Exceptional Treatment of Global Health Workers

The outcomes of Partners in Health’s (PIH’s) previous interventions imply that partnerships with community health leaders play a critical role in the success of global health programs. While these leaders are invaluable, their lives are not treated as such, especially when compared to the lives of foreign aid workers. This discrepancy indicates a rooted hierarchical structure in foreign aid groups – even in ones like PIH that recognize the necessity of collaborating with individuals who belong to the communities that are receiving aid.

PIH’s health care delivery model factors in the requisite of fostering and relying on community partnerships. This component has proven to be a critical contributor to PIH’s global health programs, which focus on combining horizontal and vertical care by integrating aggressive infectious disease treatment and structural reformation. (1) For example, PIH’s ‘Proje Veye Sante’ largely relied on “accompagnateurs,” or paid community health workers, to “interface between the clinic and the community.” (2, 3) As shown by the project’s outcomes, the success of health interventions is contingent on decreasing structural barriers through various services (e.g. provision of food, transportation, etc.) and, accordingly, on the participation of community health leaders who conduct these services. (4)

In a sense, the community members’ roles in PIH’s efforts illustrate their resilience and leadership in the face of inequality and structural violence. Rather than the community depending exclusively on an NGO to work for them, the NGO instead relies on the community in order to make a sustainable impact. This interdependent relationship also draws attention to PIH necessarily collaborating with community members to augment its biosocial view and to better understand how to meet local needs. This is seen in the story of Haitian Catholic priest and psychologist Père Eddy, who has served as director of Zanmi Lasante’s (as PIH is known in Haiti) mental health program since 2005. (5) Zanmi Lasante’s HIV and tuberculosis program recruited Père Eddy, a past counselor for sexually abused teenagers and for victims of post-traumatic stress after 2004’s coup d’etat, in order to provide better assistance to patients who were dealing with depression, psychosis, social isolation, and stigma. (6) There, he “trained social workers how to meet their patients’ psychological needs.” (7) He understood so well his community/community-based work that his methods “were later used by PIH community health workers in settlements for displaced people and were adopted by the Haitian government to help mourners nationwide.” (8) Overall, Père Eddy’s background not only as a psychologist and pastor, but also as a Haitian citizen who has experienced social inequalities and violence first-hand, provides him with a more appropriate skill-set for delivering care to the population of interest and for educating PIH volunteers.

While local health workers ostensibly play just as valuable a role in PIH’s outcomes as PIH volunteers (professionals, logisticians, etc.) do, their lives are less valued than their foreign partners’. When an American PIH volunteer in Sierra Leone contracted Ebola, he was quickly transferred to the United States for treatment. (9) The same level of care was not provided for native community health leaders: Usman Mohamed Koroma, “a ministry employee who helped oversee infection prevention and control at the site,” contracted Ebola the same week but had to wait two days before being moved to Sierra Leone’s “British-run treatment unit set up for sick health workers.” (10) Thus, despite being colleagues both essential for PIH’s work, “one [received] arguably the best Ebola care in the world [while] the other [received] the best Ebola care available in one of the poorest countries in the world.” (11)

Why, in an organization like PIH that identifies the importance of community health advocates, is there preferential health treatment for foreigners? There are potentially several factors that contribute to this disparity. Nevertheless, this situation highlights the inherent hierarchial structure of foreign aid: the best treatment is reserved for those who hold the most power – for those who, driven by morality but under no obligation, have entered and brought resources to a foreign country. On the other hand, community health leaders, who belong to the population that is receiving aid, often derive the opportunity to showcase their agency from the foundation laid by global health organizations. They are therefore seen (and treated) as lower in the hierarchal configuration; their ability to help their communities necessitates the foreign aid organization being present — not because they have no agency, but because the structural inequalities they face obstruct their agency. Only when organizations like PIH are present to diminish fundamental inequalities — by providing financial assistance and resources — are community health leaders able to further help their fellow citizens. Perhaps, though, despite PIH’s attempts to decrease structural violence by meeting basic and financial needs, the underlying inequalities of the community they are attempting to improve pervades and is reflected by their work.

Update:

Hi Everyone,

This is an update to my blog post based on the discussions that were presented in the comment section. Before I address some of my new thoughts/conclusions, I want to clarify my opinion on PIH. I think that PIH executes great work; its model (described in the readings) is quite effective, and the administrators/members have designed effective methods in order to create large impacts on communities that need aid. Furthermore, I believe that PIH does work under the idea that all lives are equal; in fact, as we discussed in class, PIH is perhaps designed to provide a preferential option for the poor (i.e. they seek to act on inequality). My blog, therefore, was not meant to completely condemn PIH and render it hypocritical/discriminatory but rather to present a concern I have about PIH’s limitations. While PIH may want to provide equal care for all of its members (Fink’s article did indicate that PIH volunteers tried to negotiate and make several calls in order to get Usman Koroma the help he needed), they are sometimes unable to. Why is this? This is one of the questions I was trying to address, and I originally proposed the inherent hierarchal nature of NGO work as a potential answer.

