Category Archives: Section 1

Regimes of Research, Section 1

Whose Consent? Vulnerable Populations and Ethical Standards

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In the expansive organism of research regimes, a.k.a contract research organizations (CROs), there seems to be a baseline standard for which all research is considered “ethical”. As Petryna notes in Ethical Variability: Drug Development and the Globalization of Clinical Trials, “the ethical universe in which researchers operate [is] an essentially procedural one” with the basic but critical concerns of obtaining informed consent from subjects and assuring investigator responsibility in case of adverse reaction or death.  Especially in the context of globalized drug development, I believe it’s incredibly important to explore the ways in which these procedural ethical standards are warped according to and “across distinct political and economic contexts”.

Still, I get a nagging feeling that at the core of the research regime’s baseline ethical standard lies a more subtle danger: it seems to me  that the definition of “informed consent” is built in to whatever subjective understanding the Independent Review Boards (IRBs) and CROs may have of it. Seeing as “informed consent” acts as foundational language for an entire ethical standard, a subjective or shaky definition of the phrase is problematic in a way Petryna does not explore at length. When taken across differential political and economic contexts, the ambiguous language of “informed consent” is further destabilized.

In the U.S., informing subjects can be relatively simple if the population is english-speaking and if they have already been exposed to the culture of research, whether through ads  for subjects or through lived experience. When in a place in which research is not the norm or is in the process of becoming a norm, language barriers, stigmatization, and local knowledges seem to lead subjects to create their own understanding of the research purpose.  In Fairhead’s article, which focuses on the MRC project in The Gambia, many parents seemed to believe that the taking of blood samples was for insidious purposes.  Although MRC fieldworkers attempted to inform subjects by “explaining the immune system as the body’s soldiers” and framing their research in an attempt to understand such a system, local knowledges still prevented people from fully accepting the idea. In the end, participants were primarily concerned about the health care that they and their infants were receiving that was unavailable through the government.

If informing subjects according to time and place can be tricky, then obtaining  valid consent might prove to be exceptionally difficult.  Although most CROs would agree that the patients in the MRC study have consented despite being limitedly informed, they fail to take into consideration the structural elements involved in these people’s lives that lead them to agree to a study despite limited understanding or informed hesitancy. It begs the question: can true consent exist in structurally violent circumstances? Even if the subject is informed, outside forces such as political instability, governmental inadequacy, and economic constraints may push people in impoverished conditions towards “consenting” to a study. In this way, consent becomes antithetical to a person’s true desires.  In that case, can it even be called consent?  CROs have no  interest or responsibility in addressing  “how true” consent may be, therein perpetuating inequality while creating ethical variability across specific populations that exploits in a way that is distinct from the crises that Petryna explores. In the article by Fairhead, some people that were not able to get the care they needed from the government consented to the  MRC study because of the benefits to them and their family.

A recent October article presents a case which is not entirely analogous but still relevant to the exploitation of vulnerable populations through research.  In their WashingtonPost article, Gowen and Lakshmi discuss the “Rent-a-Womb” industry  in India that allows foreign couples to find surrogate mothers.  If the nick-name of service and commodification of the womb is not concerning, these surrogate mothers are “often poor and illiterate women from rural areas who are paid little.” It is a largely unregulated business supported by fertility clinics and produces a whopping $400 million dollar a year. Although the “Rent-a-Womb” industry is not necessarily a research study, it is again a moment in which biological bodies are used in a manner that is exploitative, in which monetary gains drive poor women to “consent” to the use of their wombs.

In this way, the shaky foundational language of ethical standards is a powerful means to exploit vulnerable populations in quite subtle ways. Informed or not, consent hinges on the socioeconomic status of subjects in a way that perpetuates inequalities between privileged and impoverished bodies. Consent is not given by subjects, but rather created by CROs to benefit their own goal of cost-effective and rapid research.

 

Sources:

Leach, Melissa and James Fairhead. 2011. “Being ‘with the Medical Research Council’: Infant Care and the Social Meanings of Cohort Membership in Gambia’s Plural Therapeutic Landscapes.” In Evidence, Ethos and Experiment: The Anthropology and History of Medical Research in Africa. P. Wenzel Geissler and Catherine Molyneux, eds. New York: Berghahn Books.

Gowen, Annie, and Rama Lakshmi. “India’s ‘rent-a-womb’ Industry Could Close Doors to Foreigners.” Washington Post. The Washington Post, 28 Oct. 2015. Web. 8 Nov. 2015. <https://www.washingtonpost.com/news/worldviews/wp/2015/10/28/indias-rent-a-womb-industry-could-close-doors-to-foreigners/>

Petryna, Adriana. 2005. “Ethical Variability: Drug Development and the Globalization of Clinical Trials.” American Ethnologist 32(2): 183-197.

Questions:

Can the consent of people in such impoverished communities ever be taken as true, regardless of whether they have been informed?  How does allowing these people to have bodily autonomy complicate the issue?

How can IRBs or other bodies claiming to uphold ethical standards prevent exploitation of vulnerable communities given that structural violence often drives such individuals to use their biology in order to benefit themselves and their families?

Regimes of Research, Section 1

Turning people into Numbers? Downsides and Possible Solutions to Clinical Research in a Global Context

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Since the 1990s there has been rapid growth in the number of people participating in clinical research. Even though most clinical research is funded and controlled by more developed countries like the United States, the rise in human participants is primarily coming from developing low-income countries. There are a multitude of reasons why researchers are now going to low-income countries to find human subjects. Research guidelines may not be as strict, allowing researchers more freedom in conducting their studies. People may be more willing to partake in clinical trails because they are getting drugs they may not get under other circumstances. Lastly, the testing population in the United States has been gradually shrinking despite the increasing demand. Thus, compelling more researchers to adamantly search abroad from human participants (Petryna 185).

The United States drug testing pool has been shrinking since the 1970s. This was when the “use of prisoners as subjects was exposed and severely limited” (Petryna 185). Researchers had to turn directly to the American public to find human subjects since incarcerated individuals made up a large portion of their previous subject pool. The current issue at hand is slightly different. The US population has become a “treatment saturated” population (Petryna 185). Most individuals are on some sort of medication. Using medicalized individuals in clinical research could result in drug interactions and bias data. Some researchers have found a solution in using international individuals instead. Many individuals in less affluent countries have not had the same access and exposure to medications. This makes them naïve test subjects. This desire for the naïve subject is pushing American research initiatives abroad.

