Category Archives: Section 3

Section 3

Partners in Health: a Sustainable Model for Decreasing Health Disparities

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Sub-Saharan Africa is currently facing one of the highest global burdens of disease, while maintaining the world’s smallest percentage of healthcare workers. This statistic, illustrated by the graph released in the World Health Organization’s 2006 Report (Figure 2), highlights the endemic lack of health care workers across the Sub-Saharan landscape. The World Health Organization’s recommended ratio of 2.3 health professionals for every 1000 persons seems an impossibly far cry from the Sub-Saharan norm highlighted by Rwanda’s ration of 0.72 health professionals for every 1000 persons (Cancedda 2014). What has lead to this huge deficit of health workers in the developing world and what has been done to fix it? Current work has focused primarily on confronting the burden of disease that has swept through developing nations, but what about addressing the heart of the issue? Setting up a sustainable system to fight the problem in the future is just as if not more important than attacking current health issues. This disparity in health workers has been attributed in part to the “Brain Drain”, or the migration of graduates from higher education, specifically health workers, from developing nations to developed nations in order to seek better opportunities.

Paul Farmer and his organization Partners in Health have illustrated the great work that foreign aid groups can do in aiding nations during crises, however there is little these organizations can do in order to prevent crises. There must be a shift in global health thinking from responsive to preventative, and the best way to accomplish this is by making health care more readily available. The easiest way to create a sustainable system of preventative care is by increasing the number of native health workers. However, to increase local health workers, one must slow the “brain drain” that is pulling these workers away from their countries. Factors that cause this migration of workers have been organized into Push and Pull Factors. Push factors are characterized by strong reasons to leave a country of residence like; limited career opportunities and poor working conditions, whereas Pull factors are those that incentivize movement to another country like; recruitment and better wages (Kissick). This drive to leave Sub-Saharan Africa is best characterized in Figure 3, which shows the percentage of health workers intending to migrate for better opportunities. This statistic is higher than 50% in most nations, and the reason why is clear from Figure 4 which shows the average monthly wages for health workers in developing versus developed nations. Kissick points out that the United Nations Universal Declaration of Human Rights states “Everyone has the right to leave any country, including his own, and to return to his country.” Making the point that in order to stop this migration you cannot ban it, but rather incentivize staying so that health workers will not choose to migrate.

How can Developing Nations incentivize their health workers in order to make them want to stay? Higher wages are one idea, but because of the economic situation in many developing nations it is not a valid option. Creating a sense of national pride and the want to stay and help build up your nation is another idea, however one would think this already would have worked if it was ever going to. The responsibility for stopping this migration might not fall on the nations losing their workers at all, but rather on the nations that are recruiting them away. Whichever of these if any are the right answer is not yet known, but what is for certain is that this problem needs to be fixed, or else the health disparities already present around the world will just become more exaggerated.

 

 

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Discussion Questions:

  1. How would you incentivize health workers to keep them from migrating from developing nations?

 

  1. Create a policy that would still allow Health Workers to move internationally, but would keep developed nations from stealing these workers away from developing nations.

 

Sources

Cancedda, Corrado. “Enhancing Formal Educational and In-Service Training Programs in Rural Rwanda A Partnership Among the Public Sector, a Nongovernmental Organization, and Academia.” Academic medicine 89, no. 8 (August 2014): 1117-.

 

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

 

The “Brain Drain”: Migration of Healthcare Workers out of sub-Saharan Africa

Kasey Kissick

http://med.stanford.edu/schoolhealtheval/files/KissickBrainDrainFactSheetFinal.pdf

 

Figures Sources

Connell, J, P Zurn, B Stilwell, M Awases, and J Braichet. “Sub-Saharan Africa: beyond the health worker migration crisis?” Social Science & Medicine 64 (2007): 1876-91.

 

World Health Organization. “Working Together for Health: World Health Report 2006.” 2006.

 

Vujicic, M, P Zurn, K Diallo, O Adams, and MR Dal Poz. “The role of wages in the migration of health care professionals from developing countries.” Human Resources for Health 2 (2004).

Section 3, The Partners in Health Model: Vision and Expansion

Exceptional Treatment of Global Health Workers

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

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

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

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

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

Update:

Hi Everyone,

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

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

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

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

Footnotes

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

Bibliography

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

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

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

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

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

 

Discussion Questions

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

Edit 1: Spelling

NGOs, Aid, and Infrastructure, Section 3

NGO intervention in global health: a panacea or misguided donor-driven intervention?

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While most NGO interventions in global health are well-intentioned, many fail to create meaningful and sustainable change. I will analyze reasons behind this phenomenon, primarily the issue of uninformed donors directing interventions, the exceptionalisation of certain diseases, the client-patron relationship that arises and finally the expectation that NGOs are a panacea to global health problems.

A fundamental issue with NGO intervention in global health is that interventions are often driven “by purse-strings” rather than actual on the ground needs (Zaidi, 270) This is seen in HIV care and in what Whyte et. al refer to as the ‘projectification’ of HIV care. This refers to the reality that the level of care a patient receives depends in large part on the program they decide or are able to join and who is funding it. “Whether clients also receive medicines for opportunistic infections and other health problems depends upon the program they have joined.” (Petryna, 155) In this chapter, Whyte et al. provide the example of some Ugandan programs providing CD4 counts but other programs to not provide this more costly test. Whether or not a program offers certain tests and services ultimately comes down to how much money they have, where this money is coming from, and how the donor wants it to be spent. So at Ministry of Health facilities funded by the Global Fund in Uganda, most clients have never had their CD4 counts measured.

