Table of Sexiness
10/90 GAP ......................................................................................................................................................................4
4 PILLARS OF HIV PREVENTION AND TREATMENT .........................................................................................................4
ACCOMPAGNATEUR........................................................................................................................................................4
ADHERENCE/COMPLIANCE/FAILURE ...............................................................................................................................5
AGNES BINAGWAHO.......................................................................................................................................................5
AMPATH ......................................................................................................................................................................6
ANTI-HEROIC ..................................................................................................................................................................6
JEAN-BERTRAND ARISTIDE ............................................................................................................................................7
ARTICLES 25 AND 27 ......................................................................................................................................................8
BUREAUCRACY ..............................................................................................................................................................9
CARABAYLLO ............................................................................................................................................................... 10
CAREGIVING ................................................................................................................................................................. 11
CASE DEFINITION ......................................................................................................................................................... 12
CASE STUDY METHOD ................................................................................................................................................. 12
CCM ............................................................................................................................................................................ 13
CDC ............................................................................................................................................................................. 13
CLINTON FOUNDATION ................................................................................................................................................ 14
COMMODITIES .............................................................................................................................................................. 15
COMMUNITIES OF PRACTICE......................................................................................................................................... 15
COMMUNITY MENTAL HEALTH DELIVERY SYSTEM ..................................................................................................... 15
CONTESTED HISTORY (UVIN) ....................................................................................................................................... 16
CARE CYCLES .............................................................................................................................................................. 17
DE-MORALIZATION ...................................................................................................................................................... 17
DELIVERY SCIENCE ...................................................................................................................................................... 18
DIAGNOSIS OF EXCLUSION ............................................................................................................................................ 18
DIAGONAL APPROACH .................................................................................................................................................. 18
DIFFUSION OF INNOVATION .......................................................................................................................................... 19
DFID – DEVELOPMENT FOR INTERNATIONAL DEVELOPMENT ..................................................................................... 19
DONKEY FEES ............................................................................................................................................................... 20
DSM ............................................................................................................................................................................ 20
DUVALIER .................................................................................................................................................................... 21
BILL AND MELINDA GATES FOUNDATION .................................................................................................................... 21
GLOBAL FUND TO FIGHT AIDS, TB AND MALARIA (GFATM) .................................................................................... 21
HOME-BASED COUNSELING AND TESTING (HCT)........................................................................................................ 22
HEALTH CATASTROPHES .............................................................................................................................................. 22
HEALTH SECTOR REFORM (HSR) .................................................................................................................................. 22
HEALTH SYSTEMS CONTROL KNOBS ............................................................................................................................ 23
HEALTH SYSTEMS STRENGTHENING ............................................................................................................................ 24
HUMAN RIGHTS ............................................................................................................................................................ 24
HUMANE VALUES ......................................................................................................................................................... 25
IDI BOUSQUET-REMARQUE .......................................................................................................................................... 25
IMPLEMENTATION RESEARCH ....................................................................................................................................... 26
1
IMPLEMENTATION SCIENCE .......................................................................................................................................... 27
INDIRECT RULE (UVIN) ................................................................................................................................................ 28
INFECTION CONTROL .................................................................................................................................................... 28
INTERVENTION SPECTRUM (PREVENTION <--> TREATMENT <--> MAINTENANCE) ........................................................ 29
INTRAFAMILIAL EPIDEMICS .......................................................................................................................................... 30
INVISIBLE WOMEN ....................................................................................................................................................... 31
JOSEPH JEUNE............................................................................................................................................................... 31
IU-MU PARTNERSHIP .................................................................................................................................................. 31
JULIO FRENK ................................................................................................................................................................ 32
KAPOSI’S SARCOMA ..................................................................................................................................................... 33
KNOWLEDGE-ACTION GAP .......................................................................................................................................... 33
LEGITIMIZATION........................................................................................................................................................... 34
MANY FARMS............................................................................................................................................................... 34
MARSHALL PLAN ......................................................................................................................................................... 35
MEDICAL HUMANITIES ................................................................................................................................................. 36
MENTAL HEALTH ......................................................................................................................................................... 36
MENTAL HEALTH PROBLEMS ....................................................................................................................................... 37
MENTAL ILLNESSES...................................................................................................................................................... 37
MINSA ........................................................................................................................................................................ 37
PAUL KAGAME ............................................................................................................................................................. 38
PAUPERIZATION ........................................................................................................................................................... 38
PEASANTRY .................................................................................................................................................................. 38
PEPFAR ...................................................................................................................................................................... 39
PELIGRE DAM ............................................................................................................................................................... 39
PLANTOCRACY ............................................................................................................................................................. 39
PMTCT ........................................................................................................................................................................ 40
POSER......................................................................................................................................................................... 40
POSITIVE SYNERGIES BETWEEN HEALTH SYSTEMS AND GLOBAL HEALTH INITIATIVES ............................................... 40
RANDOMIZED CONTROLLED TRIAL .............................................................................................................................. 41
SOCIAL MOVEMENT ..................................................................................................................................................... 41
SOLIDARITY ................................................................................................................................................................. 42
THE GREEN LIGHT COMMITTEE ................................................................................................................................... 42
THE SOCIAL LIFE OF THINGS ........................................................................................................................................ 43
TRIPS .......................................................................................................................................................................... 43
UDHR .......................................................................................................................................................................... 45
URBANIZATION ............................................................................................................................................................ 46
USAID ......................................................................................................................................................................... 46
VALUE .......................................................................................................................................................................... 47
VALUES ........................................................................................................................................................................ 47
VALUE CHAIN .............................................................................................................................................................. 47
VOLUNTARY COUNSELING AND TESTING (VCT)........................................................................................................... 48
WELL-BEING ................................................................................................................................................................ 49
W.H.R. RIVERS ............................................................................................................................................................ 49
2
3
10/90 Gap
The vast inequity between drug R&D and neglected diseases. "Only 10% of the world
expenditure on health R&D is spent on health conditions that represent 90% of the global disease
burden".
• This is primarily an effect of the fact that the diseases creating this burden affect people that
are too poor to provide an attractive market for drug companies
• Also related to "access gap" where the patients most in need of ARVs are unable to afford
them
• Comes from Addressing Global health Inequities: An Open Licensing Approach for
University Innovations, lecture 11
4 Pillars of HIV Prevention and treatment
(versus minimum package notion)
a. HIV Prevention and Care in context of primary health care
b. TB detection and treatment
c. Women's heath and family planning
d. STI detection and treatment
(4 pillars are all are under roof of public clinic/ primary health care)
• Money came from global fund to fight AIDS, Haiti got a grant, and PIH collaborated with
public sector to begin instituting these pillars; providing high quality treatment and prevention
• Relevant to global health b/c it was first big effort to scale up program, very successful
(increased patient visit, HIV detection, prenatal care visits, etc)
• Also investment in HIV built infrastructure, created a push for better drugs, and generated
commitment to quality medicine in developing countries
o Helps with other diseases, not just HIV
• Talked about in lecture 16 and assigned case study readings
Accompagnateur
An accompagnateur is one of the most important elements of the Partners in Health care delivery
system--"Accompaniment" and "Social and economic support" are the two supplements to the
medical care that the PIH team provided. An accompagnateur is a locally-trained community
health worker, usually a local individual suggested by the patient, who provided directlyobserved therapy to the patient, whether ARVs or DOTS-Plus. Accompagnateurs sign on with
the PIH code of patient confidentiality, and may also become trained in psychological
counseling, heath education, and the provision of and instruction in how to use preventative
health tools, such as insecticide-treated nets (ITNs). Accompagnateurs are discussed in nearly
every reading discussing PIH methodology, but most importantly in Lecture 16 (Paul Farmer)
from November 6th--they are in every reading from that class, including PIH's "Accompagnateur
Training Guide". Especially in rural and/or resource poor settings, accompagnateurs are a valueeffective way of ensuring medical compliance on the part of patients (so that second line drugs
don't have to be used) and of defraying the disease burden (by helping ensure medicine is taken
properly, and being able to promptly report sudden illnesses or other negative situations that
might require clinic doctors visiting the patient instead of vice versa) and cost of compliance
(ex., transportation) or patients.
4
Adherence/compliance/failure
Adherence, compliance, and failure are value-judgment words used by medical practitioners to
signify the ability of a patient to follow medical directions for treatment and follow-up; these
terms may indicate a lack of acknowledgment that there are obstacles ranging from small to
insurmountable that can prevent patients from following directions. Paul Farmer discusses these
significations in his article "Tuberculosis, poverty, and "compliance": lessons from rural Haiti"
and also in Lecture 15 (Paul Farmer) from November 4th--in his paper, PF demonstrates that
offering free care and medicine will save fewer lives than offering free care and medicine, and
providing an accompagnateur and subsidizing clinic travel. For example, compliance is not a
good term to describe what it takes to follow medical instructions for TB recovery in Haiti,
because the poor unfairly bear the burden of the disease and are then told to adhere to programs
that are not structured to meet their needs. PF is very adamant that noncompliance should
primarily be looked at as a program failure, and only after the program has been shown to be
optimally designed for delivering care to the patient in question, should noncompliance be
considered a patient's fault. These terms also tie to the global health methodology discussed in
Lecture 11 (Jim Kim) on Oct. 21 and Appadurai's "Social Life of Things" article--tracing a
patient's health as the "thing" can reveal what the shortcomings in the health care system are.
Agnes Binagwaho
Dr. Agnes Binagwaho is the Executive Secretary of Rwanda’s National AIDS Control
Commission (NACC) and an adjunct member of Harvard faculty. (She also helps coordinate the
Global Fund for Rwanda and is the chair of the PEPFAR Steering Committee in Rwanda, and
has written a book with Jeff Sachs about combating AIDS in the developing world.) She was
appointed in 2000 by President Paul Kagame to be the first head of the NACC.
Dr. Agnes was deeply concerned that HIV control efforts by NGOs operating in Rwanda were
“piecemeal and uncoordinated.” She set up a system for disbursing the flow of grant and aid
money to local NGOs, FBOs (faith-based organizations) and community development
organizations, working to harmonize antiretroviral therapy, PMTCT (prevention of mother to
child transmission), VCT (voluntary counseling and testing), and other services to ensure that
services covered the country. She said, “Some organizations didn’t want to cooperate and
threatened to leave Rwanda. We said to them, ‘Very well, there are many countries in the world,
and you’re welcome to work in any of them.’”
It was Dr. Agnes who first approached Partners in Health about working in Rwanda in 2002, as
she was interested in bringing the PIH model to rural Rwanda. In 2005, it was decided that PIH
had enough resources to undertake operations in Rwanda. Assisted by the Clinton Foundation,
PIH undertook a comprehensive HIV care initiative in two districts in southeastern Rwanda. In
2007, Dr. Agnes reviewed a report that suggested that the PIH program was exceeding
expectations, and undertook the national scale-up of the PIH model.
Relevant lectures and readings:
Dr. Agnes attended our class on Sept. 18th and gave a presentation that evening about her work in
Rwanda, in which she talked about her frustrations dealing with foreign NGOs who failed to see
the big picture. Dr. Agnes is mentioned in the “HIV Care in Rwanda Case” reading and was
mentioned in class on November 13th.
5
AMPATH
AMPATH (the Academic Model for the Prevention and Treatment of HIV/AIDS) is an
integrated HIV control system linking care, medical education and research in western Kenya
and providing care to over 65,000 HIV-positive patients in 2008. It was established in 2001 by
the Indiana University-Moi University partnership. It operates 19 facilities in 3 provinces in
western Kenya and is Kenya’s largest and fastest-growing ART provider. It receives funding
from USAID/PEPFAR grants, other government/foundation grants, and private philanthropy.
The AMPATH care delivery model focuses on patient care services including clinical
interventions with food security, income generation, and social support services.
In late 2007, AMPATH piloted the Home-based Counseling and Testing (HCT) model, which
provided door-to-door information, counseling and testing. The pilot program was initially a
success, though scale-up presents many challenges.
AMPATH is a good example of the kind of “communities of practice” and “shared delivery
infrastructure” that Jim Kim and Paul Farmer believe are the best practices in developing
countries. Hopefully, their own innovative practices (such as HCT and their impressive
nutritional support program) can be spread to other global health practitioners.
Relevant lectures and readings:
“AMPATH Rural Case,” Lecture 19
Anti-heroic
Lecture 23
1) Definition (from: What Really Matters, p.25) - as opposed to standard heroism, there is no
victory – it may not change the world, but it helps make clear to others what needs to change if
the world is to be a less unjust and desperate place
-
It thereby legitimates alternative ways of living in the world that offer new and
different personal answers to the question of what an adequate life is
-
It includes things like protest and resistance, and disturbing the status quo which is
the most that ordinary people like us can hope to achieve
-
in lecture 23, Kleinman says that it should be cultivated to develop 3 components:
o
critical self-reflection (because of potential unintended consequences)
o
ethical aspiration
o
strategy for resistance and alternative action
2) Significance – it is the way in which most of us will be able to carry out work to make
changes – small acts of resistance rather than large changes
3) Readings – What Really Matters, p. 25, 215
-
term that used for WHR Rivers – see definition of Rivers for more info
6
-
his works were influential in his time but were not transformative or influential in the
long run, yet he "perturbed and disturbed the moral ethos of his day not as a
revolutionary but squarely from the center of the establishment"; by just living a life,
Rivers showed that we need to be aware of the dangers that are part of normal, moral
commitments (p. 215)
4) Relevance to global health – same as significance (it is how ordinary individuals can become
involved in global health because heroic acts that change society are rare and more often than not
are "meretricious fictions" – p.25
5) Readings/Lectures – Lecture 23, Kleinman's What Really Matters (Chapters on Idi BosquetRemarque and WHR Rivers)
-
in Lecture 23, we also said that this is a term that can be used for someone like WHR
Rivers, who was a critic of racism, bellicosity and the colonialism of the period and
who realized that key issues of societies in Melanesia (where he worked) had to do
with the way in which European colonizers had undercut values and demoralized the
population
-
Paul and Jim were said to be anti-heroic in their ability to be self-critical (set out in
new directions, realizing it may be unsuccessful but seeing where it led – they worked
without the romantic notion that they would succeed at the ground level)
Jean-Bertrand Aristide
1) Definition – Aristide was a Catholic priest who ran ran President in the new elections in 1990
and won by a landslide. He set about reforming the public health sector in Haiti, where the
"human suffering index" was the fourth highest in the world; in 1991 he was overthrown in a
coup led by General Cedras; some 3000 Haitians were killed over the next year and human rights
deteriorated; restored to power in 1994 and $500 million in aid was promised to help rebuild
Haiti
-
he was re-elected again in 2000; again he ran on an anti-liberal policy
o
investing in people
o
investing in public sector and re-building institutions
- He had to leave the country in 2004
2) Significance – Aristide was a figure of change in Haiti – he went against the neoliberal
policies that had caused great problems in Haiti (including making them the most open market in
the world and turning them into importers of products which they had traditionally exported)
3) Readings – HIV Voluntary Counseling and Testing in Hinche, Haiti
Aristide tried to improve public health in Haiti. In 2001, he rolled out the Interim Strategic Plan
for HIV/AIDS and launched the development of a government-led five year Strategic Plan for
combating HIV/AIDS for Haiti. He declared that "everyone has a right to live." The goals were
7
1) to reduce the HIV infection rate by 33%
2) to reduce levels of STIs by 50%
3) to reduce the transmission of mother to child transmission of HIV by 50%
- at the heart of his plan was empowering citizen and patient, with a particular focus on women
4) Relevance to global health – Aristide was interested in the human rights discourse as a part of
global health.
5) Readings/Lectures – Lectures 14/15
HIV Voluntary Counseling and Testing in Hinche, Haiti
Articles 25 and 27
1/2/4: Definition/Significance/Relevance to Global Health: In lecture, Farmer discusses
Articles 25 and 27 of the 1948 Universal Declaration of Human Rights – they are particularly
revolutionary (as compared to previous human rights- focused documents, e.g. Declaration of the
Rights of Man and of the Citizen, France, 1789) because they reveal a new focus on social and
economic rights (versus just focusing on political and civil rights, like the right to vote)..e.g.
right to health care, etc.
Specifically, Article 25 is as follows:


(1) Everyone has the right to a standard of living adequate for the health and well-being
of himself and of his family, including food, clothing, housing and medical care and
necessary social services, and the right to security in the event of unemployment,
sickness, disability, widowhood, old age or other lack of livelihood in circumstances
beyond his control.
