Citation network analysis and the social production of knowledge

I’m currently enrolled in a social network analysis (SNA) class at BU, and its proving both extremely difficult and very interesting. My primary interest in learning this method and corresponding theories is to, someday, look at the network of global health delivery NGOs and try to map the field of action in a way that could provide some structural explanation of NGO policy, structure, and action.

For now though, I’m working on a project to understand the citation network of academic / scientific papers written about global noncommunicable diseases. This builds off of my previous work with the Lancet Commission on Reframing NCDIs Amongst the Poorest Billion. Specifically, I’m hoping to explore the network of citation connections across different domains of knowledge production and look at which forms, framings, and issues tend to dominate.

I was able to scrape the Web of Science of all papers that had a topic that included one of the noncommunicable diseases (list generated from those included by the IHME) and also included the term “global health”. The search generated 9,809 total articles. I used the the CRAN bibiometrics R script to turn this data set into a sociomatrix and plotted it. Here is the result:

ncd-paper-citation-network

Basically, each node / vertex is a paper and the size of the node is proportional to the number of times it has been cited by another paper in this network.

The top ten cited papers are:

AARONSON NK, 1993, J NATL CANCER I, V85, P365, DOI 10.1093/JNCI/85.5.365
367
WARE JE, 1992, MED CARE, V30, P473, DOI 10.1097/00005650-199206000-00002
Citations: 351
AMERICAN PSYCHIATRIC ASSOCIATION, 1994, DIAGN STAT MAN MENT
Citations: 321
AMERICAN PSYCHIATRIC ASSOCIATION, 2000, DIAGN STAT MAN MENT
Citations: 221
FRIES JF, 1980, ARTHRITIS RHEUM, V23, P137, DOI 10.1002/ART.1780230202
Citations: 204
MURRAY CJL, 2012, LANCET, V380, P2197, DOI 10.1016/S0140-6736(12)61689-4
Citations: 201
LOZANO R, 2012, LANCET, V380, P2095, DOI 10.1016/S0140-6736(12)61728-0
Citations: 192
COHEN J., 1988, STAT POWER ANAL BEHA
Citations: 179
MURRAY CJL, 1997, LANCET, V349, P1498, DOI 10.1016/S0140-6736(96)07492-2
Citations: 170
LIM SS, 2012, LANCET, V380, P2224, DOI 10.1016/S0140-6736(12)61766-8
Citations: 157

I was really happy that I was able to make it work and it looks pretty cool in my opinion! But, unfortunately, it doesn’t really tell us much about the true structure of the network. I’ll have to do much more analysis. I’m going to try to do block modeling and perhaps exponential random graph models (ERGM) to see what stands out about this network.

Here are some plots that I was able to easily make with the CRAN package:

rplot

rplot02

rplot03

rplot04

Some quick takeaways? Chris Murray is dominant, especially in the modern literature on global NCDs. Similarly, the US is dominant in terms of production of these papers. Finally there has been a stable increase in the number of papers published annually, after a burst in citation of some subset of papers in the network around 1993. It will be interesting to see what those papers are and what might have triggered this sudden citation boom and the subsequent growth in the volume of literature. It will also be very interesting to see in what domain these papers fall (clinical, basic science, social sciences, engineering, etc) and see if we can develop some measure of their “framing” of global NCDs.

Postcolonial thought: the emancipation of social theory?

postcolonial-thought-and-social-theorySome thoughts on: Go, Julian. Postcolonial Thought and Social Theory. New York, NY: Oxford University Press, 2016.


From the beginning, sociology has stylized itself as an emancipatory (or at least, progressive) social science (Burawoy, 2005). What then are we to do with the fact that the roots of sociological thought are built from ideas emanating from (if not outwardly praising) imperialism, colonialism, and domination of much of the world? This is the central question that Prof. Julian Go tries to tackle. He seeks to explore how this imperial context more precisely shaped the content of sociology and social theory— and whether it still does today. Does social theory bear the imprint of its imperial origins? Has social theory extricated itself from this earlier imperial entanglement?

This is a historical and theoretical challenge. Prof. Go spends the better part of the book tracing the classical social theory that underpins modern sociology as well as the countervailing postcolonial thought that emerged in the wake of decolonialization efforts throughout Asia and Africa. This historically grounded analysis of the actors and forces shaping social theory and postcolonial thought is based in conflict and division. Postcolonial thinking emerged as a result of the cultural and epistemological roots of social theory, and in opposition to it. Sociology largely accepts the notion that ideas are shaped by the social environments in which they are formed (Berger & Luckmann, 1966). For this reason, it is not hard to understand why the ways of knowing articulated via social theory and postcolonial thought are so radically different.