There are significant downsides to conducting medical researcher abroad. This current situation puts developed countries at risk for exploitation (Emanuel et al). In developed countries this risk is minimized because there is infrastructure that protects individuals. However, developing countries are less likely to have this framework in place, leaving individuals in these communities more susceptible. Ethical Variability by Adriana Petryna presents a good example. Researchers in developed countries usually target individuals in neighborhoods with easy access to hospitals and centralized healthcare. However, while searching for research participants abroad, many researchers seek out communities with broken health care systems. These areas are more likely to have more willing participants because the people there have no other access to healthcare. It is clear that the primary goal is getting as many subjects as quickly and cheaply as possible (Petryna 187). On a similar note, Petryna also discusses questionable clinical trials shortly after Chernobyl. She claims that chaos enabled researchers to perform trials they usually would not get permission to perform (Petryna 191). Even though some kind of attention was being directed toward the issue at hand, corners were likely cut and subjects were valued less as humans and more as unique testing opportunity. An element of humanity is definitely lost in this kind of approach.

Research projects themselves have become more about the numbers produced and less about the individuals themselves. This is a concern thoroughly discussed in When People Come First by Petryna and Biehl. Evidence Based Medicine, especially Randomized Controlled Trials, are now considered research standard (Petryna and Biehl 58). The issue is that these rigid research methods are not always applicable to the broad, complicated and unpredictable field of global health. Furthermore, studies resulting in defined measurements and statistical significance do not necessarily provide helpful conclusions or a useful platform for future initiatives (Petryna and Biehl 83). Recently, studies that actually aim to help individuals are often shut down because they will not produce the desired numerical results. Forcing determined NGOs to seek private funding if they want to implement effective projects.

When faced with such a problem, it is important to consider possible solutions. If companies desire to perform research beyond their own borders it is important that some regulatory system is established. As stated in the article What Makes Clinical Research in Developing Countries Ethical? such systems should prioritize participant protection. It should set guidelines to prevent researchers from taking advantage of research subjects. Another possible solution could be achieved through partnership. Although it was not completely perfect, the Leach and Fairhead article demonstrated a relatively effective solution: combining research and direct aid. Health workers provided new mothers with good health care and then performed research on the side (Leach and Fairhead 96). This approach allows beneficial research to done while still maintaining a humanistic element. If implemented correctly the motivation to perform research may even eventually foster more sustainable experimental and medical support systems.

Discussion questions:

  1. What do you think about the research performed after Chernobyl? Even if controversial research produces favorable results is still ethically acceptable? Should medical research guidelines be loosened in a state of emergency or crisis? Who would such an act benefit more: the researchers or the participating individuals?
  2. Not all countries have sustainable systems that can regulate medical research. Who should implement medical research regulations? What research guidelines would be essential in these scenarios?

Sources:

Petryna, Adriana. 2005. “Ethical Variability: Drug Development and the Globalization of Clinical Trials.” American Ethnologist 32(2): 183-197.

Biehl and Petryna. 2013. “Evidence Based Global Public Health.” When People Come First (Ch. 2).

Emanuel et al. 2004. “What Makes Clinical Research in Developing Countries Ethical? The Benchmarks of Ethical Research.” Perspective.

Leach, Melissa and James Fairhead. 2011. “Being ‘with the Medical Research Council’: Infant Care and the Social Meanings of Cohort Membership in Gambia’s Plural Therapeutic Landscapes.” In Evidence, Ethos and Experiment: The Anthropology and History of Medical Research in Africa. P. Wenzel Geissler and Catherine Molyneux, eds. New York: Berghahn Books.

Essential Medicines and the Pharmaceutical Fix, Section 1, Unit 2 - Trying to Help

Pharmaceutical Industry: Good or Evil?

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Bringing attention to certain medications that everyone should ideally have access to by highlighting them as the “essential medications” seems like a good idea. But who gets to decide what medications are essential or non-essential; where do we draw the line? The criteria for the first list of essential medications in 1977 were based on clinical trials of safety and efficacy conducted in the global North (mainly developed countries) and cost-effective analyses in a developed nation’s economy (Greene, p. 19). Does this make sense, considering health outcomes and access to health care are vastly different between developed and developing nations as well as within each category?

As Jeremy Greene explores the (surprisingly) recent history of pharmaceuticals in global health in his article, many questions regarding “essential medications” come to mind. Something that worried me about defining essential medications in the form of a list was that such a list would affect how insurance companies consider coverage for certain medications over others. A focus on medications used to treat common diseases (Greene, p. 18), may pull attention away from essential medications for rare diseases. This could be connected to multiple harmful effects: pharmaceutical companies may not have much incentive to invest in research and development of new medications to treat those rare diseases because such products would only yield small profits from a small market, and health insurance companies may not be inclined to cover treatment involving medications that are not listed as being essential.

Greene mentions the “drug-dumping” of multinational pharmaceutical firms as they purposefully sold their products, some of which had not completed clinical trials and had questionable safety and efficacy reports, in countries with less regulations on the quality of drugs in the 1970s (Greene, p. 16). To me, this situation mirrors that of the tobacco industry, in which major tobacco companies started looking for foreign markets outside of the United States with the rise of foreign demand in the 1960s. Taking advantage of the weaker restrictions on trade and health regulations in developing nations, tobacco companies targeted women and children in Africa and China, for example, to expand their market and increase profits (Brandt, p. 454, 487). In some ways, pharmaceutical companies are just as manipulative and selfish. In response to the South Africa’s Medicines Act of 1997 that allowed for the production of generic versions of patented HIV drugs to make them more affordable to a greater population, thirty-nine pharmaceutical companies filed suit in South African courts just a year later. Furthemore, the U.S. government also expressed its disapproval, even though it later changed its mind in support of the Medicines Act in 1999 following uproar from political activists (Farmer, p. 122, 123)

Nowadays, the “cozy” relationship between doctors and pharmaceutical companies has become controversial. It is no secret that major pharmaceutical companies and doctors often work closely together – drug companies send sales representatives to speak to doctors about new medications and sponsor medical education and research. This has raised questions of conflict of interest – doctors can monetarily benefit from prescribing certain medications, biasing them towards providing certain treatments over others that could be just as effective or more effective (Glover). However, others including cardiologist Dr. Lisa Rosenbaum argue against the stigma surrounding doctor-industry collaborations. In her opinion, such a collaboration could lead to “life-saving therapies whose development requires the combined talents of clinicians and industry” (Rosenbaum). Dr. Rosenbaum contends that the conflicts of interest argument could lead to important viewpoints being discredited or ignored, simply because a doctor happens to work with drug companies

As part of the Affordable Care Act of 2009, the Sunshine Act mandates that all payments over $10 from pharmaceuticals to doctors or hospitals be made public to increase transparency and disclosure (Glover). Even so, there is always the risk of a doctor building close ties with one specific company and endorsing their products at every opportunity, blinding himself to potentially better options available for patients. The Access to Medicine Index (ATMI), implemented in 2008, is another way to keep pharmaceuticals accountable. The ATMI publicly recognizes companies for their efforts to improve access to drugs in developing nations. By ranking countries in order by their commitment to the transnational goal distributing drugs globally at reasonable prices, the ATMI encourages companies to keep up their efforts. Another way of looking at the list and rankings is that the ATMI puts pressure on the companies that ranked low on the list or did not make the list to work towards equal distribution of medications (Greene, p. 27).

