Category Archives: Section 3

THE LACK OF GLOBAL MEDICINE CONTROL IN SOCIETY

Throughout this course we have discussed the ways in which we can provide medical resources in order to improve the health of individuals in developing countries. A substantial amount of the class readings focused on the lack of medical treatments and limited access to essential resources that are desperately needed by suffering patients. However, how much knowledge and control do people trying to help possess over the quality and distribution of medicines? I believe that WHO needs to establish a more active role and evaluate the drug regulations/policies that are in society today. It is not right to take advantage of people who do not possess access to resources and technologies that inform people of medical remedies.

In a recent study, out of thirty-five samples of co-trim oxazole purchased in Ghana, Nigeria, and Britain, only sixty percent contained the requisite amount of the active ingredients needed! Another study estimated that over 120,000 children under the age of five years-old died because of ineffective malaria medicines (NY Times). The fraudulent crime of marketing these substandard medicines has increased over the past decade. Manufacturers have discovered ways to sell medicines and save money by reducing the amount of active ingredients. By committing this crime, it can accelerate the development of resistant germs, and thus, infect new people (NY Times). What steps need to be taken in order to address these issues and form regulation policies?

If you can recall from the beginning of the semester, we discussed how tobacco companies have inserted themselves in the market to poorer nations. People in the US recognized the direct correlation between tobacco users and cancers, so this once “attractive” product now possessed a “dirty and unhealthy” stigma. Therefore, the trend in the US started to decline, manufacturers had to focus on a new audience to target in order to gain a profit. Today, 80% of smokers live in poorer countries (Mason, Corporate Power Lecture). According to Allan Brandt, “This is not really consent in the meaning of consent, and that tobacco companies purposely engineer consent by marketing,” Poorer people are suffering due to the lack of knowledge and falsely advertised products (Brandt). This demonstrates how powerful marketing is in any industry. It appears that manufacturers in pharmaceutical companies are attempting to replicate similar concepts that tobacco companies successfully implemented years ago by selling “fake” drugs to people who are less knowledgeable and desperate to acquire adequate medications. Ultimately, this can cause more harm, and it also depletes poor people of the little money they have.

This proposes an issue to implement pharmaceutical infrastructures globally when we lack control over the quality of the supplements on the shelves. In Improvising Medicine, Dr. P expresses the urgent need for access to medicines for his patients. It is true that individuals in poorer countries are not provided with essential medicines, and if they are, they are listed at an unaffordable price. Not only do they not have medicines that US citizens acquire, but they barely have basic medical technologies, infrastructures, supplies-bandages, syringes, glucose sticks, and antiseptics (Livingston). Thereafter, it appeared that Halfdan Mahler had the same ideology of ensuring essential medicines were provided and affordable price to people in underprivileged nations. However, distinguishing what is an “essential” drug provoked huge debates, and people argued that the WHO was exceeding its role (Greene). Is there some way combine these ideologies that will provide fairness and equality to all people? Do we really want to implement pharmaceutical infrastructures that contain overpriced and falsely advertised drugs to poor and sickly patients? After reading “Stemming the Tide of Fake Medicines,” I am a little more skeptical about how people in developed countries should approach this issue. We could potentially making the situation worse by funding for infrastructures that contain harmful drugs.

This is not only a problem in poor nations, but this is also found in wealthier countries such as the US. The FDA is constantly recalling drugs in our local pharmacies (Prescription Drug Ads). Overall, I think this exposes the flaws that are currently found in pharmacies, and I believe that we need to address this problem before endangering the lives in other countries as well. At least we have access to knowledge about supplements; people in developing countries take what they can receive especially when it is listed at an affordable price. If the medicines are overpriced, this causes even more of a problem because now people are purchasing inadequate medicines at a price they cannot afford. They could use this money for other necessities such as food and water, which arguably could have cause the need for medicine in the first place due to the lack of sanitation.

Discussion Questions:

 

  • Harsh Chandra’s post (October 2nd, 2015) discusses how overpriced drugs are being offered to people in developing countries. It is heart-breaking to see that developed countries are scamming these poor people by selling drugs that do not contain the full active ingredients, and on top of that, they are selling these fake medicines at a price is equal to a person’s monthly salary. How do you think we (or the WHO) should address this issue? Is there a way we can regulate the drugs that offered to developing nations? Is it our responsibility?
  • Health as a human right is still not present in the US today. We have access to an abundant amount of drugs, but they are costly. Prices in the US can be up to ten times higher than other developed countries (Syrmopoulos). This is due to the US manufacturer’s freedom to set their own prices. That being said, how are we supposed to instill this ideology of “health for all” that Halfdan Mahler once advocated for? It seems implausible to implement this idea considering the US has yet to even accomplish this. Should we take a different approach to improve global health rather than the implementation of drugs?

Sources:

Outside Sources:

“Stemming the Tide of Fake Medicines.” The New York Times. Ed. Editorial Board. The New York Times, 17 May 2015. Web. 27 Oct. 2015.

“35 FDA-Approved Prescription Drugs Later Pulled from the Market – Prescription Drug Ads – ProCon.org.” ProConorg Headlines. N.p., n.d. Web. 28 Oct. 2015.

Syrmopoulos, Jay. “Chart Comparing Global Drug Prices Exposes How US Govt Creates Mega Profits for Big Pharma.” The Free Thought Project. N.p., 23 Sept. 2015. Web. 30 Oct. 2015.

 

In-Class Readings:

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.

Mason, Katherine. “Corporate Power.” BioMed Center, Providence. 21 Sept. 2015. Lecture.

Brandt, Allan M. The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America. N.p.: n.p., n.d. Print.

Moralizing Bodies: HIV and the Politics of Aid

In America, the image of HIV/AIDS activism has consistently been perpetuated and co-opted by the primarily upper class, cisgender, gay male members of the LGBTQ+ community. While I have no intention of undermining the experiences of suffering of anyone with HIV, the dominant narrative perpetuated by films like The Normal Heart[1] are wildly under-representative of the complexities and burden of this disease. The reality of HIV/AIDS – that it is one of the largest killers of people in the lowest income countries worldwide such that 66% of all HIV related deaths occurred in sub-Saharan Africa alone in 2014[2] – is one that can’t be ignored.

