Category Archives: Global Health

In Somatosphere: The De-socializing of Jim Kim?

I recently had a piece published on Somatosphere: The De-socializing of Jim Kim?

The 12th president of the World Bank Group, Dr. Jim Yong Kim, is arguably the most powerful anthropologist in the world. As the co-founder of the groundbreaking NGO Partners In Health, the former president of Dartmouth College, the former head of the World Health Organization’s 3 by 5 Initiative, and longtime champion of “the science of global health delivery” (Kim, Farmer, & Porter 2013) and liberation theology’s exhortation to make a “preferential option for the poor,” Kim’s work has routinely used the “re-socializing” disciplines of anthropology and the social sciences to build arguments for greater investment in caregiving programs for poor people around the world. As a clinician and a scholar, Kim has coupled his work as a doctor for the poor to an ongoing process of “ethnographically embedding evidence within the historically given social and economic structures that shape life so dramatically on the edge of life and death” (Farmer, 2004). This is certainly a different approach from any past—or, likely near future—presidents of the World Bank, who have tended towards business titans or highly quantitative economists.

Historically, Kim has also been a fierce critic of the World Bank. Co-editing the tome, Dying for Growth, which takes aim at the market fundamentalist policies of powerful governments and neoliberal financial architecture built into the structure of World Bank loans and development assistance through the 1990’s, Kim has routinely advocated intellectually linking the widespread suffering of the global poor, to particular neocolonial policies and extractive financial procedures of the powerful people residing in places like Geneva, New York, and Washington, D.C.

Which is why Kim’s latest reform agenda as the head of the World Bank is so puzzling. It deserves special scrutiny by social scientists interested in global governance, international development, global health care delivery, and social justice.

Check out there rest, here!

CEO pay and global health politics

Yesterday, Scott Weathers had a great piece calling out the short-sighted, faux-outrage of Ian Birrell, a British journalist whose main focus seems to be taking pot-shots at DFID and the UK’s investments in development assistance more broadly. To sum up, Birrell takes umbrage with the relatively high salary of Seth Berkley (more than $500k annually [update! turns out the salary is only approx £220k!]), the CEO of GAVI, the vaccine alliance which works to make childhood immunizations available to populations around the world. Birrell writes:

The astonishing pay arrangement is the latest outrage, exposed by The Mail on Sunday, of charity chiefs pocketing massive salaries and bonuses while taking British aid to fight world poverty.

Gavi is one of six new groups paying exorbitant amounts to senior executives. Two weeks ago, we revealed how seven major charities were doling out salary packages of up to £618,000 a year.

International Development Secretary Priti Patel demanded an end to ‘excessive profiteering’ when she was questioned over our revelations by the Commons’ International Development Select Committee two weeks ago.

But, as Weathers well points out:

Birrell’s criticism also reveals a common mistake when we talk about the “do-gooder” sector: misguided attention to inputs, rather than outputs. Instead of allowing organizations to determine how they can most effectively spend their money themselves and judging their performance based on results, critics like Birrell would rather focus on the narrowest examples of what they consider waste and fraud. This spending ― rarely put into financial proportion or given proper context ― often amounts to a small fraction of what we spend improving the lives of the poor. However, these examples are then often generalized to an entire sector in order to justify slashing donor funds that support life-saving aid.

While Birrell is playing an ideologically motivated, anti-aid game, it’s also true that relatively high pay for executives is the norm, especially for large development contractors. And, there are often large pay gaps within the pay structures for staff in capital cities / NGO headquarters versus site-based, country national staff. Weathers cites a blog post, but there is a lot of literature showing that CEO pay has very little to do with past performance and has small effects on motivating future performance: it’s mostly a function of the bargaining position of a given executive in relationship to their board of directors. NGOs, like for-profit corporations, are caught up in the same types of isomorphic pressures that cause them to look more and more like one another, often both in structure and in function, as norms, policies, and best practices diffuse through the field (Powell & DiMaggio, 1991).