Discussion Questions:

  • The Second Model List of Essential Drugs clarified that drugs not listed were not necessarily “inessential” and that the list was mainly meant to be used in the context of developing nations with the goal of making medications more affordable and accessible. Do you feel that the Second Model List of Essential Drugs adequately addressed problems of the first list?
  • While some argue that doctors working with pharmaceutical companies and being financially compensated for prescribing certain drugs will lead to biases that could potentially be harmful to the patient, others firmly believe that we could be losing out on life-saving advancements that may result from such collaborations. What do you think about doctor-industry collaborations? Is there a “happy medium” in this situation?

Course Readings:

  • Brandt, Allen. (2007). The Cigarette Century. New York: Basic Books (p. 448-492)
  • Farmer, A. Kleinman, J. Kim and M. Basilico. (2013). Reimagining Global Health: An Introduction. Berkeley: University of California Press (p. 122-123)
  • Greene, J. A. (2011). Making medicines essential: The emergent centrality of pharmaceuticals in global health. BioSocieties, 6(1), 10–33. http://doi.org/10.1057/biosoc.2010.39

Outside Readings:

UPDATE (on Nov. 25, 2015 at 10:30pm): 

At the end of September, Turing Pharmaceuticals announced a 5000% price hike of their drug, Daraprim (used to treat toxoplasmosis, especially in immunocompromised HIV/AIDS patients), from $13.50 to $750 per tablet, which (unsurprisingly) resulted in a public uproar. As I was following this story, it at first seemed that Chief Executive Martin Shkreli saw nothing wrong with this overnight price increase, reasoning that pharmaceuticals need to make money for drug research and development. (He is quoted as stating, “It is us trying to stay in business” in the New York Times.) Since then, he seems to have finally come to his senses and has announced that the price of the drug will be cut by up to 50% for hospitals only.

However, this shows just how much “power” pharmaceuticals can have over prices of their products and how they can wield this control in a way that affects the public as a whole. This is not an isolated incident in recent news. A similar price increase was applied to cycloserine, a drug used to treat tuberculosis, although this price increase was rescinded soon after. What loopholes in policies regulating pharmaceuticals allowed these significant price increases for important drugs to occur, and how can the government make sure nothing like this happens again?

Dec. 8th, 2015 at 9:50am: Sarah and I have been discussing (in the comments below) about possibly having more interaction between the government (the U.S. government in particular, since several of the major pharmaceutical companies are based here) and an established and reputable international organization such as the WHO. The purpose of this collaboration  would be to ensure that drug companies do not raise prices of their products just to make more profits. Although the WHO, a branch of the UN, does not have any teeth and does not hold direct power over national governments (as we discussed in class), I believe it would be more efficient to utilize an already established organization rather than creating an NGO from scratch, as an NGO would not hold any power over a state’s government and pharmaceutical corporations, either. The WHO would be able to monitor which organizations are engaging in philanthropy by donating important medications that would otherwise be prohibitively expensive to populations in low- and middle-income countries that need the medications, thereby encouraging other pharmaceuticals to follow suit. Because the WHO does have sway over international publicity, the organization could also publish data on what pharmaceuticals have dramatically raised prices on their products, adding to the pressure on these pharmaceuticals to reduce their prices to make their drugs more affordable.

FURTHER UPDATE (on Dec. 7, 2015 at 11:09pm):

I realize I was not very clear about how such pharmaceuticals were “allowed” to raise the prices of their drugs so drastically. Pharmaceuticals like Turing have found a loophole whereby they purchase all rights to the drug and then raise its price. This is perfectly legal, but legality does not always equate to morality, as we discussed in class in the context of corporate responsibility (e.g., Shell’s environmental pollution in the shantytown of Flammable, Argentina). While the connection between the social suffering and corporate responsibility is not as clear-cut in the case of these pharmaceuticals’ price hikes, I believe there needs to be more regulation on drug prices.

According to a Wall Street Journal article from December 5th, 2015,    there will be a congressional hearing on December 9th between the Senate Special Committee on Aging and pharmaceuticals with price jumps, including Turing Pharmaceuticals, to investigate the problem. Hopefully, this will further emphasize the message that we civilians (and most politicians) will not tolerate drastic price surges of important drugs and push forward policies to prevent another occurrence.

Dec. 9th, 2015 at 7:41 pm: Read more on the congressional hearing held this afternoon in Washington, D.C., where Senators Susan Collins and Claire McCaskill, along with specialists in the U.S. health care system such as Drs. Erin Fox and David Kimberlin, criticize four pharmaceuticals that have sharply increased the prices of their drugs out of greed for profits: http://www.theguardian.com/us-news/2015/dec/09/drug-companies-turing-valeant-martin-shkreli-daraprim

Sources:

 

HIV/AIDS Activism and Emerging Infectious Diseases, Section 1, Unit 2 - Trying to Help

Is some help better than no help at all? How do we handle the complexities of HIV/AIDS interventions in the developing world?

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In her book, Professor Benton writes, “Herein lies the double-bind of HIV exceptionalism: to deem HIV a run-of-the-mill public health problem is to understate one of the most challenging biomedical and social problems of our time.  When we ascribe such enormous cultural weight to the disease, however, it becomes almost impossible to justify sublimating HIV to a broader health care agenda–even in low-prevalence settings.”  Throughout the entire book, Professor Benton highlights how HIV/AIDS in Sierra Leone has become an exceptional disease; almost all health development programs and funding is HIV-related, while HIV prevalence is not actually that high (~1%).  This brings us back to our discussion about unintended consequences–while providing care for HIV/AIDS patients is important, and indeed a ‘good’ thing, through the reading we see that these disease specific health interventions can take away funding from other diseases and health issues that are less ‘sexy’/’attractive’ to donors, and can therefore leave people sick and at risk of mortality and morbidity from diseases that could have been prevented through primary care.