The privileging of the upper-class, western HIV experience in the understood cultural history of this disease is implicated by the example of Haiti, which Paul Farmer catalogs in his chapter, “The Exotic and the Mundane”.[3] Farmer argues that the spread of HIV in urban Haiti (mostly centered in the suburb Carrefour, home of Port-au-Prince’s redlight district[4]) is a textbook example of the “geography of blame.” Measures of guilt and accusation have been tied to the spread of HIV since it’s initial rise. Though the conservative right in America were quick to blame the “immoral,” urban men who had sex with men (MSM) for the spread of the disease, placing a moral judgment on a biological disease outcome and therefore conflating the biological body with the moral one, seropositive Haitian immigrants in America “denied homosexual activity or intravenous drug use.”[5]

Farmer criticizes American media outlets for effectively blaming Haiti for the American HIV epidemic, exoticizing and alienating the nation, as exemplified by Vanity Fair’s description of Haiti as the “black hole” of our hemisphere[6] in addition to exploiting Haitian voodoo acts as a potential source of transmission[7]. The relationship between cases of HIV in America and Haiti are clear: wealthy American vacationers came to Port-au-Prince and transmitted the disease to local sex workers, who, though many self-identified as heterosexual, would be paid into homosexual activity.[8] This conflated issues of homophobic sentiment in the U.S. with racial, gender, and economic inequality in Haiti. From here, it was found that the largest population of HIV positive individuals in Haiti were female sex workers, and Haiti became the evidence needed to suggest that HIV transmission was “more efficient” from men to women.[9] By 1986, it was impossible to deny that heterosexual activity was an ‘accepted risk factor.’[10]

Soon, a grand sentimental switch occurs in the evangelical right. Franklin Graham convinced the senator Jess Helms that “AIDS afflicted the ‘blameless’ just as often as it afflicted homosexuals.”[11] By positioning AIDS efforts towards that of the blameless, inherently moral children, we quickly saw a huge increase in the political capital of the west in AIDS treatment. The Clinton Administration, which had at first sided with pharmaceutical companies in the debate surrounding South Africa’s Medicines Act,[12] an attempt to provide more affordable, generic versions of antiretroviral therapies to HIV positive individuals, soon sided with the suffering and began providing aid directly to mothers and children who were HIV positive. By applying a moral judgment on those who were deserving of aid, there becomes a complication in the way that medications are transferred.

However, it was also this moral judgment that stirred action from abroad. The 3×5 campaign, which the WHO established as a goal to provide ARV treatment to three million people living with AIDS by the end of 2005, was unique in its efforts of establishing success as a measure of the number of people reached as opposed to the amount of money raised. By humanizing donor support under the framework of the “deserving” ill, we see the perpetuation of the implications of moral medicine. While it took until 2007 for the 3×5 campaign to be completed, it was considered a massive success in “galvanizing” the global AIDS effort.[13] By centering this mission around that of the suffering children – the people behind the disease and not the financial needs of the disease treatments itself – we see a re-affirmation of the complex power structures inherent in the way that the wealthy choose to spend their money – along moral and political lines.

 

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[1] Cast by almost exclusively white males, it is very clear where Hollywood is looking to spend their money insofar as narratives surrounding the HIV crisis.

Murphy, Ryan, Larry Kramer, Scott Ferguson, Julia Roberts, Mark Ruffalo, Jonathan Groff, Jim Parsons, Matthew Bomer, Taylor Kitsch, Julio F. De, Alfred Molina, Cliff Martinez, Adam Penn, Danny Moder, and Larry Kramer. The Normal Heart. , 2014.

[2] The American Foundation for AIDS Reserach. http://www.amfar.org/worldwide-aids-stats/.

[3] Farmer, Paul. Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press, 1999. Print.

[4] Ibid. 103

[5] Ibid. 99

[6] Ibid. 100

[7] Ibid. 106

[8] Ibid. 119, 122.

[9] Ibid. 113

[10] Ibid. 114

[11]Messac & Prabhu, Redefining the Possible: The Global AIDS Response. Reimagining Global Health: An Introduction. ed Paul Farmer. Berkeley, Calif: University of California press, 2013. Print. p 127.

[12] Ibid. 122

[13] Ibid. 114

Forgotten: Emergency Care in the Context of Public Health Care Frameworks

In the 1970s and 1980s, discussion around what and how health systems should be implemented sparked a heated debate. In 1978, the Alma-Ata declared that ‘Health for All’ should be the international goal of countries through Primary Health care. Unfortunately, the Alma-Ata failed, likely due to not specifying where how it was to be funded and the inability to hold countries to their commitment. After this, the concept of selective primary health care emerged, a way to package health services in a cost effective manner. Although both of these approaches aim to improve health, neither of them specifically mention emergency care, and where it belongs in the context of these frameworks and life.

Ziad Obermeyer conducted a study in low-and middle-income countries (LMICs) about the emergency care available. In “Rethinking emergency Care is key to ‘Health for All,’” he summarized his findings. He shed light on the fact that people in LMICs still get pneumonia, diarrhea, heart attacks and asthma. Something I think most people don’t realize is that studies consistently put emergency conditions at the top of list of causes of death and disability worldwide. The number 1 cause of death in LMIC is Ischaemic heart disease at 11.5% of deaths in LMIC, while HIV/AIDS was the 4th cause of death at 6.1% (Razzak & Arthur). Despite this, LMICs tend to have a lack of emergent care facilities, leading to an average of 10 times the caseloads of primary care doctors in the region. I believe that because of this, emergency health care should be a part of any country’s health system, even if it wasn’t in the plans of health care in the 1970s and 80s.

In the Alma-Ata Declaration, statement V says that all people should be at a level of health “that will permit them to lead a socially and economically productive life” by 2000. It then explained that the key to this target is primary health care. While I do agree that primary health care is necessary to track and prevent diseases and should be implemented around the globe, Obermeyer states that 10-15% of deaths in Nigeria occur in emergency care facilities. Most of these people are young and generally healthy, so they lose the most productive years of their lives. If primary health care and emergency health care both support preserving a productive, healthy life, then why didn’t Alma-Ata include emergent care?

Included in the principles of selective primary health care is the idea the main disease problems of poor countries can be solved through low-cost technical inventions, as Cueto explains. In this is the philosophy that “international agencies had to do their best with finite resources and short-lived political opportunities” (12). Though emergent health care was not originally discussed when it came to selective primary health care, I believe that these philosophies are very similar to what Obermeyer observed. In higher income countries, a small portion of the national medical expenditures helped emergency care providers focus on improving quality and training. As many providers in emergent care facilities in LMICs don’t have specific training, select LMICs have benefited from this training too.

