the same time, the flabby moral relativism of our times would have us believe that we may now choose from a broad menu of approaches to delivering effective health care services to the poor. This is simply not true. Whether you are sitting in a clinic in rural Haiti, and thus a witness to stupid deaths from infection, or sitting in an emergency room in a U.S. city, and thus the provider of first resort for forty million uninsured, you must acknowledge that the commodification of medicine invariably punishes the vulnerable.” 4

Connecting back to social theory and social movements, it seems clear that Bourdieu, McAdam, Fligstein, and others would see this brand of public intellectual as necessary but not sufficient for the initiation and sustaining of contested social movements. Whether viewing these individuals as “skilled social actors” (field theory) 5, progenitors of “cognitive liberation” (political process) 6, or the collective intellectual striving for a “scholarship with commitment” 7 and working to accrue forms of symbolic/cultural/scientific capital sufficient to alter the field, social movements need individuals willing to break with dominant logic and language, articulate an alternative, and then work to mobilize a new public to organize for collective action.

  1.  Robin, Corey. “How Intellectuals Create a Public.” The Chronicle of Higher Education. N.p., 22 Jan. 2016. Web. 31 Jan. 2016.
  2.  Ibid.
  3.  Ibid.
  4.  Farmer, Paul. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: U of California, 2003. Print.
  5.  Fligstein, Neil, and Doug Mcadam. “Toward a General Theory of Strategic Action Fields*.” Sociological Theory 29.1 (2011): 1-26. Web.
  6.  McAdam, Doug. Political Process and the Development of Black Insurgency: 1930-1970. Chicago ; London: U of Chicago, 1982. Print.
  7.  Bourdieu, Pierre. “A Scholarship with Committment.” Revueagone Agone 23 (2000): 205-11. Web.

CH188: Second session – social theory, history, and neoliberalism

Yesterday, we had the second session for CH188: The Right to Health – Problems, Perspectives, and Progress.  We covered a broad overview of the recent history of the the global health project and discussed a toolkit of social theories that we’ll use throughout the course to analyze and try to understand progress and challenges in the social movement for the right to health.


Dr. Salmaan Keshavjee discusses the history of neoliberalism’s infiltration of global health logic.

We were also very fortunate to have Dr. Salmaan Keshavjee, professor of global health and social medicine at Harvard Medical School deliver a guest lecture on the history of neoliberalism as a set of economic, political, and moral ideas that have shaped global governance systems writ large and have had very specific (and devastating) effects on health care systems for poor people around the world.

See his slides here. 

Dr. Keshavjee made a compelling and sweeping argument about historically rooted  political and moral battle of ideas about the role of the state and the relationship between citizen, market, state, and rights. In order to understand neoliberalism, we first need to understand the roots of the cannon of Western liberal thought: Locke, Mill, Smith. In particular, he focused on Adam Smith who, while believing in the importance of free markets, also believed that states must intervene in the face of market failures, in education, health care, social services, and other types of publicly-valuable capital investments that private actors would not be willing to make. If Adam Smith saw a vibrant democratic state–countered in power by organized guilds, corporations, and democratically engaged citizens–that created the space for a vibrant free and productive economy, then neoliberal thinkers saw it in exactly opposite terms: a completely unfettered economy is the source of free and open democratic society. In other words, the elimination of government intervention equates to greater liberty.
“The central values of civilization are in danger…. The position of the individual and the voluntary group are progressively undermined by extensions of arbitrary power…The group holds that these developments have been fostered …. by a decline of belief in private property and the competitive market; for without the diffused power and initiative associated with these institutions it is difficult to imagine a society in which freedom may be effectively preserved.”
—Statement of Aims, The Mont Pèlerin Society, April 8, 1947

Dr. Keshavjee then went through a detailed historical account of how a group of neoliberal intellectuals (Hayek, Friedman, Mises) developed a very sophisticated strategy in the war of ideas in the wake of World War II. Playing off of fear of the rise of totalitarianism, the rise of the Soviet Union and the expansion of Communism, and the expansive New Deal politics in the United States, they situated economists in major universities, created new think tanks and policy research divisions, published papers and books, and found ways to ensure that their ideas diffused through nodes of symbolic power producers. This was a very Bourdeusian strategy of amassing symbolic capital via “anointing institutions” in order to alter the shape of the field of practice of the global economy. They weren’t just playing a game of politics; they were creating an entirely new set of rules for the game of the political economy.

This ontological revolution — that democracy and liberty come from unfettered economic systems and economic growth, rather than vice versa — was important in shaping of the transnational bureaucracies in the second half of the 20th century, especially the World Bank, the International Monetary Fund, and the World Health Organization.

Dr. Keshavjee ended his talk with a specific case contained in his book, “Blind Spot: How Neoliberalism Infiltrated Global Health“, an ethnography of the revolving drug fund in Badakhshan, Tajikistan. He described this region, between Afghanistan and China that became deeply impoverished after fall of the Soviet Union. It was also the site of an ideological contest between the East and the West due to its geopolitically strategic location. He witnessed how a great organization, the Aga Kahn Foundation (AKF), came to implement a program focused on the development of a “revolving drug fund” — essentially implementing user fees and charging patients to purchase drugs. The originally proposed title for the book was something like, “Charging starving people for medicine” (because that was literally what was happening), but the editors thought it sounded too harsh. What is interesting in his account is how powerfully the history of neoliberalism came to bear on the lives and the bodies of the people in this far-flung region of the world.

After Dr. Keshajvee’s lecture, we had a great conversation about a toolkit of social theories that we will continue to revisit as we encounter more global health challenges and opportunities in the right to health movement. Specifically, we discussed:
  • Peter Berger and Thomas Luckman: The Social Construction of Reality
  • Robert Merton: Unanticipated consequences of purposive social action
  • Max Weber: Power and authority, bureaucracies
  • Michel Foucault: Biopower and surveillance
  • Arthur Kleinman and Paul Farmer: Social suffering and structural violence
As we go forth over the coming weeks in our work to try to understand some of the biggest challenges facing the realization of the comprehensive right to health, we will constantly revisit this history and these social theories.

Dr. Salmaan Keshavjee Guest Lecture:

Liberalism (17th – 18th century):
  • John Locke:
  • Stewart Mill
  • Adam Smith
  • Importance of liberty and about equality
John Maynard Keynes
  • An assault on free market capitalism; need some intervention and investment from the state
  • There can be market failures; market responds to fear and short term gain
  • Society needs to have a broader and longer vision
  • Also needs to be a provider of social services; also involved in the fiscal cycle
  • Welfare state economics
  • A response to Keynsianism
  • Hayek and Freedman: University of Chicago
  • The iron cage, bureaucracy, the result of the more state: the artibrary dictates of government bureaucrats over rational ideas of the individual. A response to Weber — a solution to Weber’s iron cage of rationality
  • Rise of fascism in Austra; Stalin; rise of the New Deal; the fear of liberalism and progressivism and this is a response to that.
  • Fear of the rise of totalitarianism.

Free political system would yield a free economic system; neoliberalism flipped it: free economics drives free political system.

Reading Notes:

