Category Archives: Unit 2 – Trying to Help

We Still Need a Grand Vision

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

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

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

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

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

Discussion Questions:

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

 

Sources:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sources from Class:

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

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

Outside sources:

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

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

Discussions Questions:

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

 

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>

 

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

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

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

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

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

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

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

Discussion Questions:

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

Works Cited:

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

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