I must admit, I chose this topic to blog about for a reason.  Over three years I have conducted cardiovascular research in Kenya and assessed the rising rates of chronic non-communicable diseases (CNDCs) in the country.  Over the last year or so I have been researching ways to integrate chronic non-communicable disease care with HIV/AIDS care structures that are already in place because of high funding for HIV/AIDS programs.  To me, it makes sense to integrate HIV (which is a chronic disease with proper treatment and adherence to care) with cardiovascular, diabetes, and hypertension care because they require similar things–adhering to drug regimens, living healthy lifestyles with proper diet and exercise, counseling, support systems, etc.  But something that I’ve struggled to answer is that by integrating HIV/AIDS with CNDCs in health care structures, are we undermining the severity and complexities of the HIV/AIDS epidemic?  By integrating care, would we be cutting options for poor persons living with HIV/AIDS, people who are already at higher risk for discrimination, stigma, poverty, etc.?  While there are unintended consequences of creating HIV-only health interventions, what are the possible unintended consequences of integrating care structures?

This relates back to the debate between the primary health care (PHC) movement and the selective primary health care (SPHC) movement.  Although both the PHC and SPHC movements were in some ways trying to address declaration III of the Alma Ata: “Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace,” the PHC movement was a horizontal approach and the SPHC movement was a vertical one.  Like the HIV/AIDS programs highlighted in Professor Benton’s experiences in Sierra Leone, the SPHC movement was specifically targeted and in some ways much more practical than the idealistic PHC movement.  This raises the question of how much idealism and how much practicality make up good health policy?  Is practicality more useful in policy-making than idealism?  Were the health gains brought about by the vertical SPHC movement better than what might have occurred from the PHC movement?  In my opinion, while the SPHC movement didn’t address or even come close to attaining access to primary health care for all, I think that the PHC movement was too broad and that without specific funding guidelines would have made even less gains than what actually occurred.  What are the unintended consequences of creating a broad public health intervention, and what are the unintended consequences of creating specific interventions?

I think that the HIV/AIDS interventions described in the Benton book really highlight what we’ve been struggling to find an answer to all semester in class: How can we do something good for health that doesn’t somehow also have unintended negative impacts?  In the book we see that HIV/AIDS funding comprised more than half the country’s health budget in 2004, but in many cases, “HIV exceptionalism actually serves to amplify existing disparities.  On the other hand, it also provides a means by which poorer HIV-positive people can benefit from a health care system that normally privileges the priorities of its wealthy donors.”  Thus it seems to be sort of a damned if we do, damned if we don’t situation–we want to help sick people, but we also don’t want to hurt other sick people in the process of that, so what do we do?

Questions:

  1. In the case of Sierra Leone are there any solutions to the problems created by HIV exceptionalism?  Would strengthening primary health care systems in order to prevent preventable diseases inherently harm people living with HIV/AIDS who already face poverty, stigma, and other inequalities?
  2. When creating health policy and health interventions is practicality or idealism more important/useful?  What are the possible negative outcomes that can occur by using one or the other?
  3. When trying to get funding from donor organizations and donor countries who should be in control of determining what programs are funded with this money?  Is there really anything we can/should do to influence where donors put their money?  Is it bad for programs that have unintended consequences to be funded in the first place?  Should donors therefore just stay out and not help?

Sources:

Alma Ata Declaration.

Benton. 2015. HIV Exceptionalism: Development Through Disease in Sierra Leone. Minneapolis: University of Minnesota Press.

Cueto 2004 The Origins of Primary Health Care and Selective Primary Health Care. American Journal of Public Health 94(11)1864-74.

Farmer, A. Kleinman, J. Kim and M. Basilico, eds. 2013. Reimagining Global Health: An Introduction. Berkeley: University of California Press.

HIV/AIDS Activism and Emerging Infectious Diseases, Section 1, Unit 2 - Trying to Help

The Right to “Rights”: Conducting Illness and Response, Performing HIV/AIDS and Activism

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In several of the class readings that touch on both anthropological and global health perspectives on HIV/AIDS and attempts to control and treat the disease around the world, a theme that arises again and again is the one of “rights.” There is, of course, the apparent “right to know” the HIV-status of someone in your family or community and the right to “know your rights” (Biehl et al., 93) in navigating the HIV-positive identity, amongst other “rights” that seem to illuminate a projected path of dignity after diagnosis, and dignity in disease.

Throughout my own work with patients who must navigate the social circumscriptions of their health statuses and health choices, I have encountered other “rights” that patients either seek to engage: the right to be ill, the right to their identity as it either transforms through illness or does not, and – in an amalgamation of the two – the right to be an ill person. The meanings of these can be nebulous, and certainly fluid between individuals and contexts of illness. They are, however, important to the development of an inclusive and thoroughly caring rubric for the protection of human health.

Since its recognition as a “distinct clinical syndrome” in 1981, HIV/AIDS and discussions about the disease have permeated public concern about health and captured the focus of international health objectives (Farmer, 60-61). Due to its prevalence in the public imagination about transmission, socialized mythologies have arisen, type-casting the apparently susceptible based on initial circumstances of visibility amongst HIV/AIDS victims. Members of the LGBTQ community, Haitians, drug-users, and people believed to be of a certain form and level of sexual activity where they may make sexual contact with these “types” of people (especially through “anal intercourse” [61]) are among some of the people who did, and still do, experience judgment and are inundated with concern (either personal, social, or both) about their HIV-statuses. Additionally, cultural pictures were painted with related assumptions about the lifestyles and habits a person susceptible to or diagnosed with HIV/AIDS enacts; these mythologies continue to reproduce themselves through certain tactics for sexually-transmitted illness screening as well as the marketing particulars of prevention and awareness programs. In Zimbabwe, Dr. Beth Barr reports that the stigma which links HIV transmission to certain behaviors, as well as certain frightening consequences of HIV/AIDS, repels people – particularly sexually active youth – from counting themselves among those in need of screening, protection, and possibly treatment. The co-production of a sort of HIV/AIDS-identity by 1) beliefs about the transmission and progression of the disease and 2) the moral valences of the behaviors believed to be responsible has driven people away from testing and treatment for fear of having to surrender their personhood in exchange for this frightening and unappealing identity (Mwakalyele, 2015).

In HIV Exceptionalism, Benton writes how, in Sierra Leone, there are established ways of appropriately disclosing one’s HIV-positive status, and, thus, how there exist established ways of appropriately enacting HIV-positivity. The performative value of disclosure of one’s status, as Benton discusses (67-88), represents a social process of transforming the identity of the person – from healthy to sick, from presumably HIV-negative to certainly HIV-positive, from one type of person to another type of person (Benton discusses the varied assumptions and cultural valences that orbit “HIV/AIDS” as it has been constructed in the social imagination) – that becomes inscribed on the the biological process of infection and disease within the body.