The end of the Alma-Ata and the Cueto article on selective primary health care both focus on cost-effectiveness and the reallocation of resources. Investing in emergency care could relieve the burden of primary care doctors, allowing them to better serve their community. Emergency care could also alleviate some of the death and disability in LMICs, allowing for a more productive workforce, possibly boosting the country’s economy. Though the Obermeyer article doesn’t suggest a specific intervention, it does mention the opportunity for low cost, quality education of providers. This, along with a possible creation or renovation of an emergency care facility, could be perceived at a cost-effective strategy. As such, emergency health care would be a valuable addition to health care around the world, even if it’s philosophy is the only thing that might line up with other health care strategies.

  1. Should emergency care systems be thought of as separate of primary health care and selective health care, or are they already integrated into this framework? Are emergency care systems necessary if a strong public health care system is in place?
  2. Would implementing an emergency care facility in rural areas be feasible due to the lack of access to them and the number of providers that would be needed? How could communities be involved in the implementation of an emergency care facility or practices?
  3. Would you consider emergency care a magic bullet?
Alma-Ata Declaration. USSR. 6-12 Sepetember 1978.
Cueto, M. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health, 2004. 94(11)1864-74.
Obermeyer, Ziad. “Rethinking Emergency Care Is a Key Part of ‘Health for All'” Brookings. N.p., 25 Aug. 2015. Web. 20 Oct. 2015.
Obermeyer, Ziad, Samer Abujaber, Maggie Makar, Samantha Stoll, Stephanie R. Kayden, Lee A. Wallis, and Teri A. Reynolds. “Emergency Care in 59 Low- and Middle-income Countries: A Systematic Review.” Bulletin of the World Health Organization Bull. World Health Organ. 93.8 (2015): n. pag. Web. 20 Oct. 2015.
Razzack, Junaid, and Arthur Kellermann. Emergency Medical Care in Developing Countries: Is It Worthwhile? (n.d.): n. pag. Web. 21 Oct. 2015.

Who and What Counts?

What and who counts? I found myself repeatedly asking this question during each distinct reading, converging the stories, separating them; piece by piece determining what and who counts. There are many different forms of contextual evidence to support what and who counts. If you look generally, of course, the people of impoverished, developing nations — benefiting exorbitantly from foreign and strange aid programs. Except, not very much. A large disconnect exists between what and who counts, whose agenda we are following, and why.

Chapter 1 of When People Come First alludes to a better future, where we have given up on the radical idea that singular-technology can “overcame any obstacle posed by social conditions and processes” (Biehl, 32). International agencies seemed to finally convene and agree upon their ignorance and lack of understanding (or desire to understand) regarding differing beliefs and ways of life. Basic power dynamics of International Givers are established, including the brief history of malariologists, and how “medical technology could only be administered by an elite group of experts.” This act made a clear distinction between ‘us’ and ‘them’ — allowing for critical knowledge and information to be kept private and isolated.

Historically, Sierra Leone has been a place of ramped colonialism and exploration — the birth ground of ‘us’ and ‘them’. In 1807, Sierra Leone became Britain’s first West African colony. At first, the location was idealized, but the rising and ferocious rate of deaths coined a new name — White Man’s Grave. Anyone who went could expect to die, or have something gravely wrong with them. I don’t believe our association between an uncivilized environment and people has ever gone away (Rankin, 3).

In 2005, when the author (Adia Benton) of HIV Exceptionalism attended a strategic-planning meeting for HIV/AIDS in Sierra Leone, she was struck by how prescribed and unoriginal the plan/information was. For example, there was one single reference to war, when refugees were mentioned, but besides that — nothing. This fact, in and of itself, is exceptional; considering the amount and degree of warfare ravaging the land.

This is is not the only issue with Sierra Leone’s AIDS work. 1% of the population is living with AIDS (18% of burden; 40% of disease), which is incredibly disproportional when analyzing others factors and determinants that lead to illness or death (whose agenda?). Additionally, the usual rhetoric for AIDS does not necessarily apply in Sierra Leone (poverty, etc.) — as AIDS does not disproportionally affect the poor. In fact, living with HIV is diversely spread across various socioeconomic classes — yet since this fact has not been taken into account, supports from the foreign and International aid highly favor the very poor individuals with HIV (Benton). As Benton states, “We are attempting to overlap poverty, social inequity, marginalization, etc. — which are not the primary determinants in Sierra Leone. There are different patterns of transmission, different strains. Factors like poverty affect where HIV-positive people seek care, the terms/quality/and efficacy of care, etc.

Benton introduces the concept of biotribalism, the carving up of spaces and distribution of resources according to presence/absence of HIV. At one Press Conference on the awareness and prevention of AID, a man stood up and stated, “How can you tell us that the disease is like any other disease but then treat it like it’s not? We’re having a press conference about it. There’s separate money for treating and dealing with the disease. Isn’t separating it also marginalizing the disease? Aren’t you marginalizing and causing discrimination by making it separate like this?” If social aspects like self-esteem and self-reliance create a healthier population (Biehl), then why are we attempting to control everything, down to there rationing of food?

So, the question begs, why do these efforts exist in isolation? Is it the generous stipends/unique benefits for workers? Is it the exceptionalist drive of living positively with HIV? Is it embedded reliance? Benton discusses how “HIV Exceptionalism amplifies existing disparities”, and I wonder if we have created a system that is un-functionable without foreign help and intervention. A report back to the World Bank in 2007 notes “projects are complex with many participants engaged in activities for which they have little … comparative advantage” (Benton, 46). Are food, natural supports, community supports, medical care, etc. not advantages in a war-torn country like Sierra Leone, with AIDS not nearly as large of a problem as starvation and poverty? Benton discusses those with HIV as a “special group” not necessarily ‘othered’ by stigma/their diagnoses, but because they have access to resources that no other individuals do. So, again, I ask the question, what and who counts?

