Category Archives: Global Health

Review of “Love, Money, and HIV: Becoming a Modern African Woman in the Age of AIDS” (2014)

Sanyu Mojola’s “Love, Money, and HIV: Becoming a Modern African Woman in the Age of AIDS” (2014) presents a compelling, multilayered, processual account of the ways that changing ideas of modernity and the expansion of a gendered market economy combines with the physiological and ecological structure of HIV transmission risk to produce the outrageous inequity in HIV burden borne by women in Africa. She says, “Specifically, I illustrate how consuming young women have been cultivated and produced, in three contexts—communities, schools, and labor markets” (p. 8). For her, the dramatically gendered disparities in HIV burden and experiences can only be adequately explored by tracing the interwoven threads of the structuring market, its shaping force on cultural norms and dispositions, and the implications for young womens’ search for love and desire amidst the specter of HIV. As Mojola describes, women are caught between the culturally and institutionally cultivated demand to consume—products, beauty goods, daily signs of status and modernity—while also being structurally excluded from the vast majority of the formal labor market and consistent income potential. The demand for stable income leads to emergence of various forms of “transactional sexual relationships” that take on different forms in different settings, but all help to satisfy consumptive needs and norms.

Mojola was born in Tanzania but attended college in the UK and graduate school at the University of Chicago. As she as a result her writing has an emotional and intellectual proximity that is unusual. It makes the evidence—qualitative and quantitative—all the more compelling. As she says, “I was Robert Park’s ‘marginal (wo)man”, belonging, yet not quite belonging, understanding yet not quite understanding…Far from an impersonal and purely academic account, then, this book is a study about the young women whose dangerous transitions I might have had to traverse except for the strange turns my life has taken” (p. 27-28). Using a life-course framework to study young people’s transition to adulthood in the context of the HIV epidemic, she mobilized interviews with 185 people (young people, middle-aged adults, and older adults) from the Nyanza province of Kenya; population-based survey data from Kenya; and, ethnographic field work.

Mojola’s central puzzle is: what social forces lead women to be so extremely vulnerable to HIV infection in sub-Saharan Africa, specifically the eastern part of the continent? Research on the issue tends to focus on three broad sets of interrelated causal factors—biophysiological, proximate explanations, and social structural causes. Biophysiological factors include the relationship of female anatomy/physiology and its relationship to HIV transmission potential. Proximate explanations tend to focus on the age at first sex, the number of sexual partners, condom use, the structure of sexual networks, and migration patterns. Mojola identifies one key social-structural cause, which is the central analytic lens of the book: consumption. She explores the how socially produced consumption desires shape behavior and consequent risk for contracting HIV; how consumption operates within networks and institutions (such as schools and labor markets) to shape HIV risk; and, how the structuring dynamics of consumption patterns are similar across high-prevalence settings across Africa.

Mojola begins her substantive argument by tracing the phenomenology of “modernity” as experienced by young women, transitioning to adulthood, in sub-Saharan Africa. Globalized notions of taste, marketing and media enable brands and consumption patters to be extended to even places “remote” from the metropole/former colonial centers. In places marked by significant poverty, “consumption is available used and at a deep discount—through secondhand North Face clothing that has made its way from Western charities, for example, or through cheap pay-as-you-go Nokia mobile phones” (p. 34). This modern (post-modern?) form of consumption has a markedly gendered dimension: “the dominant signifier of modernity for young women is the purchase, consumption, and display of modern goods. Indeed, there is a sense in reading these accounts that transactional relationships as a means for enhanced consumption are an indelible part of the landscape of young African women’s relationships” (p. 36). As has most notably been discussed by Viviana Zelizer and others, money, transactions, gifts, sex, and intimacy are often interwoven within relationships. Women and men engage in “relational work” to maintain culturally appropriate and sanctioned matches between money, media, and morals within intimate relationships. This is no less true in the relationship forms of young African women, and these structures have significant implications for the observed disparities in HIV rates. “In Kisumu, Nyanza, for example, three-quarters of men surveyed reported giving an average of 10% of their monthly income to their nonmarital, noncommercial sexual partners… transaction in intimate relationships was the norm rather than the exception in this setting” (p. 37).

