Category Archives: Global Health

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.

Robin, Corey. “How Intellectuals Create a Public.” The Chronicle of Higher Education. N.p., 22 Jan. 2016. Web. 31 Jan. 2016. ↩
Ibid. ↩
Ibid. ↩
Farmer, Paul. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: U of California, 2003. Print. ↩
Fligstein, Neil, and Doug Mcadam. “Toward a General Theory of Strategic Action Fields*.” Sociological Theory 29.1 (2011): 1-26. Web. ↩
McAdam, Doug. Political Process and the Development of Black Insurgency: 1930-1970. Chicago ; London: U of Chicago, 1982. Print. ↩
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 20^th 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 19^th 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)

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 world’s pain) with hope (experience of the world’s 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)

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

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 http://www.un.org/Overview/rights.html.

[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. http://engage.pih.org/.

[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 (20^th Edition). Retrieved from: http://apps.who.int/iris/bitstream/10665/191102/1/9789241565059_eng.pdf?ua=1

[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. http://marshallganz.com/teachings/.

[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. <http://csis.org/files/publication/120417_gf_morrison.pdf>.

[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. https://sustainabledevelopment.un.org/topics.

[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. <http://www.cfr.org/international-organizations-and-alliances/dr-kim-world-banks-health-role/p27952>.

[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. http://www.vox.com/2015/11/27/9801800/politicians-keep-campaign-promises.

[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. <http://www.rawstory.com/2012/09/five-questions-for-take-the-money-out-activist-paul-davis-about-disrupting-a-national-journal-event/>.

[lviii] “2014 Ebola Outbreak in West Africa – Case Counts.” Centers for Disease Control and Prevention. December 4, 2015. Accessed December 6, 2015. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html.

[lix] “United States Senate Committee on Foreign Relations.” Hearing. Accessed December 6, 2015. http://www.foreign.senate.gov/hearings/the-ebola-epidemic-the-keys-to-success-for-the-international-response.

[lx] “We Have Everything We Need to End Child Mortality Now.” Muso. Accessed December 6, 2015. http://www.projectmuso.org/.

[lxi] “Hope Through Health.” Hope Through Health Home Page. Accessed December 6, 2015. http://hthglobal.org/.

[lxii] “Home | Possible.” Possible Health. Accessed December 6, 2015. http://possiblehealth.org/.

[lxiii] “Home Page.” Last Mile Health. Accessed December 6, 2015. http://lastmilehealth.org/.

[lxiv] “PIVOT Health.” PIVOT Home. Accessed December 6, 2015. http://pivotworks.org/.

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

[lxvi] “Global Health Corps Home.” Global Health Corps. Accessed December 6, 2015. http://ghcorps.org/.

[lxvii] “Student Global AIDS Campaign (SGAC) Home.” Student Global AIDS Campaign (SGAC). Accessed December 6, 2015. http://www.studentglobalaidscampaign.org/.

[lxviii] “Universities Allied for Essential Medicines.” Universities Allied for Essential Medicines. Accessed December 6, 2015. http://uaem.org/.

[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. http://www.end7.org/.

[lxx] “Join PIH Engage.” PIH Engage. Accessed December 6, 2015. http://engage.pih.org/.

[lxxi] “Home – Timmy Global Health.” Timmy Global Health. Accessed December 6, 2015. https://timmyglobalhealth.org/.

[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. http://www.healthgap.org/.

[lxxvi] “RESULTS | Homepage.” RESULTS. Accessed December 6, 2015. http://www.results.org/.

[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.

PIH | Engage: Forward Progress

39,309 Replies

It’s only been about 2 months since my last post about PIH | Engage, but our progress on the spring campaign seems exponential. Early in 2014, teams across the country sat down at community “retreats” to lay out a gameplan for the spring, setting ambitious yet realistic goals and devising the timeline, roles, and sets of work necessary to make their ideas a reality. We’re approaching a crucial moment for PIH | Engage: in just a few months, the yearlong campaign will wrap up and we’ll head into a summer of reflection, re-grouping, and rebuilding for next year. The question for these retreats was: how will communities meaningfully demonstrate the significant power they’ve built through months of organizing and hard work?

The power that we’ve built:

PIH | Engage teams have built up to this moment through many small campaign successes. Just in terms of people power, the movement has grown to more than 430 members! A personal fundraising push around the holidays resulted in more than $26,000 in December alone, and events across the country have brought our total beyond $52,000 to date.