The notion of patients becoming clients brought forward in Chapter 5 of Petryna and Biehl’s work is immediately unsettling as there’s a problematic power dynamic at play. “To put it bluntly, public health in this setting does not mean rights and equal opportunities for all citizens of Uganda. Rather, it means building on patron-client relationships locally, nationally, and internationally.” (145) ‘Clients’ are at the will of their patrons and the amount of money that the program they are enrolled in has from donors and NGOs. Moreover, there is a notion of reciprocity at work here as patients enter into this contractual relationship and are thus at the will of the restrictions and inconveniences imposed on them by their ‘patron’ health program.

Zaidi’s piece condemns NGOs as a band-aid fix to health care particularly in settings where the state has failed. “Because of their limited scope and reach, NGOs are no alterative to state failure.” (Zaidi, 270) Similarly, Pfeiffer also criticizes the prevailing notion in global health that NGOs are a “panacea”. This is an extremely important point to consider because most of the time, NGOs are not in a position to address the root causes of the problems that their specific intervention is designed to handle. (Zaidi, 268) Consequently, the expectation that NGOs will solve problems that a failed state is not able to address, is completely unrealistic and more importantly, unsustainable.

Chapter 6 of When People Come First, is slightly more optimistic in that Pfeiffer highlights that despite the misguided efforts of many NGO interventions in global health, we are in a state currently of “high agitation” in global health(Pfeiffer, 181). As such, there is great potential and a wide gap for innovation and major progress in the field. However, there are so many different NGO actors currently involved that reaching this potential is complicated. This concept is echoed in the Council on Foreign Relations blog post that appeared earlier this month about the WHO. Miles Kahler offers an interesting suggestion to this issue of harnessing the potential for innovation that the WHO should act as a norm-developing body. In this way, the WHO could set best practices, guidelines and norms that would significantly improve the effectiveness of many NGO interventions.

Ultimately, as is so often in discussions of global health interventions, the issue of NGO intervention comes down to a question of population versus individual. If the aim is to save a few individual lives, then perhaps NGO interventions in global health suffice as they exist. However, if the aim is to help a broader population, it’s evident from this week’s reading that NGOs are ineffective as they are expected to be a panacea and are too often constrained by misinformed donors. Global norms for the conduct of NGOs in global health interventions would help to address this shortcoming significantly.

Discussion Questions:

  1. With such strong criticism of NGO intervention in global health, would the better alternative be for NGOs to not intervene at all? Or is some intervention, even if it is misguided, better than none?
  2. Do you think the WHO could successfully assume the role of a norm-setting leader in global health to guide NGO practices and interventions?

Sources:

  • Benton, Adia. HIV Exceptionalism: Development through Disease in Sierra Leone. Minneapolis: U of Minnesota, 2015.
  • Biehl, João Guilherme and Adriana Petryna. “Evidence-Based Global Public Health.” When People Come First: Critical Studies in Global Health. Princeton: Princeton UP, 2013.
  • Patrick, Stuart, Global Health and the WHO: Revival or Marginalization? Council on Foreign Relations Blog: http://blogs.cfr.org/patrick/2015/11/06/global-health-and-the-who-revival-or-marginalization/
  • Zaidi, S. Akbar. “NGO Failure and the Need to Bring Back the State.”Journal of International Development J. Int. Dev.2 (1999): 259-71. Web

 

NGOs, Aid, and Infrastructure, Section 3, Unit 2 - Trying to Help

A partnership between NGOs and the state: An Illusion

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Given that many developing countries are exceedingly dependent on NGOs for health services (Zaidi, 264), it is important to examine this dependency and evaluate whether or not it emerges as a sustainable relationship.  I will argue that there are three fundamental issues with this relationship that prevent it from attaining sustainability. Firstly, as long as NGOs are present in developing countries, healthcare will never be accessible to all citizens. Secondly neither entity is ever held fully accountable to its citizens. Lastly, and perhaps most worryingly, over the years, the work of NGOs has been painted as altruistic, when in reality they are providing health services that all humans have a basic right to.

A poignant example that points to the limitations of NGO accessibility can be found in the approaches toward disclosure of HIV status. Benton recalls a skit that demonstrates how disclosure of one’s status to their family could turn out positively (Benton, 75). However, Benton notes that ‘successful disclosure…hinges upon whether the ‘disclosed-to’ have internalized NGO…messages delivered through NGO communication channels’ (Benton, 76). Consequently, while there may be a safe way to disclose one’s status and ultimately reduce the anguish that endures from suffering in silence, only a few have access to this possibility. Whyte et al. further paint this image of NGO networks by claiming that Saddam’s decision to join an AIDS program was through a ‘trusted social connection,’ (Biehl, 146). Saddam, as a citizen of Mozambique, is not guaranteed any health services. However, as long as he can locate an NGO through various networks, he is guaranteed health services. This dichotomy is disconcerting as it suggests that individuals living in more isolated areas (e.g. rural areas) are at a huge disadvantage to their urban counterparts where such a network of NGO knowledge exists. In this way, NGOs buttress already existing disparities by only being available to a select number.

One would hope that the NGOs are at least held fully accountable to the citizens that they do manage to serve.   Nonetheless, this does not seem to be the case – the donor’s priorities come first (Zaidi, 265). Insofar as donor power extends to such a degree, even Presidents of countries find themselves first appealing to international donors when speaking publicly about their nation’s progress (Benton, 119). The absurdity of this situation is made more explicit when making a comparison with the west. A western government’s success is not measured by its control of infectious disease (Benton 122), yet the culture of NGOs and their presence in developing countries over the years has engendered this double standard. Furthermore, NGO presence has lead governments to assume that they need not be held responsible for the welfare of all their citizens, as some of them are receiving healthcare from NGOs. Such a dangerous belief can be attributed to the well-known mystique associated with NGOs, in which they are seen as the ‘panacea for all the ills’ (Zaidi, 260). As a result of this aggrandized image, a President that is aware that x number of NGOs are present in their country would have a hard time arguing for the funneling of state funds into public health infrastructure. Additionally, this co-existence of NGOs and the state allows both entities to assert culpability to the other in times of crises. An unfortunate instance in which this cross-talk played out was in Sierra Leone at the height of the Ebola Crisis; a reporter recalls that “there was no coordination,” between NGOs and government officials (Inveen, 2015). If state-run institutions were the only existing entities, it would be much harder for them to disseminate the blame onto others and thus would be faced with no other option but to be held fully accountable to their citizens.