For Go, social theory is rooted in an ontology and has developed an epistemological approach that made imperialism understandable and justified. Auguste Comte first used the term “sociology” in 1839 to characterize “the social” distinct from political, economic, and religious realms. In practice though, it was a way of creating a new technical domain of elite social scientific researcher. Privileged classes have been able to use the technical understanding produced through sociology to manage threats to social order from below their ranks. Its foundational concepts were developed during the Enlightenment and rested on three central concepts: humanism, that there is a universal human nature that can be improved based on Reason; universalism, that the world is made up of basic unalterable truths that can be understood independent of space and time; and positivism, the reliance on scientific method as the best approach for understanding the world in general.

This is contrasted with postcolonial thought, which is fundamentally anti-imperial and grew out of English and literature departments at the beginning of the 1980s. Writers such as Edward Said, Gayatri Spivak, and Homi Bhabha; historians including Ranajit Guha or Dipesh Chakrabarty; and anti-colonial theorists Frantz Fanon, Aimé Césaire, Amilcar Cabral, W. E. B. Du Bois, and C. L. R. James were central to these efforts. These writers, and others, sought to articulate a worldview and cultural analysis that rejected the humanist/positivist way of knowing the world. As Go says, “Fanon saw in European humanism little else than a bourgeois narcissism projected onto the entire world— a world teeming, in the view of the Enlightenment, with ignorant hordes awaiting the salvation of European colonialism.” Because of the cultural and epistemological hold that social theory has had in the academy and society at large, postcolonial thought has been relegated to the humanities and literature departments. In fact, popular culture has, at times, paid more attention to postcolonial thinking and literature than has social science. Go writes that, “The New York Times has referred to Homi Bhabha more times than the American Sociological Review.” This enabled these thinkers, however, to direct their critiques to more than simple political domination and economic exploitation—it opened them to possibilities of emancipatory futures.

Is there an opportunity for reconciliation between these two modes of knowing? Or, does social theory need to be repealed and replaced? For Go, the opportunity comes from one other central concept of modern social theory: the notion that we must be reflexive about what we know and that our conceptions of reality are fundamentally socially constructed (Bourdieu & Wacquant, 1992). For this reason, we should be critical of the social, historical roots and political usage of social theory in modernity. If all knowledge is necessarily constructed in a situated time and place by embedded actors with concrete interests and concerns, the antagonistic nature of social theory/postcolonial thought is understandable given their roots within the dominant/dominated.

Go offers a compelling turn in search of reconciliation. By seeing the threads of social theory and postcolonial thinking as bifurcated, we necessarily occlude the nature of empire and the empirical project of understanding history and modernity. A true postcolonial social theory will need to be not solely an empirical project but also an epistemological one. It must be about “finding ways of knowing and thinking that escape the strictures of the imperial episteme.” His solution is relational sociology. Relationalism gives social theory a way of understanding the world in flux and can overcome social science’s tendency toward “analytic bifurcation, which in turn has perpetuated social theory’s persistent Orientalism, its occlusion of empire, and the repression of colonized agency from its accounts.” Field theory and actor network theory are good starting points for this new analytic and theoretic project. Subaltern ways of thinking and “southern theory” rooted in the ontologies and perspectives of people coming from marginalized positions is key.

In summary, Go’s Postcolonial Thought and Social Theory reads as a good review of the roots of two ways of knowing the world: legitimated social theory coming from elite oppressors and marginalized postcolonial thought rooted in an ontology of the “wretched of the earth.” While this book does an excellent job tracing and summarizing the core themes and history linking these two literatures, I wonder what is truly novel about this synthesis? Postcolonial relationalism linked with a subaltern standpoint seems like an important way of dissolving unnecessary bifurcations and occlusions in ways that can allow new insights into social realities, especially of the dominated. Yet, after having read the book, I am still left with the question of how, exactly, postcolonial thinking will be able to emancipate social theory from its problematic history and ontological roots.


Bourdieu, P., & Wacquant, L. J. (1992). An invitation to reflexive sociology. Chicago: University of Chicago Press.

Berger, P. L., & Luckmann, T. (1966). The social construction of reality: A treatise in the sociology of knowledge. Garden City, NY: Doubleday.