I’ve thought a lot about this question since, and I have some new ideas that I’d like to share. I think that the resource-poor setting in which NGO takes place plays a large role in the preferential treatment to foreign aid workers. NGOs like PIH may emphasize this idea of ‘getting funds if you need them,’ but realistically, there are financial limitations that prevent everyone from getting access to equal care. (If there weren’t financial limitations, why wouldn’t PIH try to fly every sick person to a country with better health services?) These financial – and logistical – limitations become even more visible in the event of an emergency like the spread of ebola to volunteers. (I’m using the word ‘emergency’ in a specific way right now, but I do acknowledge that it’s difficult to define what exactly an ‘emergency’ is.) Therefore, NGOs have to make a decision about how to distribute their resources. And after more thought, I have identified three main factors that contribute to an NGO’s hierarchy and that influence an NGO’s decisions regarding allocation: 1) Place of Origin, 2) Academic Credentials/Expertise (I’m combining the two, though you identified them separately), and 3) Sphere of Influence (how much influence they have in a community — though this is hard to measure). Regarding the first point, I am assuming that foreigners are often the wealthier players in this situation; they are the people bringing resources into a country that lacks them. As for the second point, while all members (at all levels) are important to NGO work, I think it’s important to consider whether an NGO’s foundation in another country (infrastructure, health centers, logistics, etc.) would exist without the involvement of professionals.

Now that I’ve discussed more potential causes of preferential treatment, I want to focus on two of the questions I asked: Is it possible to eliminate the inherent hierarchical structure of global health organizations? Our classmates had varying opinions on this. Some argued that eliminating the hierarchy is possible. Yuki commented that NGO workers should place more value on the views of community members before doing their work to ensure that community health workers are valued as equal colleagues. Sara also shared a hope of eliminating the hierarchy. Methma, on the other hand, suggested that hierarchy is the nature of health care work and therefore cannot exactly be eliminated. I agreed with this but suggested that maybe some steps could be taken to reduce consequential inequalities of the hierarchy: perhaps instead of trying to completely dismantle the hierarchy, NGOs could give community health leaders higher positions within the hierarchy. By including them in decision-making processes and providing them with actual statuses, an NGO could possibly use its inherent hierarchy to further highlight the agency of the community. Another commenter, Niki, suggested that perhaps the problem we should focus on isn’t the hierarchy but rather safety regulations in general. After all, the lack of safety is what led to PIH’s volunteers contracting ebola in the first place. And I think Niki’s point raises yet another important idea to contemplate: as I stated in a comment, PIH strives to collaborate with governmental bodies/institutions (e.g. Sierra Leone health ministry) in an attempt to make health interventions more sustainable. This means that, unlike groups like Doctors Without Borders, PIH relies on the local government for protective gear and supplies. This obviously becomes a problem when safety lapses (e.g. faulty gear) occur because resources are less regulated. Although involving the government and making use of local resources may be critical to PIH creating self-sustaining health infrastructure, it seems like it also can be quite harmful (depending on the government’s capabilities).

Overall, maybe there is a way to abolish the hierarchy, but maybe there isn’t. Maybe we should direct our concern elsewhere. Clearly, this topic/debate is extremely multifaceted, but I hope that this blog and its comments have encouraged you to think about new ideas.

Footnotes

  1. Drobac, Peter, Matthew Basilico, Luke Messa, David Walton, and Paul Farmer. Reimagining Global Health. (Berkeley and Los Angeles: The Regents of the University of California, 2013), 133-183.
  2. Ibid, 160
  3. Farmer, Paul. Infections and Inequalities. (Berkeley: University of California Press, 1999), 211-227.
  4. Ibid
  5. “Père Eddy, Haiti’s Patron Saint of Mental Health.” Partners in Health. October 22, 2015. http://www.pih.org/blog/pere-eddy-haitis-patron-saint-of-mental-health
  6. Ibid
  7. Ibid
  8. Ibid
  9. Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” The New York Times, April 12, 2015.
  10. Ibid
  11. Huster, Karin, All Lives Matter, Slate, April 6, 2015. http://www.slate.com/articles/health_and_science/medical_examiner/2015/04/ebola_treatment_in_sierra_leone_and_united_states_who_decides_where_doctors.html

Bibliography

Drobac, Peter, Matthew Basilico, Luke Messa, David Walton, and Paul Farmer. Reimagining Global Health. Berkeley and Los Angeles: The Regents of the University of California, 2013.

Farmer, Paul. Infections and Inequalities. Berkeley: University of California Press, 1999.

Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” The New York Times. April 12, 2015.

Huster, Karin. “All Lives Matter.” Slate. April 6, 2015. http://www.slate.com/articles/health_and_science/medical_examiner/2015/04/ebola_treatment_in_sierra_leone_and_united_states_who_decides_where_doctors.html

“Père Eddy, Haiti’s Patron Saint of Mental Health.” Partners in Health. October 22, 2015. http://www.pih.org/blog/pere-eddy-haitis-patron-saint-of-mental-health

 

Discussion Questions

  • Who are more necessary, community health leaders or foreign volunteers/aid groups? Should both types of volunteers receive the same healthcare? If yes, should all members of the community also have equivalent access?
  • Is it possible to eliminate the inherent hierarchical structure of global health organizations? Is doing so necessary?
  • What factors contribute to the preferential treatment of foreign aid workers?

Edit 1: Spelling

29 thoughts on “Exceptional Treatment of Global Health Workers”

  1. Hey Diem-Khanh,

    You brought up some really good points here about the preferential treatment of foreign health care workers over the community health leaders. I agree with you that it certainly doesn’t seem fair that, in the case of PIH’s response to Ebola, the American PIH volunteer was immediately transferred to the states to be treated, whereas the community health leader in Sierra Leone had to wait a couple days to be treated at a British-run facility in Sierra Leone.

    Like you said, I think both the foreign volunteers and the native health workers in the community are necessary for an NGO’s project to succeed. However, just because the NGO is coming in to aid a community does not mean that the organization’s volunteers get preferential treatment when infections/sicknesses occur. Since the cooperation of both groups is vital, I think both types of volunteers should have access to the same level of healthcare. Otherwise, the organization would only be further emphasizing the health disparities between the area they are serving (i.e., developing nation) and the area the NGO comes from (i.e., developed nation), even though the overall goal of foreign aid is to close this gap. As the PIH model of “preferential treatment of the poor” emphasizes, the same high-quality care should also be provided for the community members where the NGO is working, no matter how limited resources may be.

    I think it is possible to eliminate this hierarchy between NGO health care workers and community health care workers. If, indeed, the community health care workers are valued as colleagues in the relationship, then there should be no hierarchy to begin with. The NGO workers should take into account the views of the community members – how they value health, what they view as being healthy, what aspects of health they prioritize (e.g., mental health, physical well-being) – before they begin their work. This assessment may take some time, but I believe it is a crucial step in making sure that the community health workers are treated as equals in this collaboration.

    One factor that contributes to the preferential treatment of foreign aid workers is the implicit, patronizing view that NGOs are somewhat “magical” organizations that come into another region of the world to help those in need. If NGOs can move towards thinking of community health workers as equals rather than people who work under the NGO’s direction, then this hierarchal structure may be eliminated.

    1. Hey Yuki,
      Thanks for your comment!
      You’ve brought up a well-founded suggestion that NGO workers should consider the health views of community members; I agree that this would encourage foreign members of PIH to treat community health as equals. (Note: I don’t mean to imply that PIH members view all community health leaders as ‘beneath them.’ I am just again referring to the inherent hierarchical structure of foreign organizations.)

      However, I wonder whether this would be enough to stop the end to preferential treatment in light of a “medical emergency” (e.g. someone contracting ebola)… Even if PIH were to work on the basis that all lives are equal (I actually think they do), and, as you point out, that care should be directed to the poor, do you think they would provide equal immediate treatment (rushing someone to another country) to community health leaders if resources were lacking?

      1. I’d also like to raise this idea that perhaps the resource-poor context in which PIH’s work takes place is also contributing to foreign aid workers receiving better care than community health workers. PIH works towards preferential treatment of the poor, which means that they most likely do want the best care for ALL of their volunteers (especially for the poor). However, because there is a lack of resources, this vision is somewhat hindered… Perhaps, then, financial dependence is the greatest barrier to providing equal treatment?

        1. Hey Nini,
          That’s an interesting way to think about it. Maybe it does stem from the fact that PIH is emphasizes preferential treatment of the poor and works in resource-limited areas, and is therefore limited by its financial dependence on donors. And if that’s where the problem stems from, then PIH (and most NGOs in general) would need to find other forms of financial support for their programs. In the film we watched during class last week on 11/18/15, Bangladesh Rural Advancement Committee (BRAC) was cited as an NGO that relies not only on donors but on profits from commercial sales of local artists’ work and tuition from BRAC University. While this funding system may not be feasible for all NGOs and may still not completely fix the problem of financial dependence, I think it’s an example of something that could potentially work to provide more funding to NGOs.

          Perhaps, like you mentioned, if there had been more reliable funding sources and more overall funding available, even in resource-limited areas of Sierra Leone in which PIH worked during the Ebola epidemic, then PIH wouldn’t have had to prioritize one volunteer over another when the emergency situations (i.e., infection of health workers) occurred.