As has been demonstrated in research on “sugar daddies” and other forms of explicit and non-explicit forms of transactional intimate relationships (in the U.S. and elsewhere), “when access to money and resources is structurally constrained, transactional sex emerges as a way of ‘redistribution and reciprocity in an unequal and uncertain world,’ where men’s dominant access to wealth and resources ‘compels them’ to have concurrent sexual partnerships involving transactional sex” (p. 42). Market demands for consumption are therefore intimately tied to the gendered risk of contracting the all consuming illness of HIV/AIDS (“Ayaki [Luo word for AIDS] came from the root word yako, which means to consume very fast, in such a way that displays greed” (p. 51)). An interesting aside is the parallelism in the discussion of consumption in HIV and the history of tuberculosis as a consumptive disease. The entanglement of aesthetic, ethical, cultural, and market demands for consumption are structuring for the experience of infectious disease transmission risk. The pursuit fo the raha—the good life of enjoyment and consumption—shaped the HIV epidemic which was “not just consuming anyone; it was consuming young women” (p. 59).

Mojola describes the “great transformation” of colonial/post-colonial settings in a Polanyian way: relationships, particularly intimate ones, are embedded within a complex, historically rooted matrix of moral, ethical, and social meanings and commitments. “It was not money that alienated or ‘ushered in moral confusion’ or that created alienated social exchange. Rather… ‘it is important to understand the cultural matrix into which it is incorporated” (p. 75). Money and the consumptive market economic logic imbricated with existing historical norms of kinship, marriage, relationship, and sexual norms. Mojola indicates two primary forms of transactional relationships that have emerged: relationships for education and relationships for sex. The former, however, often evolved into the later. “For many young men, the only fair exchange or reward for the gift of money was having sex in return. Boy did not necessarily need to be wealthy, but needed to have the ability to get or earn money to help their girlfriends” (p. 83). In Zelizerian terms, gifts of cash and consumptive products (beauty and other types) [the media] were matched with evolving transactional relationships which were not poisoned, or “tainted” by such cash and “economic” transactions, but were actually imbued with additional meaning and moral significance as a result. “Both sex and money expressed love. In other words, love = sex + provision” (p. 87).

These dispositions were actively cultivated in young women, as explored by Mojola, in two primary institutions: the school and the labor market. Puzzlingly, women with more education are observed to have higher rates of risk for contracting HIV. “The thinking goes, if education has such dramatic effects on one sexually transmitted condition—fertility—why not on HIV/AIDS?” (p. 114). Her explanation hinges on the ways that structural processes and norms, refracted through gendered practices, shaped the notion of a “modern schoolgirl” as “Consuming young women [that] had desires that could only be satisfied by consumption, desires that were considered necessities and integral to schoolgirls’ transformation” (p. 132). This culturally disciplining nature of the demand for becoming a modern, consuming, young woman combined with the norms of engaging in transactional relationships with working-class men to get money to pay for those needs, is Mojola’s main explanation for the linkage between increased education and increased HIV risk.

Finally, the gendered nature of the economy and the structure of the labor market was another way that the embedded forms of economic and meaning making became entangled in and produced the risks of contracting HIV. As she states, “In particular, the predominantly one-way transfer of money and gifts—from men to women—in transactional relationships reflect the fact that in most settings, men have relatively greater access to money and resources due to the gendered structure of local economies” (p. 151). This gender-structured labor market exacerbated the sociocultural/economic structures that produced unequal HIV transmission risk. The structural disconnect between the cultivation of young, modern, consumptive young women in the emerging mass education system and the exclusion of women from the labor market and formal income-generating mechanisms that would be necessary to finance this consumptive demand, produced the need for transactional sexual relationships with men. “They had to be continual consumers and thus continual transactors” (p. 169).