(2) Motherhood and childhood are entitled to special care and assistance. All children,
whether born in or out of wedlock, shall enjoy the same social protection.
Specifically, Article 27 is as follows:


(1) Everyone has the right freely to participate in the cultural life of the community, to
enjoy the arts and to share in scientific advancement and its benefits.
(2) Everyone has the right to the protection of the moral and material interests resulting
from any scientific, literary or artistic production of which he is the author.
The two Articles are used as a backdrop to the 24th lecture. After discussing them, Farmer asks
the following guiding question: “how do different rights regimes work in practice for people
living in poverty, and facing illness?”
In bringing in the Articles, Farmer is attempting to confirm the idea that health is a human right
(health and human rights are LINKED)
- Not a lot of physicians use rights language, but should be used…
8
-
Undergirds health people with a certain sense of power (language of rights adds another
layer of persuasiveness)
Discourse of health and human rights arose from the images, etc of people in dire poverty
 basic human nature to care about this….
Need to attach extraordinary aspirational goal with basic decency of American people
Global health concerns should become a human rights social movement! (as anti-slavery
movement in U.K. was first social movement on human rights)
3: Use in Readings:
Farmer’s Tanner Lecture “Never Again”: “Whether or not we see these horrible deaths [from
disease and poverty], whether or not we avert our gaze, they are happening. Those who must
face structural violence every day encounter precious little in the way of support for the right to
food, water, housing, or medical care. Even within the human rights movement, where civil and
political rights are privileged, there is far too little support for social and economic rights. Maybe
magical thinking persuades us that when political rights are granted, economic rights will follow.
But that step-by-step attitude has not always been the orthodoxy: there are historical
precedents for enshrining social and economic rights in official human rights declarations.
One need only read the Universal Declaration of Human Rights: articles 25 and 27 seem to
speak directly to the issue and are infused with the human values advanced in this
lecture… And these articles are actionable, at least on a small scale and almost surely on a much
larger one, if we find the rhetorical tools necessary to bring the privileged on board as we build a
movement to promote the rights of the poor.…But for these basic rights to be extended to all
those who need them—a prescription that would prevent, in my view, much of the [structural]
violence discussed here and much of the terrorism about which we read—we will need a
movement based in nations like the United States, wealthy nations that now control the fates of
billions who live far from their shores. (Farmer is basically advocating that we use the
discourse of HUMAN RIGHTS in the context of global health – that each person is entitled
to a healthy, long, fulfilling life, a life not riddled by the painful and de-humanizing
illnesses/conditions that affect the world’s poor, a life in which food and water is secure, a
life in which one has the opportunity to pursue one’s aspirations, etc etc…and so, he says
that this idea/framing (health/water/food/economic and social wellbeing as a human right)
should be used as the basis of a SOCIAL MOVEMENT, e.g. a US social movement…in
order to push for universal health/access to water, etc (just as social movements were used
in anti-slavery human rights campaign)
5: lectures and texts: Lecture 24; Notion of human rights and health as linked discussed in both
readings for Lecture 24, Farmer’s article “Never Again” in “The Tanner Lectures of Human
Vales” and Odinkalu’s “Why More Africans Don’t Use Human Rights Language”
Bureaucracy
1: Definition: According to Weber, the modern world is characterized by an ever-increasing
tendency to “rationalize” and order life – to routinize, regularize, and compartmentalize human
existence. With this systematization, diverse experiences are distilled into discrete categories of
knowledge. And intricate interpersonal interactions become patterned, enacted along particular,
9
preformed pathways. These pathways then become basis for bureaucracy – institutionalized
organization of social life
Definition according to “Theorist Points” study sheet:
Weber - On Bureaucracy:
- Rationalization of the modern world
o Bureaucratization is a form of rationalization that has led to the ever-expanding
organization of society into institutions that are "regular," "patterned,"
"routinized"; bureaucracy is a highly efficient tool for exercising power;
"instrument for societalizing relations of power"
- Bureaucracy characteristics
o Hierarchical structure of subordination; vocations clearly defined
o Bureaucrats have "expert training" "functional specialization of work”
o Bureaucrat = "single cog in an ever-moving mechanism with fixed march
o Inertia – hardest to destroy, makes 'revolution' technically more and more
impossible
2/4: significance/relevance to field of global health: Bureaucratization (the making of
bureaucracies) is a process characteristic of modernity – has upsides and downsides. Upsides:
organizing and eliminating chaos, increasing efficiency and regulation, etc; downsides: can get
trapped in the “iron cage of rationality” – too much emphasis on rules, control, etc to the point
where one cannot escape the rules, controls, etc even when they are no longer beneficial
A primary example is the Peru case – a continued emphasis on the cost-efficiency paradigm (that
treating MDR-TB is not cost effective, etc), even though that paradigm did not fit the
situation..rules were actually counterproductive (inhibited treatment of MDR-TB  and in long
term, could end up undermining cost-effectiveness anyway, as drug resistant strains will spread
if don’t treat them). Another manifestation of bureaucratization is medicalization – whereby a
condition (that may very well be rooted in normal human experience) is turned into a “medical”
problem, e.g. normal sadness becomes diagnosed as depression; PTSD; alcoholism, etc..
In general, the ideas of bureaucracy/bureaucratization/iron cage were interspersed throughout the
course – we are frequently reminded of the effects of big political institutions and structures, and
how we may get caught up in the rules, to our own – and to others – disadvantage (e.g. inability
to move away from 1961 food assistance act that requires Americans to benefit from giving of
food aid..). In the last lecture, however, we also see a positive appeal to (Obama’s) government –
a hope that rules can change, and that better policies can be put in place.
3: Use of concept in reading: concept explicated in Weber’s “On Bureaucracy”
5: lectures and texts: lecture two, Weber reading
Carabayllo
1. Define term or concept: City in Peru
2. Explain it's significance: Carabayllo was the location of one of the case studies from the
course, specifically where MDR-TB broke out, and where SES functions. It is also the place
where a 50-year-old man was doing relief work and arrived at a Harvard teaching hospital with
10
MDR-TB (a transnational problem, potentially!).
3. Describe how term concept is used in at least one reading: The Peru National TB Program
Case written by Dr. Jim Kim and others, contains a detailed setting for MDR-TB in describing
Carabayllo, Peru: It was in a state of civil war, where Sendero Luminoso (a Maoist guerilla
group) was forcing peasants into urban centers out of fear of violence, hunger, and
unemployment. It was also in Carabayllo's shantytowns that there was a lack of access to
healthcare even if it was close because cost of care was extremely high, coupled with low
income.
4. State term/concept's relevance to the field of global health: The rapid urbanization and lack of
access to affordable healthcare made it difficult for people to receive treatment for TB, resulting
in a rise of both primary and secondary MDR-TB. The lack of infrastructure made it difficult for
both the government and nonprofits like SES to treat MDR-TB as it grew. It highlights a place
where primary health care and strengthening health systems generally would contribute to
greater collaboration towards improved health for all Peruvians.
5. Cite all texts/lectures used to define term: Lecture 18 (and the following section, #9), in
addition to the Peru National TB Program Case.
Caregiving
1. Define the term or concept: According to The Oxford English Dictionary (in Lecture 22),
caregiving is characterized by attention to the needs of others, especially those unable to look
after themselves adequately; professionally involved in the provision of health or social care.
2. Explain its significance: Caregiving is important to consider because it is more about
laypeople and not just physicians or professional care. It's about seeing the social and
biomedical processes as complementary and not fixed... and also integrated, in that physicians
need to remember caregiving is part of their own role as primary care giver.
3. Describe how term concept is used in at least one reading: In the Cleveringa lecture,
Kleinman discusses the issue of a lack of caregiving in modern healthcare. Caregiving is related
to actions that “enable life” such as affirmation, assistance, responsibility, solidarity, and
acknowledgement. Kleinman argues that caregiving has become largely a matter for friends and
close relations rather than medical professionals. He thus asks the question: “Are medicine and
caregiving incompatible to the point of divorce” (1646)? To discuss caregiving, Kleinman brings
up the notion of anti-heroism by living morally (in this case, caregiving) despite the patterns of
the world. He suggests various ways to integrate caregiving into medicine such as preparing
students cognitively, affectively, and morally to relate to patients and their networks. He
promotes the idea of critical self-reflection, and emphasized the need to promote individual care
as much as population prevention.
4. State the term/concept's relevance to the field of global health: Kleinman’s lecture introduces
his basic and essential arguments for caregiving in medicine. He brings in the ideas of moral
worlds and the anti-heroic to support his case for caregiving. This concept and act of caregiving
relates back to the themes of social suffering and structural violence, which focus on the
individual and his or her illness narrative. Focusing on the individual rather than using broad
measures such as cost-effectiveness analysis is crucial, as extrapolated from Kleinman’s points.
5. Cite all text/lectures used to define term: Lecture 22, and the Cleveringa lecture by Dr. Arthur
Kleinman. Other possible texts to draw from: “Catastrophe and Caregiving: the Failure of
11
Medicine as an Art" (Kleinman), "The care of the patient" (Peabody), "The Invisible Women:
Caregiving and the Construction of AIDS Health Services" (Schiller).
Case Definition
1. A way of categorizing TB patients with distinctive clinical and treatment characteristics.
2. In order to standardize a large-scale program, such as the Peru National TB Program, one
must have common case definitions that everyone uses. If case definitions aren’t standardized,
then a patient who is actually a “treatment after failure” (e.g. successfully completed TB
treatment and wasn’t cured) could be mistaken as a “relapse” (e.g. got TB a 2nd time, but not
MDR-TB), and then be given the wrong treatment.
3. This term is used in the Peru National TB Program Case to describe one of the aspects of the
way the Peru National TB Program was in disarray before Suarez took over.
4. This term is relevant in two ways. First, it shows how expert bodies such as the WHO or
PAHO can help with providing standardized case definitions, as they did in the Peru National TB
Program Case. Second, it shows the importance of communication to quality global health
delivery, because, the Peru players getting on the same page about case definitions helped to
dramatically improve treatment outcomes in the Peru National TB Program
5. Peru National TB Program Case.
Case Study Method
1. Global health care delivery is a complex system that takes place across many different
settings. There are inevitable complexities of local cultures, politics, economics, and history that
must be understood in designing and managing health care delivery systems. There is no ‘ideal’
health care system that works everywhere; each system must be constructed to reflect and
address local conditions. This project seeks to identify principles to guide health care system
design in any location, recognizing that the details should and will vary in each setting. The
interplay of local factors is significant and the effect is sometimes difficult to quantify. To
capture this complexity, we have been using the ethnographic tools of the social sciences to
enrich our case studies of successful and unsuccessful global health programs. For instance, we
have looked at HIV treatment programs in settings and scales as disparate as Haiti, Kenya,
Rwanda, Iran, and Boston. The case study method allows for inductive insights and generates
hypotheses about the role of factors such as access to nutrition, difficulties with transportation,
family support, local cultural systems and others that can be investigated through more narrowly
focused research methods (p.6 of Kim, Rhatigan, Jain, and Porter “Values to Value”)
2. The case study method is important because it’s provides us with practice in real life problem
solving. It helps us look at problems and think through them completely candidly, not tied to
any social theory. In the case study method, we take away the analytical lens, which inevitably
creates a certain social construction of reality (e.g. thinking that every problem is caused by a
bureaucracy or every way that people are classified is an example of Foucault). We look at a
multitude of factors, not limited to one theoretical approach, which helps us to see the
complexity of a particular global health case.
3. See (1) for its exact usage in Kim, Rhatigan, Jain, and Porter “Values to Value”
4. This term is VERY relevant for global health, because it’s a teaching method that helps us see
the big picture and full complexity of global health problems – and the political, leadership,
12
communication, and other subtle factors of how they are solved. In addition, it’s interesting to
think that, in the business world, complex cases are picked apart because this is what needs to be
done to squeeze every possible profit and efficiency generating aspect from a particular case.
We can apply this to the global health world by using the case study method to squeeze every
possible health and socioeconomic well-being improving aspect from a case.
5. Kim, Rhatigan, Jain, and Porter “Values to Value”
CCM
1) Define the term or concept
CCM: Country Coordinating Mechanisms are public-private sector partnerships that develop and
submit grant proposals to the Global Fund to Fight AIDS, TB, and Malaria (GFATM) based on
priority needs at the national level. After grant approval, they oversee progress during
implementation.
2) Explain its significance
CCMs include representatives from both the public and private sectors, including governments,
NGOs, academic institutions, private businesses, and people living with the disease. It is
important to engage the public sector in GFATM grant decisions to promote local ownership,
build state capacity, and strengthen long-term sustainability of grant projects. Haiti was the first
to receive a GFATM grant in the world: $6M total, about $2.1 to PIH for Central Haiti.
3) Describe how the term/concept is used in at least one of the readings
Not sure if CCMs come up specifically in the readings, but you can go to HIV Care in Rwanda to
see other ways that PIH worked with the public sector to build local infrastructure.
4) State the term/concept's relevance to the field of global health
Refer to Farmer's mantra of "scale and rights!" The public sector grants rights, so we must
strengthen it. Many NGOs unintentionally undermine the public sector.
5) Cite all text/lectures used to define term
http://www.theglobalfund.org/en/ccm/
Lecture 11/16
CDC
1) Define the term or concept
CDC stands for Center of Disease Control and Prevention.
2) Explain its significance
The CDC is an agency of the US Dept of Health and Human Services. It works to protect public
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health and safety by providing information to enhance health decisions and it promotes health
throuh partnerships with state health departments and other organizations. It is in charge of
responding to infectious diseases. Past programs include polio surveillance, development of
national guidelines for influenza vaccine, TB program, eradication of smallpox, control of AIDS
epidemic, etc.
3) Describe how the term/concept is used in at least one of the readings
4) State the term/concept's relevance to the field of global health
I believe the only time the CDC was mentioned in lecture was in an anecdote of Prof. Kim's
about the Sugar Wars. Jim Kim was put in charge of passing a document called "WHO Global
Strategy on Diet, Physical Activity, and Health." It claimed that children should have no more
than 8 or 9% of their diet coming from sugar. The CDC and Dept of Health and Social Services
questioned his references and gave him a hard time because the US has political and economic
interests in the sugar industry and did not want to publish a document discouraging its
consumption. This illustrates a larger theme in global health: the influence of politics and
economics.
5) Cite all text/lectures used to define term
Wikipedia: CDC
Lecture 10/7
Clinton Foundation
The Clinton Foundation was established by Bill Clinton and one of their initiatives focuses on
funding large-scale AIDS prevention and treatment programs. They have also brokered drug
distribution agreements and according to Wikipedia have treated over 750,000 patients around
the world.
In 2004, when PIH was talking with the Rwandan goverment about expanding its treatment
scope to Rwanda, the Clinton Foundation, which had been working in Rwanda since 2001,
offered to provide start-up funding. In addition, the Clinton Foundation would assist the
government and PIH by taking on tasks such as drug procurement that required national
coordination. In March 2005, the Rwandan government, Partners In Health, and the Clinton
Foundation signed a memorandum of understanding to establish a comprehensive HIV care
initiative in rural Rwanda. In mid-2006, former president Bill Clinton visited the Rwinkwavu
project and broached the possibility of scaling-up the model nationwide. In September 2006, the
Clinton Foundation commissioned a team of financial analysts to conduct a detailed cost analysis
of the program and to project the cost to extend the program to all thirty of Rwanda's districts.
The report analyzed a
"district unit" comprising Rwinkwavu Hospital and three health centers (Rwinkwavu, Mulindi,
and Rukira). The report found that the PIH-directed program had been very successful.
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Reading referenced: HIV Care in Rwanda Case Study
Commodities
Commodities are objects that are exchanged, and exchanging the commodities gives them
economic value. Things become commodities when we assign value to them. The traditional
view of commodities is that they the rarer or more unobtainable a commodity is, the greater the
value. But the commodities themselves have no meaning apart from the value we give them. So
in order to study commodities, we must study our own motivations first.
In Appadurai's "Social life of things," he says that we should instead study the histories and
lives commodities, because the meaning of commodities are "inscribed in their forms, their uses,
their trajectories." He thinks that the value of commodities is not just determined by the demand
for them, but instead a complex set of social factors (e.g. politics, media, production restriction).