Along with problems of accountability, the excessive presence of NGOs corrupts the mentality the west has towards developing countries. As many NGO workers are volunteers, the work done by NGOs can be perceived as generous, and individuals who receive such aid need to ensure that they are deserving of it (Benton 133). If health services were provided by the state, its citizens would no longer be under this pressure and simply believe that they have a right to such services in virtue of being a citizen.

Despite my criticism of NGOs, I recognize that the solution cannot be to simply remove them from developing countries. Instead I think the solution would be to encourage donors to make investments in already existing state infrastructure as opposed to donations to NGOs and hope that overtime this shift in economic support leaves the state as the dominant provider. As it would be much harder to incentivize large donors to make investments into struggling state entities, perhaps more of an emphasis on obtaining multiple, smaller donations would allow for this shift in investment.

Discussion Questions:

  • How do you balance trying to elicit sympathy from donors with ensuring that you are not debilitating the image of the very people you are trying to help?
  • What is the best way to prepare state-run entities for an independence from NGOs? How do we solve problems such as government corruption?
  • Would citizens in developing countries resist to the removal of NGOs? If so, why and how could we alleviate their resistance?

Sources:

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

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.

Inveen, Cooper. “Sierra Leone Officials Say Flawed Aid Strategies Hamper Ebola Recovery Efforts – Humanosphere.” Humanosphere. N.p., 02 Nov. 2015. Web. 11 Nov. 2015. <http://www.humanosphere.org/global-health/2015/11/sierra-leone-officials-say-flawed-aid-strategies-hamper-ebola-recovery-efforts/>.

Zaidi, S. Akbar. “NGO Failure and the Need to Bring Back the State.”Journal of International Development J. Int. Dev. 11.2 (1999): 259-71. Web.

 

Regimes of Research, Section 3

Clinical Trials and Regimes of Research: Ethics, Progress, and Innovation

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As we have seen continuously through our study of global health, healthcare provided by a foreign organization in a developing country affects and is affected by the local culture to a great extent. We have studied the necessity of expecting the unexpected when it comes to the possible consequences of our actions. We have learned about the ways in which cultural sensitivity and understanding have not been adopted in past interventions, thereby permanently changing perceptions of the West and sometimes negatively affecting communities an that intervention had intended to help. The readings about clinical trials in the global sphere, and the ways in which pharmaceutical companies have both benefited as well as manipulated populations in “drug-naïve” regions, are prime examples of these concepts.

Another theme we have considered in our readings and discussions has been losing sight of the people we are trying to help. Modern day methods of creating interventions rely mostly on numerical or statistical credibility, and it has caused many to ignore the humanity of the lives in question. Chapter two of When People Come First, entitled ‘Evidence-Based Global Public Health,’ illustrates the shortcomings of evidence-based medicine (EBM) and evidence based public health (EBPH) interventions. In the modern landscape of health interventions, lack of statistical evidence is equal to a lack of reliability in terms of the potential success or failure of a given intervention (Biehl and Petryna, 2013). Even so, without EBM, the safety of many treatments could not be determined with certainty. Though it could change the outlook and the questions asked, it is ultimately necessary for EBM work to be done to insure efficacy and safety. It is, however, also necessary to do qualitative studies that examine the greater social contexts and effects of interventions, and without those studies, we are missing vital pieces of information that could be used to better actuate change.

The readings all present a few reasons why global clinical trials and EBM are positive; however, they mostly discuss failures and problems with these recent developments in global health. Looking only at the three assigned readings, it is easy to become cynical about the involvement of pharmaceutical companies in global health, taking ethical advantage of needy populations for their own economic gain. In her article ‘Ethical Variability: Drug Development and the Globalization of Clinical Trials,’ Adriana Petryna talks about Chernobyl and the manner in which the crisis was taken advantage of politically, and subsequently scientifically. Those who wanted to experiment with therapies for the horrific damage that was caused by the nuclear accident were welcomed in by the Soviet Union’s leaders, casting all questions of the ethics of these studies aside in the name of aid. Petryna questions the ethics of these decisions made in times of crisis, and laments the variability in the reasoning behind them. While there are different reactions necessary to different crises, she argues that the underlying moral code of the regulation surrounding clinical trials should not allow for such variability (Petryna, 2005).

Today, though the FDA and other U.S. agencies cannot regulate trials in other countries, pressure from humanitarian organizations as well as the general public causes pharmaceutical companies to act in a less variable manner when performing research abroad. Clinical trials performed abroad also will not get the approval of the U.S. or other Western countries if done in a manner that is explicitly harmful. Of course, as the Leach and Fairhead article demonstrates, interventions or clinical trials can change the “therapeutic landscape” of a place forever. The ways in which people had previously experienced health and health care in Sukuta in the Gambia was permanently altered, shifting cultural paradigms and values. Though this particular intervention was mainly beneficial to the community, the consequences of it, and other similar projects, appear to be almost in the vein of colonialism—both invasive and patriarchal, insensitive to whatever structures or beliefs are already in place in a community.