Mojola ends this book with a call to action: “The large number of young women currently beginning their sexual lives in high HIV-prevalence environments suggest that policy actions (or nonactions) undertaken in the next five to ten years may very well determine the course of the HIV pandemic in Africa” (p. 183). She calls for continued individual-level interventions such education and awareness raising, but also claims that this will be insufficient. As is the topic of this book, change will only occur with changes in the socio-structural determinants of HIV transmission: changing the school environment, cracking down on sexual relationships between teachers and students, legislating and making paying jobs more available to young women. Most promising is her brief summary of the potential of conditional (and unconditional) cash transfers to schoolgirls for HIV prevention. By reducing the structural/economic pull that young women feel in their pursuit of accomplishing the role of being successful young, consuming, modern women, perhaps the trajectory of the HIV pandemic can be altered.

Some key questions that come up for me:

  • Mojola seems to base her theoretical contribution building off of a combination of Zelizer and Granovetter: networks and institutions structurally shape the networks of relationships (the circuits) through which HIV is transmitted, but also reinforce the cultural feel, aesthetic view, and moral meanings associated with these transactions, interactions, and at times loving/intimate relationships. While this does seem like a powerful case example of embeddedness and relational work in an understudied setting/population—with important policy implications—what does it add to sociological theory?
  • While she clearly engaged with young women who were in difficult straights, her respondents / sample does seem to be relatively well off, urban, school-bound women. She explicitly says on several occasions that these were not transactional relationships of necessity (in order to eat, have shelter), but rather the needs expressed by the young women were structured by the demand to consume along the lines dictated by the cultural pursuit of modernity. I wonder if this presents a limitation or simply a purposeful focus for the structure of her research design?
  • A question that rises for me after having read this study is how the formal healthcare system shapes / impacts these cultural norms any of these socio-cultural structural determinants? If the school system (which arguably has a much more powerful shaping function) shapes and transmits norms, how could the healthcare system be present in schools, or more available in contexts where their prevention activities could be improved?
  • How does this research intersect with James Ferguson’s (and others) work on cash transfers? Would love to talk about this in the context of “Give a Man a Fish.”

Review of “Unprepared: Global Health in a Time of Emergency” (2017)

Andrew Lakoff’s “Unprepared: Global Health in a Time of Emergency” (2017) explores the assemblage of practices, knowledge forms, and politics that underlie the production of preparedness for the unquantifiable risk of catastrophic pandemic disease under the current global health security regime. It tells the story of how “the machinery of global health security was cobbled together over a two-decade period, beginning in the 1990s… it is a story of the assemblage of disparate elements—adapted from fields such as civil defense, emergency management, and international public health— by well-meaning experts and officials and of response failures that have typically led, in turn, to reforms that seek to strengthen or refocus the apparatus.” (p. 7).

Lakoff takes the approach of “historical ontology.” In the spirit of Ian Hacking and Michel Foucault, Lakoff seeks to unmask how “taken-for-granted objects of existence—whether the economy, the psyche, or the population—are brought into being through contingent and often-overlooked historical processes.” (p. 7). This approach enables him to observe “two [current] regimes for governing global health problems: global health security and humanitarian biomedicine.” (p. 10). For him, global health security focuses on the logic of protection of powerful nation-states, particularly maintaining the smooth flow of global capital and trade that disproportionately benefits wealthy capital holders. Humanitarian biomedicine, on the other hand, takes on the “need to save all lives, regardless of political boundaries, from treatable maladies such as malaria, tuberculosis, and HIV/AIDS.” (p. 10). The distinction and relationality between these two approaches to governing global health is a central theme of this book.

