Inequalities of Access to Medical Resources

Wealth inequalities are typically the first types of inequalities that come to mind when thinking about disparities in the world. In that context, is the world as a whole growing more or less equal? Even though this is not a simple question to answer, based on extensive research by many economists data suggests that inequalities within nations are increasing, whereas inequalities globally are decreasing, as many underdeveloped nations are suddenly producing a very large middle class. Does this mean that at some point in time all the world economies will intersect and result in total wealth equality among all nations? The answer: not really, as there are many variables that contribute to this equation, including population growth, migration, underestimation of top incomes and tax, gender equality issues, war and violence, and cultural barriers.

How does this wealth inequality relate to health equality? It has been common practice to use a nation’s GDP as an indicator of the health of that nation’s population. Until recently, it was assumed that those countries with a lower GDP had poorer health outcomes as measured by infant and maternal mortality rates, and that more affluent countries had better outcomes. It is a fact that a nation’s GDP relates to its health, but not in a positive way always. On the contrary, the economic inequality within a sample population has a bearing on many health outcomes in that population, with bad outcomes at both ends of the spectrum, as exemplified by infant and maternal mortality at one end and obesity, cardiovascular disease, and diabetes at the other end. Social habits that breed with increasing affordability affect the rich and the poor equally in their own way, as evidenced by increased rates of cancer, violence, drugs, and trafficking and their impact on the society. Inequality also causes social isolation among all ages, especially in the elderly, which in turn leads to depression and other mental illness and more morbidity and mortality.

Additionally, it is ironic to see that the economic value of health care is an oxymoron in that if a nation faces a pandemic and a lot of money is spent on medical care, the nation’s GDP will artificially rise; however, it is not a desirable situation, and it does not relate to the nation’s health in a positive way. Because GDP takes into account all work regardless of its impact on the net financial change, it is misleading to rely on that metric to evaluate the status of a nation’s health. On the other hand, other measures like standard of living, discretionary income, human utility, mental status, and general happiness present in the population are a better indicator of a population’s state of wellbeing.

As depicted in Julie Livingston’s Improvising Medicine, there is a clear difference in the care given to cancer patients in Botswana when compared to similar patients in the U.S. This discrepancy not only stems from the socio-economic conditions in Botswana but also from lack of education, awareness, and cultural beliefs inherent in that area. The attitude of the caregivers towards their patients is also less than optimal, be it because of frustration or helplessness. This also ultimately affects the health outcomes of patients. I have had firsthand experience addressing malaria in Cambodia. The global statistic that 1 child dies every minute from malaria is astounding, especially because malaria is a preventable disease. Lack of awareness of the resources available to treat and prevent the disease, combined with gender discrimination, leads to further spread of the infection. Besides not being able to afford treatments, many in these endemic areas believe that some homemade concoctions can cure malaria, a cultural belief that leads to inequality of use of medical resources. If a family believes in the power of modern medicine but has limited financial resources, a sick male in the family receives treatment over a sick female. Gender-based discrimination results in inequality of medical resources, a practice that is not easy to uproot from societies.

In conclusion, it is important to recognize that there are many inequalities in medical resources, based on not only wealth, but on the type of insurance a patient carries, the society and cultural environment one lives in, and ultimately, one’s own willingness to either accept or reject the available resources. So one formula and rule does not fit everyone and the approach should be tailor-made based on each situation.

Discussion Questions:

  1. In order to inculcate healthy habits and create wellness, it is oftentimes necessary to eliminate cultural bias. How important is it for the respective governments to get involved in the process? If there is resistance from the government, how should volunteers and health workers enter communities and impart education?

 

  1. Gender bias has been a universal problem for centuries, and even in the United States, there remains some discrimination against women. Granted, the degree of discrimination is different, but the fact that it exists is true. That said, do we as a nation have a right to expect and enforce changes in other countries? Are we the gold standard that other nations need to follow against their will?