          1. Hi Yuki,
            That’s an interesting suggestion in terms of reducing dependence on foreign donors and, instead, further integrating local resources into NGO work. Thanks for bringing it up.

          2. Hey Nini,
            I really like how you summarized everyone’s comments, integrated your own thoughts, and addressed the complexity of global health interventions into your update! I, too, like the idea of involving community members at higher stages of the intervention process – not only in the planning and organizing stages, but also in the implementation and evaluation stages. I think this would help promote a sense of responsibility, ownership, and leadership in the health intervention program among community members, making it more likely that the program will be sustainable in the long run. And of course, since community members are involved at all stages, the intervention itself will be organized around the community’s values, rather than the NGO’s ideas, promoting cultural sensitivity and awareness.

  2. Hi Nini,

    Thanks for your insightful post. I, too, was a little taken aback when reading the story of Usman Mohamed Koroma. I agree with you and Yuki about how differences in background and available resources can lead to these hierarchies. I think these can also be thought of as a kind of medical paternalism, with foreigners entering a new country and prescribing solutions.

    To answer your second question, I don’t know if it will ever be possible to eliminate the hierarchical structure of global health organizations simply due to the nature of many of these organizations being funded or carried out by foreigners. However, I agree with Yuki that the hierarchy among different members of the healthcare force can definitely be reduced, and I think this is one of PIH’s goals in training local community workers and staffing their clinics with locals.

    This hierarchy brings to mind ideas of a white savior – and I think it represents the same struggles. We can critique the negative aspects of these global NGOs and other organizations, but there is always something to be said for the fact that they are still doing good. I don’t mean to say that this can be used as an excuse for why these hierarchies exist, only that this issue may not have been addressed yet because of more pressing issues. Equal care for all health workers is definitely something that should be worked towards.

    1. Hi Methma,
      Thanks for your comment!
      I completely agree that there are more “pressing issues” in the global health field, which is why I think it’s interesting to think about whether it’s NECESSARY to eliminate the hierarchical structure of global health organizations. I found myself wondering whether this limitation of not being able to provide equal treatment for both healthcare workers and foreign aid workers in the face of an emergency was something that detracted from the overall work of PIH… What do you think?

      1. Hi Nini,

        I think there will always be some sort of hierarchical structure to global health organizations, simply due to the nature of outside aid and different levels of resources, so I am not sure whether all the hierarchies can ever be eliminated – but it still doesn’t seem useful to simply accept inequalities. Do you have any ideas of how to eliminate some of these hierarchies in a pragmatic manner?

        1. Hey Methma,
          Like you said, there isn’t really way to completely eliminate hierarchies because of the fact that privileged people are bringing resources into another country… So I think that instead of trying to completely dismantle the hierarchy, NGOs should give community health leaders higher positions within the hierarchy. By giving them positions and including them in actual decision-making processes — by providing them with an elevated “status of power — an NGO could use its inherent hierarchy as a way to further highlight the agency of the community.

          1. Hi Nini,

            That’s a great idea. I wonder if this would be feasible/accepted by many NGOs. I think it would be interesting if there could be a true partnership in leadership positions – with one community health leader and one NGO worker at each step in the hierarchy.

  3. Hi Nini,

    Thank you for your thoughful post. I really appreciate how you addressed with the issue seen with a rooted hierarchical structure in foreign aid groups. I also agree with Methma. I think that this hierarchial structure will always be in place. I would love to say that fixing this would be possible but I really don’t think that there is a quick an easy fix for this inequality. I foud your example withthe US healthcare worker and the community healthcare worker recieving Ebola treatment to be especially powerful in illustrating the point I made above.

    Even though I can’t think of a way to change the hierarchial structure doesnt mean there isn’t one. I also think that eliminating this strucutre is neccessary in order for the world to have a healthier and more just future in relation to healthcare. In relation to your third question I think this inequality plays a major role in the preferential treatment of foreign healthcare workers.

  4. Hi Nini,

    Thank you for your thoughtful post. I really appreciate how you addressed with the issue seen with a rooted hierarchical structure in foreign aid groups. I also agree with Methma. I think that this hierarchical structure will always be in place. I would love to say that fixing this would be possible but I really don’t think that there is a quick an easy fix for this inequality. I found your example with the US healthcare worker and the community healthcare worker receiving Ebola treatment to be especially powerful in illustrating the point I made above.

    Even though I can’t think of a way to change the hierarchical structure doesn’t mean there isn’t one. I also think that eliminating this structure is necessary in order for the world to have a healthier and more just future in relation to healthcare. In relation to your third question I think this inequality plays a major role in the preferential treatment of foreign healthcare workers.