Though there have been some sickening and disastrous outcomes from corporate involvement in global health—often from what is nominally humanitarian or philanthropic work—there have been many positive outcomes in recent years. During the Ebola epidemic this past year, many Western pharmaceutical companies jumped into action, quickly creating possible vaccines and launching animal and then human trials as fast as possible. What selfish motive could these companies have had in working to create vaccines for people at extremely high risk for a devastating disease? Yes, it would help their image, create positive PR, give people cause to stop hating “big pharma” as an impenetrable anathema, etc. However, these companies were at the forefronts of the effort because they had the money to back the research and the resources  ready to be mobilized for serious innovation. In their press release about the Ebola vaccine being tested, Johnson and Johnson lists organizations like Direct Relief International, Partners in Health, and other NGOs as organizations they are working with. Collaboration between the public and private sector is increasingly prevalent and is more successful than either one working without the other. While NGOs may have more expertise in countries of interest, pharmaceutical companies have the innovation and technology that is the basis of many interventions. The three vaccines shown in this image have all gone through Phase I clinical trials in Sierra Leone, Liberia, and Guinea, with mostly positive results. Can we really say that they took advantage of people in the developing world for completely selfish reasons when the outcome was not merely for their gain?

The vaccines currently being tested in communities with especially high risk for the rapid spread of Ebola. Image: 2015 Washington Post Article entitled 'How trials will work for Ebola vaccines'
The vaccines currently being tested in communities with especially high risk for the rapid spread of Ebola. Image:  2015 article by Berkowitz and Clark in the Washington Post, entitled ‘How trials will work for Ebola vaccines.’

A 2015 article in the Journal of Medical Ethics ‘Can Informed Consent to Research be Adapted to Risk?’ discusses the question of consent in different contexts, and how it can be improved to fit different research situations better.First and foremost, the article sets down the importance of consent: “Autonomy rights protect competent adults from unwanted interference and they also give them the opportunity to live their lives in accordance with their own interests, preferences and values” (Bromwich and Rid, 2014). The article states that as risk to participants in a study increases, the l consent of a patient becomes less meaningful. When performing studies, at home or abroad, language and literacy are a huge barrier between scientists and patients. As much as interventions and medications can be simplified, what details are being lost in this simplification? How can communication of risks and benefits be enhanced, and how can we ensure that these conversations are always clear on the part of the investigator as well as understood by the patient? Articles like this one are not uncommon in today’s medical and public health journals, and the way in which hulking industries and corporations, especially those coming from the West, are now treating issues like consent has become extremely visible. It seems to me that one of the more difficult issues in global clinical trials is no longer a question of blatant human rights violations, but rather more subtle consequences to the communities that participate in these trials. Though these consequences may often be unintended, at what point, in a world where cultural and anthropological knowledge is very available to those who trouble themselves to look, do these things become the result of calculated carelessness?

A qualitative study performed in Kenya in 2005, surrounding clinical trials for HIV/AIDS treatments, used focus groups to gain an in-depth understanding of the needs of participants. The study joins a large body of work on how to make clinical trials more beneficial to those who participate as well as reducing any potential long-term damage to communities. This, along with anthropological work like that of Biehl and Petryna, gives me hope for the future of clinical trials, so that, under the public eye, innovation will no longer come at the expense of vulnerable populations. However, many questions are still unanswered about the current state of medical research and the ethics and methods surrounding it. Scientists and companies that do not move forward in a humanistic way, considering the impacts of their actions down the road, may still do harm until more clearly agreed upon standards arrive.

Sources:

  1. Agnandji, S. T., et al. “Phase 1 Trials of rVSV Ebola Vaccine in Africa and Europe — Preliminary Report.” The New England Journal of Medicine (2015): n. pag. The New England Journal of Medicine. Web. 9 Nov. 2015.<http://www.nejm.org/doi/full/10.1056/NEJMoa1502924#t=abstract>.
  2. Berkowitz, Bonnie, and Patterson Clark. “How Trials Will Work for Ebola Vaccines.” The Washington Post. N.p., 8 Feb. 2015. Web. 9 Nov. 2015.<https://www.washingtonpost.com/apps/g/page/world/how-trials-will-work-for-ebola-vaccines/1594/>.
  3. Bromwich, Danielle, and Annette Rid. “Can Informed Consent to Research Be Adapted to Risk?” Journal of Medical Ethics 41 (2015): 521-28. Print.
  4. “Ebola vaccines, therapies, and diagnostics.” WHO. World Health Organization, 6 Oct. 2015. Web. 9 Nov. 2015.<http://www.who.int/medicines/emp_ebola_q_as/en/>.
  5. “Johnson & Johnson Announces Start of Clinical Trial of Ebola Vaccine Regimen in Sierra Leone.” Johnson and Johnson. Johnson & Johnson Services, 9 Oct. 2015. Web. 9 Nov. 2015. <http://www.jnj.com/news/all/johnson-johnson-announces-start-of-clinical-trial-of-ebola-vaccine-regimen-in-sierra-leone>.
  6. 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.
  7. Petryna, Adriana. 2005. “Ethical Variability: Drug Development and the Globalization of Clinical Trials.” American Ethnologist 32(2): 183-197.
  8. Petryna, Adriana, and João Biehl, eds. When People Come First. Princeton: Princeton UP, 2013. Print.
  9. Shaffer, D. N., et al. “Equitable Treatment for HIV/AIDS Clinical Trial Participants: A Focus Group Study of Patients, Clinician Researchers, and Administrators in Western Kenya.” Journal of Medical Ethics 32 (2006): 55-60.

Discussion Questions:

  • What is the best way to create ethical standards that apply worldwide for clinical trials? Or at least reduce the variability in ethical decisions? Is this even practical?
  • How can clinical trials be designed in a way that is beneficial to the health of populations in need, but not a cultural burden that follows in the footsteps of colonialism?