Works Cited:

Holloway, Kris, and John Bidwell. Monique and the Mango Rains: Two Years with a Midwife in Mali. Long Grove, IL: Waveland, 2007. Print.
Livingston, Julie. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham: Duke UP, 2012. Print.
“Malaria: Burden of Disease.” National Center for Biotechnology Information. U.S. National Library of Medicine, n.d. Web. 25 Sept. 2015.
“Report by UN and Gates Foundation Presents Vision for Eradicating Malaria by 2040.” UN News Center. N.p., 28 Sept. 2015. Web.
“Women’s Discrimination in Developing Countries: A New Data Set for Better Policies.” Women’s Discrimination in Developing Countries: A New Data Set for Better Policies. N.p., n.d. Web. 24 Sept. 2015.

20 thoughts on “Inequalities of Access to Medical Resources”

  1. Hey Shreya,

    I think you made some really great points in your post, especially about how a country’s GDP really doesn’t tell the whole story when it comes to how the wealth is distributed and how that money is spent on health care.

    In response to your first discussion question, it of course depends on each country’s situation, but I think that in general, each country’s government should be responsible for making sure that funds are allocated effectively to allow for the good health of its citizens. Governments have the power to implement certain interventions to discourage the cultural bias that you mentioned (e.g., homemade medicine for malaria, bias against the use of contraception to avoid unwanted pregnancies and STD transmission) and to raise awareness and educate citizens on the prevention of disease. Some governments may be willing to allow health workers from NGOs and volunteer organizations to come in and implement such programs, but I wonder how effective such measures would be in the long run. If the organizations worked to integrate some of the citizens and leaders of the country into their interventions, then perhaps the results would be long-lasting and effective, but otherwise, I don’t see health workers/volunteers as the ultimate solution for changing the cultural bias. I think the change needs to come from within the country — bottom-up starting from the citizens and community leaders or top-down starting from the national government.

    I don’t think the US should try to enforce changes in gender inequality in other countries. Even we as a nation haven’t really reached a “gold standard” in gender equality, as you mentioned, although there are many developing countries with much more paternalistic cultural values than our country. In order to try to encourage more gender equality in such countries, I think it is important for women to empower each other within each country. To get the ball rolling, volunteer groups may need to provide education and skills training so that women can hold positions of power in the local governments, the use of contraceptives (e.g., birth control pills and condoms) are accepted and not something to hide or be ashamed of, and women can continue education past primary school just as men do, for instance. Established gender roles in and outside of the home should be challenged, women should have control over their own bodies (e.g., when they want to get pregnant and have more children), and women should be empowered so that they know they are entitled to the same opportunities as men and thus will stand up for themselves. Of course, that is just the ideal situation of women empowerment, and such gender equality initiatives often fail, since men are usually the ones in power, and men are not willing to simply let go the power they have had for so long. I’m interested to see what other people’s ideas are about how to eliminate the discrimination against women, especially in low-income countries.

    1. Hi Shreya,

      I thought your second question was really interesting and while I don’t think the US should try to enforce gender inequality in other countries, it did make me think of the issue of FGM which is the subject of global controversy. While I certainly do not support the practice of FGM at all, I think Western efforts to ban it in other countries (West African countries for example) are an example of the US trying to export a gold standard of gender equality without properly understanding the complex ways in which FGM is part of certain cultures. Much of the Western discourse surrounding this issue presents countries that practice FGM as barbaric savages. I think that demonizing the practices of other cultures is not conducive to promoting gender equality and while this is certainly a complex issue, I think a more appropriate response from the US must involve a deeper understanding of the practice in order to better inform a less paternalistic response.

    2. Hello Yuki,

      Thank you for your comment. I do believe that engaging a nation’s government is an excellent way of making sure that efforts being taken are actually going to be effective because having government buy-in means that there are people on the receiving end willing to understand the goals of a program or project and implement the methods necessary to accomplish steps that contribute to the cause. As emphasized in the Partners in Health model, establish good relationships with a government can lead to better results than an intervention that was not supported by the government. Harnessing the power of a country’s citizens is a good idea that has proven effective in the past and could certainly work well in a variety of areas. I think that your solution of working with citizens relates well to your second answer, as empowerment of a larger proportion of the nation’s citizens, not just specific groups, will serve as a platform for healthcare improvement on a broader scale.