So, while I agree with Weathers that CEO pay cannot be a wedge used to diminish support for vital development assistance programs, I worry about the political effects of NGOs succumbing to the market-based forces of the broader institutional field in which they are embedded. Throwing up our hands and saying that its just the “market at work” for exceptional talent at the very top seems not only an insufficient answer, but also tone-deaf politically. As Kristof Decoster quipped on twitter, relatively high CEO pay is an all too easily cherry-picked argument for aid critics:

For me, all of these issues are deeply political and not simply a matter of costs and benefits. We can make all of the “rational” arguments we want by demonstrating quantitatively the cost-effectiveness of relatively small investments in CEO pay compared to the enormous benefits of lives saved. But, I worry that this line of reasoning serves to depoliticize the whole issue of delivering effective health services to the poor. We need leaders and their organizations to embody an active resistance to market forces rather than reproduce inequalities that are at the root of health injustices in the first place.

Powell, W. W., & DiMaggio, P. (1991). The New institutionalism in organizational analysis. Chicago: University of Chicago Press.

The evolving structure of a scientific citation network and its political effects

1) Introduction

Existing literature describes academic citation networks and the structure of knowledge fields: their diverse patterns, clustering, fragmentation, structural cohesiveness, and the link between micro and macro level processes in emerging domains of scientific knowledge production (Small & Griffith, 1974; Hill & Carley, 1999; Gondal, 2011; Daipha, 2001). However, little has been written to describe the specific structural changes over time of citation networks. How do certain nodes emerge and become central or structurally important over time? How and why do other nodes, important early in the citation network’s evolution, become far less important as the network matures? What are the macro and micro level processes that describe and govern this behavior and what social, epistemological, and political lessons can we draw from these changes?

These questions are important for growing our theoretical understanding of evolving scientific domains of knowledge. Practically, these questions are also important to explore the biopolitical dimensions of evolving hegemonic scientific domains and the constraints they place on practitioners making use of domains of scientific knowledge. A central notion in the sociology of health and medicine is the social construction of illness. Sickness, disease, and health problems are simultaneously materially located biological phenomena and a socially created meaning making processes through which normalcy and deviance get defined and play out in socially relevant displays of power and inequality. Some illnesses are particularly embedded with cultural meaning, others are socially constructed at the individual level–based on how individuals come to understand and live with their illness. Others are especially shaped by technical medical and scientific knowledge and are not necessarily given by nature but are primarily constructed and developed by claims-makers and interested parties (Conrad & Barker, 2010).

Additionally, the process of medicalization—the tendency to inscribe more and more social problems to be within the professional domain of medicine—continues to be a dominant trend in society. By expanding the medical domain to ever more issues and social problems, the challenges and conflicts associated with naming and framing illness comes to the fore. Rather than a given biomedical fact, we have a set of understandings, relationships, and actions that are shaped by diverse kinds of knowledge, experience, and power relations, and that are constantly in flux. This social constructionist perspective looks at how the phenomenon was identified and acted upon. Diagnosis is a matter of the “politics of definitions” (Brown, 1995).

Though medical sociology has given great attention to the complexities and power-processes associated with naming, diagnosing, and building systems to care for diseases at the population level, less attention has been paid to the ways that the structure of academic literature, and the citation networks that represent them, contributes to the processes of naming, framing and governing of illness. This paper looks at the structural evolution of the academic literature that deals with the intersection of noncommunicable diseases and “global health.” Historically and currently, both the terms “global health” and “noncommunicable diseases” (hereafter, NCDs) have been hotly contested (Airhihenbuwa et al., 2014; Whyte, 2012; Fassin, 2012; Beaglehole & Bonita, 2010). Both the broad and diffuse concept of “global health” and seemingly technical and clinically delimited field of noncommunicable diseases demonstrate the ways in which medical and scientific knowledge is socially constructed in complex ways (Keane, 1998; Brown, 1995; Lantz & Booth, 1998). The framing of NCDs in the global policy literature, in particular, has been a battle ground of biopolitics (Bukhman et al., 2015; Binagwaho et al., 2014; Katz, 2013; Mamudu et al., 2011).

Building off the current literature, I visually examine the changing structure of the global health / NCD academic literature citation network as well as quantitatively explore the changes in some of the macro-level characteristics of the citation network and their changes between 1995 and 2016. Additionally, using ERGM techniques, I also find evidence in support of important changes in the density and the emergence of a small number of structurally important paper / nodes in the network.

