Category Archives: Section 2

NGOs, Aid, and Infrastructure, Section 2, Unit 2 - Trying to Help

Caught in Contradiction: The Inverse Relationship between Funding and Freedom

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In a perfect world, every state would be able to equally serve, represent, and protect its people. However, as we know all too well, the world is far from perfect. The effectiveness of the state varies immensely across different countries, communities, and groups, leaving many individuals falling through the cracks of development in bureaucratic, impersonal systems. Non-Government Organizations (NGOs) are thought to repair some of the damage done by the state by taking more personal, community-based approaches, but they are short term fixes. As a recent Guardian article explained about NGOs in Malawi, “Many NGOs don’t work closely with local communities, so when they leave, projects collapse.” (Pensulo)

According to S. A. Zaidi, the only solution to the failures of the state is to strengthen the state itself. Zaidi argues that “NGOs are usually not in a position to address the causes of the problems their project has been designed to address.” (Zaidi, 268) While I agree that most NGOs have very limited impact on the sources of issues, I do not think the state is necessarily the solution. It is not an issue of a government versus nongovernment program, but rather the ability of a program to act without restraints and contextualize. Large scale interventions often have sufficient resources to create change, but fail to contextualize the interventions, while smaller programs have the adaptability needed to address individual needs and act without restraints, but often lack the resources to create large scale or sustainable change. The root of the problem is this: the more funding a program receives, the less ability it has to determine its own agenda.

Funding is a necessary part of any aid project, but the demands of donors can weaken the mobility and flexibility of a program. The more degrees of separation between the donors and the intended beneficiaries, the more barriers there are to the effective use of resources. Donors are often more focused on numbers than people, and statistical evidence is easier to gather for single diseases or vertical campaigns. While vertical campaigns can be effective, they attack specific problems in society without addressing the structural problems that give rise to the problem. Smaller NGOs are better able to understand underlying problems in a community, but may have difficulty gaining traction for funding. Name recognition is a barrier for small NGOs to draw in funds, so “already large INGOs are likely to further grow at the detriment of smaller and passive players.” (Greensmith) Even if a program is funded, it must produce desired results to continue to receive funding. In the case of HIV treatment in Sierra Leone as presented in HIV Exceptionalism, drugs were overprescribed because “staff members worried about if they would be perceived as ineffective bureaucratic managers of donor goods if they had an overstock of drugs.” (Benton, 126) When funding is the priority, the goal is shifted from assisting communities in need to pleasing donors.

We can continue with the example of HIV in Sierra Leone to show the importance of contextualization. Disclosure of one’s HIV status is a powerful tool – it can prevent transmission, reduce discrimination, and relieve the psychological burdens of diagnosis. With all these positive benefits, it is difficult to see why disclosure would not be encouraged and accepted, and perhaps programs would operate on the assumption that disclosure will happen between sexual partners and families, but this is often not the case. As Benton explains, decisions of disclosure must be “interpreted within local moral notions of secrecy and concealment that are linked to gender and class.” (Benton, 72) Understanding the social context of programs is so important for a program to be effective, and extremely difficult to achieve on a large scale since it varies from country to country, community to community, and person to person.

No matter the amount of funds, if the proper framework is not in place, it is a lost cause. This is not so much a matter of state versus NGO, but top-down versus bottom-up approaches. While there is no universal answer, we have seen time and time again resources lost to worthwhile causes by programs without an understanding of the target community. An example of this was PEPFAR funding in Mozambique, where “the result is an ART scale-up with millions of new dollars flowing into the health sector but little support for the building blocks of the health system that make the scale-up possible.” (Biehl & Petryna, 174) An approach that first focuses on establishing the framework at the ground level before introducing funding may be more effective. Once funding is received, the program still must have the freedom to make decisions based on the beneficiaries and not the donors. This will help ensure that the priority is where it needs to be to create change.

Questions:
1. Is it possible for an NGO to create a sustainable structural change, or as Zaidi claims, does it have to come from the state?
2. Is the type of organization (state vs. NGO) the most important consideration in determining potential impact, or is the type of intervention (bottom-up vs. top-down) more important?
3. How do we address the problem that large programs that receive the most funding are the least in control of their agendas?

Sources:
1. A. Benton. 2015. HIV Exceptionalism: Development Through Disease in Sierra Leone. Minneapolis: University of Minnesota Press.
2. C. Pensulo. “NGOs in Malawi: What Happens When Donors Leave?”The Guardian. N.p., 28 Sept. 2015. Web. 13 Nov. 2015.
Link: http://www.theguardian.com/global-development-professionals network/2015/sep/28/ngos-in-malawi-what-happens-when-donors-leave
3. J. Biehl & A. Petryna, eds. 2013. When People Come First: Critical Studies in Global Health. Princeton: Princeton University Press.
4. J. Greensmith. “Global Policy Forum.” Trends in Fundraising and Giving by International NGOs. N.p., n.d. Web. 13 Nov. 2015.
Link: https://www.globalpolicy.org/component/content/article/176/31462.html
5. S. Akbar Zaidi. 1999. “NGO Failure and the Need to Bring Back the State.” Journal of International Development 11(2): 259.

NGOs, Aid, and Infrastructure, Section 2

NGO-Donor Relationship and Pressure for Success

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I’m interested in critiquing “the demonstration of success” that NGOs are forced to produce for donors as evaluation for their efforts. I also think that evaluating the success of global health projects using a business-like model can be problematic.

Fundraising for a specific epidemic is one way to mobilize resources for NGOs using a vertical model (Biehl & Petryna, 2013). Uniting behind one health issue is a benefit of the vertical approach but as we have seen with “magic bullet” case studies for malaria and guinea worm, these programs can fail. Vertically oriented programs have major drawbacks because they don’t consider the improvement of regional health in a holistic manner. NGOs are one way to tackle issues of global health but they are dependent on donor funding (Zaidi, 1999). There exists a patron-client relationship between donors and NGOs similar to something you would find in a business.

