Our perceptions about
what constitutes “good” health care and how to go about achieving this have
shifted over time. There have been many
ideologies and interests involved in this change, ranging from global financial
policies to human rights claims on an individual level. This shift is especially important in
developing areas as these health policies are generally implemented by western-based
international organizations, both governmental and non-governmental, which usually
have no direct accountability to the people they serve. In this paper I will argue that this shift
has had a negative impact on the communities that are most vulnerable because
it is based in neoliberal ideologies that do not take into account individual
and community needs that are not economically based.
Since
the advent of international human rights, the world has been struggling with
the issue of health care for all. One of
the first attempts at codifying this idea was the Alma Ata declaration, which
was subtitled “Primary Health Care Is the Key to Health for All”, and which
also declared health to be a “fundamental human right”. (WHO, 1)
The model proposed by this meeting emphasized health services that are
“fully responsive to local needs” as well as basing them on “human rights,
social justice, and equity”. (Janes,
458) Since that time though, we have
seen a shift in ideas of primary health care (PHC) to be based on
“…macroeconomic
theory and a belief in the efficacy of market forces to deliver accessible and
high-quality health care. They hold a
conception of health care and public health that focuses narrowly on
demonstrable individual and biomedical (rather than social) outcomes.” (Janes, 459)
These new driving
ideologies behind global health management serve to accomplish several things,
including the reproduction of neoliberal ideas and the continuation of serious
inequalities regarding health care around the world.
In his article Going Global in Century XXI: Medical
Anthropology and the New Primary Health Care, Craig R. Janes discusses this
shift in primary health care and its consequences on vulnerable
populations. He argues that medical
anthropologists must “…confront narrowly technical and economics-driven
development…” that in effect produce “…little more than poor medicine for poor
people.” (Janes, 458) This shift away
from human rights, social justice, and equity and towards cost effectiveness
and privatization as guiding principles of health care has deepened
inequalities in access to health around the globe. Janes focuses his work in Mongolia, and uses
his experiences there to illustrate the impacts of global health care ideology
on local communities. He concludes that
the health system in practice there “…violates the basic principles of health
care equity…” and that an unfair burden is placed on the most vulnerable
populations, the major cause of this being that the system in place there is
not responsive to the community it serves. (Janes, 462)
Janes continues on to discuss the
roles of community and civil society in the new globalized world. He argues that globalization is embodied in
local practices, and local communities are connected to, and influenced by,
global webs of social and economic power. (Janes, 463) These webs include NGOs, which can often
conflate public and private interests through various means, and “are thus a
kind of ‘vertical community,’ created out of global centers to serve global
interests.” (Janes, 464) These NGOs, in
cooperation with transnational pharmaceutical corporations and public
institutions such as the World Bank and USAID have come to be the dominant
drivers in creating and implementing global health policy, which brings into
questions issues such as “governance, accountability, and authority.” (Janes,
466) Janes concludes his article by
arguing that it is the medical anthropologist’s responsibility to position
themselves as a representative of the local.
In this, they can situate these new global health care policies in a
local context with a critical eye towards how global webs of power are embodied
in lived experiences.
Medical Anthropology
and Global Health
In the report Global Health Watch 3: An Alternative
World Health Report, the authors are largely in agreement with Janes’
findings. They argue that
“While there is
no consistently applied, universal package, ‘health sector reform’ reflects and
reinforces neoliberal polices. It includes the restructuring of national health
agencies; planning of more cost-efficient implementation of strategies and
monitoring systems; the introduction of user fees for public health services;
introducing managed competition between service providers; and involving the
private sector through contracting, regulating and franchising different
private providers” (Cassels, cited in GHW3, 47).
In response to the
problems created by this shift in primary health care, such as continued
inequality and increased donor dependency, a number of Global Health
Initiatives (GHIs) have formed. These GHIs,
while bringing increased funding for many serious problems, have “…reinforced
the selective approach to PHC” by favoring vertically implemented programs
while ignoring the social determinants that cause such problems. (GWH3,
48) This was illustrated in our class
readings that included studies on how to implement HPV vaccination programs in
low and middle income countries. In the
study led by D Scott LaMontagne, they report that “the largest effects [of the
vaccines] have been reported in countries that have received subsidized vaccine
through the GAVI alliance.” (LaMontagne, 821)
The ways in which the GAVI alliance funds these programs is through
selling bonds that are backed by long term aid commitments from donor countries
to countries in which the vaccination programs are being implemented. They also require that recipient countries
contribute towards the cost of the vaccine programs as well. (The GAVI
Alliance, 2012) While it is accurate to
say that these programs help create more equity in the field of immunization,
they ignore many other aspects of health and the sustainability of health
programs. These practices also raise
questions about accountability to the affected communities as well as the
funneling of aid money away from improving health infrastructure to vertically
implemented programs, which may benefit economies in donor nations more than
recipient nations due to who controls the production of vaccines and the
methods through which these long term commitments are transformed into immediate
funding.