The social processes that hinge HIV/AIDS onto socially-projected information about identity and conduct, as well as that connect the perceived severity of the disease to equally severe, implicit moral allegations stemming from socialized fictions of AIDS etiology contort the social privilege of those experiencing the disease from all angles: there are intense personal, cultural, religious, interpersonal, public, and bodily sensations that follow diagnosis. The right to retain and mold one’s own identity in and through illness is squeezed through an apparatus of the “rights” of others “to know,” the consideration for the health of the community, and the urgency imbued in certain forms of disclosure. While disclosure proves a sometimes-useful tool to cultivate social support and build trust, it mandates a surrender of control over one’s own health information (Benton, 71), as well as a relinquishment of the way one may be perceived into a realm of public assumption and judgment, where one’s conduct, personhood, and legacy may be discriminated against, misread, and miscarried.

Negotiating a balance between the “rights” to community awareness of infection and the patient’s right to preserve their personhood in a climate of mythology and judgement circling HIV/AIDS may break down barriers of socialized illusions about susceptibility to transmission, and subsequently may not only strengthen prevention but also render every member of a community equal in sharing concern about HIV/AIDS transmission. Thus, each member of a community is called to responsibility in creating an environment of participation and proactivity to support the health of the whole community. Establishing a livable balance for those living with illness between the risk of stigma and the protection of others, reconstructing the cultural storytelling that once seemed to safeguard the uninfected, and cultivating attitudes of shared responsibility and equal susceptibility is integral to true protection, as well as fair and successful distribution of knowledge, prevention, treatment, care, and dignity. This, in my opinion, is activism.

 

Discussion questions:

  1. What concrete problems do you see with the stigma that underlies disease and the effectiveness of appealing to community awareness and/or delivering screenings, treatments, and care?

2. Is it possible to untangle the realities of transmission from the cultural etiologies and local beliefs that are important to respect when developing strategies for responding to infection and disease internationally?

3. What are the dangers of these sweeping cultural mythologies about transmission and susceptibility to disease, which inaccurately depict certain “types” of people as carriers from which the uninfected should distance and protect themselves? How might these forms of storytelling about disease create yet more inequality and prove damaging to overall health in a community?

 

Sources:

• Benton, Adia. 2015 HIV Exceptionalism. University of Minnesota Press.

• Biehl, João, and Adriana Petryna. 2013. When People Come First: Critical Studies in Global Health. Princeton University Press.

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

• Mwakalyele, Ndimyake. 2015 Stigma, Complacency Threaten Zimbabwe’s Gains in HIV/AIDS Fight. http://www.voazimbabwe.com/content/stigma-complacency-threaten-hiv-gaings-fight/3013729.html accessed October 20, 2015.

 

Alma Alta, Primary Health Care, and Selective Primary Health Care, Section 1, Unit 2 - Trying to Help

We Still Need a Grand Vision

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The WHO defines health as a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity. The Declaration of Alma-Ata cited this definition of health to emphasize the right to health for all and, thus, urge governments to implement comprehensive national health systems. As we discussed during lecture and section, the broad scope of this declaration was greatly criticized. The declaration set unrealistic expectations because it posed immeasurable, and seemingly unattainable, goals to achieve better health for all around the globe. In spite of all these criticisms, primary health care has set the standards for today’s expectations for health systems precisely because it encompasses a grand vision: health as a fundamental right.

The Declaration of Alma-Ata was a great tool for setting the framework around global health; it incited all countries to consider the health of their people and how these people were accessing the health care system. As broad as the overarching mission to implement primary health care was in scope, it served as the foundation for the “Primary Health Care movement,” which has trickled into today’s ambitions. For example, the WHO’s World Health Report of 2008 emphasized placing people and their health needs at the forefront of health care. In addition, the Bill & Melinda Gates Foundation, World Bank Group and WHO just came together in September to form a new partnership, the Primary Health Care Performance Initiative (PHCPI). The PHCPI’s aim is “to support [low- and middle-income] countries in improving the performance of primary health care.” It will help countries monitor, track, and share their key vital signs, which include information about the health system as a country’s priority, service delivery, and the delivery of better outcomes. In this manner, primary health care will continue to address the social determinants of health, but on a country-by-country basis. However, I wonder how exactly these three powerful organizations will work with other countries’ community values instead of imposing their own values.

In addition to addressing social determinants of health, primary health care also focuses on the need to improve value for patients, “where value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes.” (HBR) In this manner, we should be able to improve outcomes without increasing associated costs or decrease costs without worsening the outcome, thereby obtaining better health for all. The overall aim is ensure that everyone is achieving the best outcomes at the lowest costs, that we are offering a ‘ preferential option for the poor’. Yet, to what extent is this ‘preferential option for the poor’ influenced by and idealized in Western settings? Primary health care is supposed to avoid the elements of paternalism that are so prevalent among the “magic bullets,” like antiretroviral drugs and regional and global vaccination campaigns.

Magic bullets have the benefit of being simpler and more cost-effective than longer-term goals, but also distal to the social determinants of health. The global eradication of smallpox, for example, failed to address the more pressing concerns that the last communities with smallpox were facing. Further, it raised questions about the ethical implications of taking a vertical approach: How important is it to vaccinate all resistant individuals? Will this actually benefit all global citizens? Should we be more concerned with hazards, like smoke accumulating in houses when someone cooks or water contamination? These more narrow, yet measurable goals that are characteristic of vertical approaches and selective primary health care often detract from the social determinants of health, thereby ignoring the “causes of the causes” that negatively impact health.

Interestingly enough, other kinds of “magic bullets” dealing with HIV/AIDS don’t necessarily avoid social determinants of health altogether, but rather create what Dr. Adia Benton calls “methodological horizontality.” In this way, we do not place our sole focus on the disease and targeted clinical interventions or only promote evidence-based interventions to obtain funding. This combination of vertical and horizontal programmatic approaches allows us to address HIV/AIDS diagnosis, treatment, and follow-up while also conducting other health programming. Would this approach work for all diseases? Can we simultaneously work toward providing truly accessible, affordable, and coordinated primary health care and also address problems that require specialized care?

Discussion Questions:

  1. Do we need a global framework for primary health care? Or can other countries interpret primary health care as they see fit for their needs and, thus, develop nation-specific primary health care?
  2. Can we ever truly eliminate elements of paternalism from our (American) international health efforts?
  3. How can all nations work toward providing truly accessible, affordable, and coordinated primary health care to then be able to address problems that require specialized care?

 

Sources:

Benton, Adia. HIV Exceptionalism: Development Through Disease in Sierra Leone. U of Minnesota, 2015.

Bryant, J. H., and J. B. Richmond. “Alma-Ata and Primary Health Care: An Evolving Story.” Health Systems Policy, Finance, and Organization. By Guy Carrin. Amsterdam: Elsevier/Academic, 2009. 59-81.

Cueto, M. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health, 2004. 94(11)1864-74.