Burawoy, M. (2005). For Public Sociology 2004 Presidential Address. American Sociological Review70(February), 4–28. http://doi.org/10.1177/000312240507000102

My, our arrogance

Unbelievable. I can’t believe that Donald J. Trump will be the chief executive of the most powerful country in the world. My country. Our country. A nation ostensibly based on the rule of law, human rights, justice, equality will be led by someone with no interest in those values. And, with a Congress squarely in the hands of a Republican party that has a center of gravity based in white-nationalism, the potential for harm is terrifying.

Rereading my post from yesterday afternoon is painful. What arrogance!

The extent to which this arrogance was shared across the media, elites, academics — basically everyone in my entire life — is profound. We all got it wrong. The disconnect of framing / narrative / cultural understanding of what this means for the country between Trump supporters and Clinton supporters is so deep. How will we reconcile? What do I do?

Sitting in graduate school at a major university in Boston reading social theory is starting to feel less and less relevant in the world we currently inhabit.

A sociological treatment of Trump

screen-shot-2016-11-08-at-4-43-25-pm

http://projects.fivethirtyeight.com/2016-election-forecast/

I’m actually surprised to say that I am looking forward to watching the polls come in tonight, finally concluding this brutal and depressing presidential election season. It’s partially because I’m looking forward to drinking and eating with good friends and because I believe that Hillary Clinton is going to with the election (Nate Silver, as of 1:12pm ET today, has her at 71%). But also, it’s because I am fascinated and slightly terrified about what’s going to come next. How will Trump respond to a resounding electoral rebuke of his racist, sexist, demagogic campaign?

Trump is a uniquely terrible, but his popularity and rise to significant power is a fundamentally sociological phenomenon. My guess is that there will be many academic attempts (not just journalist long-form pieces) to try understand the rise of Trump coming from history, sociology, political science, and psychology.

I recently stumbled upon a piece by Arlie Hochschild, “The Ecstatic Edge of Politics: Sociology and Donald Trump” that I thought was enlightening. Hochschild is also the author of the recent book, “Strangers in their Own Land: Anger and Mourning in the American Right”, which is an ethnographic account of the political understanding, culture, and emotional meaning making of Tea Party supporters in the American South. She is well placed to create a sociological take on the rise of Tumpism. 

She says that thinking on Trump to date is insufficient to truly account for his rise and to explain his supporters’ praise. She shows the utility of Hofstadter’s view of paranoia as a source of charismatic leadership, Skocpol and Williams’ institutional approach to understanding the organizational rise of the Tea Party movement, and Lakoff’s politics as metaphor in understanding components of Trump’s rise. But alone, they are still insufficient to understand this phenomenon. Additionally, we need to understand the “deep story” that unites the shared cultural understanding of Trump supporters across the country.

For her, a “deep story” is “a metaphor-based narrative, the details of which corresponded to the emotions experienced by my informants. A deep story is a feels-as-if story—stripped of facts and moral judgment.” A story that the Trump supporters / the far right seem to share:

You are standing in a long line leading up a hill, as in a pilgrimage, patient but weary. You are in the middle of this line, along with others who are also white, older, Christian, native-born, and predominantly male, some with college degrees, some not. At the crest of the hill is the American Dream, the goal of everyone waiting in line, a standard of living higher than that your parents enjoyed. Many behind you in line are people of color—poor, young and old, mainly without college degrees. You wish them well, but your attention is trained on those ahead of you. And now you notice the line isn’t moving. In fact, is it moving backward?

You’ve suffered. You’ve had marriage prob- lems, and you are helping out a troubled sibling and an ill co-worker. Your church has seen you through hard times. You’ve shown strong character, and the American Dream is a badge of moral honor, as you see it, for that.

But look! Some people are coming from behind and cutting in line ahead of you! As they cut in, you are being moved back. How can they just do that? You’re follow- ing the rules. They aren’t. Who are they? They are black. They are brown. They are career-driven women, helped by Affirmative Action programs.

The liberal government wants you to believe they have a right to cut ahead. You’ve heard stories of oppressed blacks, dominated women, weary immigrants, closeted gays, desperate Syrian refugees. But at some point, you say to yourself, we have to build a wall against more sympathy. You feel like a refugee yourself.

You’re a compassionate person. But now you’ve been asked to extend your sympathy to all the people who have cut in line ahead of you. And who’s supervising the line? It’s a black man whose middle name is Hussein.

He’s waving the line cutters on. He’s on their side. He’s their president, not yours. What’s more, all the many things the federal government does to help them don’t help you. Should the government really help anyone? Beyond that, from ahead in line, you hear people calling you insulting names: ‘‘Crazy redneck!’’ ‘‘White trash!’’ ‘‘Ignorant southern Bible-thumper!’’ You don’t recognize yourself in how others see you. You are a stranger in your own land. Who recognizes this?