To conclude this paper, I will explore how structural changes in this citation network correspond with the content of the papers that dramatically change their structural position within the network. By linking this to a historical understanding of the changing framing of NCDs in the global policy making domain, I hope to make the argument that structural changes in the NCD/global health citation network shaped the framing for and contributed to limiting the political opportunities available to activists seeking to mobilize new resources for the growing NCD burden amongst low income populations globally.

2) Research Question

More concretely, I hope to answer the following questions: 1) How do the global characteristics of the NCD/ global health citation network change, qualitatively and quantitatively, between 1995 and 2016? 2) What were the most important micro-level structures that caused macro-level changes in the network over that time period? What historical, social, and political effects could these structural changes in the network both represent and perhaps be causing in the broader field of global health governance?

3) Data and Methods

Research focused upon the structure of knowledge production frequently relies on network data (Gondal, 2011). As Gondal describes,

“The nodes in the network may be researchers, documents, concepts, or organizations. The edges connecting these nodes correspondingly are collaborative authorship (Babchuk et al., 1999; Moody, 2004; Goyal et al., 2006), social and intellectual contacts between scientists (Lievrouw et al., 1987), co-occurrence of references in the bibliographies of other documents or co-citation (Small and Griffith, 1974; Moody and Light, 2006), shared citations of the same other documents or authors also known as bibliographic coupling (Kessler, 1963), sharedmem- bership in organizations (Cappell and Guterbock, 1992; Daipha, 2001), or conceptual similarity between documents (Small, 1978; Lievrouw et al., 1987; Hill and Carley, 1999). The analysis of such networks constructed from citation indices, organizational memberships, and authorships is largely conducted at two levels. At the dyadic level, researchers have been concerned with the meaning attributed to the edges interlinking the nodes. At the ‘global’ or ‘macro’ level, researchers analyze the topological properties of the network as a whole providing a bird’s-eye description of the research field. There is yet another level – the ‘local’ or ‘micro’ level – involving more than one tie but significantly less than the complete network which remains relatively under-analyzed in the literature.”

In this paper I attempt to show not only the birds eye view of how this citation network grows and evolves over time, but also how the micro-level structures that cause ties change evolve over time as well. I accomplished this by building a plain .txt citation data set from Web of Science ( querying the database and downloading all relevant citation and paper data for the papers meeting the search criteria. My criteria for this search were a) any of the diseases listed by the Institute for Health Metrics and Evaluation as a “noncommunicable disease” (each with logical ‘or’), AND b) the term “global health”, c) between the dates of 1995 and 2016. I then used the CRAN “bibliometrics” package, downloaded to RStudio to transform this plain text data file into an adjacency matrix (see Appendix 1 for R code). From there, I was able to generate the annual graphs of the growing NCD / global health citation networks and their corresponding betweenness, closeness, and degree statistics. I additionally used the VOSViewer software for mac to further explore the structure and patterning qualitatively for the network. Finally, using the CRAN ERGM package in R, I ran ERGM models, testing for the log likelihood of the presence or absence of various important micro-level structures that may or may not be present in the given networks and may or may not change over time. Overall, this data set give me a useful view into both the micro and macro level structures and patterns within the global health / NCD citation network, but it also gives me good resolution as to how those network properties have changed over time.

4) Results

4.1 Global Properties of the Network

Figure 1 visually shows the evolving NCD / global health citation network over time, between 1995 and 2016. We see the network going from a mere handful of papers in 1995 to a seemingly very densely packed mess of papers, citations, and nodes in 2016. Nodes are slightly expanded based on their degree number (number of papers citing that paper) and so we see, starting in about 2001, the emergence of some “key nodes”—or papers that seem to be growing quickly in the number of citations that they are receiving from other papers in the network. Starting at about 2006, we see a significant density pattern towards the bottom of the network graph.These patterns are more easily visualized in the VOSViewer software. Using this visualization software, it is easy to see the breakdown of papers, the authors, their topics, and the conceptual/issue area/disciplinary clustering. Figure 3 shows the results of the visualization of the NCD / global health citation network in 2016 via the VOSViewer. Here we see that it has grouped the important nodes in the network into disciplines / areas of research based on the number of shared citations. The blue region represents papers concerned with global mental health issues. The green region represents pulmonary disease, heart disease, and epidemiological studies focused on lifestyle risk factors and population level public health intervention. The red region has to do with chronic pain issues, arthritis, and other rheumatic diseases. Finally, the yellow region represents papers that have to do with various forms of cancer. It is interesting to note that papers of similar topic and clinical area tend to group together.