Greenough, P. “Intimidation, Coercion, and Resistance in the Final Stages of the South Asian Smallpox Eradication Campaign, 1973-1975.” Social Science and Medicine, 2005. 41(5): 633-645.

Lerberghe, Wim Van, Tim Evans, Kumanan Rasanathan, and Abdelhay Mechbal. The World Health Report 2008. Geneva, Switzerland: World Health Organization, 2008. http://www.who.int/whr/2008/whr08_en.pdf.

Porter, Michael E., and Thomas H. Lee. “The Strategy That Will Fix Health Care.” Harvard Business Review. 01 Oct. 2013. https://hbr.org/2013/10/the-strategy-that-will-fix-health-care.

World Health Organization. “New Partnership to Help Countries Close Gaps in Primary Health Care.” World Health Organization. 26 Sept. 2015. http://www.who.int/mediacentre/news/releases/2015/partnership-primary-health-care/en/.

Inequalities in Medical Resources, Section 1, Unit 2 - Trying to Help

On Visibility and Access: The Role of Non-Economic Factors in Inequalities of Medical Resources and Care

Image 37 Comments

Inequalities in health – where certain populations experience greater burdens of disease and worse health outcomes than others – are well established.  It is tempting to explain these as being caused by economic inequalities, and this is not inaccurate; there is a strong correlation between a country’s rates of income inequality and infant mortality (an important barometer of overall health) [figure 1, OECD], and it has been demonstrated for multiple countries that individuals with above average socioeconomic status have lower rates of most disease and live longer than less advantaged peers (Singer and Ryff).  However, explaining health inequality solely with economics ignores other important sociopolitical factors.  I’d like to additionally qualify health inequalities related to public perception and access to care, and argue that similar issues are at work impacting health globally, from rural Botswana to metropolitan Providence.   While economic status of individuals and regions contribute significantly to many of these factors, and the factors themselves are deeply interrelated, considering inequality from a variety of perspectives can offer novel directions for addressing these issues.

GIMP-Ratio-Top-10p-to-Bottom-10p-Income
FINAL-GIMP-Infant-Mortality-Rate Figure 1: Comparison of countries with lowest income inequality and highest income inequality (left to right), and rating infant mortality rate for same countries (bottom image)

Some authors stress the clarification between health inequalities and health inequities.  Kawachi and colleagues define health inequalities as designating “variations … in the health achievements of individuals and groups”, whereas health inequities specify those inequalities “that are deemed to be unfair” or preventable (Kawachi et al).  This distinction suggests that some health inequalities, perhaps due to chance (genetic mutation), biologic definition (cervical cancer affecting women more than men), or choice (injury in extreme sport enthusiasts) may not be inherently unjust or preventable.  I will focus on issues of health inequality that are somewhat preventable (ignoring pessimism regarding unrealistic structural changes).

One contributing factor is the invisibility or misjudgment of the burden of specific diseases on specific groups.  This can manifest in the amount of research, funding, and treatment offered to individuals, and in social stigma attached to their conditions (social perceptions and pressures have huge influences on quality of life and treatment choices).  For decades AIDS was considered to be a primarily male disease, yet by 1991 AIDS was the leading killer of young urban women in the US (Farmer, 61-62).  While this most severely affected women in poverty, the invisibility of all women with AIDS was an issue of public education and attention more than wealth distribution – and structural changes to consider the realities of and offer resources to women with AIDS would have mitigated these problems significantly.  Similarly, the experiences of cancer patients in the oncology ward of Princess Marina Hospital (PMH) in Botswana reflect how cancer in Africa is an “invisible” condition, despite epidemiologists describing it as a “common disease” there (Livingston, 8).  The lack of attention given to cancer in Africa changes the manifestation of the disease and experience of patients; later detection of cancer contributes to a trend of palliative rather than curative responses, and priority is given to funding research and therapies with minimal benefit for these populations (Livingston, 20, 31-34).

Another major consideration is access to care, which seems primarily to be socioeconomic, with poverty preventing people in the US from affording insurance or co-pays for treatment (and uninsured individuals being at least twice as likely to lack necessary care access), and tied to global conditions like Tuberculous, which is both curable and the leading cause of death for young adults in much of the world – its exists because many lack access to affordable treatments (Adrulis; Farmer, 185-186).  Poverty also contributes to health indirectly, including influencing education, proximity to environmental hazards, and availability of healthy foods (Adler and Newman).

However, access can also be politically and culturally driven.  Lovemore Makoni, who desired chemotherapy at PMH, was ineligible for free healthcare offered to Botswanese residents because he was from Zimbabwe, a mere 300 miles away.  Similarly, undocumented immigrants or legal residents of less than 5 years throughout the United States are ineligible from enrolling in state-funded programs like Medicaid.  I witness this need firsthand working at Clinica Esperanza, a free healthcare clinic in Olneyville, which serves a small subset of Rhode Island’s undocumented population (estimated to be at least 30,000), in addition to the many people enrolled in insurance programs who cannot find a PCP (Pew Research Center).  Cultural barriers to access include language barriers, distrust of physicians not representing similar ethnic backgrounds, and lack of sensitivity to unique cultural needs such as diabetic Muslim patients who desire to fast during Ramadan (Armstrong, et al; Singleton & Krause; Aboul-Enein and Aboul-Enein).  While these factors compound with issues of socioeconomic disadvantage, policy and systematic changes could be developed to address specific needs and bring access to populations without redistributing wealth, and these options are important to consider when discussing health inequalities anywhere.

Discussion Questions:

  1. What sorts of interventions might specifically address issues of “invisibility” or cultural and political barriers to access to care?  Do you think that components of these issues could be resolved without redistributing the wealth of a population?
  2. Does considering the causes of inequalities of health to be varied and complicated (rather than ultimately stemming from economic inequalities or some other cause) make the prospect of working to resolve these inequalities seem more or less daunting?  Does it suggest there is far too much contributing in conjunction to worsen certain populations’ health outcomes, or rather that some interventions (which might be more realistic and implementable than ending poverty) could be a valuable change in focus to directly improve the care of disadvantaged groups?

Works Cited:

Aboul-Enein, B.H., and Aboul-Enein, F.H.  2010.  The Cultural Gap Delivering Health Care Services To Arab American Populations In The United States.  Journal of Cultural Diversity, 17: 20-23.

Adler, N.E., and Newman, K.  2002.  Socioeconomic Disparities in Health: Pathways and Policies.  Health Affairs, 21: 60-76.  Web, accessed on PubMed.

Andrulis, D.P.  1998.  Access to Care Is the Centerpiece in the Elimination of Socioeconomic Disparities in Health.  Annals of Internal Medicine, 129: 412-416.  Web, accessed on PubMed.

