Category Archives: Global Health Education

Theorizing on the emergence of university-based global health programs

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

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

Figure 5

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

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

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

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

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

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

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

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

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

legitimation device and code

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

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

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

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

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.

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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
Neoliberalism:
  • 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.

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: http://acriticalengagement.com/
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. http://www.ucpress.edu/book.php?isbn=9780520282834

Evolution of Global Health Education – High School Edition

Working with the PIH | Engage National Team, our research focuses on the existence and possible advancement of global health curricula at the high school level.  The methodology of our research – the final project of which will be a case study – is interview-based. We have been exploring the ways in which three current high school teachers are incorporating global health issues into their curricula. The aim of our project is to create a picture of the models and structures behind each teacher’s global health curriculum, in order to explain the development, implementation, and advancement of their curriculum within their respective schools.  The valuable knowledge these teachers have shared with us will hopefully serve to inspire and empower fellow high school teachers interested in global health, and open the discussion on the broader expansion of these curricula.

The three public high school teachers interviewed for this case study project include: Jeffrey Shea, a Social Studies teacher at Belmont High School in Massachusetts, teaching a “Global Leadership” elective course to 11th and 12th grader students; Matthew Cone, also a Social Studies teacher, teaching two elective courses titled “Global Issues” to 10th through 12th grade students at Carrboro High School in North Carolina; and Bradley Lewis, an Advanced Placement Statistics teacher who teaches mostly 11th and 12th grade students at Bainbridge High School in Washington.

Thus far, we’ve conducted first-round qualitative interviews with each teacher, focusing on the teachers’ process of curriculum development and implementation, as well as the content of the curriculum itself.  The responses we received from each informant far exceeded our initial expectations, and fueled our excitement and passion for this project.

One teacher provides insight on how to incorporate global health issues into a rigid Advanced Placement curriculum… Another talks about the his global health unit, during which he brings his entire class on a field trip to Partners In Health… And the other describes the way in which his course has empowered and inspired his students, particularly minority students, who previously had self-ascribed low expectations. Most notably, however, is the fact that all three teachers stated how this topic meets their students’ passion for learning about injustice, and desire to learn about the world: giving us great hope regarding the potential for change underlying the expansion of global health curricula at the high school level.

The fact that none of the teachers teach an entire class dedicated solely to global health reflects the interdisciplinary nature of global health, and therefore its ability to be easily integrated into a broader curriculum. We believe the foundational knowledge that a global health high school curriculum could provide to students would inspire and prepare a new generation of young leaders to take on major issues facing our modern world.

We believe in the power of collective movement building, and think that high school students are often an underestimated, underutilized group filled with passionate individuals yearning to make a difference in the world. For this reason, we hope this research has the potential to inspire other high school teachers to educate a new contingent of movement builders: young leaders with the potential to advance the goal of establishing health as a human right.

We are still in the midst of interviewing and gathering our research data. But, we are excited to share our results and some ideas for the future of expanding global health education and critical discussion amongst high schoolers in the U.S.

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Post was written by Kristine Quiroz and Victoria Oliva.

Kristine is a Junior at Harvard University studying Anthropology and Global Health and Health policy. Born and raised in Southern California, Kristine enjoys going to the beach, hiking, and film/video editing. She is excited about her work thus far with Partners in Health, and hopes to continue doing global health work into the future.

Victoria is a junior at Tufts University majoring in Community Health and Anthropology. She is from Amherst, Massachusetts and enjoys photography, traveling, and playing piano.  She is really excited to be interning with Partners In Health this semester and plans to pursue a study of global health in the future. 

The evolution of global health education – Part III

This post, by Tyler Boyd, is building off of his research on the evolution of global health education here and here.

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The first significant chunk of my research has been primarily focused on structured, academic programs in global health.  While that work is ongoing, I have also begun to explore how student-led global health organizations on college campuses have grown and effected the growing field of global health education.

As a starting point, I opted to look at involvement with nationally affiliated global health organizations including: GlobeMed, Global Brigades, FACE AIDS, Student Global AIDS Campaign, The Foundation for International Medical Relief for Children, Manna Project International, Timmy Global Health, and Universities Allied for Essential Medicines.  Based on these organizations’ websites, they have organized more than 300 chapters at colleges and universities in the US.

One of the first things that struck me was a high concentration of chapters within a few institutions.  Duke and UNC Chapel hill between them boast 13 chapters, and the 8 schools with the most groups (about a third of a percent of all four year institutions) house 44 chapters or nearly 15% of all included nationally affiliated global health student organization chapters.  In terms of the reach of these organizations, at least one of these national orgs is present at 178 colleges and universities.  As a first step in visualizing this data, I graphed the geographic distribution of these chapters by state (Figure 1).  Previously, I had posted a similar distribution for academic global health programs (Figure 2), and these two figures largely parallel one another in terms of the loci of global health engagement in universities.

Figure 1

Figure 1

Figure 2

Figure 2

However, while these graphs may provide some initial insights and demonstrate the strong presence of global health programs on the East Coast and in California/Washington, these areas also have many more academic institutions in general.  In order to achieve a more proportionate perspective, I normalized the state distributions by comparing the number of global health academic programs or student groups to the total number of four year colleges and universities in each state (Figure 3).   This visualization provides an interesting counterbalance to Figures 1 and 2.  Here, states such as California, New York, and Illinois, all among the top 10 in number of global health programs, fall to near the bottom of the pack.  Although the dramatic rise of outlier Rhode Island may reflect the state’s relatively few academic institutions, proportionally around a third of institutions in states like Colorado, Washington, and Arizona boast academic global health programs.  The normalized data provides an interesting contrast, as some of these states may not come to mind as nexuses of global health education.  Both methods certainly have limitations, but when viewed in concert, perhaps a snapshot of global health education may begin to emerge.