Reimagining Global Health – Chapter 1: A biosocial approach to global health
  • Biosocial analysis: global health is not yet a discipline, but a collection of problems. It requires an interdisciplinary approach. But, there is an opportunity to transform global health into a coherent discipline.
  • Roots of limited health care in poor and marginalized community but be historically deep and geographically broad: a biosocial approach is necessary.
  • Health disparities and the burden of disease:
    • Relationship between GDP and health — domestic and national aggregate and mask local inequities.
  • Collection of disciplines that make up global health create systematic blind spots that prevent us from seeing roots of certain health disparities and problems. That’s why we need a fully biosocial approach to properly build the field of global health.
  • Global health vs international health — an important, and historically rooted distinction. Pathogens do not recognize borders, and international health has a very specific and important set of historical roots, located in the history of colonialism.
Reimagining Global Health – Chapter 2: Unpacking global health – theory and critique
  • “toolkit” of social theories relevant to global health work.
  • Global health often characterized by action — getting stuff done. Most practitioners have little patience for social theory or critical reflection on the work.
  • Historical roots of schism between theory and practice: Marx, racist anthropologists.
  • Social scientists and theorists seek to “interpret the meaning of social action.”
  • Biosocial analysis and the sociology of knowledge:
    • Peter Berger and Thomas Luckman: The Social Construction of Reality:
      • institutionalization: “reciprocal typifications of habitualized action by types of actors” leads to the objectification of that habitualized action as an institution.
      • Assumptions and accidents become historicized into truths, and knowledge is created.
      • One must understand the social organization that permits the definers to do the defining. Must move from he abstract “what?” to the socially concrete, “says who?”
      • All knowledge in society, in order to be legitimated, is socially constructed through a historical / social process.
      • Diagnostic and Statistical Manual of Mental Illness: DSM, a good example of social construction of knowledge in medicine. DSM in 1970s claimed homosexuality was a mental disease. Medicalization of grieving into clinical depression requiring pharmaceutical intervention is an example of medicalization of illness experience.
      • Important to differentiate between: illness, disease, and sickness. Illness is subjective experience, disease is reinterpretation by medical experts, sickness is a pathology at a population level.
    • Robert Merton: Unanticipated consequences of purposive social action:
      • Purposive action involves motives, and therefor, choices amongst alternatives and must also have a goal and a process.
        • Knowledge assymmetry
        • rigidity of habit
        • imperious immediacy of interest
    • Weber: Power and authority
      • Traditional authority
      • Charismatic authority
      • Rational-legal authority —> derived from bureaucracy
      • Weber predicted that institutions / bureaucracies would become the most important structures governing our society.
      • Sometimes though, create ‘iron cage of rationality’ —> difficult to reform or destroy.
    • Foucault: Biopower
      • explains how biological and medical data are used by institutions of the modern world to define, count, and divide, “discipline” populations
    • Social suffering and structural violence:
      • forms of structural violence that constitute inequity
      • what political, economic, and institutional power do to people.
Reimagining Global Health – Chapter 3: Colonial medicine and its legacies
  • Sometimes it seems like the groundswell of global health is “new” — but global pandemics are not new nor are socialized attempts to control them.
  • The modern field of global health has its roots in colonial medicine and “international health”
  • Global health and global empire:
    • Notions of global health certainly informed the desire to build the aqueducts of Rome.
    • No accident that the redefinition of public health and biomedicine as scientific profession coincided with the moment at which European power started to build empires.
    • History of colonial medicine shows that the sites of imperial occupation often served as laboratories for medical strategies later taken up by colonizers
    • History is ripe with examples of colonial projects that harmed the health of colonized people
    • Colonizers interpreted differences in infectious disease mortality as providential signs that “savage” bodies were inferior and weaker compared to Europeans
    • Colonial medicine was not primarily geared towards beneficial action for the colonized, it was primarily a tool to keep white colonizers alive in service of extractive efforts —> links between “global health” and “global security”
      • Led to the widespread (and still used) term “tropical medicine”
      • Used to reify the idea that black bodies were “hardier” in tropical climates and used to rationalize slavery / exploitation / racism.
    • Concern over poor, sick distant lands and local wealthy ones continues to animate our discussions of biosecurity —> see Ebola / SARS.
    • History of tropical medicine, in part, explains why the term “global health” tends to mean health in other places than the US / Europe. Also a source of reification of difference and double standards.
    • The new paradigm of etiology — shifting locus of disease from the “native” to the organism — should have reformed global health, but it did not.
      • The “healthy carrier” became the locus of control — “Typhoid Mary”
      • Tropical Medicine far from removed radicalized language in global health — it enabled it
  • Missionary Medicine
    • linked to spreading Christianity —> for many in colonized nations, this was their sole source of contact with biomedicine.
    • Colonial medicine focused on populations, medical missions focused on individuals
      • reforming individual souls — personal illness, personal hygiene, personal sin.
  • Global health, global commerce, and the foundations of international health bureaucracies
    • Cholera shows how rise of transnational and continental commerce drives the need for new modes of public and global health intervention
      • OIHP: The Office International d’Hygiene Publique, one of the earliest permeant public health bureaucracies, attempted to contain and prevent the spread of cholera
      • John Snow: first to use epidemiological techniques to understand and demonstrate the etiology of cholera
      • Creation of the Panama Canal: caused the development of Pan-American Health Organization (PAHO), which remains an important player in the global health field today.
        • In many ways a demonstration of Max Weber’s prediction that bureaucracies would come to be the most important forms of organization in society.
  • Health, development, and the legacies of colonialism:
    • Political realities of inequality (post-colonialism) post-war (WW1 and WW2) became reorganized around the concept / language of “development” with practices send deeply rooted in colonial history
    • Limited resources drives “socialization for scarcity”
    • By 1948 the WHO was formed and the first World Health Assembly had been convened: cholera in Egypt demonstrated its power as a convening, coordinating, and technical assistance body
      • This set it up for a much more ambitious project: Malaria eradication
        • Focus on vector control rather than microbial control / treatment: socialization drives “either / or debate”
        • People had a strong belief in the power of technological innovation as a driver of human improvement: DDT as a way of killing mosquitos
        • Donor preferences for narrow, top-down strategies for stopping disease.
        • WHO abandoned the program in 1969 — it had failed
        • Ignored the biosocial fact that malaria biology is deeply embedded within the social fabric of farming and other practices.
      • Smallpox Eradication
        • WHO started the program in 1967 as the malaria program was starting to wind down.
        • Was successful because of better management, also because of an easier biology / life cycle in which to intervene
Reimagining Global Health – Chapter 4: Health for all? Competing theories and geopolitics
  • The notion that all people deserve access to health care was gained support in the 1978 international conference in Alma-Ata, Kazakhstan; but it was soon to be eclipsed by neoliberalism: a different kind of idealism that placed its hopes in the market to efficiently deliver services to the poor.
  • This history offers insight into the evolution and action of key global health bureaucracies:
    • WHO
    • United Nations Childrens Fund (UNICEF)
    • International Monetary Fund (IMF)
    • World Bank (WB)
  • Alma-Ata and the primary care movement —> ascendance of structural adjustment —> UNICEF’s selective primary care —> emergence of the WB as key player
  • 1978: Alma-Ata and “health for all by the year 2000″
    • Divergent economic and political ideologies of the Cold War shaped the public health discourse of the 1970s
    • Vertical programs a major focus: attempt at Malaria eradication and smallpox eradication campaigns by WHO: seeking out “magic bullets”
    • Chinese “barefoot doctor” model — example of “horizontal” primary care focus.
    • Halfdan Mahler: forceful leader in global health and one of the cheerleaders of the primary care movement
    • Alma-Ata Declaration:
      • Introduces the idea of “appropriate technology”
      • Critique of “medical elitism”: lambasts top-down delivery
      • Frames health as a mechanism for social and economic development
    • Bold goals failed for several reasons:
      • It did not specify who would pay for these scale-ups and service delivery.
      • Early 1980s brought the sovereign debt crisis that left many poor countries unable to pay and dried up foreign aid.
      • Emergence of an alternative health agenda: selective primary care.
  • Selective Primary Care: an interim agenda
    • Months after Alma-Ata, group of policy makers met in Bellagio, Italy to discuss future.
    • Selective Primary Care became the idea that emerged as an interim strategy
      • High return on each dollar spent
      • Focused on a narrow set of “cost-effective” interventions termed “GOBI”
        • Growth Monitoring
        • Oral rehydration therapy
        • Breastfeeding
        • Immunizations
      • UNICEF + Jim Grant (the director) became one of the biggest champions of SPHC
    • Shifting ideologies in Washington, the WB, began focusing increasingly on market-oriented solutions to health care provision.
  • Rise of neoliberalism:
    • Reagan + Thatcher: deep belief and faith in “free markets”: neoliberalism: Friedrich von Hayek and Milton Freedman
    • Appointed free market purists to head IMF / WB: became known as the “Washington Consensus”
      • “Stabilize, liberalize, privatize”
      • Structural adjustment policies tied to World Bank + IMF loans to low income countries
      • Forced cuts to public spending on social services (health care + education) in order to meet payment schedules and stipulations imposed by WB loans
  • Commodification of Health
    • Diminished role for the public sector in provision of health services led to increase in private sector and “market” oriented solutions.
    • This was a major erosion in the notion of a “state protected right to health”
  • Bamako Initiative: 1987
    • African Ministers of Health embraced WB’s policies for financing and instituted “user fees” to meet funding gaps
    • Poor people had no money to spend on health care services so no reduction in “overconsumption”
    • Did not raise the 15 – 20% of budget revenue they had anticipated.
    • Example of unintended consequences of purposive social action
    • Berger + Luckman: social construction of reality — technical knowledge of finance supplanted other forms of knowledge (social, political, medical, etc)
  • Rise of UNICEF
    • “Child Survival Revolution: Jim Grant as forceful advocate of GOBI-FFF
    • “national immunization days”
    • Critiqued as a narrow cheap interventions services that prevented the growth of stronger delivery systems
    • Arguments of cost effectiveness and efficiency were not challenges again by values of rights, equity, and justice until the rise of HIV and the HIV treatment movement led by ACT UP
  • 1993 WB World Development Report: Investing in Health
    • Codification of “cost effectiveness”
    • Invention and recommendation of the DALY as the means of measuring and deciding what to do in health
  • Redefining the possible: HIV and a social movement for treatment
L. London: What is a human-rights based approach to health and does it matter? (Health and Human Rights Journal)
  • Three aspects:
    • Indivisibility of civil + political rights and socioeconomic rights
    • active agency by those vulnerable to rights violations
    • powerful normative role of rights in establishing accountability and protections
  • Despite incredible technological progress, less than 40% of live births are attended by a skilled practitioner in poor countries.
  • In HIV care and treatment, rights-based approaches challenged public health to think about exclusion and enable integration of rights-based approaches to health.
  • Examples where we have fallen short of the rhetoric:
    • mandatory testing vs. scale up of treatment; continued discrimination of people living with HIV
    • MDR / XDR TB treatment and therapy: the artificial dichotomy of prevention and treatment
    • “This leads logically to the second consideration: without an active civil society, paper commitments to rights mean very little.”
  • Case of informal settlement outside of Cape Town, SA:
    • The case (known as the Grootboom case) made legal precedent in establishing the justiciability of socio-economic rights in the courts and was hailed beyond just the borders of South Africa as advancing popular claims to basic needs that are socio-economic entitlements in human rights law.
      • Despite the case, there has been no major shift in the housing or access to services guaranteed by law, largely because of a large social movement demanding the right to housing.
    • Contrary case: the treatment access movement:
      • The Treatment Access Campaign (TAC) is the most obvious illustration of success.
      • mutual reinforcement of the courts and grassroots political action in advancing and actualizing rights.
      • Amartya Sen:
        • “The implementation of human rights can go well beyond legislation, and a theory of human rights cannot besensibly confined within the juridical model within which it is frequently incarcerated. For example, public recognition and agitation can be part of the obligations … generated by the acknowledgement of human rights.”
  • Opportunity with rights: Defining who is a rights holder, who is a duty bearer, and what the nature of the obligation is, allows a much clearer opportunity to establish accountability (typically of government) for the realization of rights and creates a range of mechanisms to hold governments accountable.
  • Often, rather than acknowledging health as a right, policy-makers frame health policy decisions as service delivery issues, requiring technical inputs to reach the best “evidence-based” decisions, a public health phenomenon gaining increasing popularity worldwide.
    • In doing so, the state is relieved of its burden of progressive realization.
  • Making human rights a shared objective:
    • invoking a human rights framework does not, of itself, inevitably mean a conflictual relationship between civil society and the state.

