When
tackling global health issues, perceptions around this subject are often
associated with infectious diseases, water sanitation, and malnutrition. Time
and again, these perceptions of health facilitate the shaping of discourses
for the best solution for these issues without considering other alternatives.
For example, greater immunization efforts can solve Nigeria’s reoccurring bouts
of polio and erecting more wells can provide adequate drinking water to
poverty-stricken nations. Through the notion that good health is a human right
in which collective efforts should be made to achieve for all, we often fail to
see the underlying issues that have caused many developing countries to have to
give up this right. In the Global Health Watch 3 report, a current issue in
global health is not directly medical at all but rather the report focuses on
the economical and political determinants of health. Furthermore,
anthropologist Carole E. Hill reflects on these external barriers to health
through a case study of health care in rural Costa Rica in which we will see
that the widening health gap between developed and developing nations has
cultural, social, political and economical implications.
The
big picture as seen by Global Health Watch 3, is that although significant
improvements have been made in health the rapidly widening gap in health
inequality between countries is a major problem. Statistics like the 20 years
increase in overall life expectancy from 1950 to 2002 sound great, however,
break this down and unequal distribution of improvements can be seen (Kuszler
2007). For the year 2002 the average life expectancy for a newborn female born
in a developed country was 78 years. At the same time, the life expectancy for
a newborn male in sub-Saharan Africa was significantly lower, at an average of
46 years. Drastic disparities like these prompt the current issue of what are
the causes behind these differences. As stated in Global Health Watch 3,
solutions in Primary Health Care in third world countries have a tendency to
focus on personal preventatives, promotives and therapeutic strategies like
immunization and growth monitoring. These projects are often shortsighted and
further facilitate poor health by undermining third world health systems. These
types of tactics take prioritization out of other, less medical aspects of PHC
such as equitability, social and economic development, community participation
and the need for sustainable infrastructure that would provide long-term
benefits. What it proposes is restructuring and improvements on primary health
care so that it extends beyond short-term surface solutions to optimal health.
As
mentioned, detailed in Carole E. Hill’s article “Local Health Knowledge and Universal Primary Health Care: A Behavioral
Case from Costa Rica,” is the primary health care and other modes of care
available in rural, lowland Costa Rica. Between the year of 1983 – 1984 this
research team sought to dissect the impact of rural health policies on a local,
rather than international or even national scale. They did so through observing
and participating in the daily lives of members of two rural communities,
Caribe and El Puente, and through participant-observation and informal
interviews. What they found is that for the individuals living in the rural
communities there are 4 options for receiving health services: rural health
posts, clinical hospitals, private services and physicians and/or the
traditional health system of bush medicine. They found that traditional bush
medicine was still used quite frequently of the four however, used
involuntarily. Private physicians provided little primary health care and were
expensive. In theory, rural health posts were designed to control and eradicate
transmittable diseases through vaccination, provide maternal, child and
nutritional care, create more sanitary conditions, and educate in health (Hill
1985). The barrier to this primary health care is external and structural. A
single physician was used for both communities and often time had to borrow a
jeep to transport from on area to another. In addition, the facilities were
often short of medicine and equipment. Inadequacy and underdevelopment in Costa
Rica prompted Hill to propose that the solution to poor health communities
combine micro and macro strategies.
In
the situation of Costa Rica and other developing nations, the structure of
third world economies do not have the capacity to achieve rapid progression in
health. Promoting immunization efforts in general is does more good than harm
but when the country is short of needles and equipment; efforts are undermined
because of structural barriers. These barriers are such as inadequate health
workforce or facilities are given less attention to the immediate results of
disease vaccination. Another example are wells and water sanitation efforts. If
not thoughtfully constructed, these devices only serve as temporarily relief
because these areas lack trained personnel and resources to upkeep the
maintenance.
As
an anthropologist, Carole Hill frames the issues of international intervention
in the crisis of third world health care very similar to what we learned as the
“politics of othering.” The definition of this given in lecture is, “one group
using negative representation to devalue another group. Although in the case of
many third world countries, the country as a whole is not being “devalued.”