Donor investment fads are one issue in NGO funding because popular issues are prioritized over necessities (Zaidi, 1999). Donors also have the power to decide what specific objectives are being targeted (Biehl & Petryna, 2013) and what projects to create. This makes me wonder how often project choices are based on evidence of need in a particular region or just based on the opinion of the donor, which may or may not be the best way to spend the money. Communication with community leaders about health projects they view as most important in their region should play a major role in NGO program planning to have the most effective outcomes (Ooko, 2014).

NGOS have been known to fix data for donors so they see the outcomes they want to continue to invest in the projects (Zaidi, 1999). This information is incredibly troublesome because it doesn’t show real progress or improvements of a health effort. This is similar to the portrayal and understanding of a country’s GDP, or the size of their economy. While Mozambique’s GDP increased after structural adjustment showing economic growth, the wealth of the rich increased, the poor populations grew poorer and rates of child malnutrition haven’t improved (Biehl & Petryna, 2013). The rise in GDP did not necessarily indicate an increase in health.

Statistics are one way to illustrate the “success” of a global health program to donors and specific patient examples are another. Ugandan patients in ARV programs proselytize their programs and endorse the success of treatment with their voice and bodies (Biehl & Petryna, 2013). Brenda of the HBAC program is one example of a success story from USAID support. Her story of transition, once on the verge of death to currently enrolled in college, provides evidence of success to donors and patrons, which shows the NGOs accountability. Benton (2015) also discusses the idea of successful examples of health in the context of HIV in effort to erase the stigma associated with being HIV positive. While I think that in both cases the use of specific patient examples can be motivating for either the donor or other patients, the comparison that other patients make between themselves and the example can be damaging to their own morale. Everyone recovers differently and faces different obstacles in their lives and health so modeling after one “good example” may sometimes be unrealistic.

Using a business-like model, or donors investing money with the expectation of “success” in the form of fast-improved health statistics or case studies, forces NGOs to create quick fixes to health issues rather than investing in regional structural changes that are sustainable. I draw a parallel in the US education system as teacher salaries in Florida are dependent on their student’s test scores. Studies have shown that teaching quality is not related to test scores (O’Connor, 2014) and I think this follows similar lines with the expectations of NGOs. Sometimes health improvements are difficult to measure or there are lags in the results of efforts, but these reasons should not deter donor investing in important projects.

The effects of NGO global health projects should be measured and monitored in some way to evaluate community health improvement. I suggest this be done through continued data collection, effective communication between NGO leaders and community members a part of target populations, and the donor taking a more hands-off role in program planning. We might also think about the time frame for the outcome of these efforts and consider measuring success over longer intervals so that efforts of long-term sustainable projects have time to form (Sriskandarajah, 2015).

 

Discussion Questions

  1. How can success pressure be alleviated from NGO programs? Is this necessary, or are there any alternative ways to evaluate the effects of global health projects?
  2. What role should donors play in the planning of global health programs they invest in? Does this change based on individual donors vs. government donors or their respective experience levels?

 

Sources:

  • J. Biehl & A. Petryna, eds. 2013. When People Come First: Critical Studies in Global Health. Princeton: Princeton University Press.
  • Zaidi, S.Akbar. 1999. “NGO Failure and the Need to Bring Back the State.” Journal of International Development 11(2): 259.
  • Ooko, Sarah. “NGOs and Development in Africa: Lessons for Donors.” Thomson Reuters Foundation. 3 Mar. 2014. Web. 13 Nov. 2015. <http://www.trust.org/item/20140303151017-208vf/>.
  • A. Benton. 2015. HIV Exceptionalism: Development Through Disease in Sierra Leone. Minneapolis: University of Minnesota Press.
  • O’Connor, John. “Two New Studies Find Problems With Teacher Evaluations.” State Impact. NPR, 13 May 2014. Web. 13 Nov. 2015. <https://stateimpact.npr.org/florida/2014/05/13/two-new-studies-find-problems-with-teacher-evaluations/>.
  • Sriskandarajah, Dhananjayan. “Five Reasons Donors Give for Not Funding Local NGOs Directly.” The Guardian. 9 Nov. 2015. Web. 13 Nov. 2015. <http://www.theguardian.com/global-development-professionals-network/2015/nov/09/five-reasons-donors-give-for-not-funding-local-ngos-directly>.
Regimes of Research, Section 2

When Health is for Sale: The Need for Different Levels of Regulation in Global Health Interventions

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Many of the articles this week criticize the use of strictly regulated clinical trials for being unable to treat research subjects as members of unique communities, or fully evaluate the holistic impact of a drug or intervention on a community. Simultaneously, authors like Adriana Petryna in Ethical Variability argue that the ethical standards used for research subjects in developing nations differ from those in developed nations, and she alludes to the need to implement further regulatory practices to equitize the way human subjects are treated.

I would argue that to ensure all populations are treated ethically, regulations for trials intended to create reproducible results need to be even more strict than they are now. For example, in almost no circumstances should for-profit companies be given regulatory passes, or be allowed to follow different ethical standards during situations of humanitarian crisis, becuase too often these situations are used to exploit suffering populations further. For example, when Pfizer wanted to expedite FDA approval of Trovan in 1996, they were able to successfully take advantage of a meningitis outbreak in Nigeria to conduct faster clinical trials by ignoring getting patient consent and giving their experimental pill to Nigerians who did not know they had safe and proven alternatives available to them (Petryna, 2013). Ultimately, the use of an expedited clinical process resulted in an easy way for Pfizer to hide evidence that Trovan causes severe liver damage (Petryna, 2013). Additionally, Dr. Chan of the WHO denounced how pharmaceutical companies handled developing an Ebola vaccine, claiming that there is no vaccine because “a profit-driven industry does not invest in products for markets that cannot pay” (Gladstone, 2014). Furthermore, she noted that it is subjects in the United States who were initially targeted to be the subjects for upcoming vaccines, rather than those in developing nations. This is problematic since subjects for risky clinical trials are almost always recruited from developing countries, but are unable to benefit from this vaccine that could immediately directly benefit those citizens.

