Chapter 1 Introduction

Authors: Paul Farmer, Jim Yong Kim, Arthur Kleinman, Matthew Basilico A View from the Field Mpatso has been coughing for two months. Coughing consumes his energy and his appetite. When his skin begins to sag, he takes the advice of his relatives and makes the two-hour journey to a health center. Mpatso has AIDS and tuberculosis. In his village in rural Malawian agrarian, landlocked nation in Southern Africa, hard hit by AIDS and resurgent tuberculosis Mpatsos diagnosis carries a very poor prognosis. Malawi, like most of the countries in subSaharan Africa, faces the combined challenges of poverty, high burden of disease, and limited health services in the public sector. But Mpatsos case is an exception: shortly after he arrives at the Neno District Hospitala public hospital in the rural reaches of southern Malawihe is seen by a team of clinicians. That same afternoon, he was diagnosed and began treatment for both diseases, a dizzying number of pills, but his are delivered daily by a community health worker who also helps him to follow his therapeutic regimen. Mpatsos life will likely be prolonged by a decade or more. This is modern medicine at its best. Down the hall from Mpatsos exam room, a neighbor gives birth with the support of a nurse-midwife. In an adjacent room, six women labor under the watchful eye of the clinical staff and within feet of a clean, modern operating room. In this and in many other respects, Neno District Hospital differs from most health facilities nearby (and throughout rural sub-Saharan Africa). The hospital is a comprehensive primary care facility, providing ambulatory care for more than 100 patients each day. It has about 50 beds, a tuberculosis ward, a well-stocked pharmacy, and an electronic medical records system. The facility is staffed by doctors and
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nurses from the Ministry of Health. In the midst of 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 service. 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? 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.

Overview This volume grows out of a course now in its fifth year at Harvard College. The authors and editors seek to bring our experiences as health practitioners to bear upon fundamental questions about global health delivery. Global health is not a discipline but rather a collection of problems. Describing the forces that led Mpatso to fall gravely ill with tuberculosisa treatable infectious disease that has been banished to history books in most of the rich world yet continues to claim some 1.5 million lives per year worldwiderequires both biologic and sociologic inquiry, 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. A rigorous analysis of the fundamental questions in global health demands an interdisciplinary approach. This text draws on insights from clinical medicine and public health disciplines like epidemiology and health economics. But it also seeks to critique regnant global

health discourse with what term resocializing disciplinesanthropology, sociology, history, political economy.i An exhaustive treatment of global health would be impossible in a single volume; our goal here is thus to offer an introduction to some of the principal challenges, accomplishments, and complexities that make up what has been termed global health. Most textbooks of public health have been written by epidemiologists and we draw heavily on this field. But the course we teach at Harvard College (like the courses we have long taught at Harvard Medical School and the hospitals with which were affiliated) are not the same as those developed by public health specialists. Those who have developed this course and this book are all jointly trained in clinical medicine and in anthropology. Our approach thus hinges on social theory, which we explore in the second chapter, and seeks to interrogate concepts and claims of causality widely used in the literature on global health. Our experience as medical practitioners has also shaped our approach to this material. As we demonstrate in Chapter 6, adapting a fully interdisciplinary approach to basic questions how did Mpatso become ill, and why?has directly informed our practice. We see this close coupling of inquiry and implementationthe vitality of praxisas central to our work: traversing the space between reflection and pragmatic engagement is necessary to any attempt to distill a core body of information about global health. Limitations exist in any teams knowledge of a particular field, and we draw heavily on material with which we are familiar, including the work of the nongovernmental organization (NGO) Partners In Health, the focus of Chapter 6.

Text Box 1.1 On Definitions in Global Health

How should we define health? The World Health Organization (WHO) defines it as a state of physical, mental, and social wellbeing. But is this how Mpatso understands health? Can any definition of health capture the subjective illness experience of individuals in different settings around the globe?ii 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; medicine, 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 fields must draw on 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, 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.iii All fields have myopias. The restricted gaze of each discipline can illuminate certain global health problems; but only 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 non-state institutions, including international NGOs, private philanthropists, and community-based organizations. Pathogens do not recognize international borders. But much churnsocial and microbialis introduced at borders.iv We seek to examine health disparities not only among countriesincluding our ownbut also within them. Boston (like Cape Town and Sao Paolo and Bangkok) has some of the finest hospitals in the world; it is also on the globe. A final note on definitions: global health delivery refers to the provision of health interventions, a process distinct from the discovery or development of 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 healthincluding poverty, inequality, environmental degradationrequires a broad-based agenda of social change.

An Overview of Health Inequities: The Burden of Disease We begin our overview with the global distribution of poor health and the factors that structure this distribution. 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, by comparing high- and low-income countries. Five

of the leading causes of death in low-income countriesdiarrheal diseases, HIV/AIDS, tuberculosis, neonatal infections, and malariaare treatable infectious illnesses that are not found on the leading list of killers in high-income countries. Nineteenth-century diseases like 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 medicines now cost less than $100 per year in the developing world, AIDS is still the leading killer of young adults in low-income countries. In fact, 72 percent of AIDS-related deaths occur in a single region, sub-Saharan Africa, which is also the worlds poorest. Diarrheal diseases are often treatable by simple rehydration interventions that cost pennies, yet these diseases rank third among killers in low-income countries. [tableref1.1] [Title: Table 1.1: Leading Causes of Death by Income Group, 2004] Table 1.2 presents similar data, this time using a measure that takes into account both disability and death. The measure, the Disability-Adjusted Life Year (DALY), is not without its flaws; we will examine it in Chapter 8. This tool, reflecting morbidity, shows a similar picture of health disparities between high- and low-income countries. It is also apparent that noninfectious conditionslike birth asphyxia and birth trauma, together ranked number seven in DALYs lost for low-income countriesare disproportionately distributed in low-income countries. Like the treatable infectious diseases listed above, 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. 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 20.2 years less than in high-income countries (see map).

[tableref1.2] [Title: Table 1.2: Leading Causes of Burden of Disease (DALYs), Countries Grouped by Income, 2004] [mapref1.1] [Title: Map 1.1: Average life expectancy in WHO Region] [Caption: Source (Table 1.1, Table 1.2, Map 1.1): The Global Burden of Disease: 2004 Update (Geneva: World Health Organization, 2008).] The relationship between GDP and health is one starting point for an examination of global health inequities. But GDP and GNP are terms 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. We will grapple with the many layers of these inequities throughout the text, beginning with a theory of structural violence in Chapter 2. Figure 1.1, from recent work of the World Health Organization Commission on the Social Determinants of Health, illustrates one example of the substantial differences in health outcomes between richer and poorer households within countries. Figure 1.2, from the same report, highlights another measure of social status across countriesin this case, education levelthat correlates with health outcomes, such as infant mortality. The impact of social class, among other social and political and economic factors, on health is taken as a given in this book, as it is in others. Instead we will explore 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 poor, rural Malawi, while so many others in similar circumstances are not so lucky? [figref1.1] [Title: Figure 1.1: Under-5 Mortality Rate per 1,000 Live Births by Level of Household Wealth]

[figref1.2] [Title: Figure 1.2: Inequity in Infant Mortality Rates Between Countries and Within Countries by Mothers Education] [Caption: Source (Figure 1.1, Figure 1.2): Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health (Geneva: World Health Organization, 2008). Organization of This Book Each of the chapters in this volume has been drafted by course faculty, guest lecturers, teaching fellows, andin a few instancesoutstanding former students from our undergraduate course Health, Culture and Community: Case Studies in Global Health. In developing the syllabus and course content, we observed that despite the wealth of scholarship in this area, the number of introductory texts approaching global health from a biosocial angle was limited. In positive reviews during the first year of the course, students encouraged us to find ways to make the course material accessible beyond our classroom. We decided that through this project we could do both: make our course material available to a broader audience, and begin to fill the gap of introductory materials on global health. The book is divided into ten chapters. Chapter 2, as mentioned above, lays out a framework of social theories to support the analysis of important questions in global health. We have found these theories a helpful toolkit for understanding the material covered in this volume, as well as our own varied practices within the field of global health. We assume no background knowledge in social theory, and draw on some of the great theorists of the past century, such as Max Weber and Michel Foucault, as well as more recent health-focused work, such as the notion of social suffering offered by Kleinman, Das, and Lock. For those with some

background in social theory, we hope our health focus will draw out new insights from this material and spur consideration of the relevance of other theoretical frameworks. Chapters 3, 4, and 5 continue to build our analytic framework by examining three key historical periods critical to an understanding of global health today. Chapter 3 offers an account of colonial medicine and its legacies. One particular focus is the development of major global health institutions, including the World Health Organization, and the patterns of priority-setting for health interventions in the developing world. We trace the ways in which the economic and political priorities of wealthy nations informed assumptions about local populations and corresponding modalities of intervention. These trends have often continued to structure academic inquiry and the design of health interventions well beyond the colonial era. We also study global fascination with the power of biomedical intervention, such as the development of the first antibiotics and the pesticide DDT, in the context of two of the most important global health campaigns of the Cold War era: the smallpox and malaria eradication campaigns, which achieved markedly different results. Chapter 4 analyzes two pivotal and tumultuous decades for international public health, 1978 to 1998, which have had a profound influence on health systems in developing countries, as well as on shaping contemporary discourse among global health policymakers. The chapter begins with the antecedents of the 1978 Alma-Ata conference, which witnessed worldwide adoption of the goal Health for all by the year 2000, and traces the development of neoliberalism and a shift to the selective primary health care approach throughout the 1980s. The section finally examines the way in which these geopolitical shifts led to the rise of the World Bank as perhaps the most influential institution in global health during the 1990s, and the impact of its approach on the health of the global poor.

In Chapter 5, we examine one of the most astonishing historical events in global health: the AIDS movement. Why, after decades of austerity in response to global health inequities, did rich countries devote billions of dollars in new resources every year to global AIDS efforts? Tracing the rise of the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, we suggest that it was the work of groups on the ground, teamed up with activists and economists, which led to a redefinition of the idea of the possible in global health. This radical change precipitated a dramatic shift in global policy. This shift in global thinking and resource flows demonstrates the elasticity of assumptions like limited resources and appropriate technology, and underscores the power of vibrant social movements in global health. Chapters 6, 7, and 8 build upon the historical and theoretical frameworks from Chapters 2-5 and confront many of the key questions in global health, beginning with those posed by Mpatsos case. Chapter 6 contextualizes these historical trends at the point of care: it considers the resuscitation of public sector health systems in Haiti and Rwanda, focusing, as mentioned, on the experiences of Partners In Health. We see the biosocial approach in practice, in the principles behind the organizations strategy and in the delivery of context-specific health interventions. Chapter 7 outlines a generalizable framework for effective global health delivery. We begin by defining a tangible goalpatient value, or health outcomes per dollar spentand then analyze contemporary efforts to strengthen health systems in resource-poor settings. The chapter calls for a rigorous science of global health delivery to improve health system performance around the globein poor areas and in rich ones. Chapter 8 investigates the social construction of disease categories and health metrics in the context of mental illness and multidrug-resistant tuberculosistwo pathologies which pose

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unique challenges to global health practitioners. The history and political economy of these illnesses illustrate many of the themes treated in this text, and highlight the role of biosocial analysis in unpacking some of the complexities of global health. We hope the chapter will offer lessons for other global health challenges that, unlike AIDS, rarely see media attention and are widely misunderstoodoften at the expense of those who encounter them as illness experience. Chapter 9 examines the roots of moral motivation in global health work, including the human rights tradition. It traces the genealogy of several ethical frameworks invoked by practitioners, examining their core premises and also the practical implications of their application in global health. Many people are led to global health work by an intuitive sense that it is the right thing to do; we believe that a critical investigation of several moral frameworks can both facilitate productive introspection and expand the sphere of discourse for public engagement in global health. The concluding section, Chapter 10, seeks to bridge the distance between knowledge and action, in the tradition of praxis. The chapter documents many important contours of the current geography of global health, reviewing several policy challenges addressed throughout the volume and situating them in their contemporary context. Finally, it offers a way forward for students, lay audiences, and professionals alike: by critically examining the forces that have brought important social change to global health in the past, the chapter offers a vision for translating the current interest and energy in global health into lasting change toward health equity.

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Acknowledgments The energy and inspiration for this book has come in great measure from the students and teaching fellows of our undergraduate course. In particular, Shom Dasgupta, Bridget Hanna, Emily Harrison, Evan Lyon, Jessica Perkins, Amy Saltzman, Maria Stalford, Arjun Suri, and Sae Takada have provided invaluable direction to the course over the years. Nancy Dorsinville has been a cherished mentor to both students and course faculty alike. Jan Reisss skillful eye in copyediting each line of this volume has greatly improved its quality and readability. Jennifer Puccettis unwavering support and guidance helped the project through many roadblocks (and an earthquake). We also owe a tremendous debt of gratitude to Zoe Agoos, Emily Bahnsen, Madeleine Ballard and Jon Weigel whose immeasurable contributions have extended from preparing some of the very first lectures in this course to creating a space in the Department of Global Health and Social Medicine in which this project could be completed. Likewise, Vera Belitsky, Jennie Block, Caitlin Buysse, Nadza Durakovic, Marilyn Goodrich, Mackenzie Hilde, Cassia van der Hoof Holstein, Steve Kadish, Sarah Melpignano, Haun Saussy, Gretchen Williams, and Gina Zanolli have provided invaluable creative and managerial support throughout the three years of this project. Keith Joseph, Jenna LeMieux and Jonas Rigodon, as well as Jessica Goldberg, Niall Keleher, and Dean Yang provided space and guidance for this endeavor, even in the middle of rural Malawi, while the HMS White Heat Fellowship afforded generous support in Boston. We are grateful to our many mentors and guest lecturers in the course for their intellectual guidance throughout this endeavor. We highlight here some of those who have made consistent and lasting contributions: Arachu Castro, Peter Drobac, Jeremy Greene, Julio Frenk, David Jones, Keith Joseph, Felicia Knaul, Ira Magaziner, Joia Mukherjee, Michael Porter,

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Joseph Rhatigan, and James Robinson. The responsibility for the content of this volume (including its errors and imperfections), however, lies with usthe editors and chapter authors. As this volume is grounded in our experience as practitioners, we are indebted to the many institutions and people with whom we have the privilege of working. Partners In Health and the communities in which it is based have informed our approach and shaped our lives in ways that could never be adequately described. We must settle for acknowledging all of those who work at this institution, and in particular Executive Director Ophelia Dahl, for their efforts, which continue to inspire us every day. Likewise, the Department of Global Health and Social Medicine at Harvard Medical School, the Division of Global Health Equity at Brigham and Womens Hospital, the Office of the President at Dartmouth College, and the Harvard Global Health and AIDS Coalition have provided various homes for this endeavor, in one way or another. Finally, this book is dedicated to our true heroes and teachers, who often share not language nor nationality nor gender, but their relative social positioning at the bottom of the ladder. Our hope is that this work may one day make a contribution for them.

i See Farmer ii

P. An anthropology of structural violence. Current Anthropology 2004;45(3):305-326 See for example Kleinman, A., Das, V. and M. Lock, Eds: Social Suffering. Berkeley: University of California Press 1997; Kleinman, A.: The Illness Narratives: Suffering. Healing and the Human Condition. N.Y.: Basic Books, 1988. iii Jonathan M. Mann, Medicine and Public Health, Ethics and Human Rights The Hastings Center Report 273 (1997): 8. iv Farmer PE. Social inequalities and emerging infectious diseases. Emerging Infectious Diseases 1996;2(4):259-269

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