Update:

In light of all the engaging and interesting comments, and the additional knowledge I have gained from class/readings, I am adding a short update to my blog. In the comment section, Methma asked, “I wonder how we can work to change these ideas of Africa as a “white man’s grave” and the association of an uncivilized environment and people, like you mentioned. Do you think these associations are mostly subconscious now or are they furthered by how we view aid in other countries?”  I believe it is mostly subconscious, but certain pressures and situations bring these inequities into the light. For example, many students chose to write about the difference in treatment between the foreign aid PIH worker who contracted Ebola (and was immediately sent to the US), and the community health worker for PIH (who had to wait two days before being taken to a clinic). This difference in treatment is pronounced and defined, and stands to support our historical notion of Africa being the ‘White Man’s Burden’, and the death of a white body meaning more, and being more of an ‘event’, than that of a black body.

Additionally, I want to clarify that I do not think that focusing on HIV/AIDS in Sierra Leone was a mistake — but wish these programs can be optimized, expanded, and executed properly — so as to reach the most amount of individuals, in the most successful manner. Shreya commented that “beggars can’t be choosers”, but I believe that viewing those in need of aid as ‘beggars’ meds itself to the colonialist view of the poor, desperate bodies in Africa. When discussing Improvising Medicine during Lecture, we spoke about how drastically different cancer is in the US/Botswana, yet those in Botswana were still deserving of decent, humane, and caring medical treatment. Of course, individuals will take what they can get, but we must never stop critically analyzing these interventions. We must continue to interrogate why it feels normalized and appropriate to provide Africans with no-frills care, but take extra caution to ease any ache and pain in a ‘suffering’ woman in the US. These tradeoffs are rooted deeply in colonialism, and have huge impacts and influences on the programs we provide, and the way we facilitate them.

Finally, in my blog post I state, “I wonder if we have created a system that is un-functionable without foreign help and intervention.” Through my continued learning of the PIH model, I am confident that there are solutions, however complex they may be, that can help lessen the dependence on foreign aid and international organizations. For example, PIH helped forge relations between Haiti and Rwanda, which serves as a south-south system of support and resources, capable of sustaining even after foreign aid has left. This is ultimately the goal, though utilizing services like PIH is definitely an essential part of that path.

Discussion Questions: 

1. To what extent is the newer influx/generation of Global Health worked influenced by colonialism and the original views/perceptions of Africa and the African body?

2. In terms of Global Health work, have we applied the concepts of ‘social determinants’ correctly? Biehl discusses a shift in Global Health work, acknowledging that social factors and institutions were not considered greatly enough in terms of disease (we once believe disease caused poverty, etc.), yet in terms of HIV Exceptionalism, it seems as though we are looking at and trying to overlap poverty, social inequity marginalization, etc. — which are not the primary determinants in Sierra Leone. How can we change the way we think about and apply the concept of social determinants?

3. To what extent have our AIDS-related efforts amplified existing disparities in Sierra Leone? Our are tracks traceable?

Sources: 

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

Cueto, Marcos. “A Return to the Magic Bullet?” When People Come First: Critical Studies in Global Health. By Joao Biehl and Adriana Petryna. Princeton: UP, 2013. 30-54. Print.

Rankin, F. Harrison. The White Man’s Grave: A Visit to Sierra Leone, in 1834. London: R. Bentley, 1836. Print.

Unnecessary exceptionalism

What makes a disease exceptional? In the case of HIV/AIDS, it was the long-term effects on differing demographics that elicited exceptionalism. Because of the multi-generational repercussions of HIV infection and the associated socio-economic impacts, HIV was deemed a cause necessitating an exceptional response, characterized by separate care settings, funding, and sponsoring organizations. However, as the contexts of HIV and HIV care and treatment have evolved, so has the necessity for exceptionalism.

As Adia Denton mentions in her book, HIV/AIDS is disproportionately funded (40% of funding vs. 18% of disease burden) in Africa, where prevention and treatment programs are still largely vertical endeavors. Advocates of these programs cite the “multiple vulnerabilities” of those infected with HIV, including the lingering stigma associated with the disease. These “exceptional” circumstances have been used to justify an entirely different framework of care for HIV, including separate clinics, additional food and other support for those infected, and whole new agencies such as UNAIDS devoted exclusively to the disease (Denton). While the interventions haven’t followed a purely vertical model, as in the example of the guinea worm given by Amy Moran-Thomas where the interventions (filters and larvicides) deliberately avoided addressing any issues other than the precise disease the program was designed to target, their primary focus has remained on treating HIV as a disease so “exceptional” that it could not be done in the context of primary healthcare (Biehl and Petryna).

Whereas this model may have been appropriate during the peak of the epidemic when there was truly no end in sight, today’s widespread availability of ARVs eliminates the need for such a solution. Although ARVs have previously been regarded as a “magic bullet” – a technological solution to the crisis of HIV – their reality is grounded, and should be integrated, within the same foundations as basic healthcare. ARVs don’t erase or reverse HIV infection, but are rather another aspect of one’s long-term medical reality, just like medications for hypertension, diabetes, or any other chronic illness (Smith and Whiteside). The separation of HIV/AIDS care and ARVs from the rest of healthcare is therefore predicated on stigma and perceived exceptionalism rather than foundational differences or necessity. Integrating HIV care into general health care can both bolster continuity of care for those infected and improve and expand the care available to the general population.

Calls for more universal healthcare are widespread but frequently come separately from efforts to address HIV/AIDS, including in the UN’s new Sustainable Development Goals, where “achieve universal health coverage” and “end the HIV and AIDS” are given as two separate targets under the development goal of “Good Health and Well Being.” Expanded focus on healthcare as a whole doesn’t have to mean the end of programs to combat HIV/AIDs, but the two should not be separated as their goal – improving health – are the same (The Conversation). While HIV is a unique disease in its widespread prevalence, multigenerational impact, and disparate effects on various populations, it is not wholly unique in the kind of care it necessitates, and should not be treated in such an exceptional manner.

 

Discussion questions:

  1. In what contexts is a magic bullet or vertical intervention appropriate? Does cost-effectiveness and feasibility of expanding primary care/creating a horizontal intervention affect the decision to implement a vertical approach?
  2. How can we implement health programs in “extreme” contexts (post-civil war Sierra Leone, for example) without making assumptions about the effects of such contexts on health outcomes? Does such a context matter or should interventions be defined by only the end goal – health?

 

Works cited:

 

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

 

Moran-Thomas, Amy. “A Salvage Ethnography of the Guinea Worm.”When People Come First: Critical Studies in Global Health. By João Guilherme. Biehl and Adriana Petryna. Princeton: Princeton UP, 2013. 207-39. Print.