 

Humanitarianism, Section 3

Humanitarianism: An End to Suffering or the Destruction of Dignified Humanity?

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Humanitarianism has traditionally endeavored to minimize the suffering of individuals through neutral, immediate care in crisis situations in an attempt to reconstruct human dignity (Redfield 328). Medical humanitarian organizations such as Doctors Without Borders, or MSF, whose foundations are based on the alleviation of immediate suffering, however, prioritize mere physical existence, or “bare life”, at the expense of a dignified and satisfying life that extends beyond minimal survival through a refusal to combat the structural violence that is often responsible for the suffering it attempts to treat (Redfield 329-330, 340). Such a “minimal existence” is far from dignified, as there is a sharp distinction between simply living and living well (Redfield 340). One may argue that humanity is defined by recognition of one’s individual capabilities and emotions as well as the needs and desires that are not connected to one’s basic survival; our existence as social, cultivated beings is what fundamentally separates the human race from other living species. MSF’s emphasis on immediate medical treatment thus diminishes the perceived humanity of these individuals, as alleviation of their suffering is evaluated only on the basis of physical necessity and not on their personal experience with poverty, social inequality or other forms of structural violence (Redfield 342).

Individual choice is also vastly limited within MSF’s interventions, as patients are not really given the option of deciding whether to accept treatment (Redfield 337). This raises the question of whether patients are even willing to receive treatment that will essentially prolong the misery and suffering engendered by their social conditions; to what extent can immediate medical aid satisfy victims of structural violence who feel as if they have already lost everything? Humanitarianism may therefore have an extremely limited effect on broken societies in which “temporary relief cannot repair the damage” (Mackreath). Sick individuals will continue to be sick even after momentarily recovering if the underlying social and political factors exacerbating this sickness are ignored; in this sense humanitarianism does little to truly mitigate suffering (Redfield 346; Mackreath).

In France, undocumented immigrants may acquire the legal right to live in France if they possess a life-threatening illness that cannot be treated in their countries of origin (Ticktin 1-2). These immigrants consequently become defined by their illness, as their existence in France is perpetually determined by disease (Ticktin 7). As I mentioned earlier, I believe that humanity extends beyond bare life; how can these individuals therefore be publicly perceived or accepted as part of humanity when their identities are restricted to that of the “apolitical, suffering body” (Ticktin 7)? A disregard for dignified humanity may thus exacerbate the mistreatment of immigrants, who may consequently be perceived as ‘inferior’ within French society and thus undeserving of humane treatment or the maintenance of their basic human rights. These immigrants are not even provided with the foundations of a decent or fulfilling life, as they are prohibited from working and are thus denied any economic, social or political participation in France that is essential for the preservation of a dignified human existence, forced to live “with nothing to wake up to each morning except one’s illness” (Ticktin 9).

The failures of humanitarianism are further exemplified through the experiences of Syrian refugees relocated to the United States to escape the suffering engendered by structural violence and civil war. Although they are relocated on the basis of immediate need, Syrian refugees are provided with virtually no resources to sustain themselves or maintain a sense of dignity amidst their suffering (Davis and Hemish).

One may argue that suffering can only truly be ameliorated by self-determination, meaning an individual’s ability to control his or her own life; self-determination may be perceived as essential for the preservation of dignity (Mackreath). Yet humanitarianism does not bring victims closer to self-determination, as it does not grant them the ability to truly improve their lives or even decide the fundamental conditions of their existence; self-determination is virtually impossible when one’s social status as a dignified human being is compromised. As a consequence of their inability to legally work in France, for example, many immigrants are forced to obtain the means for their survival through degrading and exploitative work in the black market that exacerbates their suffering while simultaneously diminishing recognition of their humanity (Ticktin 7).

Humanitarianism cannot fully alleviate suffering or reaffirm human dignity through a narrow emphasis on immediate care without attention to the maintenance and improvement of patients’ “elaborated human experience” that is essential for a satisfying and happy life (Redfield 330). Who will address structural violence, if not those who have volunteered to help suffering individuals? Humanitarian organizations must strive to promote a dignified existence by actively challenging structural violence and political inequality to enable aid recipients to be publicly perceived and rightfully treated as human beings.

Discussion Questions:

  1. How may humanitarian organizations successfully challenge and potentially change conditions of structural violence and political inequality? Do they have the authority or power to do so, or is this far too idealistic?
  2. To what extent does humanitarianism compromise individuality? Can individuality be perceived as essential for human dignity?

Bibliography

Davis, Charles and Mohamed Hemish. “A Refugee’s Story: From War in Syria to Poverty in the US.” teleSUR 4 November 2015. Web. 5 November 2015.

http://www.telesurtv.net/english/analysis/A-Refugees-Story-From-War-in-Syria-to-Poverty-in-the-US-20151104-0036.html

Mackreath, Helen. “The Early Plight of Humanitarianism.” Jadaliyya 26 October 2015. Web. 4 November 2015.

http://www.jadaliyya.com/pages/index/23005/the-early-plight-of-humanitarianismn

Redfield, Peter. “Doctors, Borders and Life in Crisis.” Cultural Anthropology 20.3 (2008): 328-361.

Ticktin, Miriam. “Where Ethics and Politics Meet: The Violence of Humanitarianism in France.” American Ethnologist 33.1 (2006): 33-49.