When the distance between the consumer and production increases, this results in creation of
"mythologies" surrounding the commodity and heightens demand. In studying the "social life of
things", we can use our understanding of these things to illuminate our motivations and our
social context. For example, by studying the social life of MDR TB drugs, we can figure out why
they are so expensive, even though they have been off-patent for years, and infer things about the
makers of MDRTB policy and MDR-TB drugs.
Note: commodities are not necessarily things, they can also be knowledge. For example, when
knowledge is only available to a few in society this knowledge becomes a commodity and
experts become a commoditized service.
Communities of Practice
The articulation of this phrase is attributed to Etienne Wegner, who described them as "a process
of social learning that occurs and shared sociocultural practices that emerge and evolve when
people who have common goals interact as they strive towards those goals." Basically,
"Communities of practice" are groups of people who share a concern or a passion for something
(such as introducing health interventions and projects in developing countries) and by working
together, they function and learn better as they continue to regularly interact
It was used by Dr. Kim in his Lecture 21, The Science of Delivery, II (see slide 54), explain that
an interdisciplinary approach will be necessary when implementing health care programs in
developing country settings.
Community Mental Health Delivery System
I think concept was primarily referred to in Arthur Kleinman's lecture 14 on Community mental
Health.
In this lecture, he stated that what really matters for global mental health is that (1) We have
sufficient knowledge base to proceed even in the poorest societies., (2) We don't have to hype
disease rates or burden, because the rates and burden are substantial enough. (3)We are faced
with inadequate funding, inadequate prioritization of mental health problems, and difficulties in
getting programs underway, and (4) We are ready for advocacy and the generalization of
demonstration projects via robust evaluation.
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In order for this to happen, he said that it would be necessary to: destigmatize programs and
policies, Include psychological interventions and Socio-therapies, including remoralization, and
Develop implementation science for mood disorders, psychoses, and suicide.
Finally, the Lecture 14 reading (Beyond Evidence: The moral case for international mental
health), the author acknowledges that "We need to provide technical and financial support for
hospitals to reform, to enable the development of community care programs, to raise mental
health literacy in the community and among health workers, and to ensure that basic rights are
monitored and enforced."
Contested History (Uvin)
The “contested history” refers to the history of Rwanda. 2 Historical theories
1. Hutu position – foreign Tutsi cattle rearers conquered Rwanda through economic and
military means and imposed centuries of Hutu oppression. In 1959, the Hutu finally
acquired their rightful position (This is when the Belgian left Rwanda in the hands of the
Hutu.)
2. Tutsi position – Hutu and Tutsi are a single ethnic group and the original differences
were only based on socioeconomic divisions. Tutsi were involved in better economic
pursuits. However, the colonizers exacerbated the Hutu-Tutsi divide by creating racist
categories that still exist today. (Note: When Europeans colonized Rwanda, they gave
Tutsi group more power than Hutu group up until they left Rwanda.)
Why there is a contested history:
1. Disagreement on the nature of the distinction between Hutu, Tutsi and Twa. Some say
they are distinct ethnic groups or races and others believe they are akin to different
socioeconomic classes
2. Much of the history is oral so it is hard to find the “facts.”
3. Hard to agree on historical understanding because these historical issues have acquired a
high level of contemporary political importance. In other words, each interpretation of
history helps each group to lay claim to the rights to govern Rwanda.
Significance
1. Many people are concerned with discovering the true nature of the ethnic groups in
Rwanda. However, Uvin argues that this is pointless since ethnicity is not a matter of
objective cultural or physical distinction but rather is a social construct, an imagined
community preoccupied with the creation of boundaries between in-groups and outgroups. You can nicely connect this to the Berger and Luckmann article from the
beginning of the semester about how ideas become institutionalized and then become an
objective reality.
2. The disagreement about history and ethnic divide was one of the causes of the Rwandan
genocide and the great health crisis in Rwanda.
3. We learned about the Hutu-Tutsi divide in order to better understand the context of PIH's
work in Rwanda. One needs to understand the cultural situation of a community before
attempting to implement health initiatives.
Source
1. Lecture 17 reading
2. Uvin, Peter. Aiding Violence. Kumarian Press: 1998. - Specifically Chapter 1
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Care Cycles
What it is:
1. This is the idea that health care is organized around medical conditions. A medical
condition is a set of interrelated patient medical circumstances that are best addressed in
an integrated way. This encompasses conditions as physicians usually define them, such
as arthritis, or breast cancer. But this definition differs by including all needed specialties
and the prevalent comorbidities, such as diabetes combined with vascular problems or
hypertension. Multiple specialties, services, and even entities are involved in the cycle of
care. Physicians focused on value for patients will no longer see themselves as selfcontained, isolated actors. Instead, they will build stronger professional connections with
complementary specialists who contribute to patient care across the care cycles for their
patients.
2. Currently physicians define their activities by specialty (example: cardiology) and people
get shuttled from one doctor to another. There are currently artificial distinctions like
outpatient vs. inpatient and acute care vs. rehabilitation that make it hard for patients to
feel like they are receiving a continuity of care.
Significance
1. Many people, including Paul Farmer, Jim Kim and Michael Porter, argue that using using
care cycles is key to improve value to patients. They argue that value for patients comes
from the overall effect of the entire sequence of activities, not from any individual service
2. Better integration of treatment with prevention, rehabilitation, and disease management
will reveal obvious ways to improve the overall outcomes and reduce costs (Therefore
proponents of cost-effective analysis are also proponents of this model)
3. Care cycle is in some ways comparable to the “wrap-around” care that PIH provides.
Both try to treat the patient holistically, rather than focus on only specific interventions.
Source
1. Lecture 20
2. Porter, Michael and Elizabeth Teisberg. How Physicians Can Change the Future of
Healthcare. JAMA. 2007;297:1103-1111 – This is the article that provided most of the
information from above
3. Kim, Rhatigan, Jain, Porter “Values to Value” article in forthcoming lancet on Values in
Global Health
De-moralization
-Lec 23.
-What Really Matters- Idi Bosquet-Remarque by Kleinmann.
De-moralization: moral crisis. Seeing the burden of responsibility, social jusice etc. but being
unable to significantly effect change. Not being enough to act in local humanitarian context
because there is so much to do.
Kleinmann's point: the anti-hero is these unglamorous people who challenege the status-quo,
affect change. However, one is subject to intense de-moralization.
Also, this is linked to his theories of moral life vs moral experience. Moral experience is the
local world that one lives in and the values it perpetrates. Moral life is the values that we hold
dear which correspond or conflict with this.
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"Moral experience is the flow of things at stake in local worlds. Our own moral life
may be consistent with or in conflict with our local worlds of experience. We can
collaborate with such worlds or seek to resist and transcend them by our aspiration for
ethical commitment." – Cleveringa Lecture
Delivery Science
Jim Kim/Julio Frenk
Lec 20. Jim Kim: From a Declaration of Values to the Creation of Value in Global Health.
Problem: A lot of funding, different efforts to save lives. No systematic efforts to learns which
are successful/efficient.
Solution: Need to analyze, systematize global health delivery. SCIENCE OF HEALTH CARE
DELIVERY.
Use- management science, economics- with "value for the patient"
Don't look at discrete interventions.
Mapping of activities- show interactions btwn prevention, testing, delivery. Caprute complexity,
cycles of care. (care delivery value chain)
Multi-disciplinary approach – case studies, care delivery value chain.
See also Grimshaw paper and Sanders paper - need to learn more to evaluate why there is
little/slow dissemination.
Diagnosis of exclusion
A diagnosis of exclusion is referred to in lecture 17, from Haiti to Rwanda III, and in Peter
Uvin's book "Aiding Violence". Uvin argues that the aid community may have helped the path
towards genocide in Rwanda, because they are a large influence of foreign assistance. The aid
community supported forces of exclusion that caused greater racial strife and eventually led to
the political atmosphere that supported the genocide. More specifically, the aid community
failed to prevent Hutu policies of racism and exclusion against the Tutsis, such as mandatory
identity cards, quota systems, and discrimination in employment and education. The term is
relevant to the field of global health because it important to be aware of the consequences of aid
within the settings where health care is being delivered. It is also important to create health care
system that do not support policies of exclusion, and that make it possible for everybody to
access care.
Diagonal approach
A diagonal approach to health care is one that is neither completely vertical or completely
horizontal, but which uses specific disease programs to improve primary health care and general
health of the community. A diagonal approach is discussed in-depth in our readings from lecture
21, including the Global Fund for Aids, TB, and Malaria's "Strategic Approach to Health
Systems Strengthening: Report from WHO to the Global Fund Secretariat". This reading says
that a diagonal approach is the middle ground between horizontal and vertical interventions.
This approach aims to alleviate problems of vertical programs while recognizing a need for
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specialization of some functions. The article is discussing the six building blocks of a successful
health system and stresses that the Global Fund can best invest in Health Systems Strengthening
(HSS) by creating programs that are flexible but also allow for more coordination and
cooperation at a country level.
Julio Frenk also discusses a diagonal approach in "Bridging the Divide: Global Lessons from
Evidence-Based Health Policy in Mexico". He defines a diagonal approach as one that includes
specific disease programs that improve the general health care system. In Mexico, some
examples of diagonal interventions are childhood cancer, cataract surgery, and reduced maternal
mortality. Mexico has had a great deal of success in transforming their health system and
making it more effective, and in part this is due to their ability to adapt international experiences
to their specific reality, and to use a diagonal approach to treat specific diseases that are
problematic for them but help to improve the overall health sector.
A diagonal approach is relevant to the field of global health because it provides an alternative to
a top-down disease specific program or a primary care based program that may not focus enough
on the diseases that cause the most damage. Lecture 21 discusses both of the readings listed
above.
Diffusion of innovation
(Lect. 20, Berwick reading) – rate of spread of change, based on 1) perception of the innovation,
2) characteristics of the people who adopt the innovation, or fail to do so, 3) contextual factors,
especially involving communication, incentives, leadership, and management
 Significant because correctly identifies the large gap between knowledge and practice,
which has devastating effects for our overall health care system
 Example: innovations of a few community hospital obstetricians lowered the need for a
cesarean section from 26-15%, but rates remained high for obstetricians in the same
hospital
 The same principle could be applied to the field of global health. Innovations in a
particularly effective method of producing change can take years, if not decades, from
achieving fruition.
 Rules to increase the rate of diffusion of innovation: find and support innovators, invest
in the early adopters (those who adopt innovation after the innovators but before the
majority), lead by example
DFID – Development for International Development
 The part of the UK Government that manages Britain's aid to poor countries and works to
get rid of extreme poverty.
 DFID’s eight Millennium Development Goals to be achieved by 2015 are:

Eradicate extreme poverty and hunger

Achieve universal primary education

Promote gender equality and empower women

Reduce child mortality
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


Improve maternal health
Combat HIV and AIDS, malaria and other diseases
Ensure environmental sustainability
Develop a global partnership for development
 First established in 1929 by the Colonial Development Act recognizing the UK
Government’s responsibility for the development of its colonies on a continuing basis
(Sorry! Couldn’t find this term anywhere in the readings or in lecture notes. I’ll email all of
you as soon as I find out to which lecture/reading this term is specifically relevant.)
Donkey fees
We discussed "donkey fees" during the case studies, and I believe they were used in both Peru
and Haiti. The idea is that health care in developing countries is incredibly difficult for the
poorest people to access, often because of hidden costs that make even "free" clinics and
treatment out of reach. Donkey fees were used as an example of one way to alleviate these
hidden costs, in this instance the cost of transportation. In the course, we discussed the need to
be aware of all the possible problems involved a health care system, and obstacles to treatment.
The best programs will determine creative ways to get around them. Donkey fees were
mentioned in the lecture from 11/18 on the Peru National TB Program.
DSM
The DMS is the Diagnostic and Statistical Manual for psychiatric disorders. It is significant in
the course because the DSM is what defines what is medically a "disease" and what is just a
normal human emotion. A number of times in the course professor Kleinman has discussed the
medicalization of normal emotions, so that feeling sadness becomes clinical depression. In the
lecture 14 readings, Allan Horwitz writes in "The Loss of Sadness" that the DSM has changed so
that feelings that used to be considered normal are now viewed as something psychologically
wrong. In the DSM-IV someone can be diagnosed as depressed if they have symptoms for more
than two months, but the author of this reading questions the validity of this. The DSM
definition does taken into account the context of symptoms, such as the death of a loved one, so
doesn't distinguish from natural feelings of loss. This is important because pathologization of
normal conditions may cause harm, and create inappropriate or unnecessary treatments.
Additionally, lecture 8, The Therapeutic Revolution, discusses essential medicines and global
health. Drugs are often promoted as cures of diseases, and can also be the agencies for new
diseases. For example, Serephim is a new drug that is similar to Prozac. After it was created, a
new disease (PMDD) was put in the DSM. It may have been put there just to sell the drug. Both
of these uses of the DSM show that it is relevant to global health because the DSM defines
illness and helps health care workers determine who should be treated for which diseases, and
where priority should be given. We need to be careful to understand illness and disease so we
are treating people for the right conditions, and not wasting time or resources.
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Duvalier
Francois Duvalier (also known as Papa Doc) was the president of Haiti from 1957-1971. Upon
his death in 1971, his son assumed the Haitian throne from 1971-1986, when he was overthrown
by an uprising. Francois Duvalier was a ruthless dictator who declared himself President for life;
his regime was extremely corrupt and condoned state-sponsored terrorism via his private militia.
He is often considered to blame for over 30,000 deaths and he exiled many more.
The Duvalier regime contributed to the poor health and extreme poverty of modern Haiti. The
Duvalier government perpetuated the idea that Haiti “was a diseased polity that demanded a
rapid infusion of international aid”. When Haiti received aid (some of it came from USAID), the
influx of money actually only further hurt the local economy by undercutting local businesses
and increasing dependency on international providers. (Check out the reading about the history
of AIDS in Haiti, Paul Farmer’s AIDS and Accusation). Applicable lectures include 15 and 16.
Bill and Melinda Gates Foundation
One of the largest private foundations in the world, funding by Bill and Melinda Gates. The
primary aims of the foundation are to “globally enhance healthcare and reduce extreme poverty,
and, in the United States, to expand educational opportunities and access to information
technology”. It gave away $6.6 billion for global health programs in only 6 years. It tries to apply
business technique to giving, considered one of the most important leaders in the
“philanthrocapitalism revolution in global philanthropy”. The key idea with this is simply that
modern philanthropic organizations are using business models to fund charitable work, and it has
been a pretty successful paradigm.
Global Fund to Fight AIDS, TB and Malaria (GFATM)
GFATM is an international financing institution that was created to increase resources to fight
three of the world's most devastating diseases, and to direct those resources to areas of greatest
need; it is one of the Global Health Initiatives (initiatives that are characterized by a focus on
specific diseases, products or populations, and commonly include an element of public-private
partnership). Current focus is on how to make best use of the resources of GFATM, specifically
by finding an answer to the question of how the Global Fund can best invest in health
strengthening systems in order to improve AIDS, TB and Malaria treatment outcomes. In the
2007 WHO Report to the Global Fund, a diagonal approach in has been recommended, in
addition to the "WHO Prescription": 1) Better communication and access to information, 2)
Increased Technical Assistance, 3) Flexibility is essential, as is avoidance of award ceilings, 4)
Coordination, cooperation and political will at country level is critical, 5) Creation of a health
system metrics dashboard is essential for monitoring & evaluation and developing an evidence
base.
References: Lecture 21, World Health Organization. Maximizing Positive Synergies Between
Health Systems and Global Health Initiatives. Geneva: World Health Organization, 2008.,
Global Fund for AIDS Tuberculosis and Malaria. Strategic Approach to Health Systems
Strengthening: Report from WHO to the Global Fund Secretariat. Geneva: World Health
Organization, 2007.
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Home-Based Counseling and Testing (HCT)
Based on the AMPATH Rural Case, HCT was a pilot program of AMPATH (Academic Model
for the Prevention and Treatment of HIV/AIDS: Kenya's largest and fastest growing ARV
provider) in which a group of community health workers go door-to-door to heighten prevention
efforts, ID HIV positive residents, and make referrals for rural residents. Implementers also hold
voluntary information sessions in people's homes. During the HCT pilot, 95% of the total
eligible persons accepted counseling about HIV/AIDS. Of these, 96% received HIV tests,
representing 91% of persons at-risk for HIV. All those who tested positive were referred to
AMPATH clinics for care and those who tested negative were counseled on risk-lowering
behaviors. Challenges to HCT: funding limited, maintaining quality with growth difficult,
training and support of community-based mobilizers.