How did the notion of “preparedness”—the never-ending process and series of practices of developing skills, knowledge, plans, etc. to governmentally approach managing perceived threats—come in to existence? Lakoff links the techniques of preparedness to a response to the political demand posed by the contemporary category of “emergency.” (p. 15). Different from notions of “risk” (under which probabilities of different outcomes are thought to be relatively well-known and stable, thus capable of being calculated and sufficiently technically managed) preparedness hinges on a state of emergency under which “a catastrophic occurrence… may not be avoidable and so generates knowledge about its potential consequences through imaginative practices like simulation and scenario planning. Such practices make it possible to gauge vulnerabilities in the present, which can then be the target of anticipatory intervention.” (p. 19). A strategy of government, preparedness encompasses a series of practices and techniques that are meant to support the preservation of life in a future time of emergency and includes activities such as “early warning systems, scenario-based exercises, stock-piling of essential supplies, and the capacity for crisis communication.” (p. 19).

Practices of preparedness have their historical roots in the Cold War-era national security strategies of the United States. Lakoff writes, “Given these concerns about American susceptibility to a sudden and devastating attack, Cold War national security strategists sought to ensure that the nation could rapidly put into motion an efficient military production apparatus in the midst of a future emergency.” (p. 22). Although this as a national-level civic defense strategy, Lakoff makes the argument that the normative rationality underlying these scenario-planning and preparedness exercise techniques were eventually taken up as the basis for a more general approach to health and security threats, within the United States and globally. This shift, a part of Lakoff’s historical ontology approach, is distinguished from other past regimes of governmental sovereign power. He makes the distinction between sovereign state security, population security, and vital systems security: sovereign state security being the 17th century efforts of monarchs and rulers to deploy military force to combat opposing extra-territorial forces; population security as the nineteenth century modern state’s deployment of population-level statistics to distribute risk and promote particular forms of life; and finally, vital systems security targeting the distinctive type of threat of the event “whose probability cannot be calculated but whose consequences are potentially catastrophic.” (p. 38).

The practices of stockpiling vaccine serum in preparation for potential “Swine Flu” pandemic influenza is a case example explored in in-depth by Lakoff. Under the specter of the catastrophic 1918 influenza pandemic which killed more than half a million people in the United States, President Ford made the decision to stockpile and subsequently immunize the entirety of the population of the U.S. The strategy “defied actuaries”, as no policy like this had ever been deployed and the risk of serious side-effects of the immunization were not known. Despite these various setbacks, by December 1976, forty million people had been immunized. But, because of a handful of cases of serious Guillain-Barre syndrome and no evidence of an impending pandemic, the New York Times editorialized this as the “Swine Flu Fiasco.” Rather than leading governmental leaders to question the logics ongoing preparedness in the face of unknown risks, they chose to double down instead. Failure was attributed to “administrators’ lack of foresight. The Federal health officials did not have contingency plans in place and so reacted in an ad hoc manner as unexpected events occurred. Going forward, public health authorities coalesced around the changed notion of what type of knowledge ought to be ascendant in times of emergency: “rather than statistical calculation of risk based on historical patterns of disease incidence, the emphasis of experts [should] be on knowledge of system-vulnerabilities gathered through the imaginative enactment of singular events.” (p. 65).

These logics moved to the global sphere amidst the next global pandemic threat: the so-called H5N1 influenza virus, also dubbed “avian flu.” Specifically, this situation brought to the fore the geopolitical tensions inherent in sharing biological data about viral strains, accurate epidemiological data, and other forms of knowledge necessary to assess the risk of a deadly global pandemic. Specifically, Indonesia refused to share samples of influenza virus with the Global Influenza Surveillance Network (GISN) under the—rather reasonable—assumption that this knowledge sharing (and the potential pandemic prevention it could enable) would benefit them less than the wealthy countries of the world. This example is a case study of the challenges and tensions inherent in the modern regime of “global health security” which focuses “on ‘emerging infectious diseases,’ whether naturally occurring or manmade, which are seen to threaten wealthy countries and which typically (although not always) emanate from Asia, sub-Saharan Africa, or Latin America. [Global health security] develops techniques of preparedness for potential events whose likelihood is incalculable but that threaten catastrophic political, economic, and health consequences. Its advocates seek to create a real-time, global disease surveillance system that can provide early warning of potential outbreaks, and to link such early warning to systems of rapid response designed to protect against their spread to the rest of the world.” (p. 71).