    1. Hi Sarah,
      Thanks for your comment!
      I agree that there isn’t a quick or easy way to fix the hierarchical structure of NGO work; maybe there isn’t one at all.
      If there were a way to eliminate this structure, however, how do you think it would facilitate the development of healthcare? Do you see NGO work and overall (not specific just to the area) healthcare as highly intertwined?

  5. Hi Diem-Khanh! You brought up a really important point about the interdependence of NGOs and the communities where they work. NGOs are often viewed as super-heroes swooping in to save an impoverished, struggling community, but this is a very Western savior viewpoint. The NGO depends just as much on input and help from the community as a community does on the aid they are receiving from an NGO. It must be a symbiotic relationship to be successful. For the PIH model, not only do they depend on input from a target community, but on local health workers, which you explained in detail. In regard to your final question, I think the preferential treatment of foreign aid workers stems from the fact that they are choosing to enter a community in need, whereas a local health worker is seen more as a beneficiary of the work being done. This is an unfair assessment, because both are working for a common cause, and ideally should be treated as equals. However, in response to your second question, I think it is very difficult to eliminate this inherit hierarchical structure because even if efforts are made, underlying prejudices will hold. However, this should definitely be a consideration of PIH, because a group that operates with the goal of improving human life should be very conscious of how they value human life within their framework.

    1. Hi, Leah. Thanks for your comment! ‘Symbiotic’ is a great word to use to describe the relationship between an NGO and the community among which it works. I agree with your suggestion of where the preferential treatment of foreign aid workers stems from; like you indicated, we view foreign aid workers as ‘heroes’ and the local health workers as the beneficiaries.

      I am curious as to what you mean by ‘underlying prejudices’ — could you clarify this?

      1. I wanted to add that I’m hesitant to use ‘underlying prejudices’ when describing PIH’s work because I do believe that they truly see all lives as equal; PIH tried very hard to get the community health leader proper care. However, I do think that there are limitations to their view (preferential treatment for the poor, equality of all lives, etc.) because of 1) the context in which they work (i.e. one that is very resource-poor) and 2) the nature of the relationship they hold with the people (i.e. they serve as the ‘donors’/’generous figures,’ while community members are largely seen as beneficiaries).

  6. Hello Nini,
    I appreciated your focus on the exceptional treatment of health care workers and am interested in your thoughts of how a NGO would logistically better value health workers. In health care systems in general, there is a natural hierarchy of authority that is validated by academic credentials (e.g. degrees, doctorates, etc.) and expertise (e.g. specialization, years worked within a profession, etc.). For instance, a physician might have higher health care authority than a nurse practitioner; moreover, a cardiologist might have higher authority over an E.R. physician when dealing with a congestive heart failure patient. Similarly, is there a way to “rank” or value a foreign aid physician, a foreign high school volunteer, a Haitian medical student, and Haitian accompagnateurfor instance? Do they all hold the same value since they all hold valuable roles in PIH’s global health initiative? Is there some universal standard that PIH should develop to determine if an individual will get preferential treatment in an emergency outbreak?
    Furthermore, in a hypothetical situation, let’s say all of these individuals contract Ebola like the health care workers did in Sierra Leone. What treatment should they get? Should everyone be flown to the U.K. to get “arguably the best Ebola care in the world” or should they be sent to nearest health clinic to get “the best Ebola care available in one of the poorest countries in the world?” I worry that NGOs would not have the resources to do the former, and by doing the later, we might be unjustly devaluing a health care worker. Should a foreign medical student be subjected to the same treatment a resident of a resource poor country might get when that same student has better health care options in his own country? Essentially I question what qualifies a worthy treatment and a worthy patient. Is it possible to make these distinctions?

    1. Hi Niki,
      Thanks for your insightful comment. Like you indicate, it’s important to consider that the treatment PIH (and NGOs in general) is able to provide boils down to the resources that are available. I mentioned in another one of my comments that the resource-poor context in which PIH’s work takes place largely contributes to the preferential treatment of certain peoples/volunteers. Even though PIH strives to work towards preferential treatment of the poor, they don’t always have the resources to do so — especially, it seems, in an emergency context. Therefore, they’re forced to make a decision about who to help (even though they truly want to help everyone).

      You’ve raised an interesting question. Foreign aid physicians, foreign high school volunteers, Haitian medical students, and Haitian accompagnateurs are all important for an NGO’s work in certain domains. A foreign aid physician is obviously important for his expertise (which may come from academic credentials) and for the resources/knowledge he can bring to the community. Haitian medical students and Haitian accompagnateurs are obviously important for sustainable efforts and for better communication between the NGO and the community; they are also critical for executing the NGO’s health/social interventions. And a high school volunteer — while he/she may lack academic credentials or expertise — is still important for carrying out tasks.
      But while all of these people have a job and are important for the NGO’s success, would the NGO exist without the foreign aid physicians? I think this is a question NGOs must consider when deciding where to distribute limited resources — especially in the face of a crisis (like contracting ebola).