Another interesting finding from this analysis was the see the rapid growth in importance of large scale epidemiological modeling and burden of disease measurement papers at the expense of more clinical/intervention focused papers. Specifically, the papers by Murray, Jemal, and Lozano are all large scale quantitative epidemiology papers aimed at measuring different components of the noncommunicable disease burden across the globe. This corresponds to some of the other the important findings in terms of changing structural importance within the network, which we I will discuss shortly.

4.2 The Changing Network Over Time

In addition to visually seeing the evolution of this citation network over time, I also wanted to explore some key network statistics—particularly different measures of centrality—of the papers in the network, and how those changed over the evolution and maturation of the citation network. Figures 3, 4, and 5 show all of the networks papers’ betweenness centrality, closeness centrality, and degree between 1995 and 2016. Betweenness centrality refers to the number of actors that must “pass through” a given node in order to reach other nodes. More technically, “if the geodesic between actors n2 and n3 is n2n1n4n3 — that is, the shortest path between these actors has to go “through” two other actors, n1 and n4 — then we could say that the two actors contained in the geodesic might have control over the interaction between n2 and n3” (Wasserman & Faust, 1994, p. 188). This “actor in the middle” has some degree of control over the graph, hence it is an important statistic to quantify. Closeness centrality focuses on how close an actor is to all the other actors in the set of actors. The idea is that an actor is central if it can quickly interact with all others (Wasserman & Faust, 1994, p. 183). Lastly, degree simply refers to the number of edges connected to a given node. In this case degree is equal to the number of papers citing a given paper in the network.

Viewing Figures 3, 4, and 5 together reveals an interesting and striking pattern. First, in Figure 3 we see betweenness centrality unfailingly, yet unequally increasing for all papers in the network. Figure 4 shows conversely that paper’s closeness centrality unfailingly decreases over the time period observed, but again at slightly different rates. Finally, Figure 4 shows that degree appears to go up for all papers in the network, again at dramatically different rates across this citation network.

These observations demonstrate an interesting conclusion for this network: that betweenness and closeness appear to be inversely related to one another over time as a citation network grows over time. Practically, what this means is that as papers continue to be added to the scientific network space of global health / NCD research, they are increasingly citing seminal papers and making connections with other, less cited papers in the network. This rapidly growing, but relatively sparsely connected network creates more and more betweenness for each paper—there are more steps through the networks through which to go and therefor each paper in those steps are between ever more papers. But, at the same time, papers are being added to the network at such a rapid rate (and papers can only cite so many other papers) that network is becoming increasingly less dense and therefor the closeness of the papers within the network shrinks dramatically, especially starting around 2000. Finally, it also makes sense that in general, the degree for papers in the network would grow consistently over the course of the evolution of this citation network. Papers, even those rarely cited, will only grow in their number of citations and won’t decrease.

Table 1 (to be discussed more below) shows the number of papers in the network for each year: there is an almost exponential addition of new papers to the network starting around 2002. Given this explosion of new nodes being continually added to the network, the relatively few citations any one paper can have, it makes sense that closeness centrality would plummet over the course of the evolution of this network and that betweenness within the network would increase as the sparsely—yet still completely connected—network continues to grow.

4.3 Differential Eigen Centrality Trends

So, over time, the NCD / global health citation network seems to both be growing in terms of its overall size, the number of citations, and therefor its average betweenness of the papers in the network. Conversely, the network is becoming far more sparsely connected because of the sheer rate of addition of new papers and the limited numbers of citations that each paper can make (see Figure 10). What about the importance of particular papers? Are there specific papers (or groups) that seem to be becoming more or less important in the network despite the rapid expansion of the network itself?

