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Reimagining Global Health

An Introduction

UNIVERSITY OF CALIFORNIA PRESS

Introduction

A Biosocial Approach to Global Health

PAUL FARMER, JIM YONG KIM, ARTHUR KLEINMAN, MATTHEW BASILICO

A VIEW FROM THE FIELD

Mpatso has been coughing for months. Coughing consumes his energy and his appetite, and he loses weight with every passing week. When his skin begins to sag, he takes the advice of his relatives and makes the two-hour journey to a health center. There Mpatso learns that he has AIDS and tuberculosis. In his village in rural Malawi—an agrarian, landlocked nation in Southern Africa, hard hit by both diseases—Mpatso's diagnosis carries a very poor prognosis. Malawi, like most of the countries in sub-Saharan Africa, faces the combined challenges of poverty, high burden of disease, and limited health services in the public sector. But Mpatso's case is an exception: shortly after he arrives at the Neno District Hospital—a public hospital built with the help of NGOs in a small town in the rural reaches of southern Malawi—he is seen by a team of clinicians. That same afternoon, Mpatso is diagnosed and begins treatment for both diseases. The treatment involves a dizzying number of pills, but his are delivered daily by a community health worker who also helps him follow his therapeutic regimen. His life will likely be prolonged by decades.

Down the hall from Mpatso's exam room, a neighbor gives birth with the support of a nurse-midwife. In an adjacent room, six women are in labor under the watchful eye of the clinical staff and within a few yards of a clean, modern operating room. In this and in many other respects, Neno District Hospital differs from most health facilities in the region (and throughout rural sub-Saharan Africa). The hospital is a comprehensive primary care facility, providing ambulatory care for hundreds of patients each day. It has one hundred and twenty beds, a tuberculosis ward, a well-stocked pharmacy, and an electronic medical records system. The facility is staffed by doctors and nurses from the Ministry of Health and from Partners In Health. In one of the poorest and most isolated areas in Malawi, a robust local health system is delivering high-quality care, free of charge to the patients, as a public good for public health.

How was this system put in place in a country where effective health services are typically unavailable, and how can comprehensive health systems be built across the "developing world" (perhaps better labeled the "majority world")? How is the double burden of poverty and disease experienced by individuals like Mpatso or his neighbors across the border in Mozambique? How can history and political economy help us understand the skewed distributions of wealth and illness around the globe? These are a few of the questions that motivate our investigation of global health equity.

BIOSOCIAL ANALYSIS

As the preface notes, global health is not yet a discipline but rather a collection of problems. The authors of this volume believe that the process of rigorously analyzing these problems, of working to solve them, and of transforming the field of global health into a coherent discipline demands an interdisciplinary approach. Describing the forces that led Mpatso to fall ill with tuberculosis—a treatable infectious disease that has been banished to history books in most of the rich world yet continues to claim some 1.4 million lives per year worldwide—requires an intrinsically biosocial analytic endeavor. The roots of the limited health care infrastructure in rural Neno District, a former British colony long on the periphery of the global economy, are historically deep and geographically broad.

Most textbooks of public health have been written by epidemiologists, and we of course draw heavily from this field, relying as well on insights from clinical medicine and from public health disciplines such as health economics. But the course we teach at Harvard College (like the courses we have long taught at Harvard Medical School and the hospitals with which we're affiliated) is not the same as those taught by public health specialists. We who have developed this course and edited this book are jointly trained in clinical medicine and in anthropology or political economy. Thus we also seek to critique prevailing global health discourse with what we have termed the resocializing disciplines—anthropology, sociology, history, political economy. Our approach hinges on social theory, explored in the second chapter, and aims to interrogate claims of causality widely stated in the literature on global health.

Our experience as medical practitioners has also shaped our approach to this volume. As we demonstrate in chapter 6, adapting a fully interdisciplinary investigation to basic questions—how did Mpatso become ill, and why?—has directly informed our practice. We see this close coupling of inquiry and implementation—the "vitality of praxis"—as central to our work: traversing the space between reflection and pragmatic engagement is necessary in any attempt to distill a core body of information about global health. Limitations exist in any team's knowledge of a particular field, and this book is of course based on material with which we are especially familiar, including the work of Partners In Health, the focus of chapter 6.