Instead the situation becomes framed as “we” the developed nation help “them”
the developing nations by implementing what we deem fit and what Hill brings to
light the question: “can one member of
society achieve objective understanding for another?” This question is
rarely considered in the wake of poverty and underdevelopment discourse. Hill
also asks, are our ideas and assumptions of adequate healthcare that is
internalized within us through our own culture, universally applicable to all
situations? With the globalization of health, Global Health Watch reports that
it is becoming more common to associate PHC with first line medical care
provided by doctors rather than the PHC associated with equitable economic and
social standards that promote good health. And as the problem still stands,
policies based off of urban model of health is unfit for rural places like
Costa Rica, whom cannot sustain such a model due to a lack of infrastructure
and development (Hill 1985).
Aside
from Hill’s frame of this issue, I saw many applications of medical
anthropology on this case study. A metaphor that describes competing interests
on different levels was used early on was the “Cacophony of Voices.” Global
health is a collection of problems but the problems vary depending on whose
voice is being heard. In reference to health reform, solutions may come at
different levels however, the local level is often overlooked as international
efforts are more heavily covered in the media which aids the discourse of
“othering.” Global efforts may label disease eradication efforts as the main
obstacle to worldwide good health yet, as Hill discovered in the study of
health care in Costa Rica, locals do not even have the ability to receive basic
care. For the rural towns in Costa Rica, adjustments such as efficient
transportations would significantly improve health by improving accessibility.
This ties into another general concept of global health we learned early on and
that is “to solve global health problems, social change is necessary.” There
were many ways to achieve social change that applies to this health care
discussion such as policy critique and advocacy and institutional and system reform.
With
widespread efforts and funds to aid HIV treatment or fighting vaccines,
treatment goals are often failed due to deficiencies in public health
infrastructure and workforce (Pfieffer 2007). With this in mind, a way of
addressing health in third world countries may require a multi-dimensional
approach. A multi-dimensional approach of targeting issues like infectious
diseases indirectly through sufficient support and public sectors in health may
be more effective and cost efficient in the long run.
“There is no need to teach women how to cook different foods or to clean food and utensils if they do not have clean water or money to buy such foods, nor is it practical or realistic to teach about proper sleeping patterns if families will go hungry if the adults do not work long hours” (Hill 1895).
These efforts to overhaul the basic
structure of third world countries provide long-term rather than short term and
expensive solutions to ill health because it can bring about equitable, large,
national scale treatment to the community (Pfieffer 2007). Through policies
that target infrastructure, standard of care, geographic coverage and long term
planning based on local priorities, then can we efficiently target diseases
like HIV/AIDS (Pfieffer 2007).
Another quote in Hill’s article that forced me to look at medical anthropology in a
different way was: “we cannot assume if we render something accessible,
acceptable and affordable in our terms that it applies cross-culturally.” This
is very similar to the notion that people develop habits, ideas and ways of
thinking and acting within their own societies through the cultural, social and
political institutions we interact with everyday. We embody these things and this
is how ways of thinking and behaving are developed. We internalize these
specific ways of living and thinking. When we apply international intervention
to health on say, a country like Costa Rica, these ways of thinking that we
have internalized are taken for granted and therefore, the ideas we have
embodied seem natural to apply to another culture which sometimes is not the
case.
Ti Nguyen
Hill, Carole E. 1985. "Local Health Knowledge and Universal Primary Health Care: A Behavioral Case From Costa Rica." Medical Anthropology. 9(1): 11 - 23.
Kuszler, Patricia. 2007. "Global Health and Human Rights Imperative."
Pfeiffer, James et al. 2008. "Strengthening Health Systems in Poor Countries: A Code of Conduct for Nongovernmental Organizations." Ethics in Public Health Research. American Journal of Public Health 98(12): 1 - 7
Global
Health Watch 2011. Global Health Watch 3: An Alternative World Health Report
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