 

Humanitarianism, Section 3

Stateless Humanitarianism

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As a result of the Arab-Israeli War in 1948, 750,000 Palestinians were displaced to form refugee camps across the country of Palestine and in neighboring countries like Syria, Jordan, and Lebanon. Those refugees didn’t have food, shelter, or even water, and therefore, international support was necessary in order to save them from starvation. The United Nations General Assembly resolution (302) took responsibility of this issue, stating that a new agency named UNRWA (United Nation’s Relief and Works Agency) is established to “Prevent conditions of starvation and distress… and to further conditions of peace and stability.” [1]

The complex political situation that resulted from this conflict limited the support the Palestinian refugees should get from health services and agencies. In his article, Doctors, Borders and Life in Crisis, Redfield quotes the charter of the MSF, “M6decins sans frontiers provides aid to people in need, to victims of natural and man-made disasters, wars and civil wars, irrespective of race, religion, ideology or politics” [2] Yet, this does not seem to be applied in the case of Palestinian refugees. The charter later says, “With regard to humanitarian interventions in the Palestinian territories, MSF faces difficulties when the political stakes of the situation do not easily translate into the language of victims and lives saved.” [3] According to the MSF, politics is rather disregarded when humanitarian support is needed, and at the same time members of MSF rarely suggest that their work will directly build a better social order or achieve a state of justice. “The goal is to agitate, disrupt, and encourage others to alter the world by practicing humanitarian medicine, one person at a time.” [4]

Sadly, the humanitarian support the Palestinian refugees received when they were depopulated was only a reaction to save as many lives as possible, rather than an intention to solve the causation of starvation. Palestinian refugees have been receiving basic food supplies on a monthly basis ever since, but this support is not enough to end the suffering they have to go through. Later on, Palestinians spend years inquiring for humanitarian support world wide, yet because those refugees have been stateless, humanitarianism has failed to take them seriously. In her article, Ticktin argues, “Being thrown out of one’s national community means being thrown out of humanity altogether – being stateless deprives one of the essence of humanity – its political character.” And conversely, she suggests that citizenship, a membership in a polity, conveys full belonging in the category humanity; “ humanitarianism protects individuals by virtue of their membership in humanity.” [5]

It is people who decide what they need, what rights are they missing, and the varieties of violations committed against them. Therefore, humanitarian agencies have no right to use politics, religion, or race as an excuse to reach those in need of help, and it is their responsibility to understand the needs of the victims irrespective of the systems forced upon them. As desperate as those stateless Palestinian refugees are for humanitarian support, the Rwandans are also suffering from scarce humanitarian support due to the political situation surrounding them. Ticktin argues, “The hundreds of thousands of people living and dying in awful conditions in the Rwanda-Zaire borderlands know better than anyone else on the scene what they have done, what has happened to them, why, and what they can hope for if they return to Rwanda.” [6] Yet, when voicing their suffering and struggle, Palestinian and Rwandan refugees are not taken lawfully, both because their representatives are governments that do not represent them as peoples, and also because the counter forces upon them are more powerful than they are, leaving them stateless in humanitarianism.

[1] www.unrwa.org

[2] Redfield P. 330

[3] Redfield P. 354

[4] Redfield P. 334

[5] Ticktin P. 44

[6] Ticktin P.392

Humanitarianism, Section 3, Unit 2 - Trying to Help

European Humanitarianism and the Refugee Crisis

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Stories about the “refugee crisis” in Europe are dominating the media lately, as tens of thousands of people continue to pour into Eastern Europe, most of whom are fleeing the conflict in Syria and Iraq. This has caused fracturing of the EU along ideological lines, as some states see it as their “humanitarian duty” under international law to accept refugees, while others fear “Islamization” and economic stress caused by the influx of so many people.

The framing of this as a “humanitarian crisis” is relatively recent, although thousands of people have been desperately attempting to reach Europe over the last several years. Before 2015, people trying to “illegally” enter Europe were mostly referred to as “migrants”, undeserving of asylum or refugee status. Most of these people were fleeing endemic poverty and violence in various parts of Sub-Saharan Africa, and their most common path to Europe was a treacherous journey across the Mediterranean from Libya to Italy. While thousands drowned at sea, the EU scrambled to ensure better control of its “sea borders”. [1]

This year has seen massive amounts of people crossing from Turkey into Greece and the Balkans, both by land and sea. Most of these people are Syrians fleeing the civil war, and now the term “refugee crisis” has come into use, overshadowing the issue of “migrants” arriving from Africa. Europe is again scrambling to figure out a solution. [2] Some Eastern European states such as Hungary, citing economic and security concerns, have begun building fences and enacting strict border controls, in an attempt to keep refugees out. The EU as a whole has begun questioning the future of the Schengen zone, which allows for free movement between EU member states, without requiring a visa. Germany, initially the most accepting of the refugees, is now hinting at expedited EU membership for Turkey if it is able to seal its borders. [3]

This huge influx of people has sparked debate over who is “deserving” of asylum or protected refugee status. Clearly, the EU has decided, “migrants” fleeing endemic poverty and violence in Sub-Saharan Africa are not. Here I draw parallels to Ticktin’s study of the “illness” clause in French immigration law. In both cases, the logic of humanitarianism privileges some kinds of suffering over others: “illness (or war-related trauma) can cross borders, but poverty cannot” (Ticktin 39).  To obtain the special designation of “refugee” under international law, and thus permission to stay in Europe, refugees must “prove” their status in some way, by somehow providing documentation of their persecution, or medical proof of their suffering. [4] In this way, as Ticktin describes, people are reduced to their bare life by the state, creating a “meritocracy of suffering” (Ticktin 34). Among those who are considered “legitimate” refugees, there is a general tendency for Europe to be more sympathetic to those escaping IS, rather than those fleeing conflict in Somalia and Eritrea, “failed” states whose violence is so routine it receives little media attention.