      So overall, I think an NGO’s decision is largely influenced by three main factors (perhaps ranked in this order): 1) Place of origin (assuming that foreigners are the wealthier players who are bringing resources), 2) Academic Credentials/Expertise (I’m combining the two, though you identified them separately), and 3) Sphere of Influence (how much influence they have in a community — though this is hard to measure). What do you think?

      1. Hey Nini,
        I agree and I think we are on the same page in concluding that financial and intellectual hierarchy are inherent in global health—especially at the start of an initiative—because of the nature of a helper-helped situation. In the long term, PIH is working to transfer financial and intellectual ownership. This is one way less dependence can be placed on foreign physicians (as you brought up NGO work is dependent on foreign workers) and a way in which the hierarchy in foreign vs domestic worker treatment can be broken down. Nonetheless, giving agency to the community doesn’t change the fact that hierarchy of treatment will always exist in health. If we preferentially treat community health workers, than one might argue that their fellow countrymen should also receive that quality of care. Even in a self-sustaining health system, a doctor no matter foreign or domestic will get preferential treatment in an emergency situation over a community health worker. So I don’t see hierarchy as much of an issue; hierarchy is the nature of health work. The larger problem is PIH’s safety regulations in Sierra Leone. These policies have more of an effect on the manifestation and transmission of disease than the aspects that give NGO’s temporary power in a health system ever can.

        1. Hi, Niki!
          Your comment that “hierarchy is the nature of health work” is quite interesting, and I agree with this position.
          I, like you, thought a lot about whether the hierarchy I discussed withdraws from PIH’s overall work in any way. While I agree with the other commenters who argue that we shouldn’t just accept inequality/hierarchies where it exists, I do find it difficult to distinguish the exact issues that stem from the hierarchy rather than from — as you said — PIH’s safety regulations in Sierra Leone.

          This raises another important issue to consider: PIH strives to collaborate with governmental bodies/institutions (e.g. Sierra Leone health ministry) in an attempt to make health interventions more sustainable. This means that, unlike groups like Doctors Without Borders, PIH relies on the local government for protective gear and supplies. This obviously becomes a problem when safety lapses (e.g. faulty gear) occur because resources are less regulated. Although involving the government and making use of local resources may be critical to PIH creating self-sustaining health infrastructure, it seems like it also can be quite harmful (depending on the government’s capabilities).

  7. Diem-Kahn,

    Great post! Your criticism of PIH for its seeming hypocrisy of values – prioritizing local staff and facilities when it comes to the delivery of care and prioritizing international aid workers when it comes to care in the case of crisis – is on point. I found an article which you might find interesting (http://www.theguardian.com/global-development-professionals-network/2015/jun/16/secret-aid-worker-local-staff-expats-ngo-medical-care), it discusses these issues in the context of another NGO (which the author never names specifically). He goes through multiple given reasons for this disparity of care and discusses the fault in logic or ethical grounding for these reasons.

    The comment section raises the counterpoint that in most NGOs, local workers are paid at local rates, and foreign aid workers are offered wages which would be competitive in their home countries. Local staff were also offered local health insurance – that there was never an expectation to be flown to a different country .

    The wage issue digs into a more complex debate then. Obviously, since both lives should be valued equally, similar opportunities and services should be offered both. But would offering local workers significantly greater wages and benefits than their peers (who might work for a local hospital or for their nation’s department of health, and offer the same quality of care) somehow in turn devalue and weaken the systems which they leave behind? It seems like offering international aid workers the insurance of returning to their home country to receive care if needed might be an important incentive to get workers to leave their home countries to help. Ultimately, I’m a bit torn – it might also seem to somewhat arbitrarily value some lives more than others to give local collaborators the best care available, when their peers and patients do not receive the same privilege.

    1. Hey Jacob,
      Thanks for your comment and for bringing this article to my attention! There’s one idea in the article that strikes me as quite interesting: it seems like the INDIVIDUALS working within the NGO are trying very hard to obtain access to equal health care for their local members/community health workers (they call in favors , fundraise, and negotiate). (Similarly, I’d like to point out that PIH didn’t completely disregard the community health worker; rather, they also tried to get help for Usman. However, it was definitely a lot “easier” to transport an foreign volunteer overseas than to transport a local citizen.) However, the author of the article argues that the ‘NGO’ was delaying proper action and therefore distinguishes between the NGO and the actual members of the NGO. How do you think we can solve this disconnect between the two — that is, if you consider them to be separate?