The global health security regime of global health governance is set against the regime of global health humanitarian biomedicine, which is meant to alleviate the suffering of individuals, independent of national and social identity. “Whereas global health security develops prophylaxis against potential threats to the populations of wealthy countries, humanitarian biomedicine invests resources to mitigate present suffering in other parts of the world.” (p. 72). Perhaps exemplified by Medecins sans Frontieres (MSF) and the Bill and Melinda Gates Foundation (I actually don’t completely agree with this typification, and would like to think about this more) and artfully described by Peter Redfield as having a “secular commitment to the value of human life,” it is a logic that is practiced through medical intervention. Also subsumed under this banner are the primary health care movements who have strived for a “right to health for all,” which has primarily been driven by philanthropic organizations and development aid. Lakoff links the emergence of humanitarian biomedicine to the efforts and social movements that surrounded the emerging infectious disease of HIV/AIDS.

Alongside the humanitarian biomedical response to HIV/AIDS though, was the nagging fear of the specter of continued viral and other novel infectious-agent emergence. With the advent of new tools like the internet-based reporting systems (ProMED and the Global Public Health Intelligence Network) and the outbreak of severe acute respiratory syndrome (SARS) in 2002, there was a need to govern and control the rapid circulation of information about infectious disease outbreaks across national borders: a new form of global disease surveillance was needed.

Enter the International Health Regulations. “According to legal scholar David Fidler, the 2005 IHR revision was ‘one of the most radical and far-reaching changes in international law on public health since the beginning of international health co-operation in the mid-nineteenth century.’” (p. 84). For Lakoff, these revised regulations created a new legal framework of obligations and duties—as well as obligation to accept global intervention—in a world viewed to be “under threat from ominous Emergency.” (p. 85). Central to the changes was the technical assemblage of knowledge and practices that formed the new instrument called the public health emergency of international concern (PHEIC). “This technique of classification is a way of bringing a singular event—the outbreak—into a more general category, which in turn puts into motion a machinery of action steps that guide institutional actors and limit the scope of interpretation and debate.” (p. 87). This is, purely, a mode of global governance and relocated sovereignty. “As Fidler put it, ‘the strategy of global health security is essentially a defensive, reactive strategy,’ given its narrow emphasis on detection and response to outbreaks of emerging disease. ‘The new IHR are rules for global triage rather than global disease prevention.’” (p. 94).

All told, Lakoff’s historical ontological study of changing notions and regimes of governance for managing threats of existential proportion amount to typifying the forms that biopolitics take at the world-level. As techniques of governance have moved from the relatively small-scale territories of 17th century fiefdoms and monarchies, to the post-war modern welfare nation state, to the new post-modern landscape of decreasing state-level sovereignty and fragmented/decentralized reason and authority, how does governmental power sediment and crystalize into different forms, techniques, technologies, tools, policies, and procedures? I found this book quite useful to explore these concepts through the lens of assemblages: “a grouping of heterogeneous elements that have been brought together contingently to address what is, at least in principle, a common scientific and governmental problem” (p. 122).