General skepticism, overestimation, and growing political divide

The Kaiser Family Foundation has continued their work to track and interpret American’s evolving views and opinions of development assistance for global health and recently released a report summarizing their findings. They have some of the best and clearest analysis of U.S. appropriations for global health. 1 2

Some key points that seem particularly relevant to the global health political field:

  • Americans really don’t know much about development assistance and foreign aid as it relates to global health. Americans believe that we should be the world leader in global affairs, but also that we are doing more than our fair share already.
  • Foreign aid is initially viewed with skepticism, but with a little more information and context, people’s views change favorably.
  • Americans systematically overestimate of the amount spent by the U.S. on foreign aid for global health purposes.
  • There is a growing political rift between Democrats and Republicans about the value of U.S. investments in global health.


There seems to be misunderstanding of what USG investments are being made for global health purposes and a general skepticism about their effects. People think that we should be serving as a (or the) world leader on global affairs, but then at the same time think that we are already doing our “fair share”.

doubt in value of global health investments

Additionally, people feel like corruption is one of the most important problems with development assistance for health.

corruption biggest problem


Americans also consistently and wildly overestimate the amount of money committed to global health programs, answering on average that they think at least 31% of the federal budget is spent on foreign aid.

It would be interesting to dig more into why this is the case. Do people have no idea what the federal budget really is? Do they have any sense what constitutes U.S. global health funding? Do people similarly overestimate the amount of funding for other types of programs / elements of the federal budget?

overestimation of US contribution to global health

Political Divide:

Finally, there is a growing partisan divide in the level of importance that democrats and republicans place on USG global health investments. This partisan divide on global health, though while not enormous, has grown by 11 percentage points since 2012.

partisanship in global health spending

To me, everything about this research points to why a community organizing model of movement building for the global right to health is so important. People generally have very little clue what we mean when we talk about U.S. investments in global health and they assume that we spend far more money than we actually do on programs that they assume don’t work very well. This absence of data / narrative / perspective fuels a partisan divide that stems from a fundamental difference of opinion of the role of government.

As I discussed in my recent previous post about opportunities for research in the social movement for the right to health, McAdam’s political process model 3 describes the emergence of social movements through the mobilization of organized grassroots groups, generation of new stories / narratives / evidence / data of possibilities to enable new frames of ‘cognitive liberation’ that can be disseminated by organized groups, and the harnessing of newly emergent political opportunities.

Luckily this report does point to one important political opportunity: Americans believe that investing in programs that advance global health is the right thing to do.

“Although many acknowledge there are domestic interests that could benefit from global health aid, nearly half of Americans (46 percent) say that the most important reason that the U.S. spends money on improving health for people in developing countries is because it’s the right thing to do.”

moral reason for global health spending

This is a significant political opportunity. In the wake of the Ebola epidemic, the emergence of the Sustainable Development Goals (though they note that very few Americans know what the SDGs are) and despite the skepticism and growing partisan gaps, Americans still think that we should invest in global health because it’s the right things to do. This moral imagination is something that must be harnessed.

We need to continue to share the stories of patients, of systems, of transformation, and demonstrate what is truly possible with a commitment to building systems oriented to the most poor and marginalized.

  3.  McAdam, Doug. Political Process and the Development of Black Insurgency, 1930-1970. Chicago: University of Chicago Press, 1982. 40-51.

CH188: Introduction to the right to health

Yesterday we kicked off an exciting new course at Tufts University: Community Health 188 – The Right to Heath: Problems, Perspectives, and Progress. We had the first session of our weekly, three hour, 15 person seminar focusing on an ‘introduction to the right to health’ that I co-led with Prof. Fernando Ona, who is an amazing epidemiologist, social worker, and thinker on social / political movements in health.

I have to say that I was really nervous going in to this course. I’ve never served as a listed instructor for a university course and since this is a new course, it was a bit of an uncharted territory for both Fernando and me.  But, the first class went surprisingly well. The students were excited to be there, had good ideas about global health and the right to health, and they already seemed actively engaged in participating.

In addition to going over the syllabus, getting to know one another with a fun icebreaker, and sharing a bit about our vision for the course, we engaged in two substantial activities: the drawbridge exercise 1 and the core elements of the human rights approach 2.

The drawbridge exercise in particular was a fascinating experience. The scenario essentially provides a skeleton sketch of a society in which all powerful, jealous Baron orders the death of his Baroness wife who he discovers is having an affair. Participants are asked to rank the cast of characters based on who is most culpable for the death of the Baroness. The discussion provided a great template to begin our conversation of human rights: where does power reside? What values templates and cultural values dominate? Who decides?

This led into a great conversation about the core elements of human rights discourse and practice. We discussed what it meant for human rights to be:

  • Universal and inalienable
  • Interdependent and indivisible
  • Equal and nondiscriminatory
  • Both rights and obligations

All of this sets us up well for week 2: “roots of global health and the right to health project”, which will critically unpack the history of the construction of human rights and how this history has particularly affected the emergence of the field of global health delivery. We are really fortunate to have Dr. Salmaan Keshavjee coming to speak for the first half of the seminar to discuss the the roots of neoliberalism as a collection of ideas, the politics of implementing neoliberal policies in resource flows, and the implications of that history on the current global health regime. 3

I’m really looking forward to next week!

Week 1 Class / Reading Notes:

My hopes for the class:
  • That we create a safe space of learning, encounter, and action, that opens our imaginations to new social realities and grounds those imagined ideas in rigorous scholarship and research.
  • That we  make a decent case that the right to health is a useful construction and that we can implement programs that can progressively realize this utopian idea.
  • That we can build facility with the history that has come to construct the modern notion of the right to health and the political forces which have limited progress.
  • That we can come to have a basic understanding of the sociology of social movements, community organizing, and methods of attempting to purposively drive social change.
  • That we can grow our understanding of policy making, advocacy, and action — and start to take action ourselves.
  • That I can learn from this experience — pedagogically, intellectually, spiritually, emotionally.
Follow my reflections here:
Structure of the class:
Part 1: A right to health? Building a common understanding
  • Introduction to the right to health
  • Roots of global health and the right to health project
  • Laws, institutions, and governance in the right to health
Part 2: The Right to Health: Scoping and mapping the problems
  • Key problems in the right to health 1 (structure of the “field” of global health, financing, neoliberalism)
  • Key problems in the right to health 2 (innovations, mental health, NCDs, etc)
  • Key problems in the right to health 3 (gender discrimination)
Part 3: Driving progress: Developing a right to health toolkit
  • Health systems strengthening and the science of global health delivery
  • Policy analysis and policy making 1 (applied policy analysis)
  • Policy analysis and policy making 2 (presentations on policy analysis or policy proposal)
  • Community organizing and social movements 1 (social theory and social movements)
  • Community organizing and social movements 2 (discussion of PIH Engage and ways that we could work together after the course)
  • SDGs, UHC, and the future of the right to health movement
Reading Notes:
A. Sen: why and how is health a human right?
  • Legal question: there is no legislation
    • Does a right have to be legally defined?
  • Feasibility question: no way of ensuring good health
    • Common confusion about what is/is not a right: cannot stop murder at all moments everywhere
    • It is a demand to take action to positively promote that goal
  • Policy question: why not the right the health care since policy makers can control that
    • Requires multifaceted approach, not just the provision of health care of a set of policies and programs to promote good health
C. Shuftan: A guided tour through key principles and issues of the human rights based framework as applies to health
  • Human rights paradigm contrasts with the basic human needs approach in important ways
  • Big difference between having basic needs met and the protection of fundamental rights
  • “In the basic needs approach, the individual is seen as an object with needs (and needs do not necessarily imply correlative duties or obligations, but promises). In the rights-based framework, the individual is seen as a subject with legitimate entitlements and claims (and rights always imply and are associated with correlative duties and obligations). Therein lies the big difference.”
  • “Most often, a rights-based framework to health is not even on governments’ ‘radar screens’. The United States, for example, has regarded the socio-economic rights of the Universal Declaration of Human Rights as a wishful “letter to Santa Claus” (Jean Kirkpatrick, former US ambassador to the UN). The US has little sympathy for Social, Economic and Cultural Rights, in contrast to its vociferous and selective support of Civil and Political Rights.”
  • “the process moves the debate from (the flawed approach of) charity/compassion (where there is already fatigue) to the language of rights and duties (accountable to the international community with compliance that can be monitored). [Keep in mind that, as opposed to rights, charity is given mostly when convenient]. (U. Jonsson, 1997)”
  • Adoption of a right to health framework is the beginning of a political movement to develop and implement a non-ethnocentric global, egalitarian, human rights based praxis and ethics.
  • “Is fostering a viable and militant civil society a key to pressure governments into doing what they are supposed to do in the first place after having solemnly signed all those international human rights covenants?”
  • ” The caveat here is that organizations can use (and get away with using) human rights language as non-committal rhetoric just to feel good and ‘move with the tide’.”
—> Interesting form and radical view of the right to health.
—> Nice set of principles and iron-clad rules that can give structure to our thinking and arguments for the right to health.
—> Doesn’t articulate a more specific view of what type of political projects and organizations really would be necessary for this move forward.
S. Gruskin, E. Mills, D. Tarantola: History, principles, and practice of health and human rights
  • Discuss the changing views on human rights in the context of the HIV/AIDS epidemic and propose further development with increased practice, evidence, and action.
  • Considered health and human rights a relatively new approach to thinking about public health — 2007
  • The right to the highest attainable standard of health—often referred to as the right to health —is most prominently connected to the ICESCR.43 It stipulates that:
    • The states parties to the present covenant recognise the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. The steps to be taken by the states parties to the present covenant to achieve the full realisation of this right shall include those necessary for:
    • (a) the provision for the reduction of the stillbirth rate and of infant mortality and for the healthy development of the child;
    • (b) the improvement of all aspects of environmental and industrial hygiene;
    • (c) the prevention, treatment, and control of epidemic, endemic, occupational, and other diseases;
    • (d) the creation of conditions which would assure to all medical service and medical attention in the event of sickness.
  • The idea of health and human rights as a subject of study is fairly new, and we need to recognise the diff erent ways in which advances in health and human rights can be achieved. Human rights feature in many diff erent ways in the health work of international non-governmental organisations, governments, civil society groups, and individuals. These ways can be broadly categorised as advocacy, application of legal standards, and programming (including service delivery).45 Some stakeholders use one approach; others use a combination in their work.
  • A recurring dilemma confronting these organisations is whether sustainable health action should be associated with documentation and denouncements of witnessed human rights violations, as these activities could both limit their ability to provide health services to the populations they serve, and jeopardise the safety of their workers.
  • Treatment Action Campaign in South Africa used the courts to ensure that the government was ordered to provide programmes in public clinics for reduction of mother-to-child transmission of HIV.59 Although these eff orts have resulted in positive changes in the law, advocacy is still needed to move these obligations into practice; thus emphasising how advocacy, and application of the law are interrelated.
25 Questions and Answers on Health and Human Rights — WHO
  • Human rights discourse first popularized and adopted post-WWII
  • Cold War drove a cleavage between civil and political rights and social and economic rights
  • The West argued that civil and political rights had priority and that economic and social rights were mere aspirations. The Eastern bloc argued to the contrary that rights to food, health and education were paramount and civil and political rights secondary. Hence two separate treaties were created in 1966 – the International Covenant on Economic, Social and Cultural Rights (ICESCR) and the International Covenant on Civil and Political Rights (ICCPR).
  • The right to health: The right to the highest attainable standard of health (referred to as “the right to health”) was first reflected in the WHO Constitution (1946)(20)and reiterated in the 1978 Declaration of Alma Ata and in the World Health Declaration adopted by the World Health Assembly in 1998.(21) It has been firmly endorsed in a wide range of international and regional human rights instruments.(22)
  • The principle of progressive realization  of human rights(41)  imposes an obligation to move as expeditiously and effectively as possible towards that goal. It is therefore relevant to both poorer and wealthier countries, as it acknowledges the constraints due to the limits of available resources but requires all countries to show constant progress in moving towards full realization of rights. Any deliberately retrogressive measures require the most careful consideration and need to be fully justified by reference to the totality of the rights provided for in the human rights treaty concerned and in the context of the full use of the maximum available resources.
  •  Equity means that people’s needs, rather than their social privileges, guide the distribution of opportunities for well-being.(63)  This means eliminating disparities in health and in health’s major determinants that are systematically associated with underlying social disadvantage within a society. Within the human rights discourse, the principle of equity is increasingly serving as an important nonlegal generic policy term aimed at ensuring fairness.
A. Yamin: Beyond Compassion: The Central Role of Accountability in Applying a Human Rights Framework to Health
  • Accountability enables passive beneficiaries into claims holders and identifies states and other actors as duty bearers.
  • Compassion is notoriously unstable — we as humans seeking a society with justice, should seek for more stable justice-oriented structures. Rights give such a structure.
  •  In many countries, networks and broad popular movements for social accountability relating to health issues emerged as a reaction to autocratic governments that had enacted neoliberal sector reforms and privatizations of basic services (for example, water) with virtually no consultation and often largely by executive and ministerial decrees.14  These efforts at social accountability highlight the importance of decision-making processes as well as outcomes, of increasing the voices of marginalized or excluded communities with respect not only to the diagnosis of institutional failures that most directly affect them, but also to the negotiation of social policies and health budgets. However, successful models of social accountability also point to the importance of creating coalitions and networks across class, and between grass-roots movements and NGOs.
  •  The subversive potential   and central value   of human rights lies in placing limits on both public lassitude and private greed through a framework and mechanisms for accountability.
    • We need better tools and models for robust accountability for duty-bearers in protecting the right to health.
WHO / UN – The Right to Health – Fact Sheet
  • RTH comes from the 1946 WHO constitution: “The right to the enjoyment of the highest attainable standard of physical and mental health…”
  • 1948 Universal Declaration of Human Rights
  • This is a great primer on what we mean technically by “the right to health”
  • “The right to health” is not the same as “the right to be healthy.”
  • There are immediate obligations on states, but the right to health must be progressively realized.
    • Obligation to respect
    • Obligation to protect
    • Obligation to fulfill
  • In this sense, “the right to health” contains both “positive” and “negative” components.
J.A. Singh, M. Govender, E Mills: Do human rights matter to health?
  • India and South African examples of how “the right to health” can have substantial value
  1. Judith H. Katz. 1978. White Awareness: Handbook for Anti-Racism Training. pp. 70 – 72
  2. UN High Commissioner for Human Rights/World Health Organization. The Right to Health, Fact Sheet No. 31., pages 1-39.
  3. Blind Spot: How Neoliberalism Infiltrated Global Health.

Opportunities for research and practice in the social movement for the right to health

The right to health is a contested idea.[i],[ii] Increasingly, people agree that individuals have the right to be free from disproportionate risk of illness and early death.[iii] But, there are wide disagreements about what limits ought to be set around a right to health,[iv],[v] the practical mechanisms to protect the right to health,[vi],[vii],[viii] and what type of social and political strategies should be advanced to dismantle the historically, socially, and politically constructed barriers that limit our progress.[ix],[x],[xi],[xii],[xiii],[xiv] Because the right to health is at the center of a political contest that is historically and socially constructed, we need better theory about the social construction of the field of practice of global health. We also need a deeper understanding of the nature of social movements as sources of reform efforts and the practical organizational models that can grow such movements. This paper seeks to explore a research and organizing agenda that could better elucidate the social processes that underpin social movements and point toward more robust strategies to strengthen the right to health movement. This research and practice agenda should be “historically deep and geographically broad”[xv] and connect a critical study of the sociology of social movements,[xvi],[xvii] organizational theory,[xviii] and the field of practice of international development and global health.[xix],[xx],[xxi]

Social theory is used to contextualize and interpret the complex situations that characterize global health.[xxii],[xxiii] I will briefly share the work of three scholars that are rarely cited by global health practitioners but whose ideas provide a useful toolkit in studying and advancing the social movement for the right to health. I argue that there is a significant opportunity to deploy the social theory of Pierre Bourdieu in critical study of the field of practice of international development and global health, Doug McAdam’s political process model as a way to describe the emergence and growth of social movements, and Marshall Ganz’ community organizing and leadership pedagogy. I will then use these tools to provide a brief analysis of the current moment in the right to health movement and delineate some potential opportunities to strategize about future mobilization. I will also share early experiences in developing a grassroots community organizing strategy through the global health and social justice organization, Partners In Health (PIH). Working to create PIH Engage[xxiv] has helped us to understand how regular, concerned citizens, can work together to demand new modes of solidarity and redistribution from their communities and elected policy makers. Taken together, I hope to renew a discussion about modes of collective action that could continue to dismantle the deeply held double standards that prevent poor and marginalized people from being served by health care delivery systems.

