Academic Paper: Written for Harvard University MLA Medical Anthropology course.
General Terms in Global Health
Alma Ata Declaration – The Alma Ata declaration was unveiled in 1978, in what is now known as Kazakhstan, at the International Conference on Primary Health Care. The declaration defined the need for all governments and the world community to come together as one to promote and protect health as a basic human right.
DSM V – American Psychiatric Association (APA) – The diagnostic and Statistical Manual of Mental Disorders. Currently up to Edition IV, with Edition V to be released in May of 2013. Known as “the bible” of the mental health care profession.
Liberalism – Is the belief that all people in society should live freely and equally. This includes the right to life and property and free trade.
Neoliberalism – The same ideas as liberalism apply, however government and market is divorced, as the union of the two is believed to cause distortion in the market. It is generally accepted that supply and demand will lead to equilibrium in the market.
Medicalization – Medicalization is an example of the social construction of society. Behavior, which was once considered sinful, criminal, defiant or even just plain mischievous, is now often labeled as “illness” or “disease.” A “problem” which can be cured through biomedicine. This labeling of illness and disease is often thought to be a ‘construction of illness’ by drug companies looking to introduce more products on to the market.
The “normal” and the “abnormal” in medicine – What is normal or abnormal has always been central to the practice of medicine, however in more recent times the expansion of the category known as “Abnormal” has been widened mainly through the medical interventions of pharmaceuticals companies.
Social Suffering – Pain and suffering caused to an individual or a collective group, associated with life conditions (racism, classism, sexism) which are shaped by powerful social forces, such as institutions (marriage, church, banks) and governments. The term relates to the causes and consequences of illness, which is often the result of larger social forces, including institutions that were created to counter these effects.
Social suffering types: – Structural Violence
– Interpersonal Experiences: the illness experience (e.g. diabetes, arthritis, asthma) – Bureaucratic indifference: The unintended consequences of bureaucratic action.
Examples of Social Suffering – USAID HIV/AIDS funding limited only to countries adhering to the USAID Anti-Prostitution Act, or as another example, the Pakistan floods, and the humanitarian aid that was denied to religious minorities.
Emmanuel Levinas on “Ethics and suffering” – Suffering takes its ethical significance from the reactions to the person who is suffering. The ethical demands of those suffering is interpreted as, the greater the suffering, the higher the priority.
“The suffering for the useless suffering of the other, the just suffering in me for the unjustifiable suffering of the other, opens suffering to the ethical perspective of the inter- human” –Emmanuel Levinas
Structural violence – (Johan Galtung, sociologist and founder of the discipline of Peace and Conflict studies) This term in social theory refers to violence created in society by its social structure or social institutions, and proof that when populations of individuals are oppressed or exploited in a social, political or economic manner, this reduces their life expectancy as well as their years of healthy living. Structural violence and direct violence are often interrelated to one another, as a cause and effect. Examples of structural violence are: racism, classism, ageism and sexism.
Direct Violence – Is the term used for violence, which is generally directly physical, such as: family violence, terrorism and war. Direct violence in society often comes as a result of structural violence.
The Therapeutic Revolution – Describes the period in time, the twentieth century, when medicine began to be considered the most reliable form of treatment, the time where major medicinal breakthroughs began, and the widespread use and marketing of medicine began. Specific forms of therapeutic revolutions are: paracelsian, anesthetic, diagnostic, evidence-based, antiseptic, regulatory, microbial and pharmaceutical revolutions.
Illness – The experience of symptoms and the response to them by laypersons and their networks.
Disease – The reinterpretation of symptoms as patho-physiological as understood from the practitioner’s framework.
Sickness – Symptoms and pathology understood at the population level in the broadest societal context.
Cost Effective Analysis – (CEA) Economic analysis that compares relative costs and outcomes (effects) of two or more courses of action. CEA helps to monetize health effects, such as medications, DOTS, sustainability, intervention and development programs. In health, cost effectiveness is generally expressed with a denominator and a numerator. The denominator being a gain in health from a measure (years of life, premature births averted, sight years gained, etc) The numerator is based on the cost associated with this health gain. E.g. DALY.
Structural Adjustment – (SAP) Structural Adjustment Programs implemented by the World Bank and IMF impose strict guidelines and conditions for money lent or low interest rates accorded. The point of the SAP is to ensure that money is spent in alignment with the future goal’s of the loan in question. SAP is supposed to reduce volatility and restore balance to the economy.
Primary Healthcare – (PHC) Initially introduced at the International Conference on Primary Health Care, in Alma Ata. The Key Points of PHC: (1) essential basic health care for all; (2) universally accessible and distributed resources; (3) free or low manageable cost; (4) local participation; (5) achieving a good standard of health so that people can live productive lives; (6) health care is a basic human right. WHO coined PHC, “Health For All.” PHC was considered idealistic and expensive, and was replaced with SPHC, which is a selective/specialized model with more of a disease-focus.
Specialized Primary Healthcare – (SPHC) Alternative framework to PHC, introduced at Rockefeller Conference, 1979. Focuses on a more limited set of health services, such as GOBI. Connects to the 1970’s trend on measureable results. Easily supported by donors, very influenced by NGOs and their requests for immediate measureable results.
James P. Grant – Director of UNICEF 1980-1995. Believed in measurable, time-bound targets and making the most of scarce resources. Present at the Bellagio meeting on SPHC. Major advocate for SPHC, most notably, while director of UNICEF.
GOBI – (UNICEF and SPHC) A PHC initiative aimed at improving maternal and child health. Growth monitoring. Oral rehydration. Breastfeeding. Immunizations.
GOBI-FFF – (UNICEF and SPHC) A PHC initiative aimed at improving maternal and child health. The same as GOBI, with additional aspects added: Food supplementation, Female literacy, Family planning.
Major Barriers to care in Global Health are: Diagnostic capacity
Facilities to care for sick patients
Infection Control in a high infection setting Second-line drugs Mechanism to deliver MDR-TB
Trained human resources
Local Health System Development Fosters Economic Development Direct employment (health sector jobs)
Catalyst for infrastructure (e.g. water, cell towers, internet, mapping in Rwanda) Ripple effect (e.g. PIH GPS mapping in Rwanda)
Decision Science – A theory in philosophy, mathematics and statistics concerned with identifying the values, uncertainties and other issues relevant in a given decision, its rationality and the resulting optimal decision.
(1) Explicit, quantitative and systematic approach to decision making under uncertainty
(2) Identify, measure, and value the consequences of decisions, as well as the uncertainty and risk that exists when the decision needs to be made.
(3) Elements are incorporated into a model to structure the problem over time, and used to compare the expected value of different options or interventions.
Four Social Theories
- Biosocial Interactions
- Unintended consequences
- Social construction of reality
- Weberian Vision of Modernity
Biosocial Interactions – The intertwining of biological and social factors in health. Understanding the importance of the two, rather than a more divorced view of the two. The relationship between the socially inhabited world (e.g. institutions, physical structures, social networks, ideology, and exposures), in relation to biology (e.g. bodies, health.) An example of a biosocial interaction would be infectious diseases and imprisonment.
Unintended consequences of purposive social action – (Robert K. Merton, sociologist) Parallel in context to “Murphy’s Law” ideology. This refers to the well-intended actions that are intended to be purposeful and solve problems, yet as a result may have negative consequences. The outcomes are unforeseeable and unintended, they may be negative outcomes, yet they may also be positive outcomes.
Social Construction of Reality – (Peter L. Berger and Thomas Luckmann) The term was first introduced in the book by the same name, and refers to the adopted knowledge and socially constructed beliefs of a society that are woven into its very fabric. It relates to the acceptance (whether correct or incorrect) of widespread knowledge or “fact” as being fundamentally correct, to the point where validity is no longer questioned, due to generational and societal acceptance of this knowledge. Habitualization, reciprocal typification, and ultimately legimatization.
“The sociology of knowledge must concern itself with whatever passes for knowledge in a society, regardless of the ultimate validity or invalidity (by wherever criteria) of such “knowledge” –Berger & Luckmann
“It is essential to keep pushing questions about the historically available conceptualizations of reality from the abstract “What? To the socially concrete “Says who?” –Berger & Luckmann
Social Construction of Illness – Uses the same ideology as the social construction of reality, where a disease or illness adopts a “negative reputation” or stigma, and this in turn becomes the socially accepted definition and interpretation for that disease or illness in that community or society, regardless of truth or fact to support this. Usually these misconceptions are as a result of misinformation and lack of education, often as a result of structural violence.
Examples of The Social Construction of Illness – The meanings of HIV/AIDS over time: (1) 1980s: The early AIDS epidemic seen as a Haitian disease and a disease of homosexuals. (2) 1990’s HIV Positivity seen as a death sentence, although there is still some stigma, most people are aware that it can affect them. (3) 2010, HIV Positivity seen as a manageable illness, thanks to accessibility and affordability of drugs.
Weberian Vision of Modernity – The movement of power away from family, community and local worlds, to institutions and bureaucracies. Allowing for organizations to outlive leaders. Minimal change or innovative ideas are born out of this form of modernity.
Dr. Kleinman’s Categories
Local Worlds – The networks of relationships and communities in which we live and where we experience social life.
Subjectivity – The inner world of the person.
Moral Experience – “Life is about values. Just being alive, negotiating important relations with others, doing work that means something to us, and living in some particular local place indicated that moral experience is inescapable.” – Arthur Kleinman Ethics – A trans-local aspiration among individuals to act morally within the contexts of their lives. In a professional context, it is the language of the elite.
Weber’s Types of Authority
Charismatic authority: A leader whose mission and vision inspires devotion. He/she has the characteristics of a well-loved, exemplary and respected individual. His/her power is derived from something personal, such as familial, religious or personality- based. (E.g. Martin Luther King Jnr., Gandhi, Kofi Annan, James P. Grant)
Traditional authority: A leadership achieved by heredity, tradition and institutionalization. Typically embodied in feudalism and patrimonalism. The system rarely changes or evolves. (E.g. Queen Elizabeth I, Louis XIV, and in recent times, President Raul Castro. He could be said to have inherited presidency/dictatorship of Cuba from his brother, Fidel Castro)
Legal authority: Political or economic Bureaucracy. Most common in government, public and private corporations. Power derived from law and rules (e.g. modern law, the state and its institutions, a president, judge, CEO, figure such as Kofi Annan) *You will notice, some individuals may fall into more than one category.
Bureaucracy and Rationality
Bureaucratic Authority – A hierarchical structure of subordination featuring “functional specialization” and “expert training” for each category and hierarchy of work. The hierarchical ladder of experience is yet another form of bureaucracy.
“Technical rationality” – (Max Weber, sociologist) Rationality without morality. This is based on the overt efficiency of bureaucracies, and their dehumanization of individuals. All actions are rational, labeled, and given a rule and regulation. This makes it especially difficult in terms of
health care, often demoralizing and shutting out individuals without “exact” criteria or the understanding of criteria.
The “Iron Cage” – (Max Weber, sociologist) The iron cage of rationality is said to trap individuals under strict regimes of calculation and control in the name of efficiency. The iron-cage eliminates the “human side” or “case-by-case” approach to interaction. Social actions are now based on efficiency, rather than the previous social actions, which were based on kinship. Individuals are prisoners to rules of efficiency, paperwork and regulations.
Homo Economicus – A concept in which humans are considered rational, calculating, and self interested, while also understanding the consequences of their actions. Opposite of Homo Reciprocan.
Homo Reciprocan, in which humans are innately motivated by interpersonal cooperation and improvement of the society they live in. This is the opposite of the term Homo Economicus.
Directly Observed Therapy Short-course
DOTS – (Directly Observed Therapy Short-course) established by WHO in their TB “Global Emergency” initiative, in 1993. Within three years 127 countries had adopted DOTS, international funding almost quadrupled, and millions of lives were (and still are) saved each year as a result. In 1995, WHO designed a promotional strategy to campaign policy makers and healthcare decision- makers. The health policy message was: “STOP TB, Use DOTS!” –the words upside down spell the word DOTS.
The five components of DOTS: *
(1) Political commitment with increased and sustained financing. Examples: legislation, planning, human resources, management and training.
(2) Case detection though quality-assured bacteriology. Examples: strengthening TB laboratories, drug resistance surveillance.
(3) Standardized treatment with supervision and patient support. TB treatment and program management guidelines, International Standards of TB Care (ISTC), practical approach to lung health (PAL), community-patient involvement.
(4) An effective drug supply and management system. Examples: availability of TB drugs, TB drug management, Global Drug Facility (GDF), Green Light Committee (GLC).
(5) Monitoring and evaluation system and impact measurement. TB recording and reporting systems, Global TB Control Report, data and country profiles, TB planning and budgeting tool, WHO epidemiology and surveillance online training.
* Source: World Health Organization website – http://www.who.int/tb/dots/en
DOTS-Plus – Was added in 1998, for the treatment of MDR-TB. The added differences are: Capacity to perform drug-susceptibility testing (not available in many countries) and the availability of second line drugs. Unlike DOTS, monthly surveillance is implemented, as well as re-evaluation every three months if symptoms do not reside and tests are inconclusive.
Disability Adjusted Life Year
DALY – (Disability-Adjusted Life Year) Originally, developed by WHO, now commonly used in Global Health. A metric system used to measure the overall number of healthy life lost (aka: years of life lost) to disability, disease or ill health. One DALY is equal to one year of healthy life lost. As Japanese life expectancy is the highest in the world, these statistics are used as the blueprint. DALY’s are used to measure the overall health of a population by global standards, and are used by policy makers to implement cost effective health measures.
- Reflects the total amount of healthy life lost
- Health services and research can better prioritize
- Helps to target interventions, and also prioritize
- Provides a comparative measure for evaluation and planning of research and potential interventions.
DALY Negatives: Targets “productive” adult workers based on age, illness and geographic location, as well as other “unfair” and realistically “un-measurable” statistics in regards to the notion of “productive.”
- Provides a normative value on disability. Disabilities have different levels of affliction, and this is not taken into account.
- “Time discounting” –meaning a desired result in the future is less valuable than one in the present.
- Does not account for the ethical, cultural or symbolic aspects of healthcare or a population
- Appears value-free, but is in fact value-laden.
YLL – Years of life lost.
YLD – Years lived with disability
Biomedicine – The principles of biology and biomedicine applied to the practice of medicine.
Bioethics – The study of moral values within the fields of biology and medicine. Mostly concerned with ethical questions within biology and medicine, however the sciences, politics, theology, law, philosophy, technology and medicine also have a place in bioethics.
Biopower – (Michel Foucault, French philosopher). The control over individuals and entire populations through the use of “knowledge power” –usually statistics and other forms of measurable “proof.” An early example: colonialists measuring African physiques and using such measurements to put Europeans on top of the evolutionary ladder, and Africans at the bottom.
Biocitizenship – (Adriana Petryna, anthropologist) The word first appeared in Adriana Petryna’s “Life Exposed: Biological Citizens After Chernobyl.” In Petryna’s context, the term relates to the use of citizenship (by the individual or a collective group) in the demand of financial compensation after biological harm (such as in Chernobyl) to a population. This term is based on the notion of mutual “rights and duties” of both the citizen and the state to one another, such as medical care and social goods, including the rights of citizens to demand entitlements from the state as a result of biological or ecological damage caused by the state to the citizen. The general meaning of the term refers to the marriage of biology and identity as one unified concept.
Biosociality – (Paul Rabinow, anthropologist.) This term describes biotechnological categories, and how they are able to transform human relationships, and create new bases for affiliation and kinship in the process. (e.g. a research study found that the HIV virus created kinship networks in certain subcultures, influencing intentional transmission as a means of biologizing relations with a stranger.) *[Race, Kane. University of Sydney]
Biopolitics – Can be looked at as another word for biopower. A style of government that regulates populations through the application and impact of political power on all aspects of life.
Social Marketing – While commercial marketing is used to achieve financial good, social marketing is used to achieve social good. (e.g. Advertising the latest Nike shoe to competitive marathon runners –commercial. Advertising the latest free HPV vaccination to all Australian women under-26 years of age –social). Contrary to belief, in both forms of marketing, the customer comes first, in commercial marketing as a source of financial profit, and in social marketing as a source of valuable information. This is not to say, social marketing is all good, having its fair share of unintended consequences. Social marketing, while usually non-profit, uses both commercial marketing techniques as well as social sciences policy and research, although many social marketers would dispute the use of any commercial marketing approaches.
Examples of Social Marketing and unintended consequences:
(1) The Maya contraceptive pill not responding to campaigns as the Raja condoms, which are a success. Unintended consequence: Because of “fun” campaign, the oral contraceptive loses credibility with women, and is not marketed to men, the power purchasers.
(2) Promoting condom use to break down stigma in a community; the unintended consequence results in more sexually active people, and a subsequent rise in STI/HIV and illegal abortions.
CYP – (Couple years of protection) USAID. This is the amount of contraception required to protect one couple for one year.
High Involvement Marketing – Relates to the effort (involvement) that goes into a purchasing decision or an action. Generally, a decision based on a social marketing campaign will require a high involvement decision (e.g. quitting smoking.)
Low Involvement Marketing – Relates to the effort (involvement) that goes into a purchasing decision or an action. Generally, a decision based on a commercial marketing campaign will require a low involvement decision (e.g. which detergent to use.)
Mindsets that DO fit the social marketing structure:
Customer-centered Mindset – Customer in control, customers do not serve the organization. Mindsets that do NOT fit the social marketing structure:
Product Mindset – Ours is the best product. Selling Mindset – Selling and persuasion
Organization-centered Mindset – Contrary to belief, this is also not a good social marketing technique. It still puts selling and product first, albeit a non-profit organization. Organizations should not lead customers; customers should lead organizations.
Humanitarianism – An informal ideology based on an individual’s duty to promote human welfare. Humanitarians work towards the advancement and well-being of humanity as a whole, and follow the ideology that all human beings deserve to be treated with respect and dignity, and all human beings are created equal.
Humanitarian Emergency Definition:
Circumstances that cause, or have potential to cause, mass civilian mortality or the large- scale spread of disease. These emergencies require urgent large-scale intervention(s) to reduce or prevent mortality. As well as doctors, emergency public health specialists and emergency nutritional specialists are generally on the scene, as well as media, governmental institutions and NGOs.
- – Interstate or civil wars/conflicts
- – Mass displacement
- – Exceeding local capacity, need for assistance
- – Social, political and economic crises
- – Epidemic infectious diseases
- – Acute malnutrition
- – Massive scale natural or man made catastrophe
The Disproportionate Role of Conflict – 26 of the Human Development Index’s bottom 40 have experienced war or major instability in the last two decades.
Direct Attack and Trauma:
Direct attack as a person or member of a group
Attack based on proximity or location
Direct personal violence, mass killing, wounding, torturing, sexual violence
Indirect and Delayed Side Effects: Spatial deprivation displacement (occupation, landmines) Loss of assets and livelihoods
Famine, malnutrition, infectious diseases
Emotional suffering and psychological trauma Post war suffering, economic collapse, social destruction
Traditionally vulnerable groups: Displaced due to social and political violence
Poor and socially marginalized
Infants, children and pregnant women
Elderly and those with chronic illnesses (TB, HIV) Women (and men) under threat of sexual violence
Accessing vulnerable groups that present a challenge: Repatriated refugee
Chronic migratory populations and day workers Urban displaced and slum dwellers Environmentally displaces and slow disasters Child soldiers and demobilized militia
Socially isolated (children born of rape)
Human trafficking and sex trafficking
Development and Relief Activities of NGOs
Water, sanitation, hygiene, shelter, special security, food distribution and security, nutritional support, health services, security, coordination, strategy implementation and planning, human rights preservation, mental health, livelihoods, rehabilitation, social marketing and promotion, educational programs, sustainability and education within violent areas, emergency assistance with health epidemics, wars, or after natural disasters, and sustainability after such catastrophes once the media attention has dissipated and the emergency aid has left.
PIH’s 3 key functions:
(Re)building infrastructure Training Service
- Minimization of government contact means more freedom for NGOs to focus on what they choose
- Have complete independence to intervene anywhere they want, regardless of any governments’ wishes.
- Assign programs based on need, not assignment by a higher power/government.
- They are an alternative to government, are generally neutral, and in many settings they only exist in the absence of state institutions.
- Can be a counterweight to the state
- In the absence of the state, they fill a political vacuum
- Considered innovative
- Greater ability to target the poor and vulnerable
- Better able to promote participation on the ground and develop community-based institutions because of daily contact
- Have different motivations than the state (can be good or bad)
- Rely heavily on governmental donors that often impose conditions for funding
- Budgets are always stretched to the maximum capacity – it’s a constant struggle
- They often lack accountability
- Have different motivations than the state (can be good or bad)
- More cost effective (although never proven)
Different NGOs designs
- Field based or advocacy
- Relief based or development
- Focal or broad based
- Religious or secular
- International or local
- Governmental or non governmental funding
Ways in which NGOs can potentially compromise their neutrality
- Accepting government funds
- Working with the military
- Having a religious agenda
- Distributing goods, drugs and supplies
Legal underpinnings for humanitarian standards
- Geneva Convention (1864)
- UN Charter (1945)
- Universal Declaration of Human Rights (1948)
- Constitution of the WHO Geneva Conventions (1949) and Protocols (1977)
- International Covenant on Civil and Political Rights
- International Covenant on Economic, Social and Cultural Rights
- Humanitarian Charter & Minimum Standards: Sphere (1994)
- Developing a Health Model Analytic Approach
- Develop a model: Simulate natural history of disease (biological, demographic…)
- Synthesize data: Reflect knowledge and uncertainty about model inputs/assumptions.
- Model Calibration: Ensure projected outcomes are consistent with population-based data.
- Simulate strategies: Compare short and long term consequences (e.g. cases averted, life expectancy gain, costs…)
Different Kinds of Analyses
- Evidence Synthesis, Policy Analysis, and Agenda Setting (identify promising approaches and get the problem on the agenda with stakeholders)
- Contextualization and Adaptation (adapt to local situations)
- Methodological work relevant to public health (investigate biological uncertainties)
- Rapid response to stakeholder questions (cost effectiveness, demand, forecast, etc.)
- Translation of key messages to stakeholders, policy makers, etc.
- Consensus meetings to establish new guidelines
- Additional studies to fill data gaps
- Guidance in the design of new diagnostics
- Partnering with countries, and adapting to local situations again
- Cost Effectiveness Analysis
- Value for money
- Opportunity costs of not investing the dollars elsewhere
- Generally long-term perspective
- Impact on the current budget
- Fiscal space
- Financial costs
- Often short term perspective
Sources for “TERMS FOR REVIEW”
Mainly lecture slides and lecture notes.
Various websites were consulted for additional or background information:
who.int; pih.org; thelancet.com; wikipedia.com;
RACE, Dr. Kane. “Engaging in a Culture of Barebacking” Department of Gender and Cultural Studies, The University of Sydney. http://usyd.academia.edu/KaneRace/Papers