This feels right to me. Trump’s rise isn’t just about sexism, economics failings, or pure racial resentment — though of course all of these are present. Its really about a narrative / meaning making process that is rooted in shared experiences and built upon a particular understanding of a violated sense of fairness. Trump is unique in the fact that he has found a way, better than anyone else to date, to validate and channel this narrative.

Now, what political action and response is needed? Probably one rooted in trying to listen and understand the pain and struggles of real people. As Hochschild concluded, “Whether Donald Trump rises or falls, we need sociology to take up the task of analyzing the rise of the right. And we need our government and society at large to address all the ways millions of American have been—in real life—left behind.”

On the wagon, off the wagon

It turns out that I’m not very good at blogging. Its been months since my last post… more than seven to be exact. Shit.

Well, a lot has happened over these seven months:

  • My work with the Lancet Commission on Reframing NCDs and Injuries Amongst the Poorest Billion has resulted in some very interesting data and initial findings on how global health practitioners, senior scholars, and the American public frame noncommunicable diseases amongst the poorest people globally. Lots to dig into: we have survey data from nearly 900 respondents, 45 interviews that have been transcribed and initially coded, and data from a public opinion poll as well. I’m hoping to be able to try to write up some of these findings this summer and in the mean time, I may try to post some of my ideas here too over the coming weeks / months.14516472_696939647126689_8417982573106424996_n
  • I had a chance to travel to Rwanda to present my work with the NCDI Poverty Commission, and here are the slides. It was amazing to visit a country that I’ve read so much about and to have the chance to finally visit the PIH’s Butaro Hospital.
  • I started grad school at Boston University! It turns out being a grad student is both really hard and also very fun. Its liberating to have time and energy to focus on thinking about concepts, to read more deeply, to try to write more. I also am looking forward to getting started working on shaping my dissertation research. Right now, my classes are: classical social theory, sociological methods, social network analysis, and quantitative methods.

So now, maybe actually now, I will be able to keep up with some serious blogging about the work that I’m engaging in, the ideas I’m encountering, and can use this as a space to further this critical dialogue. We shall see.

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.

sustainable

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.”

Long time, no post

Despite my best attempts, I fell off the blog bus over the last couple of months. Oh well; it’s been a hectic, challenging, and at times emotional transition out of my day-to-day role with Partners In Health and into the world of academic research. But, I’ve also had a great time officially transitioning into my work as a research assistant with the Lancet Commission on NCDIs and Poverty.

The work with the Lancet Commission is progressing well. We are about ready to submit our IRB application (yikes…) for a study that includes a large scale survey of undergraduate and graduate students interested in or currently studying global health along with a semi-structured interviews with key faculty, administrators, student-organization leaders, and activists.

Building off of some of the theoretical work considered earlier, we seek to answer three interrelated questions:

  1. What are the primary factors motivating students to choose to study global health?
  2. What types of formal academic programs, student-driven organizations, and other global health activities are emerging to meet this demand?
  3. What opportunities do these programs, organizations, networks present for future collective action?

More on this research plan soon.

Additionally, the Tufts course, “The Right to Health: Problems, Perspectives, and Progress” is coming to a close next week! It’s hard to believe how quickly a semester goes. But, it was a great time and huge honor to get to participate in developing and leading this course with a group of 13 amazing Tufts undergraduate students and Prof. Fernando Ona. I’m looking forward to writing some synthesis / debrief posts soon.

Now that I’ve gotten settled into the work with the Commission and that the semester is ending, I plan to devote more time to this space.

Lots more to come!

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.”

Joining Boston University’s Ph.D. program in sociology this fall!

2000px-Boston_University_Wordmark

I’m excited to announce that I’ll be starting my Ph.D. in sociology at Boston University this fall! I’m hoping to take my experiences working with global health organizations and building grassroots campaigns and utilize the tools of empirical sociology to understand the emergence of a right to health movement. My goal is to use this study to learn something about how global health has changed over the last couple of decades, but also (and more importantly) how we can hasten change in the decades to come.

Specifically, I’ll hopefully have the chance to work closely with Prof. Joseph Harris who has spent significant time living and working in Thailand to study the movement and political process that led to the creation of a highly successful universal health coverage system in that country. I’m also looking forward to working with scholars interested in field theory and Bourdieu and hopefully getting to contribute to the Political Power and Social Theory journal, which is based out of BU.

I’m excited for this next step in my career and in this work!

Cost effectiveness, rights, and universal health coverage

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

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

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

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

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

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

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

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

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

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

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