Eigenvector centrality is one such measure of importance or influence within a citation network. It assigns relative scores to all nodes in the network based on the number connections and quality of the scores of the connections a node has. The more important the node’s connections, the higher that node’s eigenvector centrality will be (Newman, 2014). We might hypothesize that similar to the betweenness measure, all papers would tend to become more important within the network over time. Or, conversely, perhaps, eigenvector centrality would tend to decrease rapidly with the rapid increase of the size of this citation network. Puzzlingly, neither seems to be the case: Figure 5 seems to show that some of the papers in this citation network are increasing in their eigenvector centrality score between 1995 and 2016, while other papers in the network decrease in terms of eigenvector centrality over this time period. How can we account for this?

It seems that there is some pattern—some papers increase in eigenvector centrality while other papers decrease in eigenvector centrality—over the time period observed. But, what is the relationship between the papers that tend to increase or decrease in relative importance / influence in this network over time? To explore this, using R (see code in Appendix 1) we separated out the papers that had increasing eigenvector centralities and those with decreasing eigenvector centralities. Figures 6 and 7 show the plots of the increasing eigenvector centrality papers in red and the decreasing eigenvector centrality papers in blue. What unites these papers?

To gain a better understanding of the overall network trend of eigenvector centrality for the papers in question, I decided to create a boxplot of all of the paper eigenvector centralities for each year, which is represented in Fiugure 8. Figure 8, once again, shows a striking outcome: while there certainly are some papers that become far more important, structurally, over time within the network, the vast majority of the papers are virtually inconsequential as far as eigenvector centrality goes. For instance, in 1995, the average eigenvector centrality score was close to .9 with a modest standard error; by 2001, it was less than .2. As time progresses from 2001 through 2016, the average eigenvector centrality score crashes to nearly zero, while a handful of outliers grow in their structural importance within the network. Who wrote these papers and what were they about? Why and how have they become so structurally important within this network?

4.4 ERGM and the Analysis of Micro-Level Structure

One hypothesis may be that local, or micro-level structures could have an important role to play in the structural evolution of this citation network over time, thus causing certain papers/nodes within the network to have a structural advantage over the others as the field of knowledge production expands. Here I attempted a modest ERGM analysis (exponential random graph modeling). ERGM are a class of stochastic models which use network local structures to model the formation of network ties for a network with a fixed number of nodes (Wang et al., 2009). They are a useful method that uses Markov Chain Maximum Likelihood Estimation to approximate estimates for the odds ratio of the presence of different micro-level structures within a network.

Table 1 shows the results of these modeling exercises on these NCD / global health citation networks as they evolve between 1995 and 2016. While running these models (which, it turns out, takes a ton of time and computing power) I learned that many of the network parameters that I had hoped to test within this network (such as k-star, 4 cycles, triangles, and triad census) would not produce MCMC models that would converge. So, I was not able to estimate those parameters.

However, I was able to estimate the ERGM parameters for the presence of edges, transitive triplets (ttriple), and density, and their values are found in Table 1. The column labled ERGM~EDGES can be interpreted as a log odds measure of the density of the network. As might have anticipated based on the analysis of betweenness and closeness, as well as the growth of the number of notes of the network, the log-odds of the probability of any tie (i.e. the density) crashes and starts to become negative starting in 2001. The column labeled ERGM~DENSITY demonstrate an analogues trend. The column labeled ERGM~TTRIPLE demonstrates a slightly different trend. It seems to start modestly low (I could not get the model to run for 1995 data, so it starts in 1996) and then seems to level out at approximate zero, not becoming more negative or positive as the network grows. This potentially represents the relative lack of importance of transitive triplets in the micro structure of this network.

Overall, I would be skeptical to make any grand claims about the utility of this ERGM analysis. Although my MCMLE models seemed to converge, I was not able to run goodness of fit analyses to test how well these estimates fit the model and my actual networks. Additionally, ideally, I would run these analyses on a faster computer or gain access to a university-based super computer since this is such a large data set and I am doing so many analyses with this time series panel data.