  2. Hi Shreya,
    I found your blog to be very informative and interesting. I like how you incorporated more statistical references, including that of the relevance of nation’s GDP.
    In response to your first discussion question, I think it is very important for respective governments to become involved in the overall health and wellness of their country. It goes without saying that politicians and governments have a lot of say, and essentially creates policies regarding the overall health and welfare of their nation’s citizens. Thus, it is essential for them to prioritize their health care systems and inculcate healthy habits.
    In my opinion, if there is resistance from governments to become involved, I think it is necessary for volunteers and health workers to have their voices be heard. If a government is resisting such changes, I think it is important for volunteers and supporting people to create campaigns, project potential new policies, etc. In my opinion, for a system to change for the better, it is mostly important for the people of that society to become involved in such matters. If people of that nation or society do not care to change those systems, why should other countries care?
    To answer your second question, I don’t think that we as a nation have the status and right to expect and enforce changes in other countries. I would not call the US the “gold standard” for other countries to follow. Every country is unique in its own way, and has its own culture and history. I do not believe on any level that citizens of the US have a right to tell other countries how to go about their systems. Like you said, the US still has gender biases. So why would we be considered the “golden standard?” While our country is advanced and developed more so than other countries, I believe that we have no right in telling them how to do their job and control their own policies.

  3. Hi Shreya,

    I appreciate that you acknowledged multiple facets of inequality that is prevalent worldwide (gender, tax, war & violence. etc), and explored deeper within the realm of wealth and GDP itself. I find it true that many people assume a high GDP correlates with better health, but they fail to recognize the much more complex system that you mentioned. Your personal experience shows that culture and gender play a huge part in treating illnesses, and presents an additional layer to think about when addressing inequalities in medicine.

    I feel as though the role of government and how much of an influence they have on the well being of their country greatly differs based on the relationship the people have with their government. Even if a government tries to implement regulations and programs, if it does not have a significant relationship with its people, change is unlikely to happen. This said, I do believe governments should be as highly involved as they can with alleviating the inequalities of health in their counties because they have the power to make lasting changes and may have the most influence. I believe volunteers and health workers can bring significant awareness to many issues of inequality, but this depends on where these volunteers are coming from and what goals they have in mind. If they are coming from countries such as the U.S., this pulls in your second question of where the standard should be and who is setting those standards. Like the people who commented above, I do not believe by any means that the U.S. is the “gold standard” of gender equality, and thus, it would be wrong to force our own views on other people. I think it is most important for those who want to help to truly take the time to understand the situation others are in and work together to formulate new policies and changes.

  4. Hi Shreya,

    I think your questions relating to the transfer of cultural and gender biases from one country to another plays an integral role in the success of healthcare projects and in the field of anthropology in general. While volunteers and healthcare workers bring their own values and biases where ever they work, it is important to gain an understanding of the cultural norms of the region a global healthcare project is stationed in and to have a neutral mission. Like we’ve discussed in class and section, there isn’t a singular “right” cultural model and views which is what makes our planet so diverse. I took an anthropology course called War and Society freshman year that stressed the conflict between the complex cultural dynamics within a community engaged in combat and the foreign soldiers stationed there. Understanding the different meanings behind hand gestures between cultures could mean life or death in these situations, which gets into the ethical debate of using anthropology in war but this issue can also be applied to global healthcare projects. Margaret Lock’s research which we discussed in class showed an even deeper importance for culture in that Japanese women’s menopausal symptoms were shaped by cultural contexts. If western doctors were to ask Japanese women questions about the western conception of menopause and its symptoms, they wouldn’t get an accurate number of women going through menopause or how different this experience is for them.

  5. Hi Shreya,

    The thought that went into your synthesis of this argument clearly shows. Like those who commented before me, I, too, appreciated your framing of GDP within the context of population health, especially your recognition of the spectrum of health that exists within those countries with supposedly high GDP’s per capita.

    In response to your first discussion question, I personally feel that it is the responsibility of government to be involved in the process of promoting healthy habits and creating various forms of wellness for all people (indiscriminate of any class or other identity that they may hold). Still, as we have discussed in class, imposing this model for all nations can prove problematic. Given various political dynamics, governments may have varying levels of influence with regard to changing cultural attitudes toward certain remedies, medical practices, and diseases. Furthermore, we cannot have a valid discussion of what a particular government should do without discussing how that government operates; not all political bodies share the view that population wellness is a government responsibility, and some even assert that considerations for health and wellness should be made only at the individual, doctor-to-patient level. Furthermore, I think outside volunteers and health workers entering communities to impart education often fall short; in many cases, it is difficult to task a group of typically Western-educated individuals to remove the cultural biases of a group without first being made self-aware of their culturally insensitivity.