Our winter advocacy push focused on generating media around the Global Fund to Fight AIDS, Tuberculosis, and Malaria replenishment conference. The Global Fund is an international financing institution that has brought unprecedented resources to fight these epidemics, and through submitting letters to the editor to our local newspapers, PIH | Engage called on the U.S. to pledge $5 billion to the Global Fund over the next three years. At least 8 letters were published! In addition to these campaign victories, communities hosted many awareness-raising events, panels, film screenings, and social gatherings.

The community on Bainbridge Island, Washington hosted a “Soup Night” at a local bookstore with PIH guest speaker Jon Lascher.

The Washington D. C. group held a World Cancer Day happy hour.

The team in Madison, Wisconsin bonded at their community retreat.

Where we’re headed:

Now, the question is how PIH | Engage can display this power in a final campaign push. First, teams aim to host culminating fundraising events that rally entire communities around the vision of Partners In Health. Not only can these events raise substantial funds, they can engage a broad audience about the work of PIH and PIH | Engage. One idea that many communities have taken on: “Strides for Solidarity” walkathons where people walk in solidarity with community health workers, who often travel many miles over rough terrain to reach vulnerable patients. Community health workers are the cornerstone of the health care systems PIH works to build – we employ more than 8,000 CHWs across our sites. By the end of this year’s campaign, I’m confident that PIH | Engage will host more than 10 Strides for Solidarity walkathons.

Communities are also working to push forward an exciting advocacy campaign. As I write this, Congress is debating funding levels for next year’s federal budget, including key foreign aid programs that could bring millions to global health interventions. Congress gives less than 1% of the budget to humanitarian aid – we need to tell them to do better. PIH | Engage will engage with our legislators through in-person meetings, letters, phone calls, and emails and urge them to make global health a priority in next year’s budget. Specifically, we’re asking them to increase funding levels to $800 million for global maternal and child health, and $200 million for nutrition programs.

By the end of June, PIH | Engage organizers will have held dozens of meetings with Congressmen to discuss these issues. And, as you’re reading this, I hope you’ll join us! We’ve created an easy tool that helps you write a letter to your Senators and Representative in Congress in just 2 minutes:

www.pih.org/speak-out

Sign this call to action now and share with your friends and family!

It’s taken a lot of work to get here, and I can already think of dozens of ways I’d like to change the campaign, our training, and our recruitment for next year. But thinking back to our launch in September, it’s incredible to have seen individual Community Coordinators grow into passionate, dedicated teams ready to host walkathons and meet with Congress! I can’t wait to see what we accomplish by the end of this campaign.

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By Sheena Wood

Sheena works as the Community Organizing Assistant at Partners In Health. A recent graduate from Brown University, she enjoys reading about community organizing and global health, traveling, and eating dark chocolate.

Medical-legal partnerships and the right to health

39,223 Replies

Just finished reading the fantastic article by Elizabeth Tobin Tyler on how we might start to conceptualize and advance a strategy for health as a human right in the United States. It made me realize just how weak our (in the U.S.) legal precedent and political appetite is for positive social and economic rights, including the right to health. The paper reinforced for me the history that the commitment to social and economic rights is, actually, deeply American, but was derailed by the politics of east-west / capitalist-communist posturing of the Cold War. It also gave me some hope that we may be able to begin to move away from a futile top-down, overly litigious, court-driven means of advancing the health as a human right agenda.

The idea advanced in this paper is centered around the potential power of linking health practitioners, lawyers, and community organizers: politicizing health care delivery and baking rights-based advocacy right in to the process of providing services:

“A systemic health and human rights strategy should be built upon interdisciplinary partnerships among health care providers, public health practitioners, lawyers, and community organizers. It should be founded on three principles: bearing witness to human rights violations within the community context; tracking systemic failures through data collection and monitoring; and broad-based legal strategies which include both individual and policy advocacy in a given community.”

Medical-legal partnerships are one way that this type of community-level partnership has been built between these different professional disciplines.

“The medical-legal partnership (MLP) movement in the US exemplifies a community-based health and human rights strategy that implements a legal advocacy and social accountability approach by connecting lawyers, health care providers, and public health practitioners. The MLP model, first established in a safety-net hospital pediatrics department in 1993, now exists in over 500 legal and medical institutions in the US. The model is also being adopted in both Australia and Canada.”