5) Discussion

One clear puzzle emerges from this analysis: while betweenness universally increases for this network and closeness universally decreases, eigenvector centrality climbs for some papers and crashes for others. What’s more, Figure 8’s boxplot overview of eigenvector centrality scores by year shows that, on average, the papers are inconsequential to the overall structure of the network and a handful of papers emerge to the top as by far the most dominant. What are these papers and what might it signify both for this as a domain of scientific knowledge and for the politics of global health priority setting?

Through analyzing the titles, abstracts, and authors of the papers that are most important in terms of eigenvector centrality and degree, ten papers emerge as centrally important:

  1. The European Organization for Research and Treatment of Cancer QLQ-C30: A Quality-of-Life Instrument for Use in International Clinical Trials in Oncology
  2. The MOS 36-Item Short Form Health Survey (SF-36) 1. Conceptual Framework and Item Selection
  3. Diagnostic and Statistical Manual of Mental Disorders Source Information (1994)
  4. Diagnostic and Statistical Manual of Mental Disorders Source Information (2000)
  5. Measurement of patient outcome in arthritis
  6. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010
  7. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010
  8. Statistical Power Analysis for the Behavioral Sciences
  9. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study
  10. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010

There are several things that are remarkable about this list of the (by far) most important papers in this citation network. First, aside from the first most important paper—which is about the clinical process of diagnosing and treating cancer—none of these pieces are about a specific disease or even class of diseases. Instead, they are all meta-analyses or statistical overviews of epidemiological trends in noncommunicable diseases and their relative burdens globally. Second, the disease upon which they are focusing tends to be biased towards wealthy-world health issues: the DSM for mental health issues (which has a highly western-centric focus) and arthritis (has not been considered a ranking global health priority). Finally, all them have to do with capturing global measurements, standardized practices and protocols, and dominant paradigms—built from programs and practices rooted in the U.S. and Europe—that are to serve as models for health care systems in the global south. Considering that this network, examined from 1995 through 2016 was about “global health” and noncommunicable diseases, it seems surprising that these would be the overwhelmingly dominant papers in this sparsely connected network.

6) Conclusion

I began this paper with a commentary on the ways that scientific citation networks can enable and constrain the biopolitics of global health by reinforcing the legitimated framing of diseases and their interventions in certain ways, and not others. This paper points to the possibility that the structural evolution of the NCD / global health academic paper citation network has contributed significantly to this biopolitical conundrum. Specifically, important puzzle in the field of global health is: why have non-communicable and chronic diseases been so dramatically marginalized within the global health priority mix? First, comparing the burden of noncommunicable diseases (NCDs) and infectious diseases to their relative magnitude of investment via development assistance for health (DAH) demonstrates a remarkable disparity. Despite accounting for more than 30% of the overall disease burden globally (especially in low and middle income countries), less than 1% of all DAH is allocated specifically to care, treatment, and prevention of noncommunicable disease (Daniels, Donilon, & Bollyky, 2014).

Second, there has been a concerted effort by the noncommunicable disease community of practitioners and scholars to raise the profile of NCDs on the global stage (Geneau et al., 2010). Much of this political and scientific labor has culminated in rare and highly important United Nations General Assembly High Level Meeting focused on the global burden of NCDs in 2011. This meeting was the first UNGA High Level Meeting on a health topic since HIV/AIDS in 2000. Yet, despite the attention from global leaders on the world stage, nearly no new resources have been committed and invested in global NCD care and management. Finally, central to this debate has been a question about the nature of the social construction of NCDs globally, especially with regards to the burden, causal sources, and necessary systems-level interventions to meet the burden. Leading up to the 2011 UNGA High Level Meeting on NCDs, the World Health Organization (WHO) has doubled down on a focused framework of limited shared “lifestyle modifiable” risk factors as the dominant causal source of the NCDs globally. Dubbed the “4×4 Framework”, the WHO has sought to limit the terms of debate and focus to what they deem to be the four most “important” NCDs and the corresponding individual level lifestyle modifiable risks: cancer, diabetes, cardio-vascular disease, and chronic respiratory disease; tobacco use, unhealthy diets, physical inactivity, and the harmful use of alcohol (WHO, 2013). Scholars and practitioners, especially those providing care in poor, remote regions of the world have taken aim at this framing, saying that it excludes much of the important burden of illness, especially amongst the very poor and rural populations around the world (Binagwaho, Muhimpundu, & Bukhman, 2014; Bukhman, Mocumbi, & Horton, 2015; Kwan et al., 2016; Bukhman et al., 2015).