My interests in the notion of Bourdieu’s (and other variants) field theory runs deep. A challenge, as I’ve learned and thought more a field theory, is its, at times, lack of “materiality.” I mean that sometimes it seems as if fields of practice are theorized as purely “social” in the sense that they are a “free market” of competition between different forms of field-specific capitals. I’m not sure Bourdieu well accounts for the types of power-sedimenting/crystalizing, field-distorting effects of things like material/technical assemblages developed and deployed by powerful actors attempting to govern in contingent and uncertain situations. So, some questions that emerge for me:

  • Assemblages are contingent and “sticky” techniques of government that bring together knowledge, tools, people, and procedures to manage emerging and uncertain situations. How do the conditions of their development linked to their functioning? For instance, while Lakoff does an amazing job describing the historically contingent nature of assemblages that mark our current regime of global health security governance, could fields be useful in thinking about the shaping forces of various assemblages?
  • Leadership: there is some creativity and agentic leadership involved in the creation of new governance assemblages. Could leadership (or McAdam/Fligstein’s ‘social skill’) be viewed as the field-positioned ability for an actor to assemble politically potent-assemblages?
  • Lastly, the typology of “two regimes of global health” seems overly simplistic and I’m not sure what it adds to the discussion. There seems to be more ways to view it: purely profit-driven market orientation to global health, a “developmentalist” orientation, citizen-driven popular politics, etc. Could a field-based perspective here lend nuance to his argument?

In Somatosphere: The De-socializing of Jim Kim?

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

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

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

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

Check out there rest, here!

CEO pay and global health politics

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

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

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

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

But, as Weathers well points out:

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

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

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

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

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

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

1) Introduction

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

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

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

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

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

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

2) Research Question

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

3) Data and Methods

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

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

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

4) Results

4.1 Global Properties of the Network

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

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

4.2 The Changing Network Over Time

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

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

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

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

4.3 Differential Eigen Centrality Trends

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

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

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

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

4.4 ERGM and the Analysis of Micro-Level Structure

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

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

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

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

5) Discussion

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

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

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

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

6) Conclusion

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

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

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

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

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The evolution of a citation network

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

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

1995-0011996-001

 

 

 

 

 

1997-0011998-001

 

 

 

 

 

1999-0012000-001

 

 

 

 

2001-001

2000-001

 

 

 

 

 

2003-001

2002-001

 

 

 

 

 

2005-001

2004-001

 

 

 

 

2007-001

2006-001

 

 

 

 

 

2008-0012009-001

 

 

 

 

2010-0012011-001

 

 

 

 

2012-0012013-001

 

 

 

 

 

2014-0012015-001

 

 

 

 

 

2016-001

 

 

 

 

 

 

A couple of interesting observations:

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

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

The evolving ideology of ‘sustainability’

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

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.”

Hospital investments needed in the MDG –> SDG transition

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CH188: Framework Convention on Global Health and its historical roots

This past Thursday, we had the third session for CH188: The Right to Health: Problems, Perspectives, and Progress and we focused on 1) readings that laid out the foundational texts that undergird the right to health (the Constitution of the WHO, Universal Declaration of Human Rights, Convention on the Rights of the Child, International Covenant on Economic, Social, and Cultural Rights, etc.), 2) we heard from guest lecturer Eric Friedman, JD who discussed the current work to more formally codify the right to health through the Framework Convention for Global Health (more here, too), and 3) we began a discussion about the ethical reasoning that underpins all of global health thinking and work and the notion of the right to health. It was a busy session and probably a bit too much to try to cover in a three hour seminar, but we powered through and I think it will provide, once again, a useful foundation as we begin to dive into some of the problems that delay our progress towards the right to health.

Eric Friedman skyped with CH188 and shared his view of the opportunity for renewed global governance for the right to health.

Eric Friedman skyped with CH188 and shared his view of the opportunity for renewed global governance for the right to health.

Linking to the last session’s discussion of the history of the global health project, we discussed the historically-rooted documents that to some extent define and provide the structure for arguments and action for the right to health. A couple things stand out to me upon re-reading these documents. First, it’s pretty clear from an international governance that a right to the “highest attainable standard of health” is to be protected across the board. The right to health exists. Second, its important to understand the the historical, cultural, and geopolitical context in which these documents were created. Finally, understanding that history, and the ethical roots of the documents could give us insights for ways to move forward collective work to enable their wider adoption and greater effectiveness.