Rather, if a situation is severe enough that it requires expedited processes, third party organizations that are not-for-profit should be used for conducting trials when removing certain regulations. It is not in any sense altruistic for a for-profit company to perform legally required trials in cheap areas of the world, regardless of the humanitarian need or perceived benefit in the local community, and FDA regulations should reflect this reality by ensuring that pharmaceutical companies are treating subjects the same way they would in any developed nation. It is far too naive to assume a for-profit company is acting out of humanitarian obligation, and thus the use of scrutinized trials and regulations are necessary, no matter how impersonal. Randomized clinical trials (RCTs) are considered “the gold standard” of research methods because they prove an outcome is not due to chance, and are designed to avoid observer bias (Adams, 2013). RCTs are absolutely necessary for any drug, treatment, or intervention intended to be replicated on a large scale, especially those done by  for-profit entities. Of course, RCTs will not report on many unintended consequences, but there is no guarantee unstructured observation will either.

The larger question is, how often is it preferable not to create interventions that are replicable on a mass scale? It is crucially important to recognize that the most beneficial health interventions are often purposefully tailored to a specific community and culture, and are not intended to be reproducible in other contexts around the globe. In When People Come First, Vincanne Adams talks about how problematic it has become that showing that a study is reproducible is more important than showing an intervention positively impacts health. In settings in which non-profits are performing health interventions or responding to humanitarian crises, it is essential that time, money, and health outcomes not be jeopardized by turning interventions into research studies.
In an increasingly for-profit sphere, money intended to go towards impacting communities is instead going into designing and proving the effectiveness of interventions as research studies. There is often a mandate to turn interventions into research, and hire research and consulting firms and for-profit NGOs, as well as purchase expensive ‘reliable’ assessment instruments in order for an intervention to be seen as credible. While cost-effectiveness analysis should never be the only justification for performing an intervention, it is clear in this situation that performing an RCT would be a much more inefficient use of money in the short-term. In the long-term, if we understand that different communities have individual needs, interventions must constantly evolve, so a specific RCT would not be cost-effective in the long-term either. Ultimately, nonprofit interventions should only be designed to have the most beneficial local impact, while for-profit interventions should be intensely regulated no matter the humanitarian need.

Sources:

Biehl, João Guilherme., and Adriana Petryna. “Evidence-Based Global Public Health.” When People Come First: Critical Studies in Global Health. Princeton: Princeton UP, 2013. Print.

Petryna, Adriana. “Ethical Variability: Drug Development and Globalizing Clinical Trials.” American Ethnologist 32.2 (2005): 183-97. Print.

Gladstone, Rick. “W.H.O. Assails Delay in Ebola Vaccine.” The New York Times. 03 Nov. 2014. Web.

Discussion Questions:

  1. Should global health interventions and responses to humanitarian crises be regulated differently in situations in which for-profit companies and non-profit companies are performing global health work?
  2. Is it always justified for nonprofit humanitarian global health work to avoid using the research methods of randomized controlled trials (RCTs)? Do RCTs offer substantial benefits when evaluating global health work?
  3. Ultimately does turning a health intervention into a controlled research trial create an inherent tension of academic good and rigour vs. social benefit, as Petryna suggests?
Humanitarianism, Section 2

The Most “Humane” Organization

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Médecins Sans Frontières (MSF), also known as known as Doctors Without Borders, is known across the world as a provider of emergency humanitarian aid in response to war, disease, natural disaster, and exclusion from healthcare (“About MSF”). They push to be ethical, moral, and impartial, but the problem is, there are still people behind the decisions that the organization makes, and it begs the question: who gets to define what is ethical? MSF also treads carefully in order to respond appropriately to crises, but again, what entails a crisis? There is a danger in trying to define these convoluted components of humanitarianism, since the determinant is given the power to ultimately determine the value of a life.

When I search up the definition of “ethical”, the following results show up:

  1. following accepted rules of behavior : morally right and good
  2. involving or expressing moral approval or disapproval
  3. conforming to accepted standards of conduct (“Ethical”)

All of these definitions require ethics being “accepted” or “approved”, but it is virtually impossible to gain 100% approval on anything. Individual people make these decisions, and as seen in the article by Mirian Ticktin Where ethics and politics meet: The violence of humanitarianism in France, there are nurses who read files and meet with people in order to decide if their illnesses warrant citizenship. Like gatekeepers or admissions officers, these nurses are allowed to make a subjective decision, even when their backgrounds and past experiences can easily shape their compassion and who they choose to help (Ticktin). This leaves an incredible amount of room for variability, but can a standard be set on these decisions? Is it truly humane to allow citizenship to one suffering person, while ignoring another?

Similarly, MSF responds to international crises, but there has been uncertainty—even within the organization—about what appropriate responses to these issues are.  As with almost all humanitarian aid, there are those two dreaded words: unanticipated consequences. MSF knows that a quick and temporary response to an emergency is crucial, but they have to leave as soon possible since dependence on this aid often hinders a country’s own progress. As said by an MSF administrator of Ugandan projects, “We don’t want to put a foot in the [local] hospital or we’ll be there ten years later” (Redfield).

Unfortunately, that’s exactly what happened in Syria.

In 2011, MSF responded to the Arab Spring in and around Syria by operating medical medical facilities and running field hospitals and clinics. Four years later, MSF is still involved, but is facing an entirely new problem: hospitals largely run by the organization are facing air strikes, and MSF members are being abducted by the Islamic State (IS). Six hospitals have been forced to close, and four ambulances were destroyed (“Syria”). Tens of thousands of people in and around Syria are in desperate need of aid, but MSF and other international organizations are severely restricted in the humanitarian aid and healthcare they can provide. The result is poor and unsafe conditions for refugees who must live in overcrowded spaces, subject to psychological distress. In order to tackle this issue, MSF brought in psychologist and psychiatrists to carry out consultations, but it is clear that problems are compounding onto each other and that thousands of people are still suffering (“Syrian Refugees”).