Armstrong, K., Ravenell, K.L., McMurphy, S., and Putt, M.  2007.  Racial/Ethnic Differences in Physician Distrust in the United States.  American Journal of Public Health, 97: 1283-1289.

Farmer, P.  1999. Infections and Inequalities: The Modern Plagues.  Print.  Berkeley and Los Angeles: University of California Press.

Kawachi, I., Subramanian, S.V., and Almeido-Filho, N.  2002.  A glossary for health inequalities.  Journal of Epidemiology in Community Health, 56: 647-652.  Web, accessed on PubMed.

Livingston, J.  2012.  Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic.  Print.  Durham: Duke University Press.

Organisation for Economic Cooperation and Development (OECD).  “Ratio of Top 10% Income to Bottom 10% Income (2011)” and “Infant Mortality Rate (2001) per 1,000 live births”.  2012.  Web, Accessed via Inequality.Org, A Project for the Institution of Policy Studies. <http://inequality.org/inequality-health/>

The Pew Research Center.  2011.  Unauthorized immigrant population: National and state trends, 2010.  By the Pew Hispanic Center.  Web.  <http://www.pewhispanic.org/files/reports/133.pdf>.

Singer, B.H., and Ryff, C.D.  2001.  “The Influence of Inequality on Health Outcomes”, chapter in New Horizons on Health: An Integrative Approach, Singer, B.H., and Ryff, C.D., eds., as part of the National Research Council (US) Committee on Future Directions for Behavioral and Social Sciences Research at the National Institute of Health.  Print. Washington (DC): National Academies Press (US).

Singleton, K, and Krause, E.M.S.  2010.  Understanding Cultural and Linguistic Barriers to Health Literacy.  The Kentucky Nurse, 58: 6-9.  Web, accessed on PubMed.

Inequalities in Medical Resources, Section 1, Unit 1 - Examining the Roots of Global Poor Health

Inequalities of Access to Medical Resources

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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.
Corporate Power, Inequalities in Medical Resources, Section 1, Unit 1 - Examining the Roots of Global Poor Health

Corporate Power and Access to Healthcare

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Pyrimethamine, more commonly known as Daraprim, is a drug that is frequently prescribed for the treatment of protozoal infections and malaria around the world. It is also very often prescribed for HIV positive patients in combination with other drugs. Until recently, not many knew of this drug even though it features on the World Health Organization’s List of Essential Medicines. However, that changed overnight as a new pharmaceutical company acquired Daraprim and raised its price to a whopping $750 for a pill. This development also brought attention to the rising prices of other prescription drugs, uncovering a trend which is seeing the interests of patients being pitted against the profits made by pharmaceutical and insurance companies. We know from our readings of Smedley and Smedley and Kris Holloway’s account of her experiences in Mali, that race (beyond its relation to socio-economic status) and gender are major determinants of access to healthcare around the world, but socio-economic status which is influenced by both of the aforementioned factors still remains the primary determinant. If you live in a country like the UK, where the state bears most of the healthcare costs, the inflation of pharmaceutical prices may not affect you much; however, for most of the developing world, where 70% of the world’s population resides, the price of medicines can be a barrier to being able to avail treatment for a disease.

 

90% of the people living in developing countries have to buy their own medicine. Diseases like malaria and HIV for which Daraprim is prescribed are more prevalent in developing countries. But how is an ordinary citizen from sub-Saharan Africa, where the average annual income is less than $750, supposed to afford sustained treatment for a long term disease like HIV if a single pill costs $750? This problem is not limited to HIV and malaria either. A recent study found that treatment for pneumonia in Tanzania costs an ordinary worker a whole month’s wages.

 

Some countries like India are able to subsidize some medication but most developing countries don’t have the capacity to do that. The majority of medication in most of these nations has to be imported from overseas as only 7% of world’s pharmaceuticals are produced in the developing world. Multinational pharma corporations have entrenched themselves on the global health landscape. Given that their global presence has prevented the development of domestic pharmaceutical industries, their manipulation of prices is a major concern as a lot of people depend on them for their medicines and this gives these corporations immense power. Power that they can wield in a socially responsible manner or use to milk people for their money.

 

Multinational corporations extol the virtues of corporate responsibility. Nevertheless, their track records show that they tend to exploit people and resources (their motivation for going multinational), pollute the environment and disappear once they’ve gotten what they wanted. As we learnt from our readings about the tobacco industry, profit driven corporations stop at nothing to raise their profit margins, even if that means selling addictive and harmful products like cigarettes to children or promoting a culture of smoking. If tobacco companies which sell a health hazard are able to have their way, one can’t help but wonder what pharmaceutical companies on whom the world depends on can get away with.

 

At the end of the day, the pharmaceutical sector is a business. Like many other corporations, they may not be conscientious and may even be willing to deny the poverty stricken and the impoverished their pills and let them suffer to be able to rake in more profits. This makes me wonder, are these corporations any different from the colonizers of old who used political power to exploit others economically? After all, the East India Company, the so called original corporate raiders, started out as a trade mission and evolved into a power hungry, exploitative machinery. Capitalist tendencies of pharmaceutical companies as illustrated in the instance of Turing Pharmaceuticals and Daraprim are a warning sign. In fact, journalistic organizations like WikiLeaks have being tolling the alarm bells for a while. WikiLeaks’ latest exposé, that of the Healthcare Annex to the secret draft “Transparency” Chapter of the Trans-Pacific Partnership Agreement (TPP), outlines the construction and enforcement of a transnational legal system that will allow multinational pharmaceutical corporations to exploit the world’s basic human need for healthcare by strengthening their oligopoly. While the sources may be questionable, the concern being aired is quite real… For long, public health scholars have highlighted the need for more healthcare professionals like doctors and nurses in order to improve access to healthcare globally; however, if multinational pharma companies maintain their current trajectory, we may see the need for affordable medication added to that list.

WikiLeaks-TPP-Healthcare-Cartoon

 

Discussion questions –

How can states induce pharmaceutical companies to recognize their social responsibility and provide more equitable access to drugs? How might international organizations such as the World Health Organization play a role in this?

Over-priced medicines are certainly a big problem. However, underpriced medicines can be as well. In India for instance where the government subsidizes antibiotics, a combination of over prescription and self medication have led to alarming levels of antibiotic resistance. How can we allow people the access to medication and prevent them from misusing it? How can any pertinent regulations be enforced?

 

Holloway, Kris. Monique and the Mango Rains: Two Years with a Midwife in Mali. Long Grove, Ill: Waveland Press, 2006.

Boseley, Sarah. “Dying for Profit.” The Guardian, September 8, 2003, sec. Environment. http://www.theguardian.com/environment/2003/sep/08/wto.fairtrade7.