These three interlocked challenges—the sheer disparity between NCDs / infectious diseases’ resources and burden, the negligible growth in resource commitments despite NCDs’ expanded profile on the international stage, and the dynamic scientific and political contest of NCDs’ social construction and framing—create an interesting empirical puzzle that has important implications for the politics and governance of global health. What is blocking the political progress in expanding resources and academic focus on a progressive strategy for NCD care and control?

One hypothesis—that is supported by the findings of this paper—is that the dominant NCD framing (especially from the WHO and the global scientific community) historically has been rooted in a North American / European-centric view: a narrow set of illnesses and their associated individual-level, modifiable, statistically determined risk factors as the root causes (4×4 Framework). This framing has blocked the political momentum of NCDs because 1) it situates the locus of cause in bad decisions/behaviors of individuals and 2) it appears to be an unhappy byproduct of economic development and income growth. This framing renders the true experience of the poorest and most marginalized invisible to global policy makers and makes it difficult for activists to demand new modes of financing to support ministries of health to build progressive NCD treatment and prevention programs.

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The evolution of a citation network

Building off my initial work to understand the academic citation network for noncommunicable diseases and global health, I started to wonder: how has this academic knowledge network changed structurally over time? Were the papers that were published earliest in the network the ones that remained dominant in terms of citations? What disciplines / areas of scholarship do the dominant papers tend to come from?

So, I decided to run the same analysis I did for the last post for for the cumulative citation network for each year from 1994 through 2016.










































































A couple of interesting observations:

  1. As was clear in my previous post, there seems to be an important inflection point around 1997. The plot of number of average citations over time and the number of articles published each year shows that the number of articles published each year and the average number of citations per article lines cross each other around then. Also in the network plots, we see that the network, for the first time, expands beyond the initial core of about 5 or 6 papers to a new domain of papers previously outside of the network. A question: what are those papers? What causes the change in the average number of citations and causes the rapid increase in the number of papers published annually?
  2. It appears (though I still need to test this statistically) that the core group of papers that originally made up the center of the network, remain centrally located and develop a primarily core-periphery structure to this citation network. Is this true? Are the papers that are most important early in the network still important later on in the late 2010’s?
  3. I wonder what the “framing” of these papers are? Do they tend towards the dominant 4×4 framing that the WHO has stuck by, despite the fact that it probably misses much of the NCD experience of most of the very poor people around the world?

There is much more to be done, but it’s cool to see these methods yielding an interesting story, and perhaps explanation to why we see NCDs of the poorest continually marginalized in the global health policy debates.

The evolving ideology of ‘sustainability’

Many of the lectures and discussions I’ve listened to about the launch of the Sustainable Development Goals have begun, tongue-in-cheek, with a comic satirizing the growth of the use of the word “sustainable” in our conversations about global health and international development.


It’s a funny cartoon, but it underlines an important point: what we really mean by ‘sustainability’ will become an increasingly important ideological driver for development efforts over the next 15 years.

Paul Farmer, Sarthak Das, and Norwegian researchers Eivind Engebretsen, Kristin Heggen, Ole Petter Ottersen have an interesting historical perspective on the evolving concept of ‘sustainability’ that was recently published as a Lancet commentary.

changes in sustainability

They observe that the notion of sustainability has gone through three fundamental shifts since the early 1990’s. First, sustainability was referred by Gro Harlem Brundtland as development initiatives that were fundamentally durable and built to last. The mid-1990’s saw the definition of “sustainable” move from a descriptor of the longevity of a program towards an investment criterion for programs that prioritize the ability of local efforts to demonstrate capacities for “good governance” and “democratic practice.”  The latests evolution in the ideological underpinnings of sustainability seems to be associated with “with ‘continuous improvement’ and with “monitoring” and systems which are ‘domestically driven’.”