So then, what is the job of MSF and international organizations? Radfield’s Doctors, Borders, and Life in Crisis distinguishes between two Greek terms for life: zoe and bios. Zoe entails the simple act of living or being alive, while bios represents a life with a narrative, and perhaps in their current state, MSF can only provide refugees the simple act of living. Can it be called humanitarian if the people who are “saved” live in fear, uncertainty, and distress? When is it time to change our mindset from “this is all we can do” to “what we’re doing is not enough”?

 

Discussion Questions

  1. Compassion currently plays a role in decision making (with France’s Illness Clause and Syrian refugees). Is there any possible way to remove compassion from the equation or ensure decisions are impartial?
  2. In humanitarian work, is it enough to simply keep someone alive? Who holds the responsibility of keeping people physically alive and who holds the responsibility of ensuring these people have human dignity? How do we define dignity?

Works Cited

“About MSF.” Médecins Sans Frontières (MSF) International. N.p., n.d. Web. 05 Nov. 2015.

“Ethical.” Merriam-Webster. Merriam-Webster, n.d. Web. 05 Nov. 2015.

Ticktin, Miriam. “Where Ethics and Politics Meet.” American Ethnologist 33.1 (2006): 33-49. Web. 5 Nov. 2015.

Redfield, Peter. “Doctors, Borders, and Life in Crisis”. Cultural Anthropology 20.3 (2005): 328–361. Web.

“Syria.” Médecins Sans Frontières (MSF) International. N.p., n.d. Web. 05 Nov. 2015.

“Syrian Refugees Need Humanitarian Aid.” Doctors Without Borders Canada/Médecins Sans Frontières (MSF) Canada. N.p., 14 Aug. 2012. Web. 06 Nov. 2015.

 

Humanitarianism, Section 2, Unit 2 - Trying to Help

Bring out the Human in Humanitarianism

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The context of global humanitarianism has been growing throughout the years. Peter Redfield’s Doctors, Boarders, and Life in Crisis, along with Miriam Ticktin’s The Violence of Humanitarianism in France, really paint a picture of major consequences that are associated with humanitarianism. The first are the consequences associated with this transition of humanitarianism to politics. The second is the possible dehumanization of those who are being helped. After reading the examples provided by both authors, it is clear that there has been a shift in what humanitarianism is and that sometimes it creates a limited version of what it means to be human.

This shift of humanitarianism to politics is illustrated with the “illness clause” in French law. This clause gives people with serious illness the right to stay in France regardless of if they are an undocumented immigrant. This clause was created as an alternative to human rights discourse and for those who did not obtain rights based on the states interests (Ticktin, 5). Due to this, the illness clause made sickness a primary way for undocumented citizens to get papers to stay in France. People would even go as far as infecting themselves with an illness such as HIV/ AIDs just so they could stay in France and “live more fully.” In this case, humanitarianism, seen with the illness clause, shifting to politics resulted in a consequence where the undocumented were giving up bodily integrity for human dignity. These immigrants would rather live a fuller life infected with HIV/AIDS than be completely healthy and deported. Some citizens even took up identities of friends who had died of HIV/AIDS just to stay in the country (Ticktin, 8). In essence, this clause is allowing undocumented immigrants to place less value on their lives and create a limited version of what it means to be human. In France these people are giving up an opportunity to a healthy life just to be considered a citizen.

The dehumanization that can be associated with humanitarianism can be seen in the refugee camps mentioned in Doctors, Boarders and Life in Crisis. Even though these camps foster the possibility of mass survival, the figure of a human still emerges from behind that of a citizen (Redfield, 341). The goal of these refugee camps may be to aid those who have suffered from severe political and ecological instability, however, it is important to note that they do play a role of devaluing human life. In these camps, the refugee’s dignity and citizenship are put into question. Here the only things that matter are calorie intake, hydration and shelter (Redfield, 342). Yes these are very important aspects of life that need to be protected. However, because these aspects are the biggest and only concerns of the camp, individuals loose their ability to voice their opinions and perform acts of civil virtue. In this sense, the person is being seen not as a person but just as another body in the camp.

This is again seen in the worlds second largest refugee camp in Jordan. This camp holds more that 80,000 people whose lives are on hold and going nowhere (Swan, BBC). For some of these refugees, life in the camp holds such little value and hope that they would rather return home to Syria. On one hand obviously these refugee camps are providing safety and life to those who were in danger, but on the other hand these people are losing what it means to be alive. An important question must be asked: what, if anything, should we do to help these people who are already suffering maintain the feeling of what it means to be alive?

 

Discussion questions:

  1. How do humanitarians ensure that in providing necessary materials for living, that they are also providing what is essential to feel human?
  2. Is there a way to stop or at least limit this shift of    humanitarianism to politics?

 

Work Cited:

Redfield, Peter. 2008. “Doctors, Borders, and Life in Crisis.” Cultural Anthropology 20(3): 328-361

Ticktin, Miriam. 2006. “Where Ethics and Politics Meet: The Violence of Humanitarianism in France.” American Ethnologist 33(1): 33-49.

“Lives on Hold: The Scots Helping Syrians in a Refugee Camp – BBC News.” BBC News. N.p., n.d. Web. 05 Nov. 2015.

Essential Medicines and the Pharmaceutical Fix, Section 2, Uncategorized

Are Essential Medicines Really Essential?