AN OVERVIEW OF HEALTH DISPARITIES: THE BURDEN OF DISEASE

We begin by taking a look at the global distribution of poor health and the factors that structure it. Globally, heart disease was the leading killer worldwide in 2004 (see table 1.1); cerebrovascular disease and chronic obstructive pulmonary disease ranked in the top five. This picture looks different, however, when we compare high- and low-income countries. Five of the leading causes of death in low-income countries—diarrheal diseases, HIV/AIDS, tuberculosis, neonatal infections, and malaria—are treatable infectious illnesses that are not found on the leading list of killers in high-income countries. Tuberculosis, malaria, and cholera continue to claim millions of lives each year because effective therapeutics and preventatives remain unavailable in most of the developing world. Although effective therapy for HIV has existed since 1996, and treatment now costs less than $100 per year in the developing world, AIDS is still the leading infectious killer of young adults in most low-income countries. In fact, 72 percent of AIDS-related deaths occur in a single region, sub-Saharan Africa, which is also the world's poorest. Diarrheal diseases are often treatable by simple rehydration interventions that cost pennies, yet diarrheal diseases rank third among killers in low-income countries.

Table 1.2 presents similar data, this time using a measure that takes into account both disability and death. This measure, the disability-adjusted life year (DALY), which is a way of quantifying years lost to poor health, disability, and early death, is not without its flaws; we will explore them in chapter 8. DALYs show a similar picture of health disparities between high- and low-income countries. It is also apparent that noninfectious conditions—such as birth asphyxia and birth trauma—are disproportionately distributed in low-income countries. Like the treatable infectious diseases just described, these forms of morbidity and mortality are often preventable with modern medical interventions and are thus much rarer in the wealthier parts of industrialized countries. Another stark picture of this disparity can be seen in map 1.1: despite some improvements over the last two decades, average life expectancy in low- and middle-income countries in sub-Saharan Africa stands at 49.2 years—fully 30.2 years less than life expectancy in high-income countries.

The relationship between gross domestic product (GDP) and health is one starting point for an examination of global health inequities. But national measures of wealth such as GDP and GNP (gross national product) are well worth pulling apart. "Domestic" and "national" data often (perhaps always) obscure local inequities, such as those seen within a nation, state, district, city, or other local polity. Figure 1.1, compiled by the World Health Organization's Commission on Social Determinants of Health, illustrates one example of the substantial differences in health outcomes between rich and poor households within single countries. Figure 1.2, from the same report, highlights another measure of social status across countries—in this case, mother's education level—that correlates with health outcomes such as infant mortality. The impact of social class, among other social, political, and economic factors, on health is taken as a given in this book, as it is in others. We will grapple with the many layers of these inequities throughout the text, beginning with a theory of structural violence in chapter 2. We will delve into the complexities of causation and the structures that pattern both the risk of ill health and access to modern health services, even as we explore effective and ineffective interventions in global health. Why is Mpatso able to attain good health care despite living in rural Malawi, while so many others in similar circumstances cannot?

DEFINING TERMS

Questions quickly arise in any study of this field: what do we mean when we use key terms such as "public health," "international health," and "global health"? What do we mean by "global health delivery"? More fundamentally, how should we define "health" itself? The World Health Organization (WHO) defines health as a state of physical, mental, and social well-being. But is this how Mpatso understands health? Can any definition of health capture the subjective illness experiences of individuals in different settings around the globe? Beyond the direct experiences of individuals are social, political, and economic forces that drive up the risk of ill health for some while sparing others. Some have called this structural violence. Such social forces become embodied as health and disease among individuals.

Though they share the goal of improving human health, "public health" and "medicine" are in many ways distinct. Public health focuses on the health of populations, while medicine focuses on the health of individuals. But in reifying the distinctions between them, we risk perpetuating unhelpful visual field defects in both professions. Clinical insights inform public health practice, and public health analysis guides the distribution of medical resources. But we believe both clinical medicine and public health must utilize the resocializing disciplines to address the fundamentally biosocial nature of global health problems. Microbes such as HIV and Mycobacterium tuberculosis cannot be understood properly at the molecular, clinical, experiential, or population level without analysis spanning the molecular to the social. Jonathan Mann, a physician and public health expert, put it this way: "Lacking a coherent conceptual framework, a consistent vocabulary, and consensus about societal change, public health assembles and then tries valiantly to assimilate a wide variety of disciplinary perspectives, from economists, political scientists, social and behavioral scientists, health systems analysts, and a range of medical practitioners." All fields have myopias. The restricted gaze of each discipline can illuminate certain global health problems; but only when they are taken together with a fully biosocial approach can we build, properly, the field of global health.

A word on the term "global health": An antecedent term, "international health," emphasized the nation-state as the base unit of comparison and implied a focus on relationships among states. Global health should more accurately encapsulate the role of nonstate institutions, including international NGOs, private philanthropists, and community-based organizations. Pathogens do not recognize international borders. But much churn—social and microbial—is introduced at borders. Further, we seek to examine health disparities not only among countries but also within them, including our own. Boston (like Cape Town and São Paolo and Bangkok) has some of the world's finest hospitals but also great disparities in burden of disease and access to care; it is on the globe, too.

A final note on definitions: "global health delivery" refers to the provision of health interventions, a process distinct from discovering or developing such interventions through laboratory research or clinical trials. Global health delivery begins with the question "how can a health system efficiently provide health services to all who need them?" More efficient and equitable delivery of existing health interventions could save tens of millions of lives each year. But even the best models of global health delivery cannot alone raise the standard of health care available to people worldwide. The health of individuals and populations is influenced by complex social and structural forces; addressing the roots of ill health—including poverty, inequality, and environmental degradation—requires a broad-based agenda of social change.

ORGANIZATION OF THIS BOOK

The chapters in this volume have been drafted by course faculty, guest lecturers, teaching fellows, and—in many instances—former students from our Harvard undergraduate courses, including "Case Studies in Global Health: Biosocial Perspectives." In developing the syllabus and course content, we observed that despite the wealth of scholarship in global health equity, there were few introductory texts addressing it; almost none adopted biosocial perspectives. In reviews of the first year of the course, students encouraged us to find ways to make the course material accessible beyond our Harvard classrooms. We decided that this book could achieve two aims: make our course material available to a broader audience, and help to fill the gap of introductory materials on global health.

An exhaustive treatment of global health would be impossible in a single volume; our goal here is to introduce some of the principal challenges and complexities that confront those pursuing global health equity. We also outline some of the accomplishments of this endeavor, very often drawing on our own experiences as physicians, teachers, and activists. This experience occurs in the clinic and the classroom and the field; it is rooted in time and place. For this reason, Reimagining Global Health does not seek to offer a comprehensive review of a vast literature but rather to use our field experience in Haiti, Rwanda, Malawi, China, Peru, the United States, and elsewhere to raise important issues and to link these examples to some of the key readings in a number of disciplines and from an even wider array of settings. We also seek to think hard about future challenges by taking stock of what has happened in the past and by drawing on concepts familiar to us.

The book is divided into twelve chapters. Chapter 2 lays out a framework of social theories relevant to the most important questions in global health. We have found these theories helpful in understanding both the material covered in this volume and our own experience within the field of global health. Though we assume no background knowledge in social theory, we draw on work by some of the great theorists of the past century, including Max Weber and Michel Foucault, as well as more recent health-focused work, such as the notion of social suffering offered by Arthur Kleinman, Veena Das, and Margaret Lock. For readers with some background in social theory, we hope that our focus on health will elicit new insights and spur consideration of the relevance of other theoretical frameworks.

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Excerpted from Reimagining Global Health by Paul Farmer, Jim Yong Kim, Arthur Kleinman, Matthew Basilico. Copyright © 2013 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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