The Right to Health in International Law

Summary of the right to health through the lens of the International Covenant on Economic, Social, and Cultural Rights. 1

What’s lacking is 1) accountability to these goals and mechanisms of holding individual states accountable for violations of protection for the right to health, 2) a commitment to progressive financing mechanisms to help poor countries move forwards progressive realization, and 3) the grassroots movement of people who acknowledge their right to health and who are organized enough to demand that right through their state actors and through broader international action.

I just finished reading Nitsan Chorev’s fantastic analysis of the World Health Organization2  and it’s strategic transformation during two distinct historical periods: the 1970s and 1980s, and the  1990’s and 2000’s. Her analysis, taken with Salmaan Keshavjee’s historical and ethnographic treatment of neoliberalism, construct a useful lens through which to see the changing power of human rights documents and language. Specifically, she looks at how the the WHO adapts strategically to exogenous pressures from states, private actors, and the changing geopolitical / and economic structures.

The 1970s-80s were largely shaped by the political power of the G77 — the block of the poorest countries in the world, many newly independent from their colonizers — and their ability to utilize the one-country, one-vote procedural process within the WHO to exert significant political power towards expansion of primary care and the push (led by Halfdan Mahler) of “health for all by the year 2000.” It was this balance of power within the WHO that allowed the primary care and health for all movements to gain traction and lead to the meeting at Alma Ata. It was during this period that many of the international human rights documents were drafted and when the right to health as an international legal principle gained the most ground.

But, the progressive political block of the G77 during the 1970s and 80s provoked a significant backlash from the wealthiest and most powerful countries in the world, whose action was shaped largely along the lines of the Cold War. As Keshavjee discussed, elite economists in the US and elsewhere were terrified about the potential for a re-emergence of totalitarianism and saw the expansion of Communism and Socialism throughout the G77 as a major threat to liberalism, liberty, and freedom. Hence, the rise of dogmatic neoliberal logic.

The political and financing environment of the 1990s and 00s for the WHO were very different. Understanding that the U.S. and the U.K. could apply other pressure than votes, they began withholding regularly scheduled dues and fees payments to the WHO. They gradually made more and more of the WHO budget focused on discretionary or dedicated budget line items, rather than general expenses. Additionally, the Gates Foundation and other large private philanthropies took a larger role in financing global health including funding the WHO. This precarious and narrow funding meant that the WHO was highly vulnerable to the pressures of states and organizations deeply entrenched in neoliberal logic. The WHO, which had lost stature due to the failure of malaria eradication efforts in the 1960s, had to adapt or grow increasingly marginalized in the global governance of health.

The WHO strategically adapted by transforming neoliberal logic to (to some extent) serve their purposes. Gro Harlem Brundtland, then Secretary-General of the WHO, sought to enlist economists in the effort to demonstrate how targeted, “cost effective” investments made in the health sector could be powerful drivers of economic growth for low and middle income countries. Cost effectiveness became a way of “rationalizing” spending on health services for the poor and created a technical framework by which the WHO could continue to serve as a powerful technical expert to countries around the world, thus staying relevant.

“The prominent role of the World Health Assembly, and therefore of member states, in the process of decision making has secured the dominance of geopolitical logic in the global health agenda. Especially in the first few decades of the WHO’s history, the Cold War division between East and West directly shaped international health priorities (Litsios 1997, Manela 2010). Following decolonization, the World Health Organization, along with the rest of the UN system, was greatly affected by the demands of the newly independent countries of the Global South for a New International Economic Order. In the mid-1980s, in turn, the NIEO logic was replaced with a U.S.-led neoliberal agenda, best expressed in what has become known as the “Washington Consensus” (Williamson 1990). For UN specialized agencies, including the WHO, each period was characterized by the emergence of a distinct global ideational regime and by exogenous pressures to follow that regime. An overview of the policies formulated by the WHO staff and leadership and adopted by the executive and the assembly illustrates, however, that these policies did not faithfully echo the call for a New International Order in the 1970s nor the neoliberal principles of the 1990s.”