      You’ve also brought up a great point for discussion. It’s definitely difficult to decipher what steps should be taken in terms of wage, and you’ve presented a complex issue of whether local workers in NGOs should be paid greater wages than local workers in local institutions. Honestly, I don’t quite have the answer for that, but I think it’d be helpful to consider what the NGO is trying to do long-term. If the NGO wants its work to be sustainable, it has to collaborate with local governments and receive funding. If the government and the community are to take ownership of the health infrastructure that the NGO leaves behind, should wages be decided by the government/people or by the NGO? If the NGO sets a precedence by distributing a higher wage than the local one, what will the unanticipated consequences be?

  8. Hi Everyone,
    This is an update to my blog post based on the discussions that were presented in the comment section. Before I address some of my new thoughts/conclusions, I want to clarify my opinion on PIH. I think that PIH executes great work; its model (described in the readings) is quite effective, and the administrators/members have designed effective methods in order to create large impacts on communities that need aid. Furthermore, I believe that PIH does work under the idea that all lives are equal; in fact, as we discussed in class, PIH is perhaps designed to provide a preferential option for the poor (i.e. they seek to act on inequality). My blog, therefore, was not meant to completely condemn PIH and render it hypocritical/discriminatory but rather to present a concern I have about PIH’s limitations. While PIH may want to provide equal care for all of its members (Fink’s article did indicate that PIH volunteers tried to negotiate and make several calls in order to get Usman Koroma the help he needed), they are sometimes unable to. Why is this? This is one of the questions I was trying to address, and I originally proposed the inherent hierarchal nature of NGO work as a potential answer.

    I’ve thought a lot about this question since, and I have some new ideas that I’d like to share. I think that the resource-poor setting in which NGO takes place plays a large role in the preferential treatment to foreign aid workers. NGOs like PIH may emphasize this idea of ‘getting funds if you need them,’ but realistically, there are financial limitations that prevent everyone from getting access to equal care. (If there weren’t financial limitations, why wouldn’t PIH try to fly every sick person to a country with better health services?) These financial – and logistical – limitations become even more visible in the event of an emergency like the spread of ebola to volunteers. (I’m using the word ‘emergency’ in a specific way right now, but I do acknowledge that it’s difficult to define what exactly an ‘emergency’ is.) Therefore, NGOs have to make a decision about how to distribute their resources. And after more thought, I have identified three main factors that contribute to an NGO’s hierarchy and that influence an NGO’s decisions regarding allocation: 1) Place of Origin, 2) Academic Credentials/Expertise (I’m combining the two, though you identified them separately), and 3) Sphere of Influence (how much influence they have in a community — though this is hard to measure). Regarding the first point, I am assuming that foreigners are often the wealthier players in this situation; they are the people bringing resources into a country that lacks them. As for the second point, while all members (at all levels) are important to NGO work, I think it’s important to consider whether an NGO’s foundation in another country (infrastructure, health centers, logistics, etc.) would exist without the involvement of professionals.

    Now that I’ve discussed more potential causes of preferential treatment, I want to focus on two of the questions I asked: Is it possible to eliminate the inherent hierarchical structure of global health organizations? Our classmates had varying opinions on this. Some argued that eliminating the hierarchy is possible. Yuki commented that NGO workers should place more value on the views of community members before doing their work to ensure that community health workers are valued as equal colleagues. Sara also shared a hope of eliminating the hierarchy. Methma, on the other hand, suggested that hierarchy is the nature of health care work and therefore cannot exactly be eliminated. I agreed with this but suggested that maybe some steps could be taken to reduce consequential inequalities of the hierarchy: perhaps instead of trying to completely dismantle the hierarchy, NGOs could give community health leaders higher positions within the hierarchy. By including them in decision-making processes and providing them with actual statuses, an NGO could possibly use its inherent hierarchy to further highlight the agency of the community. Another commenter, Niki, suggested that perhaps the problem we should focus on isn’t the hierarchy but rather safety regulations in general. After all, the lack of safety is what led to PIH’s volunteers contracting ebola in the first place. And I think Niki’s point raises yet another important idea to contemplate: as I stated in a comment, PIH strives to collaborate with governmental bodies/institutions (e.g. Sierra Leone health ministry) in an attempt to make health interventions more sustainable. This means that, unlike groups like Doctors Without Borders, PIH relies on the local government for protective gear and supplies. This obviously becomes a problem when safety lapses (e.g. faulty gear) occur because resources are less regulated. Although involving the government and making use of local resources may be critical to PIH creating self-sustaining health infrastructure, it seems like it also can be quite harmful (depending on the government’s capabilities).

    Overall, maybe there is a way to abolish the hierarchy, and maybe there isn’t. Maybe we should direct our concern elsewhere. Clearly, this topic/debate is extremely multifaceted, but I hope that this blog and its comments have encouraged you to think about new ideas.

  9. Hi Nini,

    I loved your blog post and found it really interesting as well as very helpful to understand the treatment gap that exists between foreign and local health workers.