References: Lecture 19, AMPATH Rural Case
Health catastrophes
1. Calamitous health experiences. Often unexpected, debilitating (financially, emotionally).
2. During the 20th century, constant hyping of the abilities of new biotechnology rendered
suffering to be understood as “utterly trivialized as an unnecessary experience that could
simply be prevented or remedied with drugs. Advertising for pharmaceuticals build on
this central message that suffering holds no value and need not be experienced.” In the
face of this unfounded faith in the medical system, at some point everyone will
experience a “calamitous” health event that they won’t be expecting. This is what is
known as a “health catastrophe” in that it is catastrophic both physically and emotionally
in a society that believes that everyone can be in perfect health all the time.
3. Found in Kleinman. “Today’s Biomedecine and Caregiving: Are they Incompatible to the
Point of Divorce?”
4. In global health, providers of care tend to create a hype around their knowledge and
capacity to cure. Saying 50% of cancers are curable is the upside, when in fact it means
50% are incurable. They hype themselves to sell products and create trust, but many
health catastrophes can be beyond recovery, especially in the developing world.
5. Julio Frenk, “Bridging the divide: global lessons from evidence-based health policy in
Mexico. Provides an alternate definition of a health catastrophe in a financial sense. In
Mexico – “the analysis for 2000 revealed that in one trimester almost 1.5 million
households had an economic catastrophe, were driven below the poverty line or were
forced deeper into poverty by out-of-pocket spending for health care. In this way, sound
evidence made the public aware of a reality that had hitherto been outside the policy
debate – namely that health care itself could become a direct cause of impoverishment”
Health sector reform (HSR)
1. A significant, purposeful effort to improve the health care system performance.
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2. Significance: absolutely necessary to carry out HSR. It focuses on reviewing causes of
poor system performance and devising reforms that produce performance changes. In
general, it can mean any changes in policy, global health initiatives, clinical treatment,
research and development, ethics, etc.
3. Kim, Rhatigan, Jain, Porter. “Values to Value”- High quality healthcare requires longterm commitment, especially when managing chronic diseases like HIV/AIDS. Focused
(verticalist) “projects” need to expand into full health care delivery systems.
Porter, Teisberg. “How physicians can change the future of health care”- Restructure
delivery around medical conditions and care cycles, rather than around specialties or
procedures. Value-based care delivery (more health per $ spent) will change the way
medical practitioners are reimbursed by insurance companies. Incentives to collaborate
and share patient information, as well as increase patient engagement.
Grimshaw, Eccles. “Is evidence-based implementation of evidence-based care
possible?”- Peer reviewed journals have critiques that never realize themselves in
practice. Along the same lines, Sanders and Haines. “Implementation research is needed
to achieve international health goals”- promote implementation research capacity in the
developing world, so that programs are evaluated for efficacy and the evaluations return
to change the organization/delivery of services. Fixsen, Naoom, Blasé, Friedman,
Wallace. “Implementation Research: A synthesis of the Literature”- same message. “The
ideas embodied in innovative social programs are not self-executing.”
WHO. “Maximizing Positive Synergies Between Health Systems and Global Health
Initiatives”- The many private GHIs need to contribute to the public health sectors where
they operate. Especially in the developing world, where state research may not have as
much funding or human resources for particular diseases, GHIs must seek to build the
primary health care, not debilitate it.
4. At the foundation of ANTHRO 1825, the term is a good idea. But “reform” is never free
of economic, political, cultural, and ethical obstacles and decisions. Programs must
compete for limited resources, proving their reform is worth funding. Future global health
reform needs to be critical of all new implementations, making sure the metrics
demonstrate high value to individuals.
5. Lecture 20/21 readings, as covered above. Many were repetitive.
Health Systems Control Knobs
The term "control knobs" is discussed by Roberts, Mark, William Hsiao, Peter Berman and
Michael Reich in "Getting Health Reform Right". Control knobs are factors that can be adjusted
by government action. Adjustments or changes in the control knob must be significant causal
determinants of health system performance. The authors propose a framework of five health
system "control knobs" that are options available to reformers (payment, financing, organization,
regulation, and behavior) for influencing health system performance. These categories provide
the focus for both conducting the diagnostic process and developing substantive policies to
achieve better performance. By combining these ideas and techniques, practitioners have a
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better chance of producing workable reforms to achieve the intended objectives. The idea of
"control knobs" is relevant to the course through the fact that the most effective global health
interventions work in the public sector and are thus able to "scale" their program and utilize the
protection of "rights". In order for health systems to be strengthened, the power of the
government can be used for progress.
Health Systems Strengthening
Health Systems Strengthening refers to increasing the capacity of health networks within
countries and globally to effectively and efficiently deliver healthcare interventions to those who
need them. Throughout the course, we have seen the argument of the vertical approach (technical
interventions) versus the horizontal approach (primary health care infrastructure) of healthcare
delivery. Systems strengthening is important because it instead adopts the "diagonal approach",
which Julio Frenk describes as a model where explicit intervention priorities are used to drive
improvements in the health system ("Rethinking the Institutional Architecture of Global
Health"). WHO describes steps for health systems strengthening as better communication and
access to information, increased technical assistance, flexibility, coordination and cooperation at
the country-level, and creation of a health systems metrics dashboard for evidence-based
monitoring and evaluation ("Strengthening Health Systems to Improve Outcomes'). Systems
strengthening is a necessary component of global health because it maximizes both delivery
capacity and efficiency of individual systems while focusing on evidence-based programs,
allowing for increased information exchange. Since this is a larger concept rather than a specific
term, see Lecture 21 and all of the associated readings as well as some from Lecture 20.
Human rights
1. Definition: basic rights/freedoms to which are humans are entitled
2. Significance: Farmer argues (in class and in the Tanner Lectures reading) that health
needs to be included in list of human rights. In the Universal Declaration of Human
Rights, health was only mentioned once! Need to change vision so that health becomes
more central. We need to understand human rights as the core of social values, and we
need to incorporate social and economic rights as well as the right to health care into our
understanding of human rights. Also, in the course, we’ve seen many instances of human
rights violations and their impacts on health. For example, slaves in Haiti did not have
access to health care.
3. (see above) Used in Farmer’s lecture and the article he wrote for the Tanner
Lecturesargues for health as a human right.
4. Significance for global health: we can’t make improvements in global health until we
understand human rights and learn to stand in solidarity with people
5. Lecture 24 (December 11); Reading: Paul Farmer Farmer, “Never Again?: Reflections
on Human Values and Human Rights.” The Tanner Lectures on Human Values.
Delivered at University of Utah, March 30, 2005.
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Humane values
1. This term describes values as health outcomes for people per dollar spent, as opposed
to thinking of value as cost or treatment. Value for patients describes much more than
treatment; it includes an account of general well being.
2. Jim Kim gave a lecture on humane values. He thinks that values have to be
understood in a local context, not as value for a drug company or a donor but value as
health outcomes per dollar for people suffering. We need to integrate health care
delivery so that it better achieves value. We can’t just focus on prevention or treatment
but need to do both depending on context.
3. Michael Porter uses this term to describe health care in the United States and claims
that health care reform needs to focus on value, or health per dollar, instead of simply on
cost or number of people on treatment.
4. For global health, humane values have to be seen as health outcomes (not just
receiving medications, but being lifted out of poverty and having the ability to care for
oneself and one’s family) for the poor. In order to obtain value, it is essential to
understand what matters to individuals in specific communities. We need to design
implementation plans that look at humane values, not cost.
5. Jim Kim Lecture 21 Science of Delivery II. Reading for Lecture 20 “Values to
Value” article by Jim Kim and Michael Porter
Idi Bousquet-Remarque
(Lecture 23: The Personal Ethnography of Global Health)
*Definitely read this chapter in Kleinman’s What Really Matters—it’s beautiful, lifechanging…
-Idi was Kleinman’s friend and mentee, who he met while she was writing her honors thesis.
During the 1970s, after graduating, she worked as a field representative for several international
aid agencies and European foundations briefly in SE Asia and then in sub-Saharan Africa for
over 15 years.
-Kleinman writes about her in his What Really Matters, saying she represents “our finest impulse
to acknowledge the suffering of others and to devote our lives and careers to making a difference
(practically and ethically) in their lives, even if that difference must be limited and transient”
(46-7).
-She was not only his motivation for writing the book, but she is also a perfect example of the
“anti-heroic” (another anthro-term!) because of her willingness to do good in the world almost
anonymously, seeking no advancement in career or attention.
-She worked in failed states, places with active civil conflicts, and places where people were
experiencing “structural violence” (another anthro-term!). She wasn’t interested in leading
programs, but in doing the programs—being out there and helping people—pragmatic solidarity
(another anthro term!). She understood the complexities of her surrounding situations by living
with the people.
-Idi believed you cannot ethically “study” disadvantaged people without helping them.
-She was critical of Euro-American social scientists, who advocated for people, fearing they
might usurp the right of local people from representing themselves, and she was critical of the
humanitarian worker as a hero.
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-She wrote critically about burnout but then came to experience it herself from the other side…”I
know I’m angry, very angry. But it’s not like before. No hot rage. It’s a cold, soul-freezing thing.
Dead. I feel like part of me is dead. I feel my will is draining away. A failure, a fucking failure”
(69). It was a moral crisis.
-“What mattered most was commitment. If you had it, you could stick it out; when you lost it, it
was time to get out” (74). “It was the quality of the human commitment to others in deep distress
with full awareness of the moral complexities of that action that stood for her as the defining act
of solidarity and practical assistance” (78-9).
-She had a life-long commitment to working with people in poverty and extreme conditions: to
her, this is what really mattered.
-It is important to look at personal ethnographies to understand what keeps people going and
being effective in the field of global health. They are inspirations for us all.
Implementation research
(Lecture 20: Contemporary Challenges I: Science of Delivery)
-Implementation = translating scientific advances into better health outcomes: discovery 
development  delivery  successful health outcomes
-Implementation research = beginning of the efforts to understand implementation as a science
-This is important because gap between knowledge and implementation, but we can’t close gap
without theoretical models of good implementation systems or without public-supported study of
successful/unsuccessful past implementation
-It is the cConcept behind Professor Kim’s Global Health Delivery project
-Implementation research is supported by the following three authors/works:
Dean L. Fixsen, et al. “Implementation Research: A Synthesis of the Literature,” University of
South Florida, Tampa FL, 2005 p.1-6.
-We know much about what’s effective in an intervention, but we don’t know how to
implement that
-Authors call for applied research to better understand service delivery processes and
contextual factors to improve the efficiency and effectiveness of program implementation
-Meta-analysis of 1054 citations
-Difficult to define scope because no standard terms (too many variables/too few cases)
-Standard Definition: implementation = a specific set of activities designed to put into
practice an activity or program of known dimensions
-Degrees of implementation:
-paper implementation (policy in writing, no steps to execute)
-process implementation (training programs and small steps in place, but no
integration)
-performance implementation (procedures executed to impact final product)
Jeremy M. Grimshaw and Martin P. Eccles. “Is Evidence-Based Implementation of EvidenceBased Care Possible?” MJA 2004; 180: S50-S51.
-Looked at quality improvement attempts (systematic review of 235 studies)
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-changing healthcare provider behavior is possible (small to moderate
improvements)
-change analyzed at individual, group, institutional, environmental levels
-lack of theoretical basis on which to design intervention
-development of better empirically tested theoretical models of healthcare
provider organizations is necessary to conduct more rigorous studies of how
dissemination works in the context of health care
Sanders, David, and Andy Haines. “Implementation Research is Needed to Achieve International
Health Goals.” PLoS Medicine 3 (June 2006): e186, 1-4.
-look at box 1: implementation research = subset of HSR that focuses on how to promote
the uptake and successful implementation of evidence-based interventions and policies
that have, over the past decade, been identified through systematic reviews. What is
happening in the design, implementation, administration, operation, services, and
outcomes of social programs? Is it expected/desire? Why is it happening the way it is?
-weak health systems in developing countries shows need for Health Systems Research
(HSR)
-health research needs to focus on the ‘knowledge-implementation gap’—gap between
knowledge of disease and knowledge of implementation—especially in poor countries.
-previously over-emphasis on cost-effectiveness analysis
-research should be interdisciplinary
-methodology: quantitative and qualitative, randomized control and descriptive
-areas for HSR: financial and human resources (equipment and personnel);
organization of health services (infrastructure); governance and stewardship;
global influences
-building HSR: no private sector support; need to build incentives through public
institutions like research and publication support: we need to overcome the three
levels of denial: we don’t need it, we’re already doing it, it’s not worthy of a place
like Harvard
Implementation Science
 It’s the science of actually implementing the knowledge we have into actual programs
and policies – seems to me to be like the science of delivery
 [David Sanders and Andy Haines] Concerns narrowing the gap between what we know
of diseases and its implementation (evidence-based interventions and policies)
o Studies the causes of this and looks towards solutions at global and local levels
o Interdisciplinary -- focus on health systems
 From “Implementation Research” review:
o Implementation: specific set of activities designed to put into practice an activity
or program of known dimensions
 3 degrees (from least implementation to most):
 paper: putting into place new policies and procedures with the
adoption of an innovation as the rationale for the policies and
procedures – recorded theory of change
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


process: related activities occurring , events are being counted,
innovation-related language used BUT not really functionally
related to the new practice. – active theory of change
 Performance: putting the functional component of the innovation
in place so consumers feel the impact -- integrated theory
talked about in Kleinman’s lecture on global mental health: destigmatizing programs and
policies, include psychological interventions and socio-therapies, need to develop
implementation science for mood disorders, psychoses and suicide
Discussed in: “Implementation Research” by USF, Sanders and Haines article
“Implementation Research is Needed to Achieve International Health Goals.”, Kleinman
lecture on global mental health, and Kim lecture on Science of Delivery
Indirect Rule (Uvin)
 Def: incorporation of native authorities into a state-enforced customary order to the
benefit of the colonial people
o refers to colonial rule in Rwanda by the Buzungu (first the Germans and then the
Belgians after 1916), who then gave political power to the Tutsi
o Buzungu helped Tutsi aristocracy to increase their control over Rwanda, reduced
the # of administrative divisions = further distance between rulers and ruled
o Increased both centralization and homogenization
o Social relationships in Rwanda became more uniform, rigid, unequal, and
exploitative w/clear hierarchy: Bazungu  Tutsi  Hutu  Twa (higher levels
got special privileges that established an ideology of racial superiority)
o Reinforced ethnically bound institutions of control and led to their explosion from
within.
 Ethnicity was both the form of control over natives and form of revolt
against it.
 Large impact on global health is that it goes to show how external powers can create and
manipulate the social framework and distinctions within a country to horrible ends.
Farmer proposes that these divisions (which have now caused genocide) were created by
the European colonizers. Shows impact of colonization still today.
 From: Uvin reading, discussed in lecture 17: Delivery, From Haiti to Rwanda III
Infection control
1) Clearly, this term is focused on the control of infection (whether bacterial, viral or parasitic,
and the prevention of its dissemination. Infection can be spread many ways, and is especially
problematic in communities where unsanitary living conditions, unclean water and an unhealthy
environment exacerbates the problem. This ties into the inequalities globally, which I will
discuss in a bit.
2) This is extremely significant, since “Infectious diseases remain the world’s single most
cause of death...although the majority of deaths occurred in the developing world, infectious
diseases remain a major killer of the US poor,” (Infections and Inequalities, 3-4). Changing this
chilling fact is impossible without effective control of infection.
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3) Infection control is referred throughout Infections and Inequalities (obviously), which
focuses on the inequalities of distribution and outcome on infectious diseases. Severe disparities
in access to quality health care, knowledgeable health workers, capital to acquire treatment, food,
clean water, and sanitary living conditions significantly the outcome of an individual who
contracts an infection. Rates of death from infection are staggeringly higher in poorer countries
and communities.
4) See part 2...it’s the most urgent global health problem. A very important portion of infection
control is to keep patients and healthcare workers in healthcare settings protected from infectious
diseases (if an individual comes into a clinic to be treated for infection A, we must ensure that
they do not leave having acquired infection B).
5) Infection control was mentioned throughout the course, since the entirety of the course
revolves around the complexity of infection (and infectious disease) in global health.
Tuberculosis, HIV, malaria were the most heavily studied; although cholera, hepatitis B, and
measles are other examples of infection we talked about in the course, and how social
inequalities affect the outcomes of infected individuals. Clearly, pubic health officials cannot
enter a community with hopes of only treating one infection, without addressing the factors that
exacerbate the problem/facilitate its spread (unclean water, lack of sanitary living conditions, etc)
– to control the infection outside of strictly medical techniques. Many of the readings in the
course discussed the necessity of strengthening primary health care systems in order to
effectively control infection (The readings from lectures 15 16 and 17 are especially salient.)
Intervention spectrum (prevention <--> treatment <--> maintenance)
1) This refers to the various ways in which healthcare workers can intervene in a community
for a given disease, and deliver care to individuals. All three components of the “intervention
spectrum” are necessary to achieve optimum success (with the ultimate goal being eradication of
the disease)
2) It’s helpful to think of the intervention spectrum as equally important parts of a machine;
without one the whole concept does not work. All three must work together simultaneously to
achieve proper treatment
3) The National Tuberculosis Program (NTP) serves as an example of the efficacy of the
intervention spectrum. (Lecture 18)
The state of the NTP in 1990 (when Suarez decided he wanted to take over)
·
Not very much/poor standardization: recordkeeping, follow up, treatment
·
Very little coordination between centers, not an effective line of communication
·
Lack of infrastructure: having appropriate medicine, appropriate facilities (treatment centers
and labs to diagnose TB)
Suarez’s strategy (highlights importance of intervention spectrum)
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·
He recognized the need for more money, but it was not going to work to demand more
money from the government. Must get the government to see that the people are upset by TB.
Able to frame this not as just another budget issue, but a SOCIAL problem – POLITICAL
implications that must be dealt with
·
As such, Suarez recruit new personnel, developed a set of guidelines (PAHO – see next
bullet points), and included everyone (community, government)
·
Come up with a new set of guidelines: create a set of shared practices (asks health care
workers why they are doing something a certain way [their practices] – and then discusses with
all practitioners what the best way technique is), transparency (getting groups to see what the
other groups are doing and the results they are getting)
·
Through these simple managerial techniques Suarez is able to recruit a core team with as
clear mission, get more $ from different sources, leverage social concerns and advocacy groups
onto Minister of Health to get more funding, coordinate health centers/hospitals/private
practitioners, develop uniform protocols.
·
One of his major successes was to bring people together: convene groups of doctors, lab
technicians, - anyone who has a role – and bring them together to disseminate info, discuss
problems, develop group identity and raise morale, share expertise and knowledge
·
Result was major improvement in diagnosis and treatment of TB; as well as maintenance of
the successful program
·
As such, the NTP utilized all aspects of the intervention spectrum (although MDRTB threw
a wrench in the whole thing :/ )
4) This is relevant to the field of global health, since the intervention spectrum is a way to
achieve disease control, treatment (and hopefully) eradication.
Intrafamilial Epidemics
Two prominent examples of intrafamilial epidemics provided in the course are MDR-TB and
mother-to-child transmission of AIDS.



Acquired drug-resistant TB occurs usually when a drug-susceptible TB patient is noncompliant with his/her medications. Improper use of the meds leads to drug-resistance.
Primary drug-resistant TB occurs when a TB patient is infected with a drug-resistant
strain. In Peru, this was due to ongoing intrafamilial transmission due to the lack of
treatment for those with MDR-TB. (See Lecture 4: Perspectives on Knowledge of
Microtrends: MDR-TB, 9/25).
Mother-to-child transmission must be dealt with by prevention/treatment (AZT for
pregnant mothers to reduce viral load and prevent transmission)
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Invisible Women
In the last two decades, health researchers have begun to acknowledge the role that women-kin
play in providing health care for family members. However, women family members that care
for HIV-infected patients are ignored, despite the fact that it is their care that allows the health
care system to work.
 Women are ignored as caretakers because of the stigmas associated with AIDS. AIDS
was seen as a disease of ‘outsiders’, and patients were looked at with very little empathy.
No empathy means that they were not seen as people with families.
Programs offer little to the (mostly female) family members that care for AIDS patients, offering
them no financial or emotional support. Here women caretakers are ignored.
 Politicians are worried that they will demand pay if they are given attention, and the
system won’t be able to support that. The current health system depends on unpaid labor,
and rests on the traditional notions of kinship and obligation.
Lecture: Caregiving as a Lay Occupation
Reading: Nina Schiller, The Invisible Women: Caregiving and the Construction of AIDS Health
Services
Joseph Jeune
Joseph Jeune is the star of the infamous PIH ‘Lazarus’ survivor story. His picture is shown in
countless PIH and AIDS work presentations, demonstrating the ‘miracle effect’ of drugs. Joseph
Jeune’s story is referenced in several of the lectures, here is his story: Jeune is a 26 year old man
who was brought into a Haitian clinic after he had been sick for months with a cough, a fever,
weight loss, weakness, and diarrhea. After visiting a traditional healer, Jeune continued to
worsen, until he was so close to death that his family purchased his coffin. One day an
accompagnateur saw Joseph and told him to visit the PIH clinic. The accompagnateur told
Joseph’s family that the clinic fees were not too expensive, and she arranged for some of
Joseph’s neighbors to bring him to the clinic. There, a doctor diagnosed Joseph with TB and
AIDS. He was given medicine and food every day. After a few weeks, his fevers went away, his
appetite returned, and he was able to walk again. When he was healthy enough to leave the
hospital, he was assigned an accompagnateur who visited him at his home every day to give him
his medicine. After several months, Joseph gained 13 kilograms.
Key words: TB-HIV, accompagnatuer, complete treatment (food and health care)
IU-MU Partnership
The Indiana University- Moi University Partnership was founded in 1989 under a tripartite
mission to develop leaders in health care for the U.S. and Africa, foster the calues of the medical
profession, and promote health for the human family. MUSM was founded in 1985 as Kenya’s
second medical school, and with a US$25,000 grant from a private donor seized the unique
opportunity to build a medical system ‘from the ground up’ and launch the partnership to create
an internationally-based medical institution. In its first decade the IU-MU partnership focused
primarily on building primary care capacity in Kenya for both Kenyan and US faculty
counterparts. The model rested upon counterpart relationships on both individual and
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departmental levels. Beginning in 1997, other North American medical schools joined the IUMU collaboration and exchange effort, culminating in the formation of the America/ subSaharan Africa network for Training and Education in Medicine, or ASANTE Consortium.
By 2000, the Partnership provided substantial progress in primary care, however, the entire
Kenyan public health system was buckling under the weight of HIV/AIDS, and the partnership
had not initiated antiretroviaral therapy for any of its patients. Three primary barriers made ART
difficult to implenment under the IU-MU Partnership: 1) no physiciants were trained in
infectious disease, 2) ART drug costs were too expensive. 3) Administrating HAART would
require lifelong patient care, making IUMU responsibilities to that of a chronic care provider.
After a medical student in the Partnership was dying from AIDS, Joe Mamlin ( Field Director of
the IU-MU Partnership) was finally moved to action. In 2001 the partnership established
AMPATH, the Academic Model for the Prevention and Treatment of HIV/AIDS, an integrated
HIV control system linking care, medical education, and research in western Kenya, and
providing care to over 65,000 HIV-positive patients in 2008.
Documents: The Academic Model for the Prevention and Treatment of HIV/AIDS, case study
(third coursepack, page 1489).
Key words: IUMU, ASANTE, Home-Based Counseling and Testing (HCT), ‘upstream’
services, Joe Mamlin, Sylvester Kimaiyo, Brain Drain, PEPFAR
Julio Frenk
Julio Frenk will be the next dean of the Harvard School of Public Health. He has important ideas
on the science of health care delivery. In his 2008 speech to the Kennedy School, “Rethinking
the Institutional Architecture for Global Health,” Frenk argues several important points. First,
there are three common misconceptions about health systems: (1) that it is a black box (“things
are too complicated and we don’t know what works, so let’s simply get technologies and other
inputs in place and then outputs will somehow work their way”), (2) that it is a black hole (“no
amount of money will suffice to achieve the desired results”), and (3) that it is a laundry list (“the
health system is a mere list of the different organizations or persons” participating, with no
requirements for “such components to be coordinated or integrated.” Frenk suggests that a more
comprehensive view includes interrelations between components, population as a co-producer of
health, equitable health distribution as a goal, and health systems performing enabling functions
including stewardship, financing, workforce training. He argues that in order to improve
coordination, the “sovereignty paradox” must be figured out. Right now, health is generally
considered a national responsibility, yet determinants of health are increasingly global.
Therefore, nation-states should share their sovereignty in health. Last, health systems must fix
accountability. The modern dilemma is that many nation-states unable to meet needs of citizens,
or are actively working against basic rights. International organizations also face fundamental
ambiguity around representation and legitimacy. We need to begin conceiving of global
citizenship, beginning with a “core of social rights” including the right to health.
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Kaposi’s Sarcoma
Kaposi’s Sarcoma is named after a Hungarian dermatologist who originally described it in 1872
Vienna. But in the 1980s it became associated with AIDS. It is a “relatively benign form” of
cancer that is usually on the skin, but can spread to the respiratory, digestive tracks. It is one of
the first diseases doctors saw in younger gay men in NY that alerted them to the epidemic. In
1981 the CDC initially named what we know as AIDS “KSOI” or Kaposi’s Sarcoma and
Opportunistic Infection. It is one of the common AIDS symptoms. On the skin it is purple,
reddish lesions. The one and only article it is found in is called Characteristics of the Acquiered
Immunodeficiency Syndrome (AIDS) in Haiti. Lecture 15, by Jean Pape and Al. The article is
about a study in Haiti in which clinicians studied 61 previously healthy Haitians who had
diagnoses of either Kaposi’s sarcoma, opportunistic infections of both. A lot of the article is
description of the symptoms experienced by the patients. The study was between 1979 to 1982.
According to the article the “clinical features of Kaposi’s sarcoma in 14 to 16 patients were
similar to those in the United States” (Pape 1230). I think the relevance and significance of this
article is that it disproves some of the rumors that existed in the United States (in the CDC) about
the origin of HIV. Some believe that HIV in the US came from Haiti. According to the article the
authors/clinicians “do not believe that AIDS was present in Haiti before 1978…It also seems
likely that Haitians would have presented to U.S. hospitals sooner if AIDS had been occurring in
Hait before 1978” (pape 1230). It seems that HIV symptoms such as Kaposi’s Sarcoma appeared
at about the same time in the US and Haiti.
Knowledge-Action Gap
The knowledge action gap refers to the gap between our knowledge of disease and the
implementation of that knowledge for the design and production of health systems, especially in
poor countries. The significance of this to global health is that we have the knowledge to
decrease the morbidity and mortality of many important diseases throughout the world, but have
not sufficiently put our knowledge to action. This wastes resources, time, and money: "failing to
use available science is costly and harmful; it leads to overuse of unhelpful care, underuse of
effective care, and errors in execution" (Berwick 1969). If we were able to implement the
knowledge we have on treatment and prevention, many of the annual deaths would be prevented:
"full use of existing interventions would cut the more than 10 million annual child deaths that
occur globally by more than 60%" and "a high proportion of the half million or so maternal
deaths that occur globally every year could be prevented by promoting access to interventions
and services of known efficacy" (Sanders and Haines 0720). Sanders and Haines use this term to
discuss the need for health systems research. According to them, health systems research is the
means to bridge the gap between knowledge and action in the local setting.
This concept is discussed in the following readings from Lecture 20, though I don't have it in my
notes from that day.
Berwick- Disseminating Innovations in Health Care
Sanders and Haines- Implementation Research is Needed to Achieve International Health Goals
Fixsen et al- Implementation Research: A Synthesis of the Literature
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Legitimization
(taken from first review- since it was already on there)
Once institutions have been created, they are legitimized. That is, people justify them by creating
explanations of their importance. This is done through incipient legitimation (the fact that they
exist in the first place gives them importance), rudimentary theoretical propositions (stories,
legends), the development of explicit theories, and the creation of symbolic universe (defended
by theology, philosophy, science, ect). By legitimizing an institution, the people who are
identified with that institution also legitimize themselves, they create a meaning for their lives
through the institution.
AND
The term legitimation describes the ways institutions that develop around us become legitimate
and exert control. There is an assumption that what they are doing is right, which gains power
through dominant discourses that discount a foreseeable alternative. Ultimately, this results in
the development of a symbolic universe, which creates the basic framework that allows us to
take things for granted (even down to definitions of good and bad).
Significance to global health:
In the second lecture (and in the last, but that's not covered by the midterm) Kleinman discusses
the creation of social realities in mental illness—many human emotions are medicalized, such as
sadness to depression, and then treated. Another example of this is trauma becoming PTST.
These "diseases" may be social constructions, and its important to bear in mind what constitutes
the normal and abnormal in medicine and to understand that at some point these distinctions are
socially constructed. Socially constructed realities can also cause pain and social suffering, for
example, institutionalized social forces such as gender inequalities or caste systems cause group
suffering and health problems.
Specifically in Rwanda, legitimization is relevant to Hutu control of the state. Two arguments
were used by the Hutu in power for legitimization of their rule. The first rested on the ethnic,
"social revolution" discourse that created a "prejudice against the large majority of the poor that
caused mass frustration, loss of self-respect, and a need for compensation through
externalization; and the official, state-sponsored racism against Tutsi that provided a convenient,
institutionalized scapegoat." The other argument was the "development" discourse of
legitimization, with a focus on development and devotion of all resources to such. This diverts
attention form all things political, usually replacing them with a top-down elitist realm of
technicality, as seen in the Habyarimana regime. Both of these arguments centralized power in
the state, bringing all aspects of society under its control.
Reading- "The Social Construction of Reality: A treatise in the sociology of Knowledge" Berger
and Luckmann (lecture 1 readings)
Many Farms
1) Define the term or concept: Many Farms is a community on a Navajo reservation that was
illiterate, non-English speaking, and very poor in the 1950s. Large families lived in one-room
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mud houses with dirt floors. The average income for a family of 4 was $586/yr. Considering
the conditions in which the community lived, the diseases they had were predictable: TB,
respiratory disease, enteric disease, skin disorders, and trachoma. The health system in place
was very rudimentary and there was no physician.
2) Explain its significance: This community was used in an “experiment” to see how
technological interventions would affect the health of the community. A whole modern health
care system was put in place in 1956, including a health center, two physicians, two nurses, a
Navajo teacher, and four Navajo auxiliary health workers. The study lasted 6 years, during
which time greater than 90% of the community was examined in the main health center and 2/3
asked for at least yearly care. They measured disease patterns, deaths, hospital records,
community censuses, and prevalence rates of diseases. Some health indicators improved, but
many other aspects of life did not, such as living conditions and education. Depending on the
manageability of microbial diseases, the prevalence of some was reduced but not others. Infant
mortality did not improve, but overall crude mortality was reduced. Some diseases could only be
managed with improvements in the home environment, including sanitation. To maximize the
effectiveness of medical systems, both the technological and care-giving aspects must be studied,
especially their effects on each other.
3) Describe how the term/concept is used in at least one of the readings: The article concerns
itself with the measurable effects of technological intervention (drugs, vaccines, diagnostic
equipment, surgery) on disease outcomes through the implementation of a full health care
system. The effects of “human support” were not studied.
4) State the term/concept's relevance to the field of global health:
“‘technological substrate--… the fitness of the system’s technological component for meeting the
disease situation as it actually existed in the community… list reveals the limits of contemporary
biomedical capability in this particular set of curcumstances” (p. 1563 of coursepack)
5) Cite all text/lectures used to define term: Health Care Experiment at Many Farms; Walsh
McDermott, Kurt W. Deuschle, and Clifford R. Barnett. Lecture 22.
Marshall Plan
1) Define the term or concept: the Marshall Plan was an aid program to rebuild war-torn Europe
after WWII. It was named after Secretary of State George Marshall.
2) Explain its significance: From 1947-1951, the United States invested $13 billion in the
program. It led to huge growth.
3) Describe how the term/concept is used in at least one of the readings: ????? if someone can
find this please send it out!
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4) State the term/concept's relevance to the field of global health: In lecture it was suggested that
we have a new Marshall Plan (a large-scale public investment) to improve the health and
wellbeing of poor countries.
5) Cite all text/lectures used to define term: Lecture 25. Another lecture too??
Medical humanities
Arthur Kleinman defines the term “medical humanities” thoroughly in his Cleveringa lecture and
in his article on “Catastrophe and Caregiving: the Failure of Medicine as an Art.” Medical
humanities is the interrelation of multiple disciplines in a medical education: medical
anthropology, medical sociology, medical history, medical ethics, pastoral counseling and
religious studies, narratives and the arts. The medical humanities are meant to (1) teach students
to be caregivers, and (2) to encourage critical self-reflection, that can help the individual’s work
and help them identify and fix problems in the health system. Kleinman emphasizes that the
medical humanities need to be incorporated more strongly into the modern curriculum for health
professionals.
Text/lectures used to define term:
1) Kleinman, Arthur. Cleveringa lecture
2) Kleinman, Arthur. “Catastrophe and Caregiving: the Failure of Medicine as an Art.”
Mental Health
Mental health is a broad term to address mental wellbeing. In class we focused on global mental
health, which is considered the “odd case” of mental health. Public health authorities often
overlook mental health, although it plays a very significant role in the global burden of disease.
Addressed in Klleinman’s World Mental Health Report (Ch.1), disparities in global mental
health are most often due to a mix of factors from economic and political structures, which affect
poor countries most. Poverty is usually the root cause of these mental health problems, because
poverty leads to and is aggravated by hunger and malnutrition, forced labor, urbanization and
social change, violence, refugees, migrants, population growth, disasters. All of these factors
encourage anxiety and depression, and take a large toll on global mental health. Although mental
health problems can have international roots, they need to be dealt with on a local level, because
local plans are more likely to be able to address the key problems in their own community and
the best ways of addressing those problems there. The management of mental health needs to be
incorporated into physical health systems, because according to Martin Prince, Vikram Patel, and
others, there is “no health without mental health.”
Text/lectures used to define term:
1) Lecture 14: The Odd Case of Mental Health
2) Kleinman, Arthur et. Al. World Mental Health Report (Ch.1)
3) Patel, Vikram et al,. “Beyond Evidence: The moral Case for International Mental Health”
4) Prince, Martin, et. Al. “No Health Without Mental Health”
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Mental Health Problems
Mental health contributes to mortality/disability, interacts with other health conditions and also
has an effect on health policy, systems and services. It encompasses the important of
psychosocial interventions in alleviating physical-health outcomes.
In the Prince article from lecture 14, the WHO assessed that there is no way to address health
without addressing mental health as well. Mental disorders make a substantial contribution to the
burden of disease, which can be seen in DALY reports. Mental illnesses such as depression can
predict the onset/progression of physical/social disability. On the flip side, disability and ill
health are risk factors for depression.
In Kleinman's book "The Illness Narratives," Kleinman addresses the lack of attention to mental
illnesses as a precursor for physical illness or distrust towards psychosocial interventions by the
practitioners of medicine. There is a strong belief that a biological problem must be solved by a
biological solution. This is very representative of the way global health addresses (or fails to
address) mental problems.
However, the interaction of mental disorders and other health conditions - affecting the rate of
other health conditions, health conditions affecting mental disorders, some comorbid mental
disorders affect treatment/outcome - suggests the need for policy, practice and research in mental
disorders, in terms of poverty reduction, integration of mental health policies across disease
categories, train practitioners to recognize/treat mental disorders.
Mental Illnesses
The most relevant information about mental health and intervention comes from high-income
countries where treatment actually exists. However, mental illnesses such as depression,
schizophrenia, alcohol disorder and developmental disabilities exist in low- and middle-income
countries. Depression and schizophrenia are both effectively treated with medication. Alcohol
abuse is rapidly growing in these countries but recognition is poor. Evidence of effective
treatment has been shown in high-income countries but only a couple trials have been conducted
in low- and middle-income countries. Post traumatic stress disorder has also been seen in
countries post conflict or natural disaster. In many of these countries, health costs fall largely on
the households. Like the effective, locally feasible and affordable treatments that exist for
depression and schizophrenia, more research is needed for developmental disabilities and
alcohol-use disorders. Governments and health organizations should consider scaling up the
coverage of mental health interventions. However, many other health issues compete for
resources.
Patel article (Lecture 14)
MINSA
 MINSA is the Peruvian Ministry of Health
 This is important in the context of the TB program in Peru. It provided the majority of
health funding and infrastructure (81%) in the nation, and most of the primary health care
services. Its TB control program was taken over by Pedro Suarez in 1990. Most MINSA
services are free, while some others had nominal fees which could be waived. MINSA
was somewhat effective, but had limited coverage in rural areas. Before Suarez took over
the TB program, only about 25% of people with TB got treatment. MINSA supported
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

him in his attempt to install uniform TB control standards; out of this came the National
TB guidelines. Once the TB program was part of the government’s struggle against
poverty, MINSA gave funds for significant improvements to the healthcare infrastructure
around the nation.
MINSA is only mentioned in one reading, the case study of the Peruvian National
Tuberculosis Control Program (coursepack p 1416). It is important in this context
because it was the major funding body behind the improvements to the National TB
program, which were incredibly successful.
This was discussed in Lecture 18.
Paul Kagame
 Paul Kagame is the current president of Rwanda, whose rise to power signaled the end of
the Rwandan genocide in 1994. He was elected president in 2000.
 Kagame was incredibly important in bringing the country together after the genocide,
which was divisive, to say the least. He built up a reputation of being strong-willed but
incorruptible. He made many changes in the structure of the Rwandan government,
including in the health sector. The formation of the National AIDS Control Commission
(NACC) and the Treatment and Research AIDS Center (TRAC) by his administration
were instrumental in improving AIDS care in Rwanda. This provided national
coordination of the many NGOs working there, leading to ARV treatment for thousands
of Rwandans.
 Kagame is only mentioned in one reading, the case study of HIV Care in Rwanda
(coursepack p 1322) and was discussed in Lecture 17. He is relevant to global health as
discussed above: he fixed the AIDS care systems in Rwanda to help them to reach the
most people possible.
Pauperization
A state of extreme destitution, or the act of rendering people paupers. Peter Uvin references the
pauperization of Rwandans as one of the processes which laid the ground for the 1994 genocide,
along with inequality, racism and oppression. He describes himself as having paid insufficient
attention to the reality of pauperization because he was there for "development". (Uvin p3,5
lecture 17)
Peasantry
The class of Haitian slaves who became the lower class of peasants, after the revolution of 1803
that led to the Haitian liberation from France. The formation of the Haitian peasantry is thought
to have been a form of resistance, as they abandoned plantation farming for export and wished to
be left alone to grow food for themselves and local markets. This lead to a sudden shift in Haiti's
social formation —it became a rural and small scale agrarian society. The peasants move to the
hills led them to areas where there was no health infrastructure. Consequently they suffered
from a lack of access to sanitation and clean water. (Farmer, Lecture 15)
38
In AIDS and Accusations (Farmer), Farmer also proposes that the spatial isolation of the
Haitian peasantry lead to their "century of isolation" on the world market. They no longer had a
plantation economy producing tropical produce, thus could not engage in international trade.
This also led to the notion that Haiti is a "black hole", a place where nothing can get done.
(starting on p. 166)
PEPFAR
President's Emergency Plan For AIDS Relief, instituted in 2003 by President George W. Bush,
rolled out 15 billion dollars between 2003-2008, was renewed in 2008 with a planned 50 billion
dollars for spending over the next 5 years. Three-pronged approach involving prevention,
treatment, and care. Jeff Sachs associated a few billion dollar increase in funding for ARVs with
huge improvements in treatment of HIV; complemented Bush and Kofi Annan's interest in
increasing access to drugs globally. A milestone in HIV treatment worldwide, the creation of the
program portrays change in perception of and commitment to treatment of the disease from the
Reagan presidency to Bush's years. Also mentioned in context of Garrett's analysis of global
health relief efforts, as an example of the immense funds available through NGOs and
philanthropy that yield suboptimal improvements in global health outcomes. Required readings
did not cover program in detail, but Helen Epstein's "God and the Fight Against AIDS" in
recommended readings notes how moral stances on the part of the Bush administration may have
sometimes trumped global health considerations, especially when PEPFAR contributed funds to
highly ineffective "abstinence-only" prevention programs. Interrelatedness of social constructs,
institutions, and global health delivery.
Peligre Dam
Discussed explicitly in Farmer's "Social Medicine and the Challenge of Bio-Social Research,"
the Peligre Dam was built on the Artibonite River in Haiti as a "poverty-reduction program"
funded by the precursor of the World Bank. Flooding of the fertile valley caused wide scale land
loss, with peasants unable to cope as they moved to the arid land above the valley. Immense
poverty in the region, forcing sometimes the peasant's sons/daughters to search for jobs in the
city; high TB rates due to poverty, but also increased risk for HIV infection from resulting work
in urban areas. From global health perspective, the dam is a product of 'development' ideologies
supported by the World Bank. Remember criticisms of 'development' by Escobar – as a form of
violence against locals – and also the dam as a representation of Merton's unanticipated
consequences in purposive social action.
Plantocracy
A plantocracy is a ruling class, political order or government composed of (or dominated by)
plantation owners. Referenced in Dr. Paul Farmer’s AIDS and Accusation, plantocracy pertains
to the Haitian sociopolitical order beginning in the Xs that consisted of a small European settler
population relying on an African slave population (that greatly outnumbered the whites) to do
their agricultural work. From 1791-1804, led by Toussaint Louverture, the slaves of SaintDomingue revolted and overthrew the plantocracy in the only successful slave revolt in world
39
history. After the revolution Haiti was in the position of being self-governed by blacks, but found
itself in a hostile world, and the next two hundred years were plagued by political instability,
coups, military dictatorship, and multiple interventions by foreign governments. Haiti was
largely susceptible to these unfortunate situations due to the vulnerabilities the plantocracy had
implanted in Haitian society.
PMTCT
PMTCT stands for Prevention of Mother to Child Transmission of HIV. It is important to note
that the new, preferred name for MTCT is “vertical transmission,” as the term does not blame the
mother for giving the child HIV. PMTCT is referenced in almost all of the case studies (HIV
VCT in Hinche, AMPATH, HIV Care in Rwanda) because it is a critical component of any
effective HIV prevention and treatment program. PMTCT interventions include the use of
antiretroviral prophylaxis, the avoidance of breastfeeding and elective caesarean section.
POSER
1) Define the term or concept
Program on Social and Economic Rights. It is a series of programs attached to PIH in Rwanda,
Haiti, and Peru meant to provide break down the economic barriers that prevent patients from
accessing health care. The most prominent example was the provision of "donkey fees" in Haiti
for TB patients who could not go to the clinic because they could not afford the transportation.
In Haiti, POSER's key projects include providing ZL patients with nutritional support, building
homes for those patients who were most in need, paying school fees for patients' families who
were unable to do so, and building well caps or filtration systems for communities to ensure
access to clean drinking water. Similar projects are being implemented in Rwanda and Peru
2) Explain its significance
POSER was founded on PIH's belief that meeting patients' social needs was just as important as
meeting their medical needs. We've had many readings that make an argument about the link
between poverty and health (see Patel for mental health and poverty, see Packard, Brown,
Farmer, etc for inequality and health…many more). Most explicitly in relation to PIH, Kim and
Farmer's reading in Lecture 15 showed that when patients were given economic support in
addition to just medication, their TB cure rates and compliance increased dramatically (the
reading explains an experiment conducted between two groups…one which receives economic
aid and one which does not). So medical care is not just about providing medication, but rather
about providing a system which takes care of patients holistically and to Farmer and Kim this
includes the provision of economic opportunities.
3) Cite all text/lectures used to define term
Lecture 16- HIV Voluntary Counseling and Testing in Hinche, Haiti
Positive Synergies between health systems and Global Health Initiatives
The concept of positive synergies between health systems and GHIs is a strategy meant to
address the fact that when financial resources are supplied to a country’s health services through
40
GHIs, there may be unexpected “spill-over” effects. Some of these effects are positive (new
infrastructure, better service distribution, etc), and some are negative (certain projects being
better financed, multiple reporting, etc); the issue is that they tend to be unplanned. Developing
a positive synergy refers to actively and systematically managing the relationship between GHIs
and already-existing health systems such that the negative spill-overs are minimized, the positive
spill-overs are maximized, and the entire process is more structured rather than consisting of
unexpected effects. The reading “Maximizing Positive Synergies between health systems and
Global Health Initiatives,” a WHO May 2008 consultation report on this process, carefully
outlines the need for this type of solution, the knowledge-gathering process and coordination
required to achieve it, and offers examples of existing work that is being done in the area.
Within the larger framework of global health, this concept is part of the goal of developing a
“science of delivery,” and addressing the proliferation of global health initiatives that operate in
isolation
Reading: “Maximizing Positive Synergies between health systems and Global Health
Initiatives,” Lecture 21
Lectures: Lecture 21, “Science of Delivery II,” December 2nd
Randomized Controlled Trial
The randomized controlled trial, considered the gold standard in experimental design for
scientific research, is an experimental model in which one tests for the efficacy of a particular
intervention by randomly prescribing it to one portion of a test population, such that all other
potentially confounding factors are distributed equally among participants. It is a useful standard
for some cases of research on healthcare interventions; however, translating interventions that
are efficacious in a controlled setting such that they are effective in a non-controlled, real-world
setting can be challenging. In Sanders and Haines’ article, “Implementation Research is Needed
to Achieve International Health Goals,” the authors discuss the limitations of randomized
controlled trial; while they are appropriate for health system research within a community or
health facility, they become more difficult to apply on the system-wide level. Thus, more
qualitative, descriptive studies are as important a component in health system research as the
more quantitative randomized controlled trial model.
Reading: Haines & Sanders, “Implementation Research is Needed to Achieve
International Health Goals,” Lecture 20
Lecture: Lecture 20, “Science of Delivery I,” 11/25/0
Social Movement
Broadly speaking, a social movement occurs when a group of individuals and/or organizations
becomes involved in resisting/encouraging social change by focusing on particular
political/social issues. Some big ones are:

Treating and improving treatment for AIDS on a local and global scale- see Behrman,
“Invisible People: How the US Slept Through the Global AIDS Pandemic”.

Improving access to biomedical innovations in middle/low income countries and
increasing R&D for neglected diseases through altered licensing practices and public-
41
private partnerships- see Kapczynski et al, “Addressing Global Health Inequities: an
Open Licensing Approach for University Innovations”.

Arthur Kleinman declares that there is “a huge societal-wide social movement in my own
country and others among students, faculty and practitioners to create a new kind of
global health that is at the cutting edge of science, that is technologically mature, that
also is committed to the highest level of clinical practice, that makes use of the latest
managerial strategies to implement scaled-up programs, and that responds to global
ethical issues that are critical to globalization such as social justice, equity, and in the
simplest and bluntest terms, bringing good into the world of the poorest.” See Kleinman,
“Today’s Biomedicine and Caregiving: Are They Incompatible to the Point of Divorce?”

The ‘human rights movement’ is discussed briefly in the last reading of the course pack,
“Why More Africans Don’t Use Human Rights Language”, which criticizes human rights
organizations for being ‘fashionable’ but ignoring the complexity of human rights
struggles in Africa. Successful social movements require popular mobilization and
inclusivity.
Solidarity
Solidarity refers to social ties that bind people together in communities. It has been discussed
throughout the course as a critical aspect of cohesive global health efforts and also in
moral/ethical considerations. Kleinman discusses solidarity as an important aspect of
‘caregiving’, which “is about acknowledgement, concern, affirmation, assistance, responsibility,
solidarity, and all the emotional and practical acts that enable life”. Solidarity is also mentioned
in Roberts et al, “Getting Health Reform Right”, who discuss how “the global turn to the market
has brought a trend toward diminished social solidarity and a parallel turn against government
action in many countries”.
Julio Frenk discusses 'global solidarity' as one of two necessary components to encouraging
international collective action (the other component being the production of global public
goods). The case for global solidarity is clearest when a country's health system is insufficient to
meet the needs of its citizens or is facing an overwhelming crisis (natural disaster, war, etc).
The Green Light Committee
1. Definition: During Lecture 11 (10/21) , Dr. Kim went into detail about when he was
pushing the WHO to do something around treatment of MDR TB, he came across the
Green Light Committee, a group that had done so with meningococcal meningitis and
leveraged it for his cause. According to it website, "Established in 2000, the GLC
Initiative is the mechanism that enables access to affordable, high-quality, second-line
anti-TB drugs for the treatment of MDR-TB. " "The GLC is a component of the GLC
Initiative that serves as a technical advisory body to the Stop TB Partnership and
WHO…. comprised of representatives from institutions with specific programmatic,
42
2.
3.
4.
5.
clinical, advocacy, scientific and managerial expertise…" Also important to note is that
for-profit institutions do not get a (direct) say in decision-making.
Significance: PIH is currently the chair of GLC. JK- it is, but that is not that crucial! The
GLC "contributes to reducing transmission of TB, preventing further drug resistance and
ultimately reducing the global burden of TB." According to Dr. Kim, GCL helped realize
a huge reduction in TB drug prices and created a model that the Global Fund now uses. It
has also been able to contribute national TB control programs in many countries.
Use in Readings- Gupta, R et al. “Increasing Transparency in Partnerships for Health –
Introducing the Green Light Committee” (in Lecture 12 rdgs.)
Relevance to Global Health- Explicitly addresses TB worldwide, particularly around
issues such as prevention and treatment of MDR TB.
Relevant Course Material- Lecture 11- Social Life of Drugs: HIV and TB; Gupta, R et
al. “Increasing Transparency in Partnerships for Health – Introducing the Green Light
Committee” (in Lecture 12 rdgs.)
The Social Life of Things
1. Definition- "Social life of things" is a reference to what Appadurai frames as the social
trajectory of things, whose "consumption is eminently social, relational, and active rather
than private, atomic, or passive" (31)
2. Significance- It can be drawn that exploration of the social life of things can help one
discern the values and social dynamics that help to inform it.
3. Use in Readings- Introduction of Appadurai's The Social Life of Things (in Lecture 12
reading)
4. Relevance to Global Health- Appadurai asserts that "we are now in a better position to
demystify the demand side of economic life," and there is a similar truth for demand side
of health. Given the prevalence of commodification in relation to global health (i.e.
drugs, cost-effectiveness discourse, specialties, etc.), understanding of the social
framework and implications around various elements offers a chance to comprehend
more subtle influences. (i.e. What does the 90/10 pattern say about governing values?) Dr
Kim also mentioned: "Commodities have unique significance for global health; drugs
today can transform outcomes for populations, so we have to think about complex ways
in which they take on meaning " and "Social, economic, and political formulations
around commodities determine their availability, use, and ultimate impact on health
outcomes" (Lecture 11) [Italics are from my notes; since slides are not available, I am not
sure if that is what he put up verbatu,]
5. Relevant Course Material- Lecture 12- Social Life of Drugs: HIV and TB; Introduction
of Appadurai's The Social Life of Things (in Lecture 12 rdgs.)
TRIPS
TRIPS (Trade Related Aspects of Intellectual Property; see p.1069, Vol.2, coursepack
1. Definition: Trade Related Aspects of Intellectual Property
2. Significance:
43
-
The foundation of treaty architecture supporting high levels of substantive and
procedural protection for IP
- Precipitating a shift in innovation policy
- A policy that serve as a barrier to affordable drugs
- Instituted by the World Trade Organization (WTO)
3. Readings
- P. 1069
- “second enclosure movement” (a time of even more restrictive patent and related
exclusive rights regimes)
- Patents are becoming increasingly supplemented by exclusivity, which is
cultivated at the drug regulatory interface
- Proponents of patents argue patents will spur innovation, thus increase aggregate
social welfare
- Economists studying patents are ambivalent about effect of strong exclusive rights
on innovation and welfare; they argue:
a. Information is both nonrival and critical for future innovation; most efficiently
accessible at zero marginal cost (MC), but firms will not invest in research
b. To solve this prob, patents are implemented:
 Pro: incentivize innovation by granting firms a temporary monopoly
period to reap supra-marginal profits
 Con: 1) create deadweight loss by raising the MC above zero, 2)
innovation can be stymied b/c information is a component in its own
production
- Result: overly expansive set of rights can lead to too little innovation; strong
patents have shown theoretically and empirically to reduce innovation and welfare
- Therefore, in developing countries, patent a) cost them significantly more b)
benefit them significantly less
4. Global Health
- WHO estimates that 10 mil lives could by saved annually by improving access to
essential medicines and vaccines that already exist, but nearly 30% worldwide do
not have regular access to essential medicines
- Price is an important factor
a. Low-middle income (LMI) consumers tend to pay a greater proportion of their
own medical costs than consumers in wealthy countries (public sector pays
less than 30% of drug costs)
- Price is affected by patent status
a. Introduction of patents has been predicted to raise drug prices; development
and aid agencies confirm
b. Medecins San Frontieres concludes the most significant factor in reducing
drug prices is introduction of generic sources in a country
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c. Oxfam International has called generic competition the “single most important
tool to remedy the access gap”
- Absence of patents
a. not the sine qua non of effective access to generics
b. b/c developing countries differ substantially in terms of their existing
pharmaceutical production capacity
c. even in the poorest countries when medicines can by locally formulated they
may be unaffordable b/c of inefficiencies in production and limited market
size
- thus,
a. we need new medicines
b. while new medicines are being developed, the confluence of a) TRIPS takes
hold in supplier countries b) TRIPS-plus provisions take effect in more
countries→ the role of exclusive rights and patents will play an increasing role
in access gap crisis
5. Citations
- Lec 12 (10.23.2008)
- 10. 23.08, p.1069: Kapczynski, Amy. “Addressing global Health Inequities: An
Open Licensing Approach for University Innovations” Berkeley Technology Law
Journal 2006
UDHR
UDHR (Universal Declaration of Human Rights); see p. 1762, Vol.3, coursepack
1. Definition: Universal Declaration of Human Rights
2. Significance:
- Lec. 24, 12.11
- Significant break from previous right definitions
a. Over Declaration of Indep. And Declaration of the Rights of Man
- Right to social security
- Right to standard of living and health ie food, housing
3. Right to participate in cultural life- scientific and arts; share in the advancement
4. Readings:
- P. 1762, “Why More Africans Don’t Use Human Rights Language”
- Africa is undergoing a human rights crisis and a crisis for human rights
- The hope for human rights offered by UDHR for African ppl is often assaulted by
confluence of a) public pwr, b) private privilege, c) resulting popular destitution
- African ppl involved in social injustices fear to champion UDHR or the language
inspired by it as a mascot or medium to advance human rights movements
- This is because Africa was hardly represented when UDHR was negotiated and
adopted; African independence predated UDHR, which is known as an anti-
45
apartheid campaign and the most successful human rights movement known to
the African ppl
- Eg Some African languages do not have a language equivalent of “human rights”
suggesting that African ppl have neither a) notion of justice that underlies human
rights nor b) the experience of struggle to realize these rights is unknown
- Although African ppl are aware of injustices
5. Global Health:
- Although African are aware the injustices imparted upon them and that it is a life
or death matter (eg child soldier, rural dweller deprived of basic healthcare,
mother unaware her next pregnancy could be fatal, city dweller living in fear of
burglar, the worker owed several months of wages, the activist organizing vs. bad
gov’t, grp of rural women seeking access to land in order to send their children to
schools with proceeds); knowledge of the contents of the UDHR will be fruitless
- Need a movement that will channel frustrations into articulate demands that will
evoke responses from the political process, but human rights movement is
unwilling to provide this
- Although this movement (struggle) will continue to fight for their rights
regardless of the language of human rights is accessible to them; but the
movement will not be built around the notion of human rights unless the language
and those that wish to popularize it speak directly to their aspirations and survival
6. Citations
- Lec. 24 (12.11.2008)
- 12.11.08, p.1765: Ondinkalu, Chidi. “Why more Africans don’t use human rights
language.” Human Rights Dialogue 2.1 1999.
Urbanization
The social process by which more and more people come to live in cities. The concept is used in
"The Peruvian National Tuberculosis Control Program" case study. The Sendero Luminoso's
strong presence in rural regions of Peru led to a lot of people heading for the cities and driving
people to live in shanytowns in straw and carboard dwellings. Guerella warfare at the hands of
the Sendero Luminoso destroyed many rural health clinics which disrupted health infrastructure
in Peru. The government began rebuilding them after international press showcased a threeyear-old boy who had contracted the last case of polio in the Americas due to lack of childhood
immunization and health center access.
USAID
USAID stands for the United States Agency for International Development. It is a government
agency that has provided economic and humanitarian assistance for more than 40 years. The
term is used to address socioeconomic concerns of relief aid in the "Peruvian National
Tuberculosis Control Program" case study. USAID initially funded Proyecto de Desarrollo
Integral con Apoyo Alimentario (PRODIA), but pulled its support in 1995, which resulted in the
network of soup kitchens decreasing from 7,000 in 1993 to under 1,000 by 1997. Furthermore,
46
some patients in Lima reported receiving food supplements only twice in 1997 despite the
program's aim to provide them at least monthly, and one third of patients received no nutritional
support.
Value
Readings- This is discussed in the Appadurai article and applied to the discussions on the social
life of things and the costs of pharmaceuticals. According the Appadurai value is linked to
exchange of a commodity. Things do not have absolute value but instead value is driven by
demand and the difficulty of acquisition of a thing. This is exemplified in the act of bartering
when the value of the commodity is determined by what people are willing to exchange in that
given situation. Therefore the value of things is socialized instead of absolute. Appadurai delves
into the marxian view which is that value is only linked to capitalism. Engel further states that a
product does not become a commodity and therefore have value until it can be exchanged. Bayl
expands on this analysis of value in his description of the politics of demand which states that
demand is subject to cultural and social forces as exemplified in luxury goods. Further because
value is attached to cultural norms, it is ever shifting based on shifts in cultural norms.
Lecture 12 - The professors apply the theories of Appadurai and Bayl to the costs of
pharmaceuticals specifically MDR TB medication. The WHO stated that they could not pay for
medication with people with MDR TB in the developing world because of the costs of the
pharmaceuticals. But, the professors asserted that the price of the drugs was not stagnant and
could be influenced by changes in policy and demand through placing them on the WHO model
list to encourage the production of generic drugs from China and India. But the WHO feared that
the free use of these drugs would foster resistance. To quell this fear, the professors established a
green light committee to monitor drug use in order to prevent resistance. From this the price of
those drugs was dramatical reduced. This was further applied the ARVs and HIV in which the
production of generic drugs also reduced the price.
Values
Readings- Jim Kim “Values to Value” - In this writing Professor Kim asserts the values of
Global health. He states that health must become a right. He states that health projects are not
effective and that we should concentrate on the establishment of integrated health systems. He
states that within these values should care based on local settings, assessments of cycles of care,
minimization the duplication of services, engaging local practitioners, and the utilization of
academia.
Value Chain
Value chain describes the activities, costs and collective effects for a technology or
intervention that is delivered. The term is significant to understanding how health interventions
and innovations can be delivered appropriately, and for determining how health systems can be
strengthened. It is one of the areas to give particular attention to when conducting health
systems research.
Porter emphasizes that when creating health systems, the focus must be on delivering
value and that the product that is valued is not the treatment/program but instead the health
47
improvement that results from the treatment. Thus, to ensure that you are delivering maximum
health, you have to examine all aspects of the system that deliver it, a.k.a the value chain. The
value chain is tied heavily into the complex delivery infrastructure.
The relevance of this term is that it incorporates a concept widely used in business analysis of
product deliveries to health. It is a more systematized way of understanding and improving
health care delivery. Physically mapping the value chain affords two benefits: it allows us to
visualize all the players and activities that go into delivery, and make investment or policy
choices based on regions of the chain that are most critical, and it helps to create a framework for
understanding delivery in all settings, populations, etc. My understanding from Kim’s article is
that by distilling health care cases into value chains, we might also be able to see similarities
among health conditions or settings that will eventually help create a more universal model for
health delivery (making it into a science).
Relevant lecture: Science of Delivery II (Jim Kim – 12/02/08)
Relevant readings: “From a Declaration of Values to the Creation of Value in Global Health”
discussed on pp. 1519-1523; diagram of chain on pp. 1525; “How Physicians Can Change the
Future of Health Care” (more for understanding how to define value as health)
Voluntary counseling and testing (VCT)
Voluntary counseling and testing is a system employed by Farmer/Zamni Lasante in
Haiti. The process identifies symptomatic and asymptomatic HIV patients and is a way of
beginning care delivery to these populations. For those who are not infected, VCT also serves to
deliver preventive education. The complete services include pre-test counseling, blood draw,
testing blood and post-test counseling; if the test is positive for HIV, a repeat blood test is
performed.
In the Haiti case study, the overall goal to help lower HIV infection rates and mother-tochild transmission was to scale up VCT throughout Haiti. The VCT clinic in Hinche, which
began in 2003, was not proving very effective in providing its necessary services. It was not
very visible and mislabeled; the services required a previous referral from a physician or midwife
in the hospital. Its services were not advertised to the larger Haitian community. There were
variable wait times and there was no follow up treatment at the Hinche clinic for those who
tested positive for HIV. Additionally, though the VCT was free, the clinic visit required to
obtain a referral for VCT was costly.
Mukherjee also describes the integration of VCT with primary health care services using
the PIH Four Pillar Model in his guide book. It is very important to integrate VCT with other
health tests performed at primary health care screenings because it allows quick diagnosis and
prevents losing patients in follow-up visits to another VCT-specific clinic. Also, if VCT is
routine in health care clinics, then everyone is tested, and the stigma around AIDS and being
tested for it (death sentence concept) is minimized.
Relevant lecture: “Building the PIH model: Strengthening Primary Health Care in Rural
Haiti (Paul Farmer – 11/06/2008)
Relevant readings: “HIV Voluntary Counseling and Testing in Hinche, Haiti” (Case
Study) pp. 1240; “
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Well-being
expands the concept of "health" beyond just biomedical definitions... You could argue that the
concept wellbeing supports for the need for PHC as opposed to just vertical interventions...
From alma ata "The Conference strongly reaffirms that health, which is a state of complete
physical, mental
and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental
human right and that the attainment of the highest possible level of health is a most important
world-wide social goal whose realization requires the action of many other social and
economic sectors in addition to the health sector."
I'm not sure if there's another reading that invokes this term in a more specific way; I'll keep
looking and sen you anything I find...
W.H.R. Rivers
(From Kleinman's lecture on the personal ethnography of global health): He worked on mental
health with WWI soldiers suffering from neurasthenia 'shell shock.'
W.H.R. Rivers—treated the traumatized in WWI
o Measured all conditions of patients—but realized you couldn't do research without
understanding the language and societal factors, see holistically the context of society
o In WWI he joined the army medical corp and was stationed in Craiglockhart Hospital near
Edinburgh
This was where they shipped officers who suffered from Post Traumatic Stress
Disorder—WWI was thought of as a great meat grinder, the British lost 450,000
soldiers in one week
Trauma of WWI—old men sending young men to their death
Rivers attempted to treat the war hero Sassoon who opposed battle
Rivers fought for compensation of soldiers who had psychological as well as
physical ailments
It wasn't enough to be in the classroom or field, but needed to impact policy
Antiheroic; became self-critical of who he was and what he was doing
O Recognized that a number of the key issues of colonized peoples was
due to the way that the empire had undercut the key factors of
societies
Kleinmann viewed Rivers as a failure: however, he recognizes the moral change that
occurred in recognizing the biosocial failures of his time and how things should be
49
reshaped and redone
Courageous enough to be self-critical and to set out in a new direction, not that you
will be successful, but that you will take a new turn
50
Anthropology 1825
FINAL STUDY GUIDE, Fall 2008
{Jacob Bor’s Sections}
LECTURE 11
Behrman, Greg. Invisible People: How the US Slept Through the Global AIDS Pandemic.
(Ch. 7-8)
Chapter 7 of this book is about how the US AIDS activist movement developed a global
consciousness. During the 1980s and up until the introduction of highly active antiretroviral
therapy (HAART), there were very few prominent US activists interested in global AIDS issues
– the concerns were very much about getting more funding for research for drugs in the US and
speeding up the approval process. Two notable exceptions were Paul Boneberg, a longtime
activist from San Francisco and Eric Sawyer, a co-founder of ACT UP/NY. Therefore when
HAART became approved, these two men (and several others) talked about “bridging the gap”
and bringing access to AIDS drugs to the more than 95% of total AIDS patients living in the
developing world.
Chapter 8 traces the work of the AIDS activists during the early days of the Gore 2000
campaign. Though Gore was an early voice on the importance of addressing the AIDS crisis in
Africa in a major way, little progress was made during most of the Clinton years. A rogue
American expert (not with the government – a Nader guy) named Jaime Love suggested “parallel
imports” and “compulsory licensing” to the South African government. Compulsory licensing is
a process in which South Africa would grant licenses to manufacturers to produce ‘generic
drugs’ at home cheaply. Parallel trade enables a country to import drugs from another country
(other than the US) where they are cheaper. These policies were strongly unpopular with Big
Pharma. Thus the Medicines Act of 1997 was met with lawsuits against the South African
government and with penalties from the US government, specifically the Trade Office (the
USTR). This exploding health emergency was being viewed in the US as a problem of trade.
With this background, a group of activists began led by Eric Sawyer began disrupting Gore at his
rallies holding signs such as “Gore’s Greed Kills: AIDS Drugs for Africa.” Then with Gore’s
leadership and advocacy, the policy of the Clinton administration switched and President Clinton
signed an executive order saying that no punitive measures would be taken against any subSaharan African countries pursuing parallel imports or granting licenses.
After this, UN Ambassador Richard Holbrooke worked to make the focus of the first session of
the UN Security Council focus on AIDS. This was extremely difficult as never before had a
health issue been the focus of a Security Council session. Gore ended up addressing the session
and outlining the extent of the pandemic and the necessity for immediate action.
Consensus Statement on Antiretroviral Treatment for AIDS in Poor Countries – Harvard
Consensus
The Harvard Consensus statement offers a perspective into strong and effective HIV/AIDS
initiatives. It illustrates the need for well-designed and well-financed efforts to improve AIDS
programs in poor countries. This article states that effective AIDS/HIV treatment in low-income
areas is crucial for optimizing prevention efforts, saving children, and continuing economic
development. Its main argument is that HIV treatment IS possible in low-income countries. They
use HAART as the primary example of treatment success in poor settings (in this case Haiti).
HAART utilized the DOT-based TB treatment model in order to address HIV. This article
51
suggests the following techniques for successful treatment efforts: 1. Multiple pilot programs
that differ from place to place, 2. Large scale trials are highly encouraged with strong gov’t
support, 3. Preventative pilot programs should be designed, 4. Since TB is the cause of death of
AIDS patients, TB should be treated as well, 5. Simplified regiments and direct observation need
to be combined for best patient adherence, 6. Education and training is crucial, and 7. Provide
necessary infrastructure for treatments. Since prices have begun to fall for AIDS treatment
almost by 90%, it has become much more possible to treat those living in poor settings. The
authors conclude by stating that every treatment effort should be carefully monitored and
evaluated in order to determine the efficacy of treatment and overall success. This article
attempts to directly address the question this class has been posing since the beginning - what
needs to be done to have a successful treatment program?
Appadurai, Arjun. “Introduction” The Social Life of Things
In the Introduction to his book, Appadurai explains the way in which things, just like people,
follow life cycles that move along a social vector. According to Appadurai, things are valued not
for their inherent worth as a utility, as a Marxist might argue, but rather, for the worth that is
attached to them as they move from one appraiser to another. While utility is certainly a factor
in determining the up- and down- value swings in the “social life” of a thing, there are many
other influences which are much more “social” by nature. For example, a significant amount of
this worth is determined by value judgments concerning authenticity, originality, and scarcity.
An analogy to the valuation of art is made, as art carries little to no inherent worth in its utility,
but rather is made valuable by the cult of authenticity surrounding it. While this piece is
abstractly theoretical, it is important in the context of our understanding of drug pricing. As
explained in lecture, as “things,” drugs follow a “social life” that is likewise determined by
subjective value judgments aligned with our social values. Concretely, for example, the price of
second-line TB drugs would remain high not necessarily because such drugs were inherently
more useful than first-line drugs, but rather, if the social significance assigned to such drugs was
such that they were not deemed as “essential medicines.”
Rauch, Jonathan. This is not Charity.
Bill Clinton, head of the Clinton Foundation, and Ira Magaziner, a business consultant, attempted
to find solutions for people with HIV / AIDS. Magaziner brought business strategies like
consolidating orders, automating communications, and working with suppliers to find an
efficient solution to the problem. Clinton and Magaziner attempted to bring the prices of HIV /
AIDS drugs down. They realized that by raising demand for the drugs in the developing world,
they could bring down prices. So the foundation went to governments in Africa and the
Caribbean and organized demand for AIDS drugs, obtaining intentions to place large orders if
prices could be cut. Generic manufacturers were interested, but brand name manufacturers
weren't. There were large price cuts; the Clinton Foundation certainly helped, but prices likely
would have dropped anyway.
Clinton and Magaziner's focus on efficiency and business strategies is part of a somewhat new
approach in global health. We can connect this to Prof. Kim's argument that people who work in
global health must aim for efficiency and good results; simply working for global health is not
enough.
52
Addressing Global Health Inequities: An Open Licensing Approach for University
Innovations -Amy Kapczynski
Patent regimes that have originated in developed countries are being extended to developing
countries pose a danger regarding access of drugs and research on neglected areas of global
health. Efficient generic production of ARVs has been shown to cut costs from $10,000 a year
to $168 in some areas. But some pharmaceutical companies insist on enforcing patents of their
drugs in developing countries, posing a significant price barrier for patients to access life-saving
treatments. Universities can play a significant role in helping to increase access to therapeutics,
and in 2004 Yale, a patent holder for stauvidine, approached Bristol Meyer Squibb and pressured
them to allow generic importation of ARVs into developing countries while dropping
simultaneously lowering the price of their drug for patients in developing countries. However,
pharmaceutical companies have often enforced their patents in developing countries, or
attempted to restrict supply chains of generic drugs produced in other countries, often to the
detriment of the poorest.
Patents of scientific discoveries and innovations also constitute an effective barrier to the
dissemination of research and further innovations in some cases. The current patent regime has
encouraged the research of profitable diseases, not ones that affect the most number of people.
Indeed, 10% of research money on diseases goes towards addressing diseases that constitute 90%
of the global disease burden. Further, patents increase transaction costs to access other
researchers’ methods and results, placing a burden on public-interest researchers. A new
intellectual property rights system is needed to address the needs of the poorest segments of the
population.
Gupta, R et al., “Increasing Transparency in Partnerships for Health: Introducing the
Green Light Committee”
In 1999, the WHO established the Working Group on Dots-PLUS for MDR-TB. The Working
Group includes institutions from the public and private sector. Also in 1999, the Subgroup on
Drug Procurement Issues (part of the Working Group) highlighted the high cost of second-line
drugs as one of the major impediments to implementing Dots-Plus pilot projects. The Green
Light Committee (GLC) was formed by the WHO in 2000 in order to establish a mechanism to
increase access to these drugs, under tightly supervised conditions to promote their rational use
and minimize resistance emergence. The GLC can be described as a "health-based partnership"
because it does not use the for-profit sector in its decision making, but does involve the for-profit
private sector in terms of supplying concessionally priced drugs. The GLC involves academic
institutions, civil society organizations, bilateral donors, governments of resource-limited
countries, and a specialized United Nations agency. The GLC is so effective because of its
review process, its flexibility to modify its way of working to overcome obstacles, its
independence from the commercial sector, and its ability to link access, rational use, technical
assistance, and policy development. The GLC mechanism may be useful in the development of
other partnerships needed to allocate resources and to combat additional infectious diseases.
This article discusses the potential benefits of the private and public sectors working together.
Perhaps the most interesting part is that while the private sector is included, it does not have a
role in decision making. This suggests the realization that a for-profit organization may not
53
make the best decisions for poor people. This article fits into the context of the course because it
asks what the best way is for private and public to work together. Is there any way to include
private organizations in Working Groups in order to raise more money for global health, while
simultaneously using the expertise of these organizations but not sacrificing the goal of helping
the sick and the poor.
LECTURE 12
Part 1 – Age of AIDS (film)
When HIV was first diagnosed in the US, over 250,000 people had been infected. At the time,
HIV was a mysterious virus that had yet to be identified. People who were infected were dying
from rare diseases that had killed relatively few people before. It was later discovered that the
virus first surfaced in the 1930s from a chimp virus in central Africa, but only started spreading
rapidly during the 1970s. Early patients with HIV died within a few months, and young
homosexual men who got it were often stigmatized, losing contact with family and friends, their
job, and encountering social isolation. HIV/AIDS in the 1980s was met with decreased social
sector spending during the Reagan era, and funding for HIV/AIDS research at first was dismal.
There was no treatment during this time, and a tremendous amount of stigma and fear associated
with the disease. During the 1980s the CDC budget was extremely constricted, but they did
manage to go to the Congo and discovered that the same virus was also infecting people there. It
was in the Congo that doctors realized that HIV could be transmitted heterosexually as well as
homosexually. The virus spread to Haiti, and the media blamed Haiti for the origin of the
disease, depressing their tourism industry and leading to stigmatization of Haitians. The mid
1980s saw little political support from President Reagan, who failed to even utter the word
“AIDS “ in public until 1987. The death of All-American television actor Rock Hudson,
however, propelled HIV/AIDS into the national consciousness. While governments in Uganda
and Thailand created community support groups for AIDS prevention (TASO, ABC) and had
strong political support, the United States’ HIV prevention efforts were hampered by political
stigmatization of the issue, blocking needle exchange and some forms of federal funding of
HIV/AIDS education regarding homosexuals. When the first treatment, AZT, was released, the
prices were astronomical ($10,000/year), and later patients developed AZT resistant strains of
HIV. While the price of HIV/AIDS was lowered, only after the Reagan era would there be
social sector support in the US for poor families who could not afford HIV/AIDS treatment.
Farmer, Paul et al. “How to Promote Global Health: A Foreign Affair”
Paul Farmer, Jeffrey Sachs, Alex de Waal, Roger Bate & Kathryn Boateng, and Laurie Garrett
discuss Garrett's essay "The Challenge of Global Health" and debate how best to help the world's
poor and sick. This is pretty interesting, but probably not really worth summarizing. If you want
to see what varied figures in GH had in response to Garrett’s essay you’re probably best to read
their portion….here are super brief summaries
Paul Farmer argues that although sometimes AIDS funding may be misdirected etc. in general,
AID’s funding has brought welcome relief to the traditionally underfunded field of global health.
Paul argues that Garrett’s critique should be directed primarily at badly designed programs.
Jeff Sachs agrees with Garrett that there is urgent need for improvement found Garrett’s article
to be full of misguided aid bashing.
Etc. (really there is no point in summarizing these…)
54
These responses to the article provide an interesting discussion on aid, use of money and
structure. The debates of vertical/horizontal structures and development aid, debate on best
implementation is critical.
Garrett, Laurie. “The Challenge of Global Health,” Foreign Affairs (2007).
(Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations.)
This article from Foreign Affairs is Laurie Garrett’s comprehensive assessment of the major
challenges and opportunities in global health today. It is impossible for me to summarize
everything mentioned in the article in 150-250 words, so I have chosen what I feel to be her most
interesting assertions as well as the topics most commented on by the other participants in the
Global Health Roundtable that follows this reading in the syllabus (by the way, those Roundtable
articles are all truncated in the PDF readings and in the printed coursepack; go to
http://www.foreignaffairs.org/special/global_health/).
Less than a decade ago, the major problem in global health was lack of funding. Today, thanks to
an unprecedented surge in giving, the problem has become managing funds in a way that doesn’t
waste them or make things worse (though in the roundtable she agrees with Jeff Sachs that more
funding is still needed for global health). Her main argument is that funds are often spent in an
overly disease-specific way (“stovepiping”) and that efforts should focus more on “broad
measures that affect populations’ general well-being.” This ties in closely with the portion of this
course devoted to health systems strengthening. She also identifies the crisis in health workforce
(often caused by brain drain to first-world countries) as a major problem, citing the fact that 1 in
5 practicing physicians in the US is foreign trained and blaming policies such as a lack of public
funding for US nursing schools that limits the number of American nurses and forces the hiring
of nurses from countries that cannot afford to lose them. This is definitely an unintended
consequence, though perhaps not of purposive action. Third, Garrett argues that (at the time of
the essay’s publication) there is a lack of visionary leadership on global health, with the new
WHO Director-General (Margaret Chan) not yet having proven herself and with the Global Fund
mired in squabbles about leadership. Finally, and related to health systems strengthening, Garrett
argues that too few global health projects have methods for assessing their own efficacy, too
many ignore local needs, the poor, and the public sector, and nearly all lack exit strategies that
will actually leave behind better health systems that produce better health outcomes in a
sustainable way.
Garrett summarizes these challenges and lays out general remedies in this way: “…the health
world is fast approaching a fork in the road. The years ahead could witness spectacular
improvements in the health of billions of people, driven by a grand public and private effort
comparable to the Marshall Plan – or they could see poor societies pushed into even deeper
trouble, in yet another tale of well-intended foreign meddling gone awry. Which outcome will
emerge depends on whether it is possible to expand the developing world's local talent pool of
health workers, restore and improve crumbling national and global health infrastructures, and
devise effective local and international systems for disease prevention and treatment.”
LECTURE 14
No Health Without Mental Health – Prince, Martin and et al.
55
Even though mental health disorders account for a significant portion (14%) of global
burden of disease, they are not address appropriately. Neuropsychiatric conditions accont for a
1/4th of DALYs. Most people don’t recognize the direct connection between mental illness and
other health conditions. It has been proven that mental disorders increase the risk for noncommunicable disease, and conversely, health problems consequently increase the risk of mental
illnesses. Depression leads to both physical and social disability. Additionally, 1/3 of all
medically unexplained symptoms are associated with mental disorders. There have been strong
associations between depression and the onset of stroke and diabetes. On the other hand, many
chronic diseases create a huge psychological burden that is difficult to overcome and further
exacerbate situations. Maternal depression has led to decreased child-health promotion and
prevention measures. The authors of this article provide a strong case for the impending need to
address mental health problems around the world. They stress the potential capacity for
psychosocial interventions to improve physical health outcomes and they feel that an explicit
mental health budget is needed to address such concerns. This article addresses the odd case of
mental health that is rarely mentioned when talking about global health. However, the authors
prove the importance of addressing such pressing issues. The title addresses it all – no health
without mental health.
Patel: “Poverty and common mental disorders in developing countries”
The authors searched medical journals from 1990 (I assume up until 2003) in order to study the
relationship between poverty and mental health risk in developing countries. They found that
most studies showed an association between poverty and common mental disorders, with the
most constant association being with low levels of education. They believe that there is only
weak evidence to support a specific association with income levels. Factors such as the
experience of insecurity and hopelessness, rapid social change and the risks of violence and
physical ill-health may be one explanation of the poor’s vulnerability to common mental
disorers. The costs of mental ill-health worsen the economic condition, setting up a vicious
cycle. The authors suggest that common mental disorders be looked at with other diseases
associated with poverty by policy-makers and donors. Investment in education and microcredit
may reduce the risk of mental disorders. Strengthening primary care services to work with
mental health may also be effective.
Analysis: By suggesting that poor mental health is associated with poverty (and particularly with
low education levels), the authors provide more evidence that structural violence can lead to bad
health outcomes. The article is notable because often mental health is left out of discussions of
health care for the poor.
“Beyond Evidence: The Moral Case for International Mental Health” – Vikram Patel, et
al.
In this editorial, the author presents seven arguments for why mental health care is morally
required on a global scale in the same way we think about the moral argument for health care, in
the author’s own analogy, when it comes to access to ARVs for AIDS. The first premise
presents the inextricable link between mental health and all other physical health concerns, as
there is compelling evidence for the interrelationship between psychiatric risk factors and
physical health outcome in almost every public health domain. The second premise points out
that evidence-based treatments do not only exist for the major causes of psychiatric morbidity,
but that they are also affordable for developing countries. The third premise argues that
psychiatric drugs ought to be granted “exception” status in the TRIPS agreement as other public
56
health issues are, so as to make them affordable for individuals in developing countries in the
same way ARVs have. The fifth premise comments on the ethical obligations of institutions in
developed countries to stop perpetuating the brain drain of mental health professionals in
developing countries. The sixth premise discusses the human rights violations that are so often
observed in mental health care facilities in developing countries, and the urgent need for health
care literacy reform to ensure that the rights of the mentally ill are not violated. The final
premise argues that the striking correlation between suicide and premature mortality and rapid
social change means that mental health care for the impoverished should not be considered
anything less than an essential aspect of health and wellbeing.
Patel, Vikram et al., “