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The field of global health is constantly evolving. From its murky origins in colonial medicine, to its shift from vertical to horizontal care, to today’s technological age, global health has been shaped by a variety of societal forces. Today, we observe the phenomenon of pharmaceuticalization (Biehl et. al).  With scientific and technological innovations, diseases like tuberculosis, malaria and AIDS, that were once thought to be fatal are now treatable. It is unjust to discriminate who deserves biomedical cures for life-threatening diseases based on race or socio-economic status. Doing so would deepen inequities and promote forms of structural violence (Farmer 265). In response to this problem, in 1975, WHO Director-General Halfan Mahler highlighted the need for a list of basic, essential medicines that every individual deserves access to. The WHO published this list of “essential medicines” two years after his speech. This list was assimilated after consulting ministry officials, doctors and health care providers across over twenty-five countries (Greene 17).

While the document was no doubt well intentioned, the subjectivity of the word “essential” itself makes me question its effectiveness. The criteria used to dictate which medicines made the list and which did not, were not necessarily comprehensive. The idea of “local biologies,” itself shows that there is a great deal of regional disparity among the symptoms of various afflictions; certain diseases have more potent effects than others due to cultural and social differences among nations (Lock 1). How can we create a blanket list of only 186 worldwide “essential medicines,” when each region and its government have specific health issues and unique barriers to access drugs?

Furthermore, our list of “essential medicines,” may in fact perpetuate inequities rather than eliminate them. For example, it favors prevalent conditions over rare diseases (Greene 18). In the summer of 2013, I interned with the Rare Genomics Institute, an organization focusing on developing treatments and bringing awareness to those suffering from rare genetic diseases. After interviewing over thirty individuals with rare diseases, a common theme emerged. There was a lack of research and development for cures due to the low profitability of rare disease ventures. Rare disease drugs, also known as “orphan drugs,” were not seen as profitable by large biotech companies (Jessop). Or, if the drugs were available, they were placed at exorbitant prices. Is it just, to tell a woman I interviewed with Gaucher disease, that she deserves to pay $310 250 for one therapy treatment? Neglected by the health care system, many individuals suffering with rare diseases succumb to despair and hopelessness. Is it fair to favor the majority in our definition of “essential”? The blanket statement of the word “essential,” gives biotechnology companies and governments an excuse to not care for those in the minority. In addition, its inflexible structure obstructs new medicines from being added, preventing individuals from benefiting from the dynamic innovation occurring in the global market.

What truly is concerning, is that pharmacologists developed the first list of essential medicines (Greene 24). In today’s market, pharmaceutical companies have the power in deciding what these “essential drugs” are and how much they should cost. A recent controversy regarding drug pricing has emerged from an agreement known as the Trans-Pacific Partnership (TPP). A Wikileaks document shows one of the final drafts of its chapter on intellectual property, which entails policies that will limit the competition of generic drugs. Through allowing patent term extensions and market exclusivity for drugs, this agreement will result in higher drug prices (Gleeson 1). Especially in developing countries, with weakened economies, this agreement will prevent access to affordable medicines. Medicins Sans Frontiers and other international organizations have protested the institution of this plan due to its destructive effects on the poor (Medicins Sans Frontiers). In Julie Livingston’s Improvising Medicine, we can see the devastating effects resulting from a scarcity of affordable medicines. In PMH, “some people shared stories of a profound physical agony and deaths born of the near total lack of medicines, sutures and bandages” (Livingston 177). It is not ethical to have a system where corporations and market- driven governments profit from causing misery and death. Yet, Greene notes that pharmaceutical companies brand themselves as “global health,” companies, falsely portraying themselves as supporters of the WHO’s initiatives.

And so as we shift towards emphasizing PHC, we must recognize that in some ways, the WHO’s list of essential medicines is enabling the oppression of the poor and supporting pharmaceutical companies in their profit- driven initiatives. While the WHO’s list of essential medicines was an important start to promoting health equity, I believe that we must look towards new approaches in the 21st century.

Discussion Questions 

  1. The definition of “essential,” has caused great debate in the global community. Currently, the WHO has defined its list of essential medicines based on popularity, previous establishment, efficacy and cost. How do you think the word “essential” should be defined? Do you think it is necessary to have a list of essential medicines? Should the WHO redefine or modify its list?
  2. In the case of pharmaceuticals, do you think it is possible to balance profit- driven incentives with a desire to improve the common good? In other words, can we still create incentives to innovate while ensuring the affordability of essential drugs?

Works Cited

In Class sources 

Biehl, Joa. When People Come First Critical Studies in Global Health. Princeton: Princeton UP, 2013. Print.

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

Greene, Jeremy A. “Making Medicines Essential: The Emergent Centrality of Pharmaceuticals in Global Health.” BioSocieties 6.1 (2011): 10-33. Web.

Livingston, Julie. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham: Duke UP, 2012. Print.

Lock, Margaret. “Menopause, local biologies, and cultures of aging.” American Journal of Human Biology 13, no. 4. 2001.

Out of Class Sources 

Gleeson, Debrorah. “Comments on the Completed Trans Pacific Partnership (TPP) Intellectual Property Chapter.” N.p., 10 Oct. 2015. Web. 01 Nov. 2015.

Jessop, Nathan. “The Dilemna with Orphan Drugs.” PharmaTech. N.p., 1 Aug. 2013. Web. 2 Nov. 2015.

“Statement by MSF on the Conclusion of TPP Negotiations in Atlanta.” MSF USA. N.p., 05 Oct. 2015. Web. 01 Nov. 2015.

 

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

Defining Efficacy: The Pharmaceutical Industry and Access to Treatment

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During the 1990s and 2000s, HIV/AIDS activism made huge strides in reducing antiretroviral treatment (ART) prices and making HIV treatment more globally accessible. Through extensive human rights campaigns, activism efforts, and support from a host of governmental and supranational bodies, expensive drugs that were once deemed not cost-effective to provide in developing nations were made available to many of the world’s poor suffering from HIV/AIDS. The authors of Reimagining Global Health note that “The lowest available annual per-patient price of the most common first-line HAART regimen in the developing world fell from $10,000-$15,000 in the late 1990s to $300 in 2002 to $87 in 2007” (Farmer et al., 2013). For many infected with HIV, these improvements meant that HIV/AIDS would no longer be a death-sentence, but could be managed as a life-long chronic illness.