    This segues into my thoughts about your second discussion question. Again, a moral compass would dictate that the US has an ethical obligation (I hesitate to use the word “right”) to spread its core values of equality and equity for all. Still, going forth and enforcing this is tricky for the same reasons why public health workers cannot at times effectively impart education. Furthermore, being that women’s access to health is treated more like a hot-button issue in this country instead of a natural right that all women have, I think the US as a nation lacks the necessary ethos to dictate what qualifies as complete gender equality (we are by no means a gold standard to be followed). I believe that gender inequality in health is part of a larger problem of the subjugation of women in vehemently paternalistic societies, and the first step to challenging such systems is empowering women and giving them the agency to demand their equal rights.

  6. Hi Shreya,
    I find your blog’s conclusion insightful and valid; I agree that there is no one formula or rule to delivering healthcare. Rather, medical care should attempt to take into account people’s individual experiences. I can, however, see why this might be an idealistic view for global health projects who are trying to help large populations.

    In regards to your first question, I believe that government intervention is crucial to cultivating health in a country. Governments should be held responsible for distributing funds towards healthcare so that their citizens have proper access to care. In addition, a country’s government should play a large role in not only diminishing cultural bias, but also in distributing/encouraging modern, tested medications. There is no reason that governments should not have access to modern information/news, and as such, it is a large deficit on their side if their citizens are lacking this information. But if there is resistance from the government, I, like Yuki, think that outside volunteers and health workers should seek to form partnerships with in-country health workers before attempting to implement education and clinical programs. This might make dispersion of information more approachable, trustworthy, and effective; however, it would be difficult for volunteers to alter ‘cultural bias’ because it, as its name suggests, is rooted in culture. However, I’d also like to point out that, in my opinion, cultural bias plays a much smaller role in health inequalities than do socioeconomic status and uneven distribution of resources. In this sense, I prioritize making medicines/resources accessible over eliminating home-remedies.

    Your second question, like the first, brings about complex issues. I agree with the fact that women in the United States, while not yet equal to men, do not experience the same degree of discrimination than do women in other countries. I’d like to expand on this idea by referring to our class discussion on the idea of “romanticizing” natural childbirth. In the United States, choosing to have a natural childbirth is a way women can feel as though they are taking control of and embracing their own bodies. In other countries (like Mali), women do not have the privilege of making this choice; rather, they have no other options and, as a result, are very much at risk of complications during deliveries. I do not bring up this example to downplay the discrimination that American women face but rather to illustrate your point of varying degrees of discrimination. I also bring up this point in order to argue that the United States and other leading countries – whether in the form of volunteers, advocates, or government (though the latter perhaps may be less likely due to political interests) – to some extent have a moral obligation to spearhead change for those who are less privileged. We may not be a golden standard, and we do not have the right to enforce changes in other countries. And, granted, we cannot expect nations to follow us against their will; social changes come from within a country. However, I think it is just as important to seek to become a better example, to voice concern, and to advocate for change rather than to step back because it is not in our jurisdiction to impose amends.

    I’d also like to comment on another element of your blog. You have made a critical point that GDP and economic health are not good methods of measuring healthcare/health. I agree that world economies will most likely not intersect and result in total wealth equality among nations. Even more importantly, equal wealth among nations would definitely not guarantee wealth equality among peoples. In fact, the latter would most likely worsen. I also concur that GDP does not always have a positive correlation with health outcomes; this is evident from the fact that the US still has high levels of infant mortality, iatrogenic diseases, and cardiovascular diseases despite spending so much on healthcare. However, I do not know if it is fair to say that “social habits that breed with increasing affordability affect the rich and the poor equally in their own way…” Yes, it is true that cancer, violence, trafficking, and drugs can find their way into any populations, regardless of their wealth. But, as evidenced by the literature we have read (Infections and Inequalities to name a main one), populations who live in poverty are considerably more vulnerable to developing these “social habits that affect health” because of their surroundings. Furthermore, let’s say that a low-income individual and a wealthy individual have equal chances of developing lung cancer. Who is more likely to be able to afford or seek out treatment? Even if they are equally as likely to succumb to the disease, I think it is problematic to compare their outcomes as though they share equal ability to address that risk. Similarly, I think it is problematic to suggest that poor populations and rich populations both face equal risks of experiencing health problems. For example, we learned in class that chronic diseases, such as obesity, are high in wealthy countries; in poor countries, however, there are high levels of both chronic and infectious diseases.