  • Chorev, Nitsan (2012-05-01). The World Health Organization between North and South (p. 5). Cornell University Press. Kindle Edition.

The Framework Convention on Global Health (FCGH) is a modern attempt to once again move the balance of power towards the right to health. Eric Friedman gave a great presentation outlining the growing movement towards a convention, modeled after the Framework Convention on Tobacco Control.

See his slides here.

In hist view, the FCGH couple help address key gaps in financing, work to curb the power of non-health sectors, address problems with health worker migration and “brain drain”, and address health disparities within countries. It could accomplish this by leveraging the power of law (powerful norms, facilitation of collective action, and binding responsibilities to support local advocacy), taking advantage of a globalized world in which nation-states should not be sole unit of analysis, and learning from past experience (FCGTC).

There is much, much more to say on the topic of a Framework Convention for Global Health, but suffice it to say, there is stark opposition to such an idea. See the piece from the Health and Human Rights Journal on “the dark side of the FCGH.” I’m hoping to do another post soon diving in to the debate and potential future of global governance in global health.

Reading and Class Notes:

Grodin et al Chapter 2:
  • Direct human rights abuses continue: Abu-Ghraib, botched executions, torture, etc.
  • Subtle human rights abuses like lack of health systems, discrimination, etc
  • Brief history:
    • Nuremberg Trials — since then interest in health and human rights have grown.
    • Since HIV in the 1980s, health / human rights have had parallel but distinct tracks.
    • Jonathan Mann and the HIV treatment movement was the first global effort to link health and human rights explicitly.
    • Since the AIDS treatment movement, almost all development agencies and UN programs must acknowledge rights in their health work. Even some governments are building legislation / incorporating into their constitutions.
      • Yet, lots of work yet to do and many gaps to be filled.
    • WTHO constitution: one of the best sources of “the right to health.”
  • The idea of health as a human right as a subject is fairly new.
  • Advocacy and bearing witness:
    • Complacency of governments in their response to HIV: activists demanded and pushed for action. Result was dramatically reduced cost of HIV medications
    • A key dilemma: sustainable action, should it be connected to documentation and denouncements of human rights violations? How would that limit the ability to deliver the services that people need / jeopardize the safety of their workers?
  • Rights in Delivery of Care and Programming:
    • Examining laws and policies under which programs are being run
    • Systematically integrating core human rights principles such as participation
    • Focusing on key elements of the right to health.
  • Concerns for the future:
    • Government roles / responsibilities are increasingly being relegated to non-state actors (NGOs corporations, etc): accountability poorly defined inadequate monitoring.
    • Ways forward:
      • need to educate staff and engage them in conversations about right to health.
Lecture Notes:
–> Send class information on the TPP.
Consequentialist / Nonconsequentialist Logitcs + Ethics
  • Rightness / wrongness based on the consequences / outcomes of actions
    • Consequentialist: Utilitarianism is a function of this: action to take is to produce the greatest good for the greatest number. The end is more important than the means.
    • Nonconsequentialist: rightness / wrongness are due to the content of the actions. The means matter more than the ends. Actions can be right or wrong. Libertarianism, contractarianism: No policy that causes compensated harm is allowed.
  • FCGH: what are the values that are underlying this? What are the values and ethics?
    • What constraints will it place on non-state actors?
    • What effects will it have on the SDGs? 17 SDGs
  • Objective <–> Subjective
  • Radical Change <–> Status Quo
  1. http://www.who.int/hhr/Economic_social_cultural.pdf ↩
  2.  The World Health Organization Between North and South. Ithaca: Cornell University Press. (http://www.amazon.com/World-Health-Organization-between-North/dp/0801450659/ref=sr_1_1?ie=UTF8&qid=1454782336&sr=8-1&keywords=world+health+organization+between+north+and+south) ↩