Brandt, Allan. The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America. 1 Reprint edition. Basic Books, 2009.

Brink, Susan. “Why India Is A Hotbed Of Antibiotic Resistance And Sweden Is Not.” NPR.org. http://www.npr.org/sections/goatsandsoda/2015/09/17/441146398/why-india-is-a-hotbed-of-antibiotic-resistance-and-sweden-is-not.

Comaroff, Jean. 1997. “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body.” In Knowledge, Power and Practice, S. Lindenbaum, and M. Lock. University of California press, 305-29.

Cox, Joseph. “Surprise! Big Pharma Don’t Want Developing Countries Having Access to Cheap Medicine | VICE | United Kingdom.” VICE. http://www.vice.com/en_uk/read/american-lobbyists-are-fighting-to-halt-the-availability-of-affordable-medicine-to-the-3rd-world.

Dalrymple, William. “The East India Company: The Original Corporate Raiders.” The Guardian, March 4, 2015, sec. World news. http://www.theguardian.com/world/2015/mar/04/east-india-company-original-corporate-raiders.

Dorling, Philip. “Medicines to Cost More and Healthcare Will Suffer, according to Wikileaks Documents.” The Sydney Morning Herald. http://www.smh.com.au/national/medicines-to-cost-more-and-healthcare-will-suffer-according-to-wikileaks-documents-20150610-ghkxp0.html.

Kelly, Stephanie. “Testing Drugs on the Developing World.” The Atlantic, February 27, 2013. http://www.theatlantic.com/health/archive/2013/02/testing-drugs-on-the-developing-world/273329/.

McGee, Suzanne. “Daraprim ‘Profiteering’ Controversy Lifts Lid on Soaring Cost of Prescription Drugs.” The Guardian, September 27, 2015, sec. US news. http://www.theguardian.com/us-news/us-money-blog/2015/sep/27/daraprim-profiteering-cost-prescription-drugs-martin-shkreli.

“Medicinal Drugs in the Third World.” Text. Cultural Survival. http://www.culturalsurvival.org/publications/cultural-survival-quarterly/brazil/medicinal-drugs-third-world.

Pollack, Andrew. “Drug Goes From $13.50 a Tablet to $750, Overnight.” The New York Times, September 20, 2015. http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html.

Smedley A. and Smedley, B. 2005. Race as Biology is Fiction, Racism as a Social Problem is Real: Anthropological and Historical Perspectives on the Social Construction of Race. American Psychologist 60(1): 16-26.

Turnbull, Nancy. “Turnbull: On Inequality In Medical Spending And The Cost Hearings.” Commonhealth, June 26, 2011. http://commonhealth.wbur.org/2011/06/inequality-medical-spending.

Section 1, Trauma and Violence, Unit 1 - Examining the Roots of Global Poor Health

Trauma and Violence

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In the chapter of Abramowitz’s text, Searching for normal in the wake of the Liberian war, Abramowitz describes the post-war Liberian society and the collective trauma engulfing its members after years of civil war violence. The statistics that begin the author’s exploration are sharp: 50% of the country’s population reported “significant levels of PTSD symptoms,” 40% reported symptoms of depression. However, as the author mentions herself, these statistics allow one to understand the symptomatology of mental illness in the population, but to really understand the trauma one must look at the stories of the people.

Stories of the Liberian civil war feature atrocities ranging from human sacrifice to child soldiers being provided with cocaine and guns in preparation for battle. The war ended with an estimated 200,000 dead and 1.5 million displaced, and a society in complete disarray. As Abramowitz mentions, “violence had transgressed the most basic social values” during this war. I did not fully comprehend what this meant until I read an article in Newsweek featuring an interview with an ex-combatant named Mary who was 16 when the war ended in 2003. After the bar, she opened a bar which she manages with another 10-year-old girl, catering to “homeless crack-smoking teenagers” and older men. The article reports that Mary frequently engages in violence, beating and kicking her “manager” in the stomach if she breaks glasses, and getting into fights with adults.

Such a story can only be imaginable within the context of a place that lacks any sense of social order and sense of normalcy. It seems to me that the point Abramowitz is conveying is that the collective trauma of the Liberians stems from not only the violence of the war, but additionally from the collapse of social order under the pressures of civil war. The author retells the stories of those who have lost their roles in society – Valentine, who has lost his role as a loving son and student; Kumba’s neighbor, who has lost his role as the sub-chief of his village. In sociological theories pertaining to violence, when people can claim well-defined identities and roles in a given context, the situation is problem-free. Problems start to arise when a society cannot afford for its members to have well-defined situated identities and roles, because the societal structure is a mess. This lack of definition is echoed in the text – there were “voids of social and cultural space” allowing for violence to breed. This, in turn, would lead to more trauma, and more disorder and violence. Valentine describes feeling stuck without “forward momentum,” as his society continues to spiral down into more trauma and violence.

Present-day conflicts have the possibility of following the same trend as Liberia. What will post-war Syria look like? Already the war has been taking place for 4 years, with over 300,000 killed (June 2015 SOHR estimate) and over 4 million refugees (July 2015 UNHCR estimate). Already horrific stories have spread of children beheaded and women forcibly impregnated by members of the Islamic State. When Syria emerges from this civil war, will it have a functioning societal structure in place to prevent the downward spiral of post-war trauma and violence?

As Abramowitz mentions, Liberians who had fled during the war were the ones who seemed happier and healthier in the post-war society. The solution I have to prevent societal collapse in Syria is improvement in the global effort to accommodate its refugees. If people can be allowed to live and work in functioning environments with strong moral codes, if and when they return to their home country these people can transition back into recreating a sense of normalcy for themselves as they rebuild their country.

Discussion Question 1: Is it idealistic and demanding to think that European countries should just “open up their borders” and allow in as many refugees as they can without collapse of their infrastructure and economy?

Discussion Question 2: How can one even judge how many refugees countries can take in without total collapse? Many countries have stated that they can only take in and handle a few thousand. This to me appears to be out of Islamophobia and laziness.

Additional sources:

Left, S. (2003, August 4). War in Liberia. Retrieved from The Guardian: http://www.theguardian.com/world/2003/aug/04/westafrica.qanda

MacDougall, C. (2013, July 31). When Liberian Child Soldiers Grow Up. Retrieved from Newsweek: http://www.newsweek.com/2013/07/31/when-liberian-child-soldiers-grow-237780.html

Writer, S. (2014, November 14). ISIS Accused of Crimes Against Humanity. Retrieved from Al Arabiya News: http://english.alarabiya.net/en/News/middle-east/2014/11/14/ISIS-commits-crimes-against-humanity-in-Syria.html