Much of this price-drop was attributed to the increased production of generic forms of brand-name treatments. Through partnerships with governments of developing countries and adapted business models, generic drug manufacturers were able to sell generic antiretrovirals at set—and comparatively low—price points (Farmer et al., 2013). This new wave of generic antiretroviral drug production was spurred in part by the passage of the South Africa’s Medicines Act of 1997. This act gave the government the right to allow compulsory licensing of brand-name drugs in the case of a public health emergency, meaning that patented antiretrovirals could be made by generic drug manufactures without permission of the patent-holder. Although 39 pharmaceutical companies filed lawsuits against the act in South African courts, political and social support for the Medicines Act caused them to withdraw their complaint three years later. Indeed, later that same year the World Trade Organization recognized that South Africa had not violated trade agreements concerning intellectual property rights, further solidifying the precedent that public health matters could override intellectual property rights (Farmer et al., 2013).

While the HIV/AIDS movement for access to ART is a truly remarkable example of harnessing social and political forces to make life-saving pharmaceuticals available in resource poor settings, it stands as the exception to the rule. Indeed, as Nicholas King describes in his article “Security, Disease, Commerce: Ideologies of Postcolonial Global Health,” pharmaceutical companies continue to have little incentive in developing effective and affordable treatments targeted at populations of developing nations. Not only is the Western pharmaceutical industry ill-designed to cheaply produce and sell important medicines to developing nations, but these same manufacturers whose product is inaccessible in poor settings continue to fight against the production of cheaper generic alternatives in non-Western countries—despite the public health importance of the medicines and the low-purchasing power of developing nations.

The battle surrounding patent protection is far from over. Recent trade negotiations concerning the Trans-Pacific Partnership—a trade agreement that would link nations including the United States, Japan, Australia, Canada and Chile, among others—are rife with controversy over the issue of pharmaceutical patenting. Many countries in the partnership want the United States to reduce their patent protection from the current 12 years to allow generics to enter the market sooner, while members of United States Congress have asserted they will not support the deal without a strong intellectual property rights component (Weisman, 2015).

Incidentally, the timing of these trade negotiations coincided with another controversial case involving the pharmaceutical industry. In September, the American pharmaceutical company Turing Pharmaceuticals made headlines when they purchased the rights to the drug Daraprim—a drug developed 62 years ago that treats toxoplasmosis—and increased the price from $13.50 a pill to $750 a pill (Pollack, 2015). The increase in price was not due to increased manufacturing costs of the drug, but due to the desire for an increased profit margin on part of Turing Pharmaceuticals. Unfortunately, this case is not isolated, but only one of many in a series of similarly inexplicable price-hikes enacted by drug companies.

How did the precedent set by the successful price reduction in HAART due to generic manufacturing during the early 2000s fail to translate to other life-saving medications? Aside from cases of “public health emergencies,” the pharmaceutical industry has near complete control over the production and pricing of many crucial medicines. Advocates of the pharmaceutical industry argue that a system based on profit-motive supports industry innovation and the production of better, more effective drugs. And yet, how effective can a medicine really be when it is out of reach of those who it would help the most? The efficacy of a medicine should not be measured simply by its biomedical utility, but also by its accessibility. If a pharmaceutical treatment is not available to a population for social reasons, it cannot be available to treat or cure on a biological level—bringing into question how exactly pharmaceutical companies should approach creating “effective” medicines.

 

 

Sources:

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

King, N. 2002. Security, Disease, Commerce: Ideologies of Postcolonial Global Health. Social Studies of Science 32(5-6): 763-789.

Weisman, J. (2015, July 30). Patent Protection for Drugs Puts Pressure on U.S. in Trade Talks. New York Times. Retrieved October 20, 2015, from http://www.nytimes.com/2015/07/31/business/international/pacific-trade-deal-drugs-patent-protection.html

Pollack, A. (2015, September 20). Drug Goes From $13.50 a Tablet to $750, Overnight. New York Times. Retrieved October 20, 2015, from http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html

 

Discussion Questions:

  • How much control should the pharmaceutical industry have on setting prices for life-saving treatments? If their control should be limited, which governing body should have the power to decide pharmaceutical pricing?
  • How likely is it that another massive activist movement, such as the movement for access to ART for HIV/AIDS treatment, will be able to drastically change the accessibility and affordability of important medicines?
  • Turing Pharmaceuticals argued that their price increase of Daraprim was justified because the drug is not commonly used anymore, and the increased profits generated from this price-hike will allow the company to expand research and development into other more effective drugs to treat toxoplasmosis. Do you agree with this justification? Why or why not?
Alma Alta, Primary Health Care, and Selective Primary Health Care, Section 2, Unit 2 - Trying to Help

Vertical vs. Horizontal Approach: The drawbacks of each and a need for a merging or “diagonal” approach

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When thinking about how to address health problems around the world there were two ideas that seem to arise, vertical and horizontal approaches. The vertical approach being a disease specific top-down approach that makes it easier to obtain funding and measure results and the horizontal approach being a more comprehensive approach that seeks to treat all the underlying issues a population that cause various diseases and health problems but that is more abstract.

These approaches are also intrinsically related to the debate of Magic Bullets vs. Primary Care and even in the debate of Comprehensive Primary vs. Selective Primary Care. The vertical model relies on the use of magic bullets, simple and fast acting biomedical advances, in order to implement their programs. When a so-called magic bullet is available and completely effective a vertical approach would be successful as you can reach many people give them a one-time treatment and solve the specific health problem.

The issue arises because there doesn’t exist a magic bullet for the vast majority of diseases that developing countries face, therefore when global health organizations come into these countries with specific disease approaches they are overlooking the structural factors that give rise to health concerns. Comprehensive Primary Care aims to be the opposite of this; it is basically a horizontal approach. The issue there, of course are concerns over cost-effectiveness. Quick-fix and Magic bullet programs come out with a much better ranking in regards to cost-effectiveness which favors downstream medical interventions and finds upstream interventions, such a school-based programs largely ineffective, because it will take several years for the health effects to take place and even when they do it is not easily measurable.

