Category Archives: Magic Bullets Redux and Vertical Programs

Magic Bullets Redux and Vertical Programs, Section 3, Unit 2 - Trying to Help

Who and What Counts?

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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.

Magic Bullets Redux and Vertical Programs, Section 3, Unit 2 - Trying to Help

Unnecessary exceptionalism

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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.

 

Colonial Medicine and Magic Bullets, Magic Bullets Redux and Vertical Programs, Section 3, Unit 2 - Trying to Help

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

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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>