 

Penfold, Erica. “New Development Goals on Health Need More Work to Be Realistic.” The Conversation. N.p., 21 Sept. 2015. Web. 22 Oct. 2015.

 

Smith, Julia H., and Alan Whiteside. “The History of AIDS Exceptionalism.” Journal of the International AIDS Society. The International AIDS Society, 3 Dec. 2010. Web. 22 Oct. 2015.

 

AFRICA: A VICTIM OF THE BATTLE BETWEEN PRIMARY HEALTH CARE AND MAGIC BULLETS

At the turn of the Twentieth Century, at a time when many of today’s nations, especially Africa, were colonized by the major powers of Western Europe, Paul Ehrlich, a German physician and scientist, discovered that a certain chemical compound, Arsphenamine, effectively combatted spirillum spirochaetes bacteria, the subspecies of which caused syphilis. The treatment of syphilis, using this compound, that targeted only the specific bacteria causing the syphilis, and had few if any negative side effects, was, in short, a miracle. Ehrlich reasoned that if other medications could be created that “selectively” targeted specific disease causing organisms, with few side effects, it would be a “magische Kugel”—magic bullet.

In 1908, Paul Ehrlich received the Nobel Prize in Physiology/Medicine, for his contributions to immunology. As a direct result of Ehrlich’s “magic bullet” theory, scientists and physicians around the world began their own research and experiments to discover more and more magic bullet cures.

Various and thoughtful people, from around the world, have posed an important philosophical and moral question, “Should First World countries intervene in the politics, medical practices, and social structures of Third World countries, in any manner whatsoever, even if it is to save their lives?” After much reflection, I believe the correct answer is yes, for the following reason: lives matter—all lives matter.

I would like to expand on the definition of a magic bullet, defined, “as selectively targeting a specific disease, with few or no side effects;” and create a “financial” magic bullet that selectively targets specific health needs, in a positive way, with as little collateral damage as possible. And, once again, the “financial” magic bullet will be played out in the villages of Africa.

Although Measles, in the United States and Europe, is now virtually a disease of the past, measles has been increasing dangerously in many countries in West Africa, hit hard by the recent outbreak of Ebola. A Time’s article titled, Why West Africa Might Soon Have 100,000 More Measles Cases, talks about how the Ebola epidemic has caused a disastrous overwhelming of the Primary Health Care system in West Africa, leading to increased mortality and morbidity rates, due to Measles. The author then goes on about the eradication campaign that was set up to vaccinate all the children who were born during the Ebola epidemic, before expanding to older children and adults, who are more susceptible to dying from Measles, in order to prevent an even greater Measles epidemic, in the future.

Who lives, and who dies? Who decides? Who funds the Primary Health Care facilities? In the end, the decisions are obviously made by the First World countries.

Packard, in his chapter, Malaria Dreams: Postwar Visions of Health and Development in the Third World, explains how there has been a long reach of colonial medicine and how medical colonialism and imperial conquest set the stage to practice science and medicine, abroad—mostly, in Africa.

Looking at the medical history of Africa, since the time of Ehrlich, there have been many serious outbreaks of deadly diseases, in Africa—some of them eradicated by magic bullet cures, some of them tackled and overcome by the hard work performed by Primary Health Care doctors and nurses who have employed both magic bullet cures to eliminate small pox, prevent cholera, mitigate diarrhea, treat malaria, and a host of other remedies to assuage suffering and prevent deaths.

Returning to the “financial” magic bullet, how do we know which is more effective and efficient: funding Primary Health Care systems; funding research in hopes of developing another magic bullet cure; or, funding both? And, what are the possible unintended consequences? Because there will be collateral damage, and the outcry of unwanted intervention and colonialism. For example, during the Ebola outbreak, which killed thousands, in West Africa, before the First World countries, decided it might be in their own best interest to develop a magic bullet vaccine to protect themselves—of course, the vaccine had to first undergo clinical trials in a lab setting, before being guaranteed safe for use. And, of course, there has to be a controlled study—those who receive the vaccine (and live) and those who receive placebos (and die).

As mentioned in Determining Global Health, by Farmer et al., medical history is essential to understand and predict the intended and unintended consequences of different global health interventions, and many attributes of medicine and public health are due to the unintended consequences of globalization.

 

Discussion Questions:

  1. To effectively treat diseases, does it make sense to go where the diseases exist? If there is resistance from the local population, what other methods could we use to eradicate these diseases?
  2. One or two hundred years from now, with all of the eradication campaigns and programs that are set up, do you think that most if not all diseases now existing in Africa will be eradicated? And why?

 

Course Readings:

Packard, Randall. “Malaria Dreams: Postwar Visions of Health and Development in the Third World.” Medical Anthropology . 17 (Sep 1997).: 279-296.

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

 

Outside Sources:

Kluger, Jeffrey. “Why West Africa Might Soon Have 100,000 More Measles Cases.” Time. Time, 12 Mar. 2015. Web. 17 Oct. 2015. <http://time.com/3742361/ebola-measles-alliance/>.

“Paul Ehrlich – Biographical”. Nobelprize.org. Nobel Media AB 2014. Web. 21 Oct 2015. <http://www.nobelprize.org/nobel_prizes/medicine/laureates/1908/ehrlich-bio.html>

 

Inequalities in Medicine: Where did they come from and How to Fix Them

The idea that there are drastic inequalities of medical resources between developed and undeveloped nations is not a new idea to emerge in global health. It is an issue that is not only almost universally agreed upon, but also documented and addressed in a variety of fashions. In the paper ‘Ethics and Governance of Global Health Inequalities’, author Ruger provides some bleak statistics: “Global health inequalities are wide and growing: a child born today in Afghanistan is 75 times as likely to die by age 5 years as a child born in Singapore. A girl born in Sierra Leone can expect to live 50 fewer years, on average, than her Japanese counterpart. The number of African children at risk of dying is 35% higher today than it was 10 years ago. Although the average global life expectancy has increased by 20 years over the past five decades, the poorest countries have been left behind.” In Improvising Medicine, author Julie Livingston documents these inequalities in stark clarity by telling the story of an oncology ward in Botswana. The doctors and nurses who work in the ward not only have very little medical equipment and treatment, they are also severely understaffed. Although these inequalities exist, the underlying causes of them are not so easily apparent. In addition, it is not certain how to change them in a favorable way.