You see this sort of idealistic approach and mentality at the Alma-Ata conference in 1975, with the desire of “Health Care for all by year 2000”. But this model was ultimately unsuccessful and the Selective Primary Care Model that emphasized GOBI (growth monitoring, oral rehydration therapy, breast feeding and Immunizations) triumphed. Selective Primary Care operates more as a vertical approach even primary care in the name because it emphasized only specific issues. While it was an “interim” strategy there were never plans of shifting to more comprehensive primary care.

These two approaches seem like they would have to be competing ideologies, where only one can be correct. I believe that this is not necessarily true. Because both of these approaches have considerable drawbacks and unintended consequences of implementation, the merging of both these approaches would actually increase the benefits while minimizing the risks and drawbacks. In an article by Gorik Ooms, he addresses this as a need for a “diagonal” approach. He suggests that we should be aiming for “disease-specific results but through improved health systems”. This is an interesting idea and definitely important to consider when planning and designing interventions. I believe it is possible to create a new approach that will be more effective; it will however require funding and commitment. Tore Godal suggests the shifting to a Global Health fund that would “consolidate towards a global health fund with one health sector funding channel”. He argues that with an increase in funding and supplies it is possible through a unified effort to simultaneously achieve disease-specific success while strengthening the health system.

Gijs Elzinga also discusses this in an editorial piece titled “Vertical-horizontal synergy of the health workforce” in which he states that while certain components of vertical programs are vertical in nature there is an interface when it comes to the delivery of interventions. Because intervention delivery requires the greatest number of workforce involvement, there is some room for the interventions to be more integrated into a horizontal system, in which health care workers seek to address all the issues. I think vertical approaches can enhance vertical horizontal collaborations and attempt to decrease the polarization of the vertical vs. horizontal debate. The use of more of the existing personnel of healthcare workers is one way this can be achieved.

I believe the strength in this idea of a “diagonal approach” comes from not shifting to a horizontal approach overnight and the integration of the benefits of each. It is important to change the mentality around our approach as only being able to fit into these categories. Although pragmatism is important when it comes to implementation, we need to think about the long-term results and the programs sustainability. We need to implement programs that have the ability to change over time, shifting its goals with increasing resources.

Sources from Class:

Paul Farmer, e. A. (2013). Reimagining Global Health An Introduction.

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

Outside sources:

“Vertical–horizontal Synergy of the Health Workforce.” WHO. N.p., n.d. Web. 22 Oct. 2015.

“The ‘diagonal’ Approach to Global Fund Financing: A Cure for the Broader Malaise of Health Systems?” Globalization and Health. N.p., n.d. Web. 22 Oct. 2015.

Discussions Questions:

  1. Do you think merging the different approaches that we have discussed will yield successful outcomes? Do you think it is possible to implement programs like this?
  2. Do you think the idealism of the Alma-Ata Declaration was influential in making change by getting people to talk about health, or did its lack of pragmatism and ability to be implemented render it basically useless?

 

Inequalities in Medical Resources, Section 2, Unit 1 - Examining the Roots of Global Poor Health

Race Correction and Inequalities in Medicine

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The history of medicine is fraught with unnecessary racialization. In “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body,” Comaroff writes about how the black body became “associated with degradation, disease, and contagion” and how colonial medicine “link[ed] racial intercourse with the origin of sickness.” These overtly racist ideas have decreased in influence over time. However, even today, the remainders of these ideas still manifest themselves in racial inequalities in treatment and access to medical resources, and in the general racialization of medicine, both in the U.S. and around the world.

Smedley and Smedley write about the consistent racial and ethnic disparities in health care in their paper, “Race as Biology is Fiction, Racism as a Social Problem is Real.” They report a series of shocking statistics, which include that Africans Americans and Hispanics in the U.S. tend to receive lower quality health care across many different disease areas, African Americans are more likely than whites to “receive less desirable services, such as amputation,” and that these disparities are “found across a wide range of clinical settings including public and private hospitals, teaching and nonteaching hospitals.…” Similarly, Livingston details a scenario where a patient O (a black man) is expected to endure an incredible amount of pain during a bone-marrow biopsy without making any sounds of pain. When Mr. J (a white man) undergoes a similar bone marrow aspiration, Dr. A holds his hand and the Motswana nurse comforts him. Livingston writes that “his whiteness apparently creates different expectations around his stoicism.” Smedley and Smedley write that racialized science (and any science that looks for differences between racial groups) can only maintain and reinforce existing inequalities. Although many racial disparities in health are also the product of socioeconomic differences, Smedley and Smedley argue that when we accept this concept, there is the implicit idea that these socioeconomic differences are acceptable.

In her recent book, Breathing Race into the Machine, Lundy Braun writes about racial comparisons in lung capacity and about the race correction of spirometers. Since the 19th century, it has been a well-established concept in scientific literature and in the medical community that African Americans (and most other racial groups other than people classified as whites) have a lower lung capacity than whites. Therefore, when doctors measure patients’ lung capacity even today, their spirometer values are “race corrected.” This means that the spirometer values considered “normal” for black patients are reduced, and black patients are not offered treatment or any sort of medical interventions for lower lung capacities than white patients with the same numbers. There are a few issues with this practice.

First, using race to correct for lower lung capacity ignores socioeconomic or environmental reasons for this decreased lung capacity. Often race issues are tied to socioeconomic differences and socioeconomic factors in lung capacity can also be connected to environmental explanations. Neighborhoods with lower socioeconomic status and high rates of minorities have also been shown to have higher rates of environmental pollution. Secondly, there is the issue of whether race should even be considered when taking this kind of medical measurement. When Braun interviewed physicians, they did not have a standardized way of determining race. Some physicians determined their patients’ race by looking at them and others asked patients to self-identify. Modern genomics show that there is more genetic variation within a race than there is between races, so using race as a biological concept seems even more flawed.