    I am also curious about problems that might potentially arise from measuring a population’s wellbeing through use of standard of living, mental status, and general happiness. In particular, the Black-White Depression Paradox comes to mind. We know for a fact that black Americans are exposed to higher rates of stressors (i.e. instability, poverty, violence, etc.). However, on average, they have lower rates of depression than white Americans. While this may in part be due to underreporting and other stigmas, it is probably also in part to resilience and self-recognition. In this phenomenon, it is evident that general happiness and mental status are difficult to measure – and even when measured, they may not indicate the actual state of a population. I was wondering what your opinion on this is; how do you think we can use the dimensions you suggested as measurements for wellbeing?

    1. Nini,

      Thank you for your comment. You bring up a very good point about the metric of overall wellbeing. I think that it is incredibly difficult to come up with a universal measurement for wellbeing. I think that it is possible to weigh different factors differently to create a composite measure of wellbeing that works to standardize or Normalize the effects of a given factor. Rather than simply measuring difficult-to-measure data, I think that by combining information that we know about a variety of aspects a community can provide a better idea of the big picture of the population we are studying.

      In class we mentioned the problems associated with a system of DALYs and I believe that we face a similar one in understanding a population’s wellbeing. Although I do not have a clear answer as to what dimensions to use and how to factor them into a calculation of wellbeing, it is a thought-provoking question that I hope to be able to explore in further studies of Anthropology.

  7. Hi Shreya,

    I loved your blog post and found it really interesting as well as very helpful to understand health inequalities better. I entirely agree with you when you say that GDP does not reflect a country’s health outcome because it only shows one side of the story. Using your own experience made it a lot easier to understand your point of view and illustrates how inequalities within and between countries can have a major impact on a population’s health.

    Regarding you first question, I think that in order to eliminate culture bias, it is essential for the respective governments to be involved in the change. Although health organizations could set up health interventions, there might be resistance to them by the population because it can be difficult for them to trust foreigners trying to impose new treatments and eliminating some of their traditions considered “unsanitary” by western countries. Imposing new treatments and the distrust of the population would lead to an increase in homemade remedies and in the spread of disease as well as health inequalities. I think that governments are the only ones who have the power in their respective countries to implement new health interventions that can be 100% efficient. If the government is behind those interventions by advertising it as a national movement to decrease health inequalities and by allocating funds more equally, the intervention is bound to work. However, there are always some exceptions, if the population does not trust the government or if there is resistance from the government, which sometimes, can make health inequalities more pronounced. In this case, I think that it is important for the volunteers to try to understand the culture of the population and try to educate and integrate the new health interventions in a collaborative way instead of imposing them.

    Concerning gender bias, even developed countries like the US still have some bias present in the workplace and, like many said previously, shows that we should not impose our values to others. I think that only the population itself can achieve this. However, even if we are not the “Golden standard” of gender equality, I think that we should still try to educate people about the importance of gender equality and the impact it will have on the health of its population. We should try to empower women by showing all the incredible things they can do and by trying to give them the tools to get higher roles or positions and a drive to achieve equality in their own society.

  8. Hi Shreya!

    I found your blog post to be thought provoking and generally very informative. I never thought about how high GDP doesn’t necessarily correlate with better health outcomes (I’m not an economics person), though it does makes sense. The US spends an exceptionally high amount of money on health, and we still have high rates of infant mortality, suicide, cancer, heart disease, and many other health problems.

    In response to your first question, I do think it’s important for respective governments to get involved in the health and well-being of their country. The government, I would say more often than not, knows more about the culture of their own country than an outside or neighboring country would. That being said, volunteers and health works from more developed countries often enter less developed countries to try to create change. However, this isn’t always helpful because they are an outsider to the local culture. This reminds me about the passage in “Monique and the Mongo Rains” that discussed diarrhea. Monique had to explain to the women how giving their children water is actually good because it keeps them hydrated. As a local, she knew that the women would stop giving their children water because they saw that it stopped their diarrhea. Kris Holloway, the Peace Corps worker with Monique, didn’t know that this was why the women weren’t giving their children water. Because of this, I think it’s also important for the government to support their own citizens in education endeavors to help with the healthcare industry.