How did these inequalities in medicine arise? Are they solely due to differences in socioeconomic status? Does the privatization of healthcare exacerbate these inequalities? Could be due to the fact that we as a global society place more value in some lives than others? As I attempt to explore each of these questions, keep in mind that the inequalities in medical resources are not only on a country to country basis. There are also inequalities between states, between towns, and between individuals.

In Improvising Medicine, the author uses case studies to explore the level of care provided in countries that have universal care compared to those where the medical industry is privatized. Although the level of care at the oncology clinic in Botswana (where they have universal healthcare) was significantly lower than in the US, the Batswana that arrived at ward fared better than their Zimbabwe counterparts, who at many times couldn’t afford the treatments.

Another way inequalities in medical resources can exist for so long is the differential values placed on human life. In the book ‘In the Company of the Poor’, Paul Farmer makes the encompassing statement, “The idea that some lives matter less is the root of all that’s wrong in the world”. This different valuing of human lives is apparent not only in the severe inequalities of medical resources but also when it comes to our response to large scale global health issues.

For example, during the Ebola outbreak last year, the WHO declared it a “public health emergency of international concern” on August 8th 2014, after there were already 1,779 infections, and 961 deaths. Had these deaths been majorly Americans rather than Africans, would we have spurred our reaction to the epidemic sooner? In fact, when only one or two Americans were infected with Ebola, the nation watched their cases very closely, and knew their individual stories, while the many deaths of Africans were little more than statistics and numbers in a chart.

So what can we do to alleviate these inequalities in medical resources? Should the whole global health system be completely changed to account for these inequalities? Or is humanitarian aid enough?

These questions are not easily answered. In the essay ‘Governance of Global Health Inequalities’, the author proposes a universal healthcare system that would not only encompass nations but the world as a whole. He called for a mass redistribution of medical resources. For this distribution to occur, he relied on people’s morals and good heartedness, rather than coercion.

Although his method sounds ideal, it’s hard to tell how realistic or feasible it actually is. Many people would most likely object to having any of their medical resources taken away from them after they are already used to having them, even if they are going to people who have virtually no medical resources. However, on the other hand I don’t think humanitarian aid is quite enough either. Humanitarian aid only goes so far as to help individuals who are in need of help in the present, but does not extend to drastically alter the health system in any way.

There are no simple answers to these questions. Although the path to take is not clear, there is no uncertainty that these inequalities must be abolished if there is going to be real, large scale improvement in global health.

Sources:

Griffin, Michael, and Jennie Weiss. Block. In the Company of the Poor: Conversations between Dr. Paul Farmer and Fr. Gustavo Gutierrez. N.p.: n.p., n.d. Print.

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

Ruger, J. P. “Ethics and Governance of Global Health Inequalities.” Journal of Epidemiology and Community Health. BMJ Group, n.d. Web. 01 Oct. 2015.

Schnirring, Lisa. “WHO Declares Ebola a Public Health Emergency.” CIDRAP Center for Infectious Disease Research and Policy CONNECT WITH US Newsletter Signup Facebook Linked In Twitter Email Alerts Contact Us MAIN MENU Main Menu. CIDRAP News, 8 Aug. 2014. Web. 1 Oct. 2015.

Health Literacy and Patient Empowerment

Those concerned with health literacy hold the conviction that there is a standard of health-related knowledge that individuals must be familiar with in order to make lifestyle and medical decisions and govern their lives with intention. Inadequate health literacy has serious consequences in rates of individuals seeking care, ease of diagnosis, adherence to treatment, and health outcomes. In this way, health literacy itself functions as an unequally distributed medical resource. Yet most troubling is that poor health literacy can transform the healing processes that take place in hospitals into demeaning experiences in which desperate patients must surrender control over their bodies.

In Improvising Medicine, Julie Livingston writes that patients arriving at Botswana’s Princess Marina Hospital may not know the difference between diagnostic and therapeutic procedures, the purpose of the blood tests and biopsies being done to them, and even what exactly is the mass growing inside them that is threatening their lives. Despite the fact that a patient’s lack of understanding of his or her illness makes treating and helping the patient more difficult, doctors often do not answer patients’ questions. For instance, Dr. P., the sole oncologist at PHM who sees between 25 and 40 patients per day, usually does not have time to talk with patients much past laying out treatment plans and giving instructions (Livingston).

This lack of respect for patients’ understanding of their illnesses seems foreign to many Westerners who are accustomed to the privilege of doctor visits concluding with responses to laundry lists of questions and worries. But doctor-patient interactions in Botswana, which were born out of colonial and missionary medicine, are defined by a very different and stark power imbalance. Livingston writes,

The etiquette of the clinical encounter in Botswana…  has long been based on a top-down model. Patients do not expect to ask many questions…  while some patients were content to leave expert knowledge to the doctor, many others expressed a pent-up desire for biomedical knowledge, knowledge that might give more precise shape to their existential and phenomenological concerns. (76)

Further, the obvious gravity and urgency of cancer leads patients to feel understandable desperation, which strips them of even more of their authority over decisions regarding their body.

Another troubling consequence of poor health literacy and patients’ being forced to trust their doctors blindly is that doctors cannot be held accountable for their decisions. Because of strict TB treatment protocol in Carabayllo, Peru, Farmer recounts how poor individuals are frequently treated with drugs to which their strain of TB has already shown resistance (237). Of course, it is the health authorities and policies that are at fault for this ineffective and dangerous occurrence, but one must question whether an upper-class citizen of Carabayllo with a full understanding of drug resistance and treatment options could ever be manipulated and abused in this way. Health literacy gives individuals a voice and allows them to advocate for themselves.

Increased health literacy in impoverished communities could lead patients to develop heightened awareness of the substandard care they are receiving. The more that an individual understands about his or her condition and the treatment he or she should receive, the more aware an individual will be when treatment doesn’t proceed as it should (because of interrupted supply of medicine, lack of technologies, physician neglect, etc.). There is a moment in Monique and the Mango Rains when Kris Holloway notes, “I had noticed that the villagers loved shots. To many of them, shots represent the pinnacle of Western medicine, and Western medicine is good” (7). The ignorance behind the idea that shots are the pinnacle of Western medicine reveals how much medical technology the villagers don’t realize that they don’t have. While one could argue this ignorance is benign, our accepting this ignorance serves to validate the horribly damaging and dehumanizing conception that Africans are somehow ‘living in the past.’