    Regarding you first question, I think that both community health leaders and foreign volunteers are very important in providing health care to a community. I think that in the short run, foreign volunteers are essential to train community health leaders and to provide some immediate treatments and medications. However, in the long run, community health leaders are crucial for providing sustainable health care to their local community. This being said, I think that it is unfair that local community health leader should have a lower quality of healthcare and I think that everyone from the community should have the same access to quality health care.

    Moreover, I think that because this hierarchical structure of global health organizations has been present for so long and has, in some way, been internalized, that it would be difficult to completely eliminate it. Like Niki said, I think that the more efficient way to go about this would be to focus on safety regulations for both foreign volunteers and community Health leaders. However, like you mentioned in your update, it would require more funding from the local government, which can be harmful to building a sustainable health system.

  10. Hi Nini,

    First of all- fantastic post and update! The hierarchical nature of NGOs may not be something that we want to admit exists, yet is a very deep-rooted and significant problem with – as we read in the Ebola article – fatal consequences. This is a much more abstract factor than the ones you proposed, but I strongly believe that the one of the under-lying reasons for why a foreign aid worker would be given better treatment than a community health worker is because of the overriding mentality that exists towards developing countries. I know that those of us that have taken this class do not think this way, but when the rest of the world is constantly confronted with images of starving children, of painfully skinny fathers or young mothers suffering from HIV, the common response tends to be ‘we must help those poor people.’ The problem with such a response is that the very people that the NGOs are trying to dignify are viewed as just that – ‘poor people.’ Meanwhile the NGO workers going in to help these ‘poor people’ are seen as incredibly invaluable additions to society through the lives they save from poverty . Thus since an NGO worker is being perceived as able to save many lives, their life is valued as greater than the life of the community health worker who is from that community of ‘poor people.’ Now I am not saying that NGO workers and NGOs in general are specifically at fault for this sort of mentality. I don’t even know if there is a way to find one single entity culpable of this rhetoric. However, I strongly disagree with the publication of images that depict people as helpless and I do think that the media is complicit in forming the hierarchical structure of NGOs. We rarely see a picture that depicts the resilience, intelligence or brilliance of people in developing countries. I think that this is a large contributor to the hierarchical structure to NGOs; NGOs exist in a society that deems those in developing countries as ‘poor’ and foreigners who work for NGOs as ‘incredibly selfless individuals.’

    1. Excellent point, Pauline! What you mention is something I’ve actually thought about a lot, and I appreciated the episode we watched in class because it definitely highlighted the resilience of community members.

      I do find myself wondering if the same level of care (both figuratively and literally) would be provided to a people in need if they were portrayed as resilient. Would NGOs and volunteers still be moved to help? Or would they become desensitized to need?

      On one hand, the overwhelming assumption that developing countries need our resources is what motivates us to help… On the other hand, it is this same assumption that often forces people in need into submission. We must find a balance.

  11. Hey Nini! Thank you for your engaging and insightful post. In unpacking the complex question of “whose life matter’s more?” as you stated, multiple factors need to be taken into account. As Methma stated, I believe this internalized almost god-like treatment of foreign healthcare workers, and in return, their paternalistic nature, allows them (in their eyes) the ‘privilege’ to be taken care of in a different manner than community healthcare workers. In addition, some might think that there are so few, for example, Paul Farmer’s, and many individuals in the community who could be trained to do the same job. These subtle hierarchical dynamics are even present in novels such as Monique and the Mango Rains, where Kris is offered her own bowl for dinner, whereas the other women eat the leftover scraps from the men.

    I think it is essential to shift this focus, even completely to what you suggested, where NGO foreign aid workers feel as though they are working for community health care workers. You example of the community health care worker who trained the social workers, and whose methods were later used by the PIH workers is a wonderful example of the importance that these individuals have in the development, success, and sustainment of local efforts.

    Additionally, as much as PIH preaches their philosophy of a preferential option for the poor, and pragmatic solidarity, when it came time to a crisis, to a real like moment, the poor were truly not treated the same way. Should the American doctor been treated in a local clinic? Should the community worker have been flown to the US? I am unsure of the answers to these questions, but when one’s organization practices such a model of equality, these difficult questions must be asked, analyzed, and interrogated.

    1. Thank you for your comment, Stefanie!

      I think shifting the focus (from foreign aid workers to community health workers) could be a potential fix, but I wonder whether foreign aid workers would be as compelled to help if they felt as though they were working FOR community health workers. If the community workers held all of the power in the relationship, I think volunteers might turn their thinking away from “these people need help” to “these people can handle their problems by themselves.” I hope I articulated that well enough for you to understand what I am trying to get at. What do you think?

Leave a Reply to Sarah Peters Cancel reply

Your email address will not be published.