In the scene from Improvising Medicine, the doctors expect different things from the black man than from the white man and accordingly treat the two patients in different manners. However, juxtaposing Braun’s work on spirometers and race correction with Smedley and Smedley’s statistics on racial inequalities seems to create a sort of tension. Medical professionals are acknowledging how a certain minority group has worse health than others, but at the same time, they continue to be given worse care in the hospital. Race is one of the major factors in health care inequalities, and it would seem like acknowledging it would help fix this problem. Often, the first step to resolving an issue is addressing the issue and determining the roots of the problem. Nonetheless, the race correction of spirometers seems racist and unproductive in its current use.

It would be incredibly problematic if this type of race correction occurred globally and included other measures of health. Race correction could become a way of explaining structural violence and inequality produced by racial and socioeconomic factors, as well as becoming a method through which further inequalities were perpetuated through the decreased distribution of therapy or other medical interventions to these groups.

 

Discussion Questions:

  1. How do we move forward from simply acknowledging and naming racial inequalities in health to working to eliminate these inequalities (especially if simply making physicians aware of these inequalities doesn’t change anything)?
  2. If race is more of a social concept than a biological one, how productive is it to acknowledge race in terms of medical inequalities?
  3. How can race correction (and other similar viewpoints in the general public or in the medical community) be eliminated?
  4. Thinking about how “normal” is thought of differently (in relation to PTSD symptoms in Liberia, or classifying “normal” around the world), can race correction be justified if it shifts measurements towards the average value of the under-privileged community?

 

Sources:

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.

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

Shaban, H. 2014. “How Racism Creeps Into Medicine.” The Atlantic. [http://www.theatlantic.com/health/archive/2014/08/how-racism-creeps-into-medicine/378618/, accessed Sept 29, 2015].

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.

Section 2, Trauma and Violence, Unit 1 - Examining the Roots of Global Poor Health

Trauma and Violence

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Post-traumatic stress is something that can take on many forms and arise from many different circumstances. It is also known at post-traumatic stress disorder (PTSD) but sometimes the word disorder is removed to decrease the stigma surrounding it. In an article in Vanity Fair called How PTSD Became a Problem Far Beyond the Battlefield, the author, Sebastian Junger, explains that “Because PTSD is so adaptive, many have begun leaving the word “disorder” out of the term to avoid stigmatizing a basically healthy reaction.” PTSD was originally associated with combat soldiers, but has since been recognized as something that can affect anyone who faces any trauma. As Junger explains in his article, sometimes those who experience the most severe forms of PTSD are victims of rape, and those who witnessed but were not directly involved in combat, such as himself, as journalist who travelled to Afghanistan. Sharon Abramowitz explains, in her article, Searching for Normal In the Wake of the Liberian War, people are forced into a condition they are not accustomed to, where the suffering detaches them even before they have made a trial run. Abramowitz states, almost fifty percent of the population living in Liberia at the time of the Liberian war reported severe symptoms of PTSD.

Unfortunately, there is very little treatment for this and any other form of mental disorder due to many different barriers to care. Based on research for a paper I wrote discussing PTSD in American soldiers returning from war, the two biggest barriers were stigma and lack of access to care. In Farmer et al.’s book, Reimagining Global Health, one way to decrease the lack of access to care is to combine mental health care with primary health care. Many countries have found this to be more efficient and reach more people, either by having psychiatrists located in the same location as primary care physicians or having primary care providers trained in psychological health maintenance and care.

As I found in my research, the VA (Veteran’s Association) had tried to implement something similar based on survey results from soldiers saying this would be helpful. Unfortunately what this does not help is the stigma associated with any mental health diagnosis, as Farmer et al. describes as something that can greatly affect someone’s life, causing them to not be able to gain employment, and affecting the way family and friend’s view them.

Abramowitz explains that the entire mental and physical demeanor changes in people affected by PTSD, to the point that their own friends and family do not even recognize them. Because of this, often the friends and family try to get the person help before they themselves will reach out. Both in Liberia and the United States alike, many people who wish to seek treatment cannot afford the treatment they need. Farmer explains that neuropsychiatric morbidity is underdiagnosed and antidepressants are underutilized in rich and poor countries alike. In Reimagining Global Health, the DSM-V manual of mental disorders is discussed as something that can be a barrier to care because of the different forms across different cultures. The DSM-V describes PTSD and the symptoms associated with it, and is something for health care providers to use as a baseline to help diagnose different mental disorders and illnesses. Farmer et al. explains that the DSM-V is written based on American and European cultures, which may limit its use across culturally diverse populations.IMG_2374

 

Discussion Questions:

  • Do you agree that stigma is one of the biggest barriers to mental health care, especially the treatment of PTSD? What do you think might be other effective ways of dealing with stigma as a barrier to care? If you can think of any other major barriers to receiving mental health care, what are they and what might be some possible solutions?
  • Based on Farmer et al., the DSM-V can limit utility across cultures, which might reduce the diagnosing and care of mental health disorders around the world. What might be some of the cultural barriers caused by the DSM-V and what are some possible ways to address these problems? What might be some ideas for a more universal approach to mental health diagnosis and treatment?

Additional Sources:

Junger, Sebastian. “How PTSD Became a Problem Far Beyond the Battlefield.” Vanity Fair June 2015: n. pag. Web. <http://www.vanityfair.com/news/2015/05/ptsd-war-home-sebastian-junger>.

Doolin, D. T. (2009). Healing Hidden Wounds: The Mental Health Crisis of America’s Veterans. DTIC Document.

McNally, R. J. (2012). Are We Winning the War Against Posttraumatic Stress Disorder? Science, 336 (6083), 872–874. http://doi.org/10.1126/science.1222069