Health literacy can be transformative when it empowers individuals to appreciate their rights regarding health and spread their knowledge. We see in Monique and the Mango Rains that Monique visits neighboring towns to teach women how to prevent diarrhea through basic sanitation and how to treat diarrhea with rehydration drinks (Holloway 56). In addition, a 15-year old named Emelin spoke to the U.N. earlier this year about the health issues that girls in her rural Guatemalan community face such as early pregnancy and gender-based violence. Emelin said, “We [adolescent girls] have a voice and we are going to use it” (Cole).

While putting the burden of reducing health inequalities on the shoulders of the oppressed is unjust and unproductive, it is important to acknowledge that improved health literacy does give oppressed individuals the ability to become catalysts for social change. Health literacy unites individuals over commitment to health and inspires communities to advocate collectively for their health needs.

 

Discussion Questions:

  1. What responsibility, if any, do you think physicians have to ensure that their patients understand and are comfortable with courses of treatment? Is this responsibility greater in a place like Botswana where there exists a very tangible power imbalance between doctor and patient? Considering the dilemmas of language barriers and busy schedules, how much should we expect of doctors?
  2. Outside of the doctor-patient interaction, how can health literacy promotion be incorporated into global health initiatives? What are the important aspects of effective health education programs (such as cultural sensitivity)?
  3. Can health literacy empower patients to advocate for their health needs and even become catalysts for social change in their communities?

Course Readings:

Farmer, Paul. Infections and Inequalities: The Modern Plagues. Berkeley: U of California, 1999. Print.

Holloway, Kris. Monique and the Mango Rains: Two Years With a Midwife in Mali. Ed. John Bidwell. Long Grove: Waveland, 2007. Print.

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

External Sources:

Cole, Diane. “Meet The 15-Year-Old From Rural Guatemala Who Addressed The U.N.” NPR, 12 Mar. 2015. Web. <http://www.npr.org/sections/goatsandsoda/2015/03/12/392174520/meet-the-15-year-old-from-rural-guatemala-who-addressed-the-u-n>.

Kanj, Mayagah, and Wayne Mitic. “Health Literacy.” Health Promotion Conferences. WHO, 26 Oct. 2009. Web. 2 Oct. 2015. <http://www.who.int/healthpromotion/conferences/7gchp/Track1_Inner.pdf>.

 

Trauma and Violence: From Liberia to Katrina

The debate surrounding the importance of mental health is complicated by personal experience and the aggregate prevalence of mental disorders. In America, we focus on treating mental health on a case-by-case basis through psychiatric services that utilize therapy and prescription medication. Individuals who have the resources and information can seek out treatment from health care providers to unpack traumatic experiences or other sources of emotional stress.

But what happens to our conception of trauma and the treatment of mental illness when conflict arises, and a thousand people in Monrovia are killed in less than a month? What, if anything, can be done to assess and “diagnose” the experience of trauma on a population level?

Abramowitz examines the experience of Liberians after the nation’s second civil war, and explains the struggle for people to regain, reconstruct, and reconfigure their identities in the aftermath of extreme violence. She defines trauma as “a rupture of the self,” and describes the need for people to cope with their experiences in order to build new lives in the midst of pervasive cultural and social uncertainty (Abramowitz). The collective memory of thousands of people who were witness to the most horrid acts of violence committed against their family members and communities now had to negotiate social values and terms of peace whilst dealing with immense emotional suffering.

To understand the mental health needs of this “traumatized nation” using the western model of a per person, by request basis would be a mistake. Health care services provided by NGOs and government agencies must be proactive in recognizing symptoms of mental illness and recommending treatments.

Yet, these solutions are complicated by the link of trauma and violence to poverty and socioeconomic disparity. It is often asserted that mental illness requires resources that low-income nations cannot afford, and usually conflict torn places do not have secure institutions to deliver services anyway. Additionally, social stigmas associated with mental disorder discourage people to question or report their emotional states, and diminish the opportunities of the mentally ill in employment, education, and marriage (Farmer 217). Not only that, but co-morbidities between mental illness and communicable disease mean that the burden of all disease is compounded on those worst off in the world.

Socioeconomic disparity can also serve as a lens to understand the parallels between the experience of trauma in post conflict countries and the trauma from natural disasters. Violence and disaster both produce conditions that affect people on a mass scale, especially poor people, and lead to the deprivation of torn communities. The stress from disaster and violence are both characterized by uncertainty and existential crisis – not knowing where your family is, not knowing if they are okay, not knowing what will happen to you tomorrow.

For example, in the aftermath of a devastating earthquake in Nepal in April of 2015, the rate of suicide increased by 41% over a period of three months since the event, according to police data (“Suicide Rate Surges Post Quake: Report”). It has been studied that in places where disasters occur, the initial shock and trauma usually subsides within a year. This has the implication that the suicide rate will normalize in Nepal soon after the earthquake. However, the case of hurricane Katrina conveys that different chronic problems persist long past the initial disaster event. A recent survey reports that ten years later 47.7% of participants were living with PTSD in New Orleans (Kelley). Though many studies done in the past of survivors of previous hurricanes “showed quicker and more complete recovery from mental disorders,” the high rate of PTSD in Katrina victims stands out as a failure of services to return to New Orleans (Kelley). Additionally, the survey validates the need for consistent mental health treatment beyond the first years that follow a disastrous event.

The relationship between violence and disaster reveals the complexity and extensive domain of trauma experienced by large populations. Paul Farmer points to one solution that can address this trauma by singling out successful, low cost programs in Ecuador and Colombia that train primary care workers in the recognition and treatment of mental disorders (Farmer 219). He quotes Arthur Kleinman about the standard practices of mental health that can be utilized across cultures, “serious psychiatric disorders such as schizophrenia and depression are recognizable around the world, even if they differ in their course and convey different meanings depending on the local context” (Farmer 224). This offers some hope for the abilities of communities to incorporate mental health testing into their current routines in a way that is practical and substantive. If the world is going to continue to see large-scale violence and natural disasters, and we know that it will, then mental illness is not just a nation-state issue; it is global issue and should be included in the determination of the UN’s Millennial Development Goals.