Bourdieu and theory in the right to health movement

Pierre Bourdieu, a giant of 20th century sociology, built a theory of social action based on field research ranging from kinship relationships in isolated villages in Algeria to the social processes of production, circulation, and consumption of art and literature in 19th century France. His work sought to bring “reflexive”[xxv] sociological methods into building a whole understanding of social action: to “uncover the most profoundly buried structures of the various social worlds which constitute the social universe, as well as the ‘mechanisms’ which tend to ensure their reproduction and their transformation.”[xxvi] If the movement for the right to health is a process of social transformation, Bourdieu gives us a way to understand the ‘buried’ mechanisms that could be useful in hastening that transformation. Particularly useful to this understanding, Bourdieu describes three fundamental ideas that govern social action: field, habitus, and capital.

The field of social action is produced and reproduced by individuals and organizations that do not exist in a vacuum. Individuals and organizations exist in relationship to one another as they work in pursuit of shared aims, develop shared taken-for-granteds, grow shared interpretations, and come into competition for scarce resources. Loïc Wacquant offers a succinct definition: “a field is a patterned system of objective forces (much in the manner of a magnetic field), a relational configuration endowed with a specific gravity which it imposes on all objects and agents which enter it… Simultaneously, [it is] a space of conflict and competition, the analogy here being with a battlefield, in which participants vie to establish monopoly over the species of capital effective in it.”[xxvii] This social jostling and competition between actors in the field set up the terrain of a social game that is played out by social actors vying for dominance.

The habitus can be understood as an individual’s patterns of thoughts, behaviors, tastes, and actions acquired by their experienced participation in the social field of action. Bourdieu describes it as: “embodied history, internalized as a second nature and so forgotten as history—the active presence of the whole past of which it is the product.”[xxviii] Wacquant expands, “Cumulative exposure to certain social conditions instills in individuals an ensemble of durable and transposable dispositions that internalize the necessities of the extant social environment, inscribing inside the organism the patterned inertia and constraints of external reality… habitus is creative, inventive, but within the limits of its structures”.[xxix] The field of practice tends to produce individuals who have experienced and internalized the rules of the game as their habitus. Those individuals tend to then act in a way that reproduces the socially constructed field of practice, which, in turn, reinforces the internalized habitus of those in the field.

Finally, Bourdieu conceptualizes capital as multifaceted forms of field-specific power: economic, social, and symbolic. Economic capital is immediately transformable into money, but social capital (social relationships, friendships, partnerships), symbolic capital (prestige, clout), cultural capital (credentials, awards), and other forms of field-specific capital aren’t immediately transformable into financial resources. Non-economic forms of capital can be used to dominate fields of practice that organize society. Bourdieu compares each field to a market in which individuals and collective actors compete for the accumulation of the various forms of capital. In a field of practice, an agent with more capital will be successful over those actors with less capital.[xxx]

Again, Wacquant summarizes: “together, habitus and field designate bundles of relations. A field consists of a set of objective, historical relations between positions anchored in certain forms of power (or capital), while habitus consists of a set of historical relations ‘deposited’ within individual bodies in the form of mental and corporeal schemata of perception, appreciation, and action.”[xxxi] For us to build better theory and strategy for the right to health movement, we will need an effort to better construct an understanding of the field of practice of global heath within the broader field of international development and humanitarian relief.

Monika Krause has an important and penetrating analysis of the field of humanitarian reason and international development.[xxxii] In it, she takes a “Bourdieusian” approach to the description of the field of practice of humanitarian organizations. Organizations in this field, no matter how large, must make decisions about what to do, who to serve, and how best to serve them, in order to make their missions manageable. She describes this field as a set of relationships between large, international NGOs. These NGOs inhabit a shared social space and logic of practice that is governed by the pursuit and production of ideal “good projects”—those that can produce short term, quantifiable effects and serve groups that are relatively easy to assist. Krause argues that, “humanitarian relief is a form of production, transforming some things into other things. Agencies produce relief in the form of relief projects. As the unit of production is the project, managers seek to ‘do good projects.’ The pursuit of the good project develops a logic of its own that shapes the allocation of resources but also the types of activities that we are likely to see—and the type of activities we are not likely to see.”[xxxiii] The logic governing the production of the “good project” is driven by the habitus of “desk officers,” who are responsible for making these decisions and in doing so, practice a process of triage in response to resource constraints. International development financing and bilateral foreign aid programs create a global market of easily comparable “good projects” that are driven by principles of efficiency, cost-effectiveness, sustainability, and short term intervention: principles of neoliberalism.

These principles are generally incompatible with the goal of enabling governments, over the long term, to protect the right to health. The logic of “the good project” serves the practical function of transforming the role of the public sector through competitive contracting to for-profit and nonprofit private actors. The emergence of a global scale of comparison for relief projects drives the “projectification” of the field of global health and international development.[xxxiv]

If we accept Krause’s analysis of the current field of practice of humanitarian relief—one that drives the structured production and financing of narrowly defined good projects—organizations with a different logic might be able to mount an insurgent response. For instance, organizations with the explicit purpose to accompany ministries of health and governments to be effective in delivering on commitments to protect the right to health for their citizens could band together to demand new policies and financing mechanisms that are well suited to those ends.

This understanding may shed light on the ways that the history of neoliberal ideology is reproduced throughout financing, policy, and the organizational practices of international NGOs. It could also provide new insights for the network of organizations and individuals who strive for a different reality: one where the access to high-quality health care services is not a function of one’s ability to pay for them. To build this new reality, we need a social movement. But, first we must understand how social movements come about; especially how they emerge, expand, and decline.

McAdam and the emergence of social movements

Doug McAdam’s political process model is a very useful framework for analyzing social movements. It identifies three sets of factors that are considered to be crucial for the emergence and development of social movements. First, organizational strength—the degree to which an aggrieved population is organized, formally or informally—is an essential component to the successful emergence of a social movement. Second, the collective assessment of political opportunities and chances of success is necessary to build momentum within grassroots organization. Finally, a degree of political alignment between the locally organized insurgent groups and the broader political and socioeconomic environment is necessary to be able to exploit spaces of opportunity for the social movement to expand. These three factors could be thought of as “degree of organizational readiness”, the level of “insurgent consciousness”, and finally the “structure of political opportunities.”[xxxv]

This model for conceptualizing social movement emergence can be visualized like the diagram below. Broad socioeconomic processes create the space (or remove space) and develop expanding (or contracting) political opportunities for insurgent groups to advance their movement. Yet, relying on an overly deterministic and structural set of factors to explain social movement emergence is insufficient to describe the range of movements and insurgency we see in the world. These structural factors enable a certain “structural potential” for political action, but they do not guarantee it. The final factor necessary for the emergence of social movements is the notion of “cognitive liberation”—the capacity for a group to transform their understanding, name their situation as unjust, and have the capacity to imagine an alternative reality that could be transformed together.[xxxvi] This cognitive liberation is a function of leadership, narrative, teamwork, and action.

Figure 1: Political process model for social movement emergence (McAdam, 1982)

Figure 1: Political process model for social movement emergence (McAdam, 1982)

Bourdieu’s notions of field and capital and McAdam’s political process model were brought together in an analysis of the reform process that produced a major shift in global multi-drug tuberculosis (MDRTB) treatment policy in the late 1990’s.[xxxvii] Victor Roy, in his Cambridge University master’s thesis, builds an understanding of the field of social action that led to the WHO’s focus on Directly Observed Therapy Short Course (DOTS)[xxxviii] as the single and only means of tuberculosis (TB) treatment from the 1970’s through the early 1990’s. This treatment regimen categorically excluded attempts to treat people with drug-resistant disease. Roy links this understanding of the field of global TB policy making to reform efforts made by Partners In Health and the organization’s strategy to demonstrate that MDRTB could be treated and cured effectively in poor settings like the slums of Lima, Peru. Leaders of PIH were able to mobilize field-specific scientific and cultural capital that became significant enough to alter the “cognitive cues” of those in the field. Together, they created a new “frame” of cognitive liberation that enabled potential allies and others to understand that the field was increasingly vulnerable to potential change.[xxxix]

The case of reform in MDRTB treatment policy is not, in the full sense, a “social movement”. Although, Roy’s analysis does demonstrate the significant opportunity to utilize the joint tools of Bourdieu and McAdam in studying reform efforts in global health policy, it is important to understand the shortcomings. The global tuberculosis epidemic has not abated and TB recently became the largest infectious disease killer in the world.[xl] Higher prices for key MDRTB drugs, lack of new pooled donor financing mechanisms, and perpetually weak health systems all present significant barriers to making progress in ending TB.[xli] Why has this reform effort been unsuccessful or, at least, incomplete?