    I think we all understand that the US is not a perfect place to live, and is therefore not the gold standard. However, we have made many medical advances that cause other nations to look to us for knowledge and guidance. I think the US has the ability to create worldwide movements that cause change when it comes to gender bias and inequality. The US can’t expect other countries to enforce changes if it hasn’t made those same changes. A worldwide movement could create the expectation of gender equality in health care in the US and abroad, but what would this equality look like? Every culture is different. Yes, there should be a right to fair treatment of all individuals, but would equality in the US for a woman look the same as equality for a woman in Botswana? Probably not. So, is this idea of gender equality something that’s globally the same, or does gender equality mean something different to each culture in the world?

  9. Hi Shreya! I really enjoyed your post and have a lot of thoughts moving through my head. I think through these comments we’ve found some overlap, which might suggest a small consensus of how governments should promote wellness and fair treatment at home and abroad.

    To answer your first question, it’s definitely complicated… does a nation’s government have the most responsibility and the greatest ability to address cultural bias? I think most would say yes. But if a nation’s government is repressive, or not representative of the people’s desires, then who can claim responsibility? Outside government interference I think should be limited to actions that aim to put pressure on the government that is unfavorable by its own people. Sanctions, embargos or trade restrictions, cutting the flow of money to that government are all options that can have a great impact (an obvious example of this is apartheid in South Africa). The problem is that cutting resources to a government might mean the further deprivation of nation’s people, and if the that government is able to receive enough capital from another country or resource, then these kinds of restrictions might not be effective. The world community can also exclude certain countries from world events as well such as the Olympics and world cup, and these actions can have some influence. It is difficult to define what an outside country’s involvement should look like in another countries’ welfare because it really needs to be evaluated on a case by case basis, but any actions should be evaluated and discussed amongst other nations and international bodies.
    In terms of your second question, I agree with many of the commenters on this post that we are certainly not the gold standard for gender equality. Despite that the discrimination of women in the US is perhaps lower than in other places, we are at complete odds in this country about what constitutes a woman’s right to health care. As a student a Brown who is most often surrounded by liberal friends and classmates, I think I can at times (briefly) forget what America is really like – it’s pretty conservative compared with other western nations. Though my point is not to equate conservatism with gender discrimination, its that we, firstly, don’t have any standing as a gender equal nation to be offering or imposing equality measures on another country, and, secondly, its not our “right” anyway. I do think that IF we are a nation of people who care about others, that there are things we can do to encourage equality around the world by assisting governments to empower their citizens with the resources they need (education, health care) to live their lives. When people are gravely concerned with feeding their families and fulfilling the basic requirements of life, then they may not necessarily have the time or energy to consider combating discrimination. But if these burdens can be lightened, then people have more opportunity to organize and build social movements to address their treatment in society. Though we might be tempted to interfere more directly, I think that this is the better approach that compromises the want to help with the potential to disrupt.

  10. Thank you, Shreya, for an insightful post. I also enjoyed reading everyone’s thoughts on your questions about the role of government in promoting health and the problem of gender bias.

    As many have discussed already, a nation’s GDP is a poor indicator of the health of that nation’s population. GDP is generally measured in two ways: you can either add up what everyone earned in a year or add up what everyone spent. But what can income and/or expenditures tell us about health outcomes? As many of us are aware, the U.S. spends more money on our health care system than any other country in the world, yet it consistently fails to achieve better health outcomes than other countries. So if we can’t measure wellbeing with a country’s GDP, as Nini wrote, then what measures should we use? Should we rely on self-reported overall health or will this measure also be tainted by a fair amount of participant bias and confounding?