Clearly, MLPs should play a role in a rights-based advocacy strategy in the U.S. But, I wonder how this type of patient-provider-level accountability and advocacy could be used to politicize the act of global health delivery in low income countries? If the goal is to enable MOHs and governments to take on the responsibility for protecting the right to health of their citizens, don’t those citizens need mechanisms to hold those governments accountable for delivering on that duty?

It seems like a movement for the right to health requires both the “supply side” — creating the policy and financing space through foreign aid and “accompaniment” — and the “demand side” — legal recourse for those receiving substandard care or none at all.

Definitely some interesting stuff when considering a country like the U.S., which should have dealt with these issues long ago. But, for nations interested in building the systems of social protection and healthcare delivery to protect citizens’ right to health, ideas such as MLPs should be built in.

The evolution of global health education – Part III

40,184 Replies

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

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

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

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

Figure 1

Figure 2

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

Figure 3

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

Figure 4

Figure 5

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By Tyler Boyd

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

Advancing the case for investing in health

39,413 Replies

A nice piece was published this week in the Huffington Post summarizing the conclusions of the Global Health 2035 commission. Larry Summers and Gavin Yamey write that, “We are on the cusp of a once in human history achievement.” Major claims that seem hyperbolic until you dig into the report, as I did here. The report is significant because it brings together modern health and development economics and new methods to analyze what value could be created by building policies that consider health a public good and protect the health of the poor and marginalized in particular. From the HuffPo piece:

“Perhaps the most striking finding of The Lancet report is that the economic payoff from investing in a grand convergence would be enormous. We used new research methods from health economics to put a dollar amount on the direct value of greater survival. We found that every one dollar invested in achieving the grand convergence over the period 2015-2035 would return between 9 and 20 dollars. This return on investment is nothing short of astonishing. In financial markets, investments with foreseeable returns of between 9 to 1 and 20 to 1 over reasonable time horizons simply do not exist.”

But, of course, this achievement will take significant investment, much coming in the form of development assistance and foreign aid.

“Though low-income countries will still need direct financial support, we should begin to shift global health aid to providing global public goods. We must double our investment in research and development for vaccines, diagnostics and drugs for those conditions causing the most deaths in the poor world. We must invest more heavily in what is called “implementation science”–the identification of the most cost effective modes of treatment in different kinds of environments. And we must start to get serious about tackling cross-border threats, like antibiotic resistance, counterfeit medicines, and flu pandemics. The next flu pandemic could be far deadlier than the 1918 epidemic that killed 50 million people in an era before mass, international transit.”

The Global Health 2035 commission is coming on the heels of the expiration of the Millennium Development Goals and there seems to be a growing alignment of people in power – from Jim Kim to Bill Gates – that investment in public health is one of the best ways to view foreign aid in the coming decades.

“Something like a movement”

40,210 Replies

Dr. Sriram Shamasunder has a beautiful and moving short essay about his time working at the PIH supported hospital in St. Marc, Haiti. A great quote:

International Solidarity: Nothing beautiful and lasting can be done alone. It also cannot be done immediately at scale nor should it. We need human relationships, built over time to transform systems. In global health the people we are trying to serve are by definition poor and sick. They are not the best constituency to organize themselves. This leads to policies and programs that don’t really have the people we serve at the table. I recently saw the film “Dallas Buyers Club” about the early days of HIV. Matthew McConaughey plays Ron Woodroof, a cowboy who contracts AIDS in an era where the FDA had not yet approved any medication. He goes on a personal mission to travel around the world and gain access to medications in the early 1980s. He is fearless, aggressive, and does not yield to the medical establishment. The story of the HIV movement has been told so many times, in so many elegant ways. Almost all versions detail how the afflicted pushed the establishment. Populations most devastated raised their collective voice and pushed. They had some political power because many were White or middle class. When they gained access, they aligned themselves with other HIV patients around the planet. Of course this is a simplified version of the story, but it illustrates to some degree what is happening in the immigration reform movement in the United States. Think tanks, policy advocates, academic scholars, and NGOs are certainly shaping the conversation. But the most compelling immigrant rights advocates I have witnessed are the “DREAMers” – the undocumented youth who came here when they were very young through no decision of their own. Like the protagonist in Dallas Buyers Club, the DREAMers are fearless and have the most to gain or lose. Their fight is intimate, personal and profound in a way that a Global Health movement confined to the walls of academia, or halls of the Gates foundation, or board rooms of the World Bank can never be. Those of us who are front-line workers but straddle the globe and work closely with our colleagues from Haiti to Liberia who have dedicated their lives to healing poor, sick patients and poor, sick systems would do well to imbibe their stories and tell them again and again and make sure they have the space to tell their story themselves. It is a small piece of having the most afflicted and the most poor at the table in a Global Health context that is almost inherently hierarchical, exclusionary, and fragmented.