Figure 3

Figure 3

That’s not to say that the sheer number of programs, or their location, is the optimal or most important indicator of global health education. Instead, they are two of the easiest ways to quantify and begin to understand this complex and emerging field.  To build off of this understanding, I am working to catalogue the establishment of each academic global health program and the total number of participants since its inception, constructing a timeline for the rise in university global health participation since the 1990s.  Although I currently have this data for about half of the existing programs (Figures 4 and 5), the current data suggests a steady increase in the number of programs established.  When complete, I hope this timeline will prove another foundational pillar for understanding the short legacy of global health education.

Figure 4

Figure 4

Figure 5

Figure 5

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By Tyler Boyd 

Tyler is a biochemistry and American studies double major at Middlebury College in Vermont.  Hailing from outside Chicago, he enjoys graphic design and is interested in travel and global health. He is excited to be working on this project this month and into the future.

The evolution of global health education – Part II

On to my second post and now midway through my second week in the PIH office, it seems we have just begun to scratch the surface of the vast, rather chaotic and disjointed wealth of information regarding global health education programs.  Using the CUGH database as a foundation, our first goal is to chronicle the growth of global health education by pinpointing when each program in the database was established.  Since this data has never been compiled, I had rather few tools at my disposal.  After digging through several hundred university websites and launching a volley of emails, I have slowly started adding to the database.

In the meantime, I have also played around with the existing database, looking at the distribution of global health education (both geographically and by type of degree).  Although these visualizations don’t reveal any earth-shattering conclusions, they do suggest some interesting preliminary trends.

Figure 1 breaks down global health education by type of degree, illustrating the heavy concentration of global health degrees, certificates, etc. at the graduate and professional level (while a rather anemic 41/207 programs at the undergraduate level).  However, many leaders in the field of global health have pointed to the undergraduate level as the crucial locus for global health education.  This is due, in part, to the inherent interdisciplinary nature of global health, which undergraduate programs are ideally situated to address.  Perhaps, looking forward, a greater emphasis on undergraduate global health education must emerge.

Figure 2 points to a heavy concentration of global health programs on the East Coast and California.  Containing many of the nation’s more prestigious, well funded academic institutions, it seems they may have played an integral role in establishing the legitimacy global health education (more to come on that later).  Like I said, nothing too mind-blowing, but certainly a start as we find the direction we want to take this work.

Figure 1: 

N=207 Graduate Degrees: MA, MS in Global Health Graduate Academic Track: Certificate in Global Health within various degrees, PhD Professional Track: Concentration or Certificate in Global Health within MD, residency, MPH, MSN Undergraduate Track: minor, concentration, focus, track, or certificate in Global Health within various majors Undergraduate Degree: BA in global health

N=207
Graduate Degrees: MA, MS in Global Health
Graduate Academic Track: Certificate in Global Health within various degrees, PhD
Professional Track: Concentration or Certificate in Global Health within MD, residency, MPH, MSN
Undergraduate Track: minor, concentration, focus, track, or certificate in Global Health within various majors
Undergraduate Degree: BA in global health

Figure 2:

N=207

N=207

The data used for Figure 1 and Figure 2 is from the 2013 CUGH Global Health Programs Database.  According to their website, the data contains information current as of February 2013.  All information was drawn directly from the program websites, and may not be comprehensive.  The database only contains programs that have an explicitly stated “global health” focus either within the degree title or as a track title within the degree.  “International health” programs were not included.

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By Tyler Boyd 

Tyler is a biochemistry and American studies double major at Middlebury College in Vermont.  Hailing from outside Chicago, he enjoys graphic design and is interested in travel and global health. He is excited to be working on this project this month and into the future.

The evolution of global health education

Tyler BoydOver the past few months Jon Shaffer, the Community Engagement Coordinator at PIH, and I began to toss around questions concerning the short history and current state of global health education.  As a student at Middlebury College up in Vermont, I have spent most of that time engrossed (buried) in macromolecules and early American literature.  However, amid frequent email exchanges, phone calls, and a bit of preliminary research, Jon and I have started to focus these ideas, and a foundation for a sort of meta-analysis of global health education has emerged.   

Jon invited me to PIH’s main offices to help further develop these thoughts and I elected to forsake Middlebury’s “J-term,” and transplant myself to Cambridge for the month, exchanging one frigid winter landscape for another.  As I begin to hang out around the PIH office in Boston, reading up on “theoretical frameworks in global health education,” and “the dramatic expansion of university engagement in global health,” we uncovered a small niche of literature addressing the surge in the study of global health education, and sparingly few databases cataloging global health programs at academic institutions in the US.  While organizations such as the Consortium for Global Health (CUGH) have begun to compile this type of data, it seems that the most of this work largely lacks an in-depth academic analysis.  Drawing on some sociology of higher education theory, perspectives from leading figures in the field, and both qualitative and quantitative data surrounding the growth of global health education, Jon and I seek to better understand how and why global health has ascended as a field of academic study since the late 90s, identify the factors that have fueled this rise, and perhaps look the future trajectory of the blossoming discipline.

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By Tyler Boyd 

Tyler is a biochemistry and American studies double major at Middlebury College in Vermont.  Hailing from outside Chicago, he enjoys graphic design and is interested in travel and global health. He is excited to be working on this project this month and into the future.