    To address your question about obtaining government involvement, some would argue that the U.S. has the government structures in place to get involved with the population’s health. I would like to push back on this point and ask: does it really? In reality, the CDC, a federal agency, can only recommend immunization schedules for infants, children, teens, and adults. It traditionally acts in an advisory role because it relies on the population’s compliance to promote health. As Sachit mentioned, governments may need to get involved, but we also need to consider who holds the power and who can implement the necessary changes to promote overall health. In thinking about the CDC again, the CDC relies on state public schools to require children to be vaccinated against certain vaccine-preventable diseases. Thus, how do we find the structures that actually hold power and can exert change in other countries? Can foreign volunteers and community health workers identify these powerful structures to work alongside the people and encourage them to advocate for their own wellbeing? Lastly, how can these “outside forces” implement culturally relevant and sensitive interventions to address gender-based discrimination when we don’t know what gender equality looks like in an international context, as Katherine posed?

    http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror
    http://time.com/3516827/cdc-constitution-quarantine/
    http://www.sciencedirect.com/science/article/pii/S1047279706002584

  11. Hi Shreya,

    Thanks so much for your post! Your questions are really great, and sparked many thoughts for me–particularly in relation to human rights and FGM. You asked how volunteers and health workers should act with communities where governments are resistant, and you asked whether we [the US] are the gold standard that other nations need to follow against their will? I think these questions are really relevant in the discussion of FGM. FGM is still largely practiced around the world today.

    In a class I took while I was at Emory, we learned a lot about FGM and read many articles and watched many documentaries on the topic. In the film, “Moolaade,” Collé—like many other women—suffers greatly from FGM, and vows that any daughter of hers will not be circumcised. Collé endures pain and discomfort during intercourse. She also suffers several miscarriages that directly result from circumcision. In the film, other side effects include infections, and even death, from the mutilation practice. While Moolaadé depicts some horrors surrounding the practice, it also shows how the tradition has been embedded into many societies in Burkina Faso, and how it may be unrealistic to attempt to wipe it out. Some women want to be circumcised, for it is a rite of passage for girls. Some people assert that it is practical for a girl to be circumcised; many men would not consider marrying a bilakoro (unpurified female), and in many patriarchal societies, women need to marry in order to satisfy basic living needs–and being uncircumcised could lead to economic inequalities, which could then translate into further health inequalities. In Thomas’ Politics of the Womb, she demonstrates that even when men enforced bans against circumcision in Kenya, groups of Ngaitana (girls who ‘circumcised themselves’) formed because they felt the practice was essential in their transformation into womanhood and wifehood. Thus, in some parts of the world the practice is so embedded in culture that some women feel the health risks do not outweigh the tradition, pride, and even economic security (which can also lead to health security) they feel are involved in the practice of FGM.

    FGM can be an extremely unsafe practice, but is it a Westerners role to stop this practice from occurring in parts of the world? Can we advocate for safer circumcision practices (there are four different types, and some are more invasive and dangerous than the others), or is that completely unjustifiable? Is it a human rights abuse if many women desperately want to be circumcised? This is a largely controversial topic–and I have no answers to these questions, but I think that the topic is really relevant in terms of the questions you brought up regarding inequalities in health. It’s hard to determine how to combat some inequalities that are so culturally ingrained in societies…

    Thanks again for your post!

    -Rebecca

    1. Hello Rebecca,

      Thank you for providing such a detailed response. It is interesting how you brought up an additional link between economics and healthcare, the economic security that sometimes comes with a woman agreeing to accept FGM. As Westerners, I do not believe it is our role to stop the practice and thereby deny women the right to potential long-term benefits of complying with the traditional, albeit dangerous, practice. Cultural barriers are a very large part of what makes it difficult to fully understand how to approach a healthcare project without imposing views on those that are being helped. Your idea of providing information about the risks of certain methods of circumcision over others and then allowing women to make their own decisions about their bodies is an interesting one that I think applies to other cultural practices. Perhaps although we should not try to force people to change their beliefs in the name of health we can work towards clearing up certain misconceptions and affording people the ability to make more informed choices about their actions.

  12. Hi Shreya,

    I appreciated your macroeconomic analysis of global health disparities. You made a lot of enlightening observations about the relationship between health and GDP.

    Like most others who have commented, I think it’s clear that the United States is extremely far from the gold standard of gender equality. To take one small example, in a study conducted by the Organization for Economic Cooperation and Development (OECD), the US ranks last in a study of 38 nations in the amount of protected maternity leave required in the workforce (12 weeks in the US), and offers no guaranteed paid maternity leave unlike the 37 other countries studied. To compare, the highest ranked nation, Estonia, offers 108 weeks of guaranteed paid leave and 180 weeks of protected leave.