Additionally, the terming of this a refugee “crisis” has interesting implications. As Redfield writes, a “crisis” is a “rupture from the normal that demands a decisive response” (Redfield 336). In this case that involves both providing for basic biological needs and creating a long-term solution for resettlement. Humanitarian groups providing aid to these refugees (in Europe as well as in Turkey) tend to reduce these people to their “zoë”: they provide food, shelter, and basic medical care. However, in most places, refugees are denied the right to work, and are not granted equal citizenship status, even if they are residing in their host countries indefinitely. This is best illustrated by the camps in Turkey and Jordan, which resemble cities and have housed some of the same Syrian families for up to 4 years: refugees are kept alive, but given no social, economic, or political rights. [5] As Redfield suggests, humanitarian groups, in their effort to stay “neutral” or “apolitical”, tend towards providing for basic needs rather than intervening in the conflicts that cause the displacement in the first place. Europeans and Americans are able to fulfill their “humanitarian duty” by taking in refugees displaced by the Syrian war, while also maintaining the guise of neutrality in the conflict. However, is was arguably Europe and America’s refusal to intervene meaningfully early in the Syrian conflict to push out Assad that has led to such a protracted, fragmented conflict. As Ticktin notes, the “crisis” of migration does not happen in a vacuum: immigration to France is a result of colonialism, and the displacement of millions of Syrians is partly due to Western complicity in a brutal war.

Under the system currently in place in Europe, this huge movement of people unfortunately necessitates some kind of “triage” in determining who is allowed to stay. However, the EU should look into the causes of these mass displacements and migrations (economic as well as war-related) and attempt to address them, rather than blocking out people who haven’t suffered “enough” to justify entry. Europe and the West have long been complicit in the conflicts and economic crises that lead to mass migration.

Questions:

  1. How should wealthy countries decide whom to let across their borders? Is there any kind of ethical way to do this?
  2. How might the ability to enact “humanitarianism” in itself be a privilege? What are the power dynamics at play here?

[1] http://www.nytimes.com/interactive/2015/04/20/world/europe/surge-in-refugees-crossing-the-mediterranean-sea-maps.html

[2] http://america.aljazeera.com/articles/2015/9/7/european-union-struggles-to-formulate-refugee-crisis-response.html

[3] http://america.aljazeera.com/articles/2015/9/12/refugee-crisis-forces-eu-to-rethink-open-borders.html

[4] http://www.nytimes.com/2015/10/11/world/europe/the-refugee-crisis-in-europe-how-is-asylum-granted.html?_r=0

[5] http://www.nytimes.com/interactive/2015/11/04/world/middleeast/syria-refugees-europe-crisis-maps-explainer.html

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.

Essential Medicines and the Pharmaceutical Fix, Section 3, Unit 2 - Trying to Help

Expensive Essential Medicines: The Return of the “Appropriate Technology” Dilemma

23 Comments

The WHO recently widened its list to include new (and costly) treatments for cancer and Hepatitis C in a move that “ opens the way to improve access to innovative medicines that show clear clinical benefits and could have enormous public health impact globally.”(WHO). Emphasis on the “could.” While these new medicines have been deemed highly effective and safe,  they are extremely expensive; they can cost from $63,000 to $94,500, “depending on the drug and regimen.” (Silverman). These new drugs do make curing Hepatitis C a reality, but how realistic is it to make these newly minted essential medicines available and affordable on a global scale when we still struggle to provide consistent access to the more affordable essential medicines and other basic health rights, such as clean water?

Whether it is idealism that placed these drugs on the list of essential medicines or not, the placement of these new and expensive drugs on the essential medicines list is a mark of the huge disparity and inequality present in global health. Simply conceding that  some “uniform measure” to lower the prices of these essential medicines needs to be put in place in order for the health benefits to come to fruition is not enough to justify the decision to sponsor these drugs (in a way, putting a new drug on an essentials list is a form of advertising…).  

Farmer argues that we fall back too often into low-tech solutions  because they are deemed “appropriate,”  and “sustainable” instead of providing high quality treatments and care, even though both are needed to improve health on a global scale (Infections and Inequalities 21). Making a list of essential medicines attempts to encourage providing higher quality treatment, but including expensive therapies in an “essentials” list without any clear direction as to how their cost can be lowered continues to perpetuate the low-tech approach to improving global health. I would even argue that it is counterproductive to prioritize these new Hepatitis C and cancer treatments, though they are new and effective, if more affordable, newer (though not the newest) medicines exist and have yet to be implemented. Quite the opposite of blazing a trail in global health for innovative medicines.

More importantly, making new pricy therapies essential could jeopardize the funding for providing other basic rights: “On paper, essential medicines joined clean water, adequate housing, and a safe food supply” in a list of universal human rights (Greene 11). These rights lead to better health outcomes, but essential medicines weigh more heavily than due their higher relative expense and (more) immediate benefit. Additionally, these new and innovative drugs are so costly that providing them would logically come at the expense of providing other essentials, such as clean water and adequate housing, in a global health delivery. It seems intuitively wrong that a basic necessity would come at such a cost. This being said, if the prices were to be successfully lowered, the benefits alluded to in the WHO report would then be twofold: lowering the cost would make the medicines more accessible in general and would lower the competition between essential medicines and basics like clean water and housing for funding and attention.

Access to medicine and to care is essential, clean water is essential, safe housing is essential, food is essential… but prioritizing one essential  over the others in our approach to Global Health implies that some of the essentials can be overlooked, and are therefore secondary to that essential that takes precedence, whether that is effective drugs or sustainable changes to the infrastructure.

Questions for discussion:

  1. When do the essentials stop being essential? Does prioritizing one negate the others?
  2. Should the list of essential medicines be narrowed or done away with entirely?
  3. Should there be a system of weights that prioritizes more affordable medicines? What about more effective ones?
  4. How should the human rights relating to health listed by Greene be weighted, if they had to be weighed?