“An important aspect of the conceptual transformations is that the term sustainability has gradually changed from being a goal (durability) to acquiring connotations that serve as a selection criterion for development aid. Using sustainability as a selection criterion risks privileging recipients who have the capacity to gain control over health and living conditions and exclude others as unworthy needy. It would be a paradox if emphasis on sustainability ended up in preventing global equity and justice instead of promoting it.”

The neoliberal processes tend to push obligations from the collective to the individual. This seems like an important and cautionary observation for the coming “age of sustainable development.”

Hospital investments needed in the MDG –> SDG transition

University Hospital in Mirebalais: a state of the art 300-bed teaching hospital in rural Haiti.

University Hospital in Mirebalais: a state of the art 300-bed teaching hospital in rural Haiti.

The right to health movement is a political struggle for moving resources down the gradient of inequality in ways that can strengthen public sector universal health care delivery systems that meet the needs of citizens. Current policy, governance, and financing structures are insufficient for this aim. But, how should it be governed? What changes are needed at the WHO? What types of investments should be prioritized?

A recent post to the Health Affairs blog, written by heavy hitters such as the founding executive director of the Global Fund to Fight AIDS, TB, and Malaria, Sir Richard Feachem amongst others, highlights one of these debates: at what level of the health system should investments primarily be made?

The authors argue that we’ve focused heavily (perhaps too heavily) on funding narrowly constructed, vertical disease-specific programs:

“For the past four decades, donors have mainly funded disease-specific programs and global discourse has focused on the need for better primary care. In combination, these have contributed to remarkable progress in meeting many of the MDG health targets, especially those relating to child mortality, HIV/AIDS, and malaria.

Targeted programs and a primary care focus have been less successful, however, in achieving some of the other MDGs — most notably in the areas of maternal and neonatal mortality. While many papers and conferences have been devoted to the topic of “health systems strengthening,” funding priorities and programmatic approaches have remained narrowly targeted on diseases, or on a single platform of delivery: primary care.”

They argue that to meet the broader and more ambitious targets in the Sustainable Development Goals (specifically, to “ensure healthy lives and promote well-being for all at all ages.”) we need to have a renewed focus on hospitals and similar secondary/tertiary-level facilities as a crucial component of integrated primary care.

“Within the continuum of care services, insufficient attention has been paid to access to high quality hospital services. In both low- and middle-income countries, hospital quality and safety has lagged; in 2009, 15.5 million disability-adjusted life years (DALYs) were lost due to in-hospital adverse events. Despite domestic resources in most countries being disproportionately allocated to hospital care,hospitals in many low-income countries are inaccessible or are in a dismal state. Even with comparatively large expenditures on hospitals versus other modes of delivery, total domestic health expenditures are often too low to provide a good quality health system. These conditions are exacerbated by ineffective spending and lack of management accountability.

As a consequence, public hospitals in these countries are often dilapidated, lacking a reliable water supply, sanitation, and electricity. Drugs and other supplies may be unavailable, equipment is frequently broken, and basic infection control is absent. This makes it difficult, if not impossible, for limited medical personnel to ensure good health outcomes.

We argue that for personal health services, which are the focus of this perspective, it is now timely to rebalance the global health discourse and focus on the integration of primary care with essential hospital services. A strong health system needs both.”

They point to narrowly conceived cost-effectiveness analysis as a reason for insufficient investments in the capital intensive process of building and maintaining adequate tertiary-level facilities. They liken it to the investments in education made across Africa which have avoided higher education and specialty training, deemed too expensive for poor people.

“The SDGs call for health for all individuals, present and future. All platforms of care delivery are necessary for health system success, and none are individually sufficient. Building health systems with a long view—to sustainably preserve and attain health—requires an integrated approach where one platform supports, rather than competes with, another. Putting hospitals on the agenda alongside other platforms of care is not the whole solution, but it is a necessary part of the solution, if we are to have any likelihood of achieving the SDGs.”

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

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

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

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

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

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

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

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

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

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

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

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

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. (

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.

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.