Turning back to Bourdieu and McAdam we could understand the gap in terms of the types of capital that were chosen and available to PIH to mobilize their reform effort. The PIH team was able to enter the field of global TB policy making primarily due to their ability to mobilize the symbolic and scientific capital available because of their position within Harvard Medical School. The limited capital available to PIH structured and limited its strategy to focus primarily on technical policy changes—shifting DOTS protocol to DOTS-plus[xlii] and the development of the Green Light Committee at the WHO[xliii]—rather than a more broad-based political strategy. In Bourdieusian terms, the limitation could be understood as a lack of access to political capital that would be necessary to mobilize democratic pressure for larger redistributive financing mechanisms. Similarly, using McAdam’s political process model we would interpret this as a gap in local organizational strength of the reform movement. The PIH experience with TB stands in contrast to the AIDS treatment movement during which large numbers of activist groups were involved in grassroots political mobilization to exert local-level political pressure on key policy makers responsible for U.S. government global AIDS policy-making and funding.[xliv] These two historical examples and the theoretical tools of Bourdieu and McAdam are useful to understand the current moment in the movement for the right to health. But, if strong, local grassroots organizations are an important source of field-specific capital for global health reform, it is important to consider how they are built throughout social movements.

Marshall Ganz, organizing, and social movement leadership

Doug McAdam’s political process model gives us an elegant means of describing the emergence and growth of social movements, but it does not give concrete tools or specific practical guidance for individuals and organizations seeking to advance a particular struggle. Marshall Ganz’ work to build a practical and theoretically deep pedagogy of community organizing gives such a framework. Ganz’ organizing pedagogy enables individuals and organizations to identify, cultivate, and grow the capacities of leaders to advance collective action. Central to Ganz’ view of organizing is a deep notion of social movement leadership:

Leading in social movements requires learning to manage the core tensions at the heart of what theologian Walter Brueggemann calls the “prophetic imagination”: a combination of criticality (experience of the worlds pain) with hope (experience of the worlds possibility), avoiding being numbed by despair or deluded by optimism. A deep desire for change must be coupled with the capacity to make change. Structures must be created that create the space within which growth, creativity, and action can flourish, without slipping into the chaos of structurelessness, and leaders must be recruited, trained, and developed on a scale required to build the relationships, sustain the motivation, do the strategizing, and carry out the action required to achieve success.[xlv]

Successful social movement leadership is not something innate in individuals, it is something that can be learned and purposefully cultivated. Ganz has developed a robust practice of community organizing training[xlvi] that closely links a set of iteratively developed leadership practices. Relationships that are purpose-based and rooted in shared values, built on commitments, and grown from an exchange of resources and interests must be formed. New stories about the potential for a shared future that links values, emotion, and action into a “story of self,” a “story of us,” and a “story of now” must be told. Social movement leaders must develop creative strategies to successfully challenge those with more power by harnessing opportunities that arise due to environmental or context changes. Organizations must create purposeful structure amongst membership and organize time into campaigns for real action that grows power over time. Finally, teams must be developed that enable “snowflake-like” leadership structures and are capable of collaboratively deliberating, making decisions, and holding members accountable.[xlvii]

Moving from theoretical to organizationally pragmatic, Pierre Bourdieu, Doug McAdam, and Marshall Ganz give us an extremely useful set of ideas that should be more systematically deployed by scholars of and practitioners within the movement for the right to health. Bourdieu gives us a way to imagine the field of global health as a collection of actors working to expand their economic, social, and symbolic capital to control the “rules of the game”. The social movement for the right to health is a reform effort that seeks to shift the field away from neoliberal-dominated practice towards the aim of expanding state-protected rights. McAdam gives us a more specific way to view the social movement for the right to health. Using the political process model, we can analyze the structure of political opportunities that characterize the current moment for the right to health movement, the strength of local, grassroots organizations, and opportunities for “cognitive liberation” to imagine new realities of health care delivery in settings of poverty. Finally, Ganz gives a pragmatic model of local community organizing leadership training that civil society, grassroots community groups, and health care delivery oriented NGOs could adopt to grow the local capacities of actors in the struggle for the right to health.

The current moment: the urgent need for a revitalized movement

In certain circles, the current narrative around political opportunities for the right to health movement is pessimistic. In 2012, the Institute for Health Metrics and Evaluation asked if we were nearing the “end of the golden age of global health”.[xlviii] Decrying the weakening of bipartisan leadership in global health and a precipitous decline in the number of direct action activist organizations focused on expanding global AIDS funding,[xlix] it may appear that the movement that spurred the creation of the Presidents Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, TB, and Malaria (The Global Fund) and the corresponding “delivery decade”[l] may be waning. However, four trends ought to give us hope.

First, the rise of universal health coverage (UHC) as a key global goal in the unanimously adopted UN Sustainable Development Goals[li] presents an important opportunity to create more political space for the right to health agenda. While this is an opportunity to demand access to quality health services far more broadly, it is also a contested concept that the right to health movement will need to make claims and build consensus around.[lii] A clear definition of UHC is necessary if we are to avoid the pitfalls of “Health for All” in 1987’s Alma-Ata Declaration which had high level leadership, but lacked sufficient political and budgetary space to realize its aims. It is clear that political will and engagement with civil society will be necessary to promote a rights-based approach and to institutionalize accountability to meet the needs of disadvantaged people.[liii]

A second important expanding political opportunity is the election of Dr. Jim Yong Kim as the president of the World Bank Group in 2012.[liv] Dr. Kim is a long-time right to health activist and his book Dying for Growth: Global Inequality and the Health of the Poor[lv] is a compilation of essays detailing how neoliberal policies deployed by the World Bank have harmed the health of poor and marginalized people and hampered states’ capacity to protect the right to health of their citizens. We should see his appointment as an opportunity to deploy this powerful position to imagine and actually create new financing mechanisms for the expansion of rights-based UHC in low-income countries.

Third, we are in an open U.S. presidential election in which candidates on both sides of the aisle must actively campaign. This presents a significant opportunity for right to health activists to engage with them on the campaign trail at small and mid-sized events in early-primary states. Commitments matter during campaigns (presidential campaigns in particular) when candidates are forced to take specific stances on issues and make pledges to quantifiable targets.[lvi] We have an opportunity to birddog[lvii], a tactic pioneered by AIDS activists, to gain commitments from politicians, many of whom have been significantly supportive of global health efforts in the past.

Finally, the Ebola epidemic in West Africa decimated already beleaguered health systems and killed more than eleven thousand people.[lviii] This has driven significant new discussion by policy makers on the role of U.S government development assistance in strengthening health systems in low-income countries.[lix] This framing—Ebola as a failure of already weak health systems—creates a powerful window for activists in the right to health movement to advance calls for new legislation that could enable new investments in health systems strengthening in poor countries.

With these factors taken into consideration, the structure of political opportunities seems robust. But, what about the “structural potential” of locally organized constituencies and grassroots organizations? Globally, there is a growing network of global health delivery organizations working with a rights-based approach that seek to link delivery of services to accompaniment of the public sector and the generation of new knowledge.[lx],[lxi],[lxii],[lxiii],[lxiv] Additionally, a large network of student driven global health organizations[lxv],[lxvi],[lxvii],[lxviii],[lxix],[lxx],[lxxi] is moving forward and expanding global health academic programs at universities across the U.S.[lxxii],[lxxiii]

Figure 2: Growth of academic global health programs in the U.S. (majors, minors, study abroad programs, centers, and other formal programs dedicated to global health studies)

Figure 2: Growth of academic global health programs in the U.S. (majors, minors, study abroad programs, centers, and other formal programs dedicated to global health studies)

Although many of these student driven global health organizations are primarily service and education oriented, students are increasingly engaged in politics and activism.[lxxiv] Other global health activist networks are also working hard to advance justice-based policies in health.[lxxv],[lxxvi] All told, there seems to be growing “structural potential” in the right to health movement. There are more rights-based delivery organizations, more scholarship and university engagement in global health, and more potential global health justice activists than ever before. This structure can potentially be mobilized and directed toward the immense challenges faced by the right to health movement.