 

Works Cited:

Farmer, P. (1999). Infections and inequalities: The modern plagues (p. 21). Berkeley: University of California Press.

Greene, J. (2011). Making medicines essential: The emergent centrality of pharmaceuticals in global health. BioSocieties, 6(1), 10-33.

Silverman, E. (2015, May 8). WHO Adds Gilead Hepatitis C Drugs to its List of Essential Medicines. Retrieved November 2, 2015, from http://blogs.wsj.com/pharmalot/2015/05/08/who-adds-hepatitis-c-and-cancer-drugs-to-its-list-of-essential-medicines/

WHO moves to improve access to lifesaving medicines for hepatitis C, drug-resistant TB and cancers. (2015, May 8). Retrieved November 3, 2015, from http://www.who.int/mediacentre/news/releases/2015/new-essential-medicines-list/en/

 

Essential Medicines and the Pharmaceutical Fix, Section 3

The Benefits and Limitations of an Essential Medicines List

27 Comments

From our discussions in class thus far and our current understanding of global health, accessibility to certain essential medicines would appear to be an idea that has been universally accepted for many years. The reading by Jeremy Greene, however, paints a very different picture as he argues that a list of essential medicines for global health was not successfully achieved until 1977. This marked the first time that pharmaceuticals were featured in the “public health commons” (Greene 10) and integrated into fieldwork.

One point from the reading that was particularly noteworthy was that the concept of essential medicines was originally employed by colonial powers to augment military control over other groups. Yet, it is important to note that one positive legacy of this was the enforcement of “new humanitarian standards for care” (Greene 14) to combat treatable diseases. I would argue, though, that having a standardized list of medicines deemed “basic, indispensable, and necessary for the health of a population” (Greene 10) carries both positive outcomes as well as some unintended consequences.

In lectures, we’ve discussed the issues global health workers face in reconciling their objective analyses of certain groups with their moral obligation to intervene in the lives of those they observe. To me, this parallels the dual role of the WHO in serving as a standard-bearer of pharmaceuticals as well as an active entity in responding to epidemic outbreaks of disease. Personally, I agree with the course that the WHO has taken since the 1970s by deciding to play both roles. The best example of this is the successful eradication of smallpox in 1980. Here, the combination of the WHO’s vaccination campaigns, coupled with its aggressive surveillance and prevention strategies, demonstrates that the organization’s undertaking of this dual responsibility can have positive outcomes at a population level (“The Smallpox”).

However, these strides forward come with their fair share of setbacks. For example, Greene’s articulation of “drug dumping” demonstrates the market power that pharmaceutical companies continue to wield. Firstly, this creates a culture in which outdated drugs are reserved for poorer countries and newer, more effective ones are allocated to more developed nations. This casts doubt over the relevance of the essential drugs list. If these new drugs are not widely accessible, populations may miss out on medications that are essential to maintaining health and consequently, potentially efficacious medicines may slip the public consciousness.

Furthermore, I would argue that an international pharmaceutical regulatory body like the WHO is indirectly affected by the corruption plaguing individual federal entities. For example, the FDA is often criticized for being too slow to approve certain critical medical developments and too hasty to back medications that may lack sufficient data to support their efficacy. With regard to the latter, there has been countless speculation suggesting that the FDA’s close financial ties to big pharma groups has made it more likely to approve drugs that can “cause serious harm, hospitalizations, and deaths” (“Is the FDA”). The internal corruption within these regulatory bodies has made it more difficult to ascertain these drugs’ “proven safety and efficacy via randomized, controlled trials and cost-effectiveness” (“Is the FDA”). This story is not unique to the U.S.; Chapter 9 of When People Come First describes the monopoly-like control exercised by the company Lupin over the production of certain drugs. Ecks and Harper further this point by describing the struggle to obtain certain medicines for government-sponsored programs due to the interest of profit-maximizing companies to privatize certain medications (Ecks and Harper 253). This underscores the greater conflict between moral idealism of health interventions and the economic pragmatism of drug companies.

Lastly, I think the idea of an essential drugs list takes away from the multifaceted public health approach that we’ve discussed over the course of these past few weeks. As stipulated by Max Weber, one way to understand the biologic processes of a disease is to view it in an appropriate societal, political, historical, and cultural context (Farmer et al.). In so doing, outcomes can be prescribed through a combination of biological and social processes. Furthermore, the labeling of certain medicines as “essential” detracts from the social suffering and structural violence that are responsible for many of the healthcare issues in these areas. Thus, by addressing medication accessibility without regard to these important social issues, the WHO is only remedying a small part of the problem.

 

Discussion Questions:

  1. The Greene reading introduces the reader to the concept of drug dumping yet this is only the tip of the iceberg with regard to the overall issue of updating the essential drugs list. What are some long-term negative ramifications of using less efficacious drugs to combat widespread disease incidence? What are ways to mitigate (if not solve) this issue?
  1. We’ve established that the symptomatic treatment of a disease does little to improve health outcomes and to sustain positive change. Given the many approaches that one can utilize to promote better population-level health, how “essential” is a list of essential drugs? For example, is it more important to treat infrastructural shortcomings?

 

Class Readings:

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, 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:

“The Smallpox Eradication Programme – SEP (1966-1980).” WHO. Web. 3 Nov. 2015.

http://www.who.int/features/2010/smallpox/en/

“Is the FDA Being Compromised by Pharma Payments.” Forbes. Forbes Magazine. Web. 3 Nov. 2015.

http://www.forbes.com/sites/johnlamattina/2013/08/07/is-the-fda-being-compromised-by-pharma-payments/