Whatever this movement is, we need to continue to find ways of collapsing the enormous chasms of inequality and geography that currently exist between those bearing the brunt of ill health and disease and those working to create policies and systems to protect rights.

Haiti’s first Cardinal: A movement towards O for the P

38,962 Replies

Here is something interesting: Pope Fancis recently appointed the first ever Haitian Cardinal during the appointment of new Cardinals which occurred on January 12th, the fourth anniversary of the devastating earthquake in Haiti. His name is Bishop Chibly Langlois of Les Cayes, Haiti.

“The appointment this January 12, 2014 will help focus attention on Haiti, especially on our Roman Catholic Church in Haiti, where the realities, the needs and the challenges will be brought up to a much higher level,” Cardinal-designate Langlois said in statements to Alter Presse.

Some analysts suggested that the Pope’s decision to announce the cardinal appointments on the four-year anniversary of the earthquake may have been a sign of special consideration for the devastated country.

The 2010 earthquake killed more than 200,000 people in Haiti and left more than 1 million homeless. It destroyed dozens of churches, including the archdiocesan seminary. Archbishop Serge Miot of Port-au-Prince also perished in the quake.

As president of the Haitian bishops, Cardinal-designate Langlois has worked in recovery efforts. He has also led the Church’s mediation efforts in talks between Haitian President Michel Martelly, the opposition and the parliament, in order to help carve out a path towards rebuilding the country.

First, I had no idea that Haiti had never had representation in the College of Cardinals. So, this is a big deal for Haiti, and the Catholic Church in that regard alone. But, it turns out that Haiti is not alone and Pope Francis is appointing Cardinals from poor countries around the world — from Asia, Latin America, the Carribean, and Africa — bucking the historical trend of Cardinals hailing almost exclusively from Europe and North America.

Why does this matter?

Well, it’s important to reflect on this as a matter of theology, and Pope Francis’ alignment with Liberation Theology, as demonstrated in his first Apostolic Exhortation which dismisses trickle down economics and the continual growth in economic inequality. Pope Francis recently met with one of the founding Fathers of Liberation Theology, Fr. Gustavo Gutierrez, a landmark for a theology that has at times been at odds with the Vatican. Making a preferential option for the poor certainly means bringing those who have been marginalized or excluded to the decision making table.

Second, this has the potential to have significant implications for those concerned about global health equity and our ability to bring millions of more people into the fight for health as a human right. From the same article in the New Catholic Reporter, Paul Farmer links these developments to the movement towards a focus on a preferential option for the poor:

Farmer, who is Catholic and says liberation theology inspired him, said he hopes that Francis’ meeting with Gutiérrez does mean an easing in the Vatican’s stance toward liberation theology, because that would allow the theology to spread more widely.

In particular, he said, he hopes that agencies, nonprofit groups, and governments that provide assistance to the world’s most impoverished people would adopt Gutiérrez’s ideas about a “preferential option for the poor” and his work on issues of structural violence.

Those groups “need this kind of inspiration,” Farmer told NCR.

“They need to understand that it’s wrong not to use these ideas,” he said. “That if you don’t understand structural violence, for example, you’re grasping around in the dark in public health, public education [and] poverty reduction. These ideas really warrant not just rehabilitation but widespread dissemination.”

All of this is amazing to think about: we now have the President of the World Bank, The Pope, and the President of the United States all expressing serious concern with inequality and the social problems it creates. This seems like a major moment of political opportunity. Will we be able to mobilize the grassroots pressure to capture this growing political opportunity and demand that real programs, policies, and systems be put in place to protect the poor and marginalized?

The evolution of global health education – Part II

39,351 Replies

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

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

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

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

Figure 1:

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

Figure 2:

N=207

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

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