 

Discussion Questions:

  1. Are western practices of therapy and psychiatry appropriate blueprints from which to model mental health services in low-income, post-conflict nations?
  1. As world temperatures rise and the effects of climate change continue to impact populations, the rates of violence are expected to increase. In the case of Syria, it is claimed that drought led to the insurrection and political instability that has produced millions of IDPs and refugees. And in the case of Nigeria, it has been argued that drought created the conditions of instability that were exploited by Boko Haram (Shockman). Do you think climate change will have a role in the violence and rates of trauma-related illnesses of the future?

Outside Sources:

Kelley, Kendra. “10 Years After Hurricane Katrina, Mental Trauma Remains.” Mississippi News Now. WorldNow and WDAM, 31 Aug. 2015. Web. http://www.wdam.com/story/29837949/10-years-after-hurricane-katrina-mental-trauma-remains

Shockman, Elizabeth. “Is Global Warming Contributing to the Current Refugee Crisis?” Pri.org. Public Radio International, 28 Sept. 2015. Web. <http://www.pri.org/stories/2015-09-27/global-warming-contributing-current-refugee-crisis>.

“Suicide Rate Surges Post Quake: Report.” The Kathmandu Post, 9 Sept. 2015. Web. <http://kathmandupost.ekantipur.com/news/2015-09-15/suicide-rate-surges-post-quake-report.html>.

Trauma and Violence

Increased conflict in developing nations has caused a surge in trauma-related mental health issues around the world. With significantly less access to funds and resources, lesser-developed nations are facing a monumental problem in combating the proliferation of mental health issues. A lack of understanding surrounding mental health only exacerbates social issues for patients suffering from mental disabilities in developing countries; they fear speaking out and ultimately receive sub-par care, if they are lucky enough to get any whatsoever.

In her book, Searching for Normal in the Wake of the Liberian War, Sharon Abramowitz examines the societal impacts of trauma as a result of war. She describes how the Liberian people who are not suffering from mental disability view others around them as “not normal,” or “totally traumatized” (65). Due to the lack of mental health education, Liberians believe trauma is a step on the “continuum of mental illness”, which begins with a person being normal, and results in insanity and ultimately death. While one may be quick to jump to the conclusion that the Liberian opinion of mental health is an uneducated one, I do believe that they accurately describe at least one social aspect of mental disability. To some extent, Liberians understand the debilitating effect an untreated mental disability can have on one’s livelihood. However, the understanding of mental health is quite limited, as many Liberians also believe that “people experiencing severe trauma or psychosis must have seen or done something to have incurred this terrible fate,” and the mental disability must be “God’s punishment” (79). A mental disability not directly caused by war or some other horrific event does not appear to fit within the Liberian description of trauma.

Farmer et al.’s Reimaging Global Health offers a more broad definition of mental health conditions, claiming that they are not all “neatly packed as disease[s],” like PTSD is in the developing world (222). Many people across the world suffer from PTSD; it is a very crippling disorder. However, not all mental health conditions are PTSD, and trauma does not necessarily develop into PTSD. Providing care to a plethora of mental health conditions is essential. The example of Valentine from the Abramowitz’s book depicts someone who is not directly traumatized from fighting in the Liberian War, but rather from living day to day during a time of conflict. I would argue that “traumatization” has much more to do with his social situation than direct violence However in places such as Liberia, that form of a mental health condition is not well understood. The problems and inequality that people face everyday can have just as great of an effect on mental health as one catastrophic event. I found the study published by The Lancet to be incredibly interesting, as it explained that “mental disorders increase the risk of both communicable diseases … and noncommunicable diseases” and that alternatively these diseases increased the risk of developing a mental disorder (215). Healthcare funding in developing nations should focus on both mental health and disease in order to most effectively care for patients.

Perhaps the most glaring obstacle to providing widespread care for mental health disorders is self-reporting, as social stigmas prevent many from seeking help. This lack of self-reporting is echoed in Mark Anderson and Achilleas Galatsidas’ article for The Gaurdian entitled “Mental Healthcare 50 Times More Accessible in Wealthy Countries”. Many people who suffer from mental illness do not come forward, due to shame. “They feel if they disclose that they have a mental disorder they will be discriminated against” and their societal value will decrease (Anderson). While almost one in ten people have a mental health disorder, the world’s poorest countries have a dearth of mental health workers. The need for mental health care is only rising with the “increasing prevalence of conflicts and natural disasters,” which increases stress on developing communities (Anderson). Mental health needs to be given a higher level of priority, on par to that of diseases such as HIV/AIDS, malaria, and TB in developing countries.

It is challenging to emphasize care of mental health issues when there is no distinct treatment. The gap in our medical knowledge of how to best care for patients suffering from mental health disabilities is expansive. Our best chance of bridging this gap is integrating our clinical understanding with ethnographic studies of populations in developing nations to understand who is suffering and why. Providing mental health care is an incredibly complicated task; one that developed nations have yet to understand. I would argue the only way to currently provide care to developing nations is by training local traditional healers and medical professionals. While we may never be able to quell violence and its associated trauma, with greater scientific and cultural understanding we may be able to provide care for enduring mental health problems and better grasp the growing mental health crisis.

Discussion Questions:

  • In Searching for Normal in the Wake of the Liberian War, Abramowitz highlights the result of mental disorders and trauma postwar. Attention is only paid after a traumatic event has occurred, not before. Would it have been beneficial to this population to provide mental health care and education before violence ensued? Should mental health care be provided as a preventative measure in developing countries? If so, how can that be achieved?
  • What is the best way to determine if mental health care provided to developing nations is “adequate” or helpful? With communicable and noncommunicable diseases there is either treatment or disease. However, with mental health disorders there is no direct cure. How do NGO’s, the WHO, or developing nations themselves deem a public mental health effort as successful?

Outside Source:

Anderson, Mark and Achilleas Galatsidas. 2015. Mental Healthcare 50 Times More Accessible in Wealthy Countries. The Guardian, 20 July 2015. http://www.theguardian.com/global-development/datablog/2015/jul/20/mental-healthcare-world-health-organisation.

Class Readings:

Abramowitz, Sharon. 2014. Searching for Normal in the Wake of the Liberian War. Philadelphia: University of Pennsylvania Press. (Ch. 3)

Farmer et. al. Reimagining Global Health. p 213-225