    I think the US as a nation absolutely cannot serve as a model for other nations. However, the question you brought up about the dilemma of when foreigners are providing humanitarian work turns into them imposing their own beliefs on a society is an important question to think about. I think often in cases involving FGM, the only correct response is to listen to the wants and concerns of the women affected (or who could be affected), and educate communities in an unbiased manner all of the health risks involved. Women in these areas should be able to make their own decision about their bodies, whether it is one that follows their religion’s mainstream cultural norms or not. While humanitarian workers cannot “expect and enforce” change in other countries, they can serve as a supportive resource for those looking to make change in their own communities or get help in some way, in an effort to fight gender inequality without further disempowering the women they are trying to help.

    Maternity Leave Article: http://www.pewresearch.org/fact-tank/2013/12/12/among-38-nations-u-s-is-the-holdout-when-it-comes-to-offering-paid-parental-leave/

  13. Hi Shreya, thanks for your post! Given what we’ve learned in class about the way GDP is often conflated with health, it was interesting to hear more about what this means in terms of health inequalities. I was particularly impressed by the example you brought up about pandemics and GDP – this is not something I would have ever thought of or considered until you presented it in this context.

    In response to your questions, I agree with some of the readings we’ve done for class that point to the limitations of NGOs, and discuss the strengths of the government in dealing with certain problems. Only governments can confer health as a right, and are often more effective at scaling up and developing nation-wide infrastructure. They also have more incentive to be sustainable as well, and more likely to remember and consider longer-term repercussions. I recognize though that if there is resistance it can be problematic, and really don’t know what we should think about supporting corrupt governments… I feel pretty conflicted too about the second question you brought up as well. It’s one that I’ve thought about for basically years at this point, and just still have no answer… Egregious human rights abuses should be stopped, we certainly aren’t a gold standard, but there will always be borderline cases that are complicated…

    1. I just wanted to add that I wish I felt I could provide more of a response, but even after this class I don’t think I can. What I do know now, though, is that there are so many pretty clear and straightforwards cases where we can and should be helping right now, that perhaps we can put off some of these questions for a little while. What I’m trying to say, I guess, is that we shouldn’t let such questions stop us from trying to help, but should rather inform the way that we do help – much like Merton’s theory of unintended consequences.

      1. Hello Allison,

        Thank you for your comment. I appreciated how you saw the questions that I brought up not as reasons to delay or decide against an intervention, but rather as additional considerations for how we should approach the process of implementing interventions. The process of effecting the types of healthcare changes we wish to see is a complex one, and I think that if we get too caught up in all of the external questions that might reduce the effectiveness of a measure that we are trying to enforce, we will likely not take any actions at all. This is an important ethical dilemma that we touched on in class, and if we are to decide against a particular plan because of potential setbacks, then we may end up hurting a population even more than if we had simply decided to take our original approach in the first place.

  14. Hi Shreya,

    I really enjoyed reading your blog post- it was very well thought out! With regards to your observation about an increasing GDP widening health inequities, I can’t help but think about our reading of “Dying For Growth.” Kim, Millen, Irwin, and Gershman argue that neoliberalist policies and economic growth can inflict structural violence and further disadvantage the poor. We can see the downside of neoliberalism in historic events such as the Washington consensus.

    With regards to your first question, governments should be the foremost leader in creating change. As we discussed in class, the difference between a successful health initiative and an unsuccessful one can be the degree of governmental participation. This can be seen in the example of Rwanda (Cancedda), where positive relations between governments and NGOs were established.

    In response to your second question, I am hesitant to say if nations should “enforce” their own views on other nation states. I can’t help but think back to the murky origins of global health. Global health was rooted in colonialism, with imperialist countries enforcing their views on other populations. Enforcing western ideals can result in paternalism and the propagation of the “white saviour complex.” Furthermore, in no way is America the gold standard for gender equality, as seen by the statistics Alana provided in the post above. We are in no place to advice other countries. Therefore, rather than enforcing our views on other countries, we should work in collaboration with them to improve access to health care.

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