Figure 3: Political process model adapted to model the current moment in the right to health movement

Figure 3: Political process model adapted to model the current moment in the right to health movement

Cognitive liberation—imagining new realities that are not immediately available to our socially constructed notion of reality, our habitus—is necessary to translate this structural potential into action and momentum for the right to health. From demonstrating an effective model for curing MDRTB in Lima, Peru[lxxvii],[lxxviii] to demonstrating that HIV treatment could be scaled in places of extreme poverty like central Haiti,[lxxix] PIH has worked to prove the possible in global health. Roy demonstrates how this proof, which is developed via the accrual of scientific capital, can catalyze policy reforms by altering the balance of power within a field of global health practice. These beacons of hope should serve as an antidote to despair in the midst of a culture that is socialized for scarcity.[lxxx] The future to the right to health movement is dependent on recasting the global health equity narrative towards one of possibility, growing new grassroots organizations that have the capacity to do political work, and creating the policy space for novel financing mechanisms.

PIH Engage: An organizing model in practice

PIH Engage was launched in 2011 with the goal of harnessing the goodwill and enthusiasm for the right to health mission of Partners In Health that has grown during its 25 years of work fighting for global health equity. We are attempting to deploy Marshall Ganz’ model of community organizing—identifying and recruiting volunteer leaders, building community around that leadership, and generating power from that community—as a way to enable regular, concerned citizens, to work together to demand new modes of solidarity and redistribution from their communities and elected policy makers. So far, we have organized more than 90 teams of volunteer community organizers across the U.S. to engage their local communities, organize campaigns that raise funds for health care delivery efforts, and take on direct advocacy campaigns to create new policy space for rights-based financing mechanisms.

By the end of this year, we hope to have raised more than one million dollars from grassroots supporters, gained real commitments from political actors, from U.S. senators and representatives, as well as held demonstrations on dozens of college campuses and cities across the U.S., and moved forward a major new piece of health systems strengthening legislation. This work has a long way to go before it could be characterized as a social movement. And, even if successful, this effort will only be one small component of a much larger trans-national effort. But I believe that our experience so far shows that it has been a worthwhile investment. Hopefully PIH Engage can serve as a model for other rights-based healthcare delivery and advocacy organizations to strategize on how they could grow networks of organizers dedicated to advancing right to health campaigns in their local communities.

There is an opportunity to more systematically build theory and practice in the study of the right to health movement. Pierre Bourdieu gives us a theoretical framework with which to analyze the socially constructed field of practice that mediates and constrains the way organizations and individuals in the right to health struggle engage in the world. Doug McAdam gives us a model of social movement emergence and tools to analyze the structure of political opportunities, organizational strength, and narrative-driven cognitive liberation that can help direct strategic action. Finally, Marshall Ganz gives a concrete community organizing training and organizational framework that can be deployed by organizations to build a more powerful base of grassroots activists. If we take these linked frameworks as useful, we can see our collective work as growing the types of field-specific capital necessary to reorient the “rules of the game”, especially the way in which global health delivery gets financed. This field-specific capital could be grown through a wide variety of tactics: growing fundraising capacity, building the evidence base for effective rights-based delivery efforts, creating new narratives of possibility and beacons of hope, mobilizing the grassroots around this narrative of possibility, and developing grass-tops and grassroots political power capable of implementing new policy and financing mechanisms.

This essay is not meant as a comprehensive analysis of the right to health movement or a full review of the scholarship of social movements, community organizing, and their application to the right to health movement. It is however an attempt to sketch out an opportunity for expanded research and practice directed towards building a better understanding and more robust strategy for the practical effort of advancing a successful right to health movement.

Works Cited:

[i] Barlow, Phillip. “Health Care Is Not a Human Right.” British Medical Journal, 1999, 321.

[ii] Farmer P. Pathologies of power: rethinking health and human rights. American Journal of Public Health. 1999;89(10):1486-1496.

[iii] Universal Declaration of Human Rights (UDHR), G.A. Res. 217A (III) (1948), Art. xxv. Available at

[iv] Kingston, Lindsey N, Elizabeth F Cohen, and Christopher P Morley. “Debate: Limitations on Universality: The ‘right to Health’ and the Necessity of Legal Nationality.” BMC International Health and Human Rights: 11.

[v] Boggio, Andrea, Matteo Zignol, Emesto Jaramillo, Paul Nunn, Geneviève Pinet, and Mario Raviglione. “Limitations on Human Rights: Are They Justifiable to Reduce the Burden of TB in the Era of MDR- and XDR-TB?”Health and Human Rights, 2008, 121.

[vi] Kim, Jim Yong, Paul Farmer, and Michael E Porter. “Redefining Global Health-care Delivery.” The Lancet, 2013, 1060-069.

[vii] Frenk, Julio. “The Global Health System: Strengthening National Health Systems as the Next Step for Global Progress.” PLoS Medicine 7, no. 1 (2010).

[viii] Binagwaho, Agnes, Cameron T. Nutt, Vincent Mutabazi, Corine Karema, Sabin Nsanzimana, Michel Gasana, Peter C. Drobac, Michael L. Rich, Parfait Uwaliraye, Jean Nyemazi, Michael R. Murphy, Claire M. Wagner, Andrew Makaka, Hinda Ruton, Gita N. Mody, Danielle R. Zurovcik, Jonathan A. Niconchuk, Cathy Mugeni, Fidele Ngabo, Jean De Dieu Ngirabega, Anita Asiimwe, and Paul E. Farmer. “Shared Learning in an Interconnected World: Innovations to Advance Global Health Equity.” Globalization and Health Global Health, 2013.

[ix] Gostin, Lawrence O. “A Framework Convention on Global Health.” JAMA, 2012.

[x] Forman, Lisa, Gorik Ooms, Audrey Chapman, Eric Friedman, Attiya Waris, Everaldo Lamprea, and Moses Mulumba. “What Could a Strengthened Right to Health Bring to the Post-2015 Health Development Agenda?: Interrogating the Role of the Minimum Core Concept in Advancing Essential Global Health Needs.” BMC International Health and Human Rights, 2013.

[xi] Gamson, Josh. “Silence, Death, and the Invisible Enemy: AIDS Activism and Social Movement “Newness”” Social Problems: 351-67.

[xii] Kapstein, Ethan B., and Joshua W. Busby. Kapstein, Ethan B., and Joshua W. Busby. AIDS Drugs for All: Social Movements and Market Transformations.

[xiii] Keshavjee, Salmaan. Blind Spot: How Neoliberalism Infiltrated Global Health. N.p.: n.p., n.d. Print.

[xiv] Epstein, Steven. Impure Science AIDS, Activism, and the Politics of Knowledge. Berkeley: University of California Press, 1996.

[xv] Farmer, Paul. Pathologies of Power Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press, 2003.

[xvi] McAdam, Doug. Political Process and the Development of Black Insurgency, 1930-1970. Chicago: University of Chicago Press, 1982.

[xvii] Ganz, Marshall. “Leading Change Leadership, Organization, and Social Movements.” Handbook of Leadership Theory and Practice: An HBS Centennial Colloquium on Advancing Leadership. Boston: Harvard Business, 2010.

[xviii] Davis, Gerald F. Social Movements and Organization Theory. New York, N.Y.: Cambridge University Press, 2005.

[xix] Krause, Monika. The Good Project: Humanitarian Relief NGOs and the Fragmentation of Reason. The University of Chicago Press, 2014.

[xx] Viterna, Jocelyn, and Cassandra Robertson. “New Directions for the Sociology of Development.” Annual Review of Sociology, 2015.

[xxi] Roy, Victor. “The Politics of Reform in Global Health Policy: The Case of Multi-Drug Resistant Tuberculosis, 1991-2001.” Dissertation for University of Cambridge, 2010.

[xxii] Kleinman, Arthur. “Four Social Theories for Global Health.” The Lancet, 2010, 1518-519.

[xxiii] Farmer, Paul. “Unpacking Global Health: Theory and Critique.” In Reimagining Global Health an Introduction. Berkeley: University of California Press, 2013.

[xxiv] “PIH Engage.” PIH Engage. Accessed December 6, 2015.

[xxv] Bourdieu, Pierre, and Loi Wacquant. An Invitation to Reflexive Sociology. Chicago: University of Chicago Press, 1992. 36-46.

[xxvi] Ibid., 7.

[xxvii] Ibid., 17.

[xxviii] Bourdieu, Pierre. The Logic of Practice. Stanford, CA: Stanford University Press, 1990. 56.

[xxix] Bourdieu, Pierre, and Loi Wacquant. An Invitation to Reflexive Sociology. Chicago: University of Chicago Press, 1992. 13-19.

[xxx] Ibid., 18.

[xxxi] Ibid., 16.

[xxxii] Krause, Monika. The Good Project: Humanitarian Relief NGOs and the Fragmentation of Reason. The University of Chicago Press, 2014.

[xxxiii] Ibid., 37

[xxxiv] Biehl, Joao. “Therapeutic Clientship: Belonging in Unganda’s Projectified Landscape of AIDS Care.” In When People Come First Critical Studies in Global Health. Princeton: Princeton University Press, 2013.

[xxxv] McAdam, Doug. Political Process and the Development of Black Insurgency, 1930-1970. Chicago: University of Chicago Press, 1982. 40-51.

[xxxvi] Ibid., 35.

[xxxvii] Roy, Victor. “The Politics of Reform in Global Health Policy: The Case of Multi-Drug Resistant Tuberculosis, 1991-2001.” Dissertation for University of Cambridge, 2010.

[xxxviii] World Health Organization (1998). Basis for the development of an evidence based case management strategy for MDR-TB within WHO’s DOTS strategy. Geneva: WHO, accessed at “World Health Organization & Library Information Networks for Knowledge Database (WHOLIS).” Web. March-May 2010.

[xxxix] Roy, Victor. “The Politics of Reform in Global Health Policy: The Case of Multi-Drug Resistant Tuberculosis, 1991-2001.” Dissertation for University of Cambridge, 2010.

[xl] World Health Organization (2015). World Tuberculosis Report (20th Edition). Retrieved from:

[xli] Hwang, Thomas J., and Salmaan Keshavjee. “Global Financing and Long-Term Technical Assistance for Multidrug-Resistant Tuberculosis: Scaling Up Access to Treatment.” PLoS Medicine 11.9 (2014): e1001738. PMC. Web. 6 Dec. 2015.

[xlii] Farmer, Paul. “DOTS and DOTS-Plus. Not the Only Answer.” Annals of the New York Academy of Sciences: 165-84.

[xliii] Gupta, Rajesh, Alexander Irwin, Mario Raviglione, and Jim Kim. “Scaling-up Treatment for HIV/AIDS: Lessons Learned from Multidrug-resistant Tuberculosis.” The Lancet 363 (2004): 320-24.

[xliv] “The Troubled Path to HIV/AIDS Universal Treatment Access: Snatching Defeat from the Jaws of Victory?” In Global HIV/AIDS Politics, Policy and Activism: Persistent Challenges and Emerging Issues, edited by Raymond A. Smith, by Patricia Siplon. Praeger, 2013.

[xlv] Ganz, Marshall. “Leading Change Leadership, Organization, and Social Movements.” Handbook of Leadership Theory and Practice: An HBS Centennial Colloquium on Advancing Leadership. Boston: Harvard Business, 2010.

[xlvi] Ganz, Marshall. Marshall Ganz Teaching Comments. Accessed December 6, 2015.

[xlvii] Ganz, Marshall. “Leading Change Leadership, Organization, and Social Movements.” Handbook of Leadership Theory and Practice: An HBS Centennial Colloquium on Advancing Leadership. Boston: Harvard Business, 2010.

[xlviii] Institute for Health Metrics and Evaluation. “Financing Global Health 2012: The End of the Golden Age?” Seattle, WA: IHME, 2012.

[xlix] Morrison, J. Stephen. “The End of the Golden Era of Global Health?” Editorial. Center for Strategic and International Studies. Web. <>.

[l] Farmer, Paul E. “Chronic Infectious Disease and the Future of Health Care Delivery.” New England Journal of Medicine, 2013, 2424-436.

[li] “Goal 3.8 in the UN Sustainable Development Goals.” Sustainable Development Knowledge Platform. Accessed December 6, 2015.

[lii] O’Connell, Thomas, Kumanan Rasanathan, and Mickey Chopra. “What Does Universal Health Coverage Mean?” The Lancet: 277-79.

[liii] Ibid.

[liv] Garrett, Laurie. “Dr. Kim and the World Bank’s Health Role.” Council on Foreign Relations. April 13, 2012. Accessed December 6, 2015. <>.

[lv] Kim, Jim Yong. Dying for Growth: Global Inequality and the Health of the Poor. Monroe, ME.: Common Courage Press, 2000.

[lvi] Nelson, Libby. “Campaign Promises Matter.” Vox. November 27, 2015. Accessed December 9, 2015.

[lvii] Davis, Paul. “Five Questions For: ‘Take the Money Out’ Activist Paul Davis about Disrupting a National Journal Event.” Interview by David Ferguson. Raw Story 6 Sept. 2012. Accessed October 30, 2015. <>.

[lviii] “2014 Ebola Outbreak in West Africa – Case Counts.” Centers for Disease Control and Prevention. December 4, 2015. Accessed December 6, 2015.

[lix] “United States Senate Committee on Foreign Relations.” Hearing. Accessed December 6, 2015.

[lx] “We Have Everything We Need to End Child Mortality Now.” Muso. Accessed December 6, 2015.

[lxi] “Hope Through Health.” Hope Through Health Home Page. Accessed December 6, 2015.

[lxii] “Home | Possible.” Possible Health. Accessed December 6, 2015.

[lxiii] “Home Page.” Last Mile Health. Accessed December 6, 2015.

[lxiv] “PIVOT Health.” PIVOT Home. Accessed December 6, 2015.

[lxv] “GlobeMed | Developing 21st Century Leaders for Global Health.” GlobeMed. Accessed December 6, 2015.

[lxvi] “Global Health Corps Home.” Global Health Corps. Accessed December 6, 2015.

[lxvii] “Student Global AIDS Campaign (SGAC) Home.” Student Global AIDS Campaign (SGAC). Accessed December 6, 2015.

[lxviii] “Universities Allied for Essential Medicines.” Universities Allied for Essential Medicines. Accessed December 6, 2015.

[lxix] “Help @end_7 End 7 Diseases and Lessen Suffering for over ½ a Billion Kids in the Developing World.” END 7 Home. Accessed December 6, 2015.

[lxx] “Join PIH Engage.” PIH Engage. Accessed December 6, 2015.

[lxxi] “Home – Timmy Global Health.” Timmy Global Health. Accessed December 6, 2015.

[lxxii] Merson, Michael H. “University Engagement in Global Health.” New England Journal of Medicine: May 1, 2014. 1676-678.

[lxxiii] Matheson, Alastair I., Judd L. Walson, James Pfeiffer, and King Holmes. Sustainability and Growth of University Global Health Programs. Rep. Washington, DC: Center for Strategic and International Studies, 2014.

[lxxiv] Stolberg, Sheryl Gay. “Colleges Are Producing New Style of AIDS Activist.” The New York Times. November 30, 2010.

[lxxv] “Health Global Access Project (Health GAP).” Health Global Access Project (Health GAP). Accessed December 6, 2015.

[lxxvi] “RESULTS | Homepage.” RESULTS. Accessed December 6, 2015.

[lxxvii] Shin, Sonya, Jennifer Furin, Jaime Bayona, Kedar Mate, Jim Yong Kim, and Paul Farmer. “Community-based Treatment of Multidrug-resistant Tuberculosis in Lima, Peru: 7 Years of Experience.” Social Science & Medicine, 2004, 1529-539.

[lxxviii] Roy, Victor. “The Politics of Reform in Global Health Policy: The Case of Multi-Drug Resistant Tuberculosis, 1991-2001.” Dissertation for University of Cambridge, 2010.

[lxxix] Farmer, P, Léandre, F, Mukherjee, J, Gupta, R, Tarter, L, Kim, J Y. “Community-based treatment of advanced HIV disease: introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy)” Bulletin of the World Health Organization, 2001, Vol.79(12), pp.1145-51

[lxxx] Farmer, Paul. “An Anthropology of Structural Violence.” Current Anthropology, 2003, 305-25.

Relaunching for 2016

It’s been a very long time (more than two years!) since I’ve spent time writing / working on this website, and I’ve decided that this is as good of a time as any to start to do some more writing and reflection. Specifically, there are a couple of new opportunities that I’m excited to engage in a bit of a broader dialogue around.

First, I’ll be co-teaching a class this spring (starts Thursday!) at Tufts University titled “The Right to Health: Problems, Perspectives, and Progress”. Take a look at the syllabus here. I’m looking forward to sharing my experience from the course and trying to process what I learn along the way. I’m certain that I’ll learn as much, and probably much more, than the students.

Second, I’ll be working as a research assistant with the upcoming Lancet Commission on Reframing NCDs and Injuries for the Poorest Billion. Through the history and advocacy working group, we hope to:

  1. Clearly define a social theoretical framework through which to analyze and interpret the history and current position of the NCDI poverty field
  2. Develop a historical perspective on the construction of the NCDs as a field of strategic action
  3. Situate the NCDI poverty field in the current mix of competing global health priorities, frames, and initiatives
  4. Shape the strategy for the Commission’s key messages and audiences

And finally, of course, I’ll continue to work alongside the PIH Engage team as it continues to grow and build the capacity for grassroots advocacy and fundraising within Partners In Health.

So, I’ve got lots of moving pieces and exciting endeavors and I hope that this can be a useful forum to continue to push forward my own thinking on global health, social movements, and social theory.