Both the authors of The Global Health Watch 3
(GHW) and Craig R. Janes seem to agree on many aspects of the problem facing
PHC today. The GHW continually
reinforces the idea of community participation in health care, and the role of
power, politics and policies in shaping the hegemonic views on global
health. They also argue for the need for
social movements as a way to gain more access to health resources and to
improve health equality. A way that the
GHW illustrates this problem is by looking at quantitative population data,
such as health expenditures per person or as a percentage of GDP. They connect this data to larger political,
social and historical problems to show how they fit in with our global economic
structure and how that interacts with those populations. They do this by using case studies of
individual country’s health care systems and how well they work, again by
illustrating population statistics, usually related to economic status.
The difference
between this and how Janes approaches the problem from a medical anthropology viewpoint
is that while the GHW is looking at population statistics, usually on a
nation-wide basis, Janes is interacting with communities in an attempt to
illustrate the lived experiences of these health care systems. He is interested in producing a qualitative
understanding of global health problems by integrating local experiences across
global policy. Both Janes and the GHW
use some of the same core principles, such as human rights, social justice and
equality, to explain the same problem, but they illustrate the problem on
different levels and with different methods.
They both come to many of the same conclusions, as Janes also argues for
more social action and participation saying “My Mongolia work suggests that
community participation is an essential first step toward ensuring that health
systems are locally responsive and equitable” (Janes, 465).
One way in which medical anthropology is useful in
illuminating problems, is by contrasting the local and the global in order to
understand why we think and act the way we do, and what the consequences of
these are. It accomplishes this by
situating problems within a local and historical context, and illustrating the
social and individual embodiment of these problems. This has the effect of juxtaposing hegemonic
ideologies with local ones, as well as shedding light on some of the
determinants which influence these dominant ideologies, and offering
alternative ways of thinking.
In the case of PHC Craig Janes challenges the neoliberal
ideologies that drive global health by illustrating the local consequences of
the new model of primary care.
“In this new
world the medical anthropologist must confront narrowly technical and
economics-driven development to argue persuasively that individuals,
households, and larger social groups pursue other than pure economic ends, that
humans are not necessarily, or even mostly, economically rational actors, and
that market fundamentalism destabilizes an already frighteningly fragmented,
inequitable world” (Janes, 458)
He continues on to
argue that this shift in the dominant idea of PHC towards cost effectiveness
and “narrowly demonstrable individual and biomedical (rather than social)
outcomes” (Janes, 459) have been influenced by certain interests, and has
fundamentally changed the ways in which we see global health. Once we look at health problems in a local
and global context and use this to illustrate how we frame our understanding of
them, we can then use this to re-frame our ideas and open up new possibilities
for action.
Another way in which medical anthropology helps to
illuminate problems is through the practice of ethnographic research. This qualitative research method provides an
alternative method of knowledge production, which can be used to challenge
current representations regarding global health. The ways in which we attach symbols to ideas
concerning global health is related to access to power in general, and bio-power
in the case of global health. Those
interests which have more control over our perceptions of health influence us
in ways we cannot always see and ethnography can illuminate these perceptions
by presenting an alternative narrative that is more removed from some of those
interests. For example, Craig Janes uses
these tools in Mongolia to show that international institutions that shape
global health policy, and subsequently individual perceptions on global health,
are connected to public and private interests and guided by neoliberal
policies, which in effect produce poor standards of health for poor
people. As discussed in class, a key
strength of ethnography is that it does not only engage with methods, but also
ethics, theories and epistemologies. In
this way it is better suited to examine how knowledge production interacts and
reproduces social relationships.
Finally, the ideas of governance and bio-politics help us
to structure this problem in another way.
Using these ideas, we can ask which actors in this narrative have more
access to political and economic power and how this shapes our perceptions and
representations, as well as the legal and administrative applications of global
health policies. This formal framework
combines with an informal network, which includes favors and bribery among
other things, to create health systems that interact with specific communities
at specific times to create lived experiences of health. We can also ask where the source of power for
these institutions that guide global health policies comes from and how that
interacts with our ideas of good governance.
Janes and GHW illustrate these points by arguing that contemporary
control of international health organizations stems from control over access to
resources rather than a local public mandate.
This in turn allows for the promotion of certain ideologies, such as
neoliberalism, as a guiding principle for the creation of global health
policies.
Conclusions
In applying these medical anthropology concepts to the
particular problem of primary health care, we can begin to interrogate why we
understand PHC the way that we do, and the consequences of this
understanding. How are our ideas of
“good health” created? Where does the
knowledge that produces these ideas come from and who has access to create and
shape this knowledge? What are the lived
experiences that result from these ideas?
In addressing these questions in the context of PHC we see that current
ideas in global health do not always align with local realities, and that this
is a result of power imbalances between those that shape international health
policy and the communities that these policies are practiced on. How then do we go about balancing this access
to power?
Both Craig Janes and GHW advocate for more community
action as well as understanding and targeting the larger processes and forms of
power which restrain local action.
Social movements are necessary to move away from the narrow, economics
driven idea of PHC, and towards health in a human rights and social justice
framework. While these movements are
hard to construct and maintain, they provide a needed counterbalance to
dominant global influences on PHC, and are better able to take into account all
of the determinants of health to provide a more equitable and locally
appropriate idea of “good health”.
Bibliography
World Health Organization (WHO). "Declaration
of Alma-Ata." International conference on primary health care,
Alma-Ata, USSR. Vol. 6. 1978.
The GAVI Alliance. http://www.gavialliance.org/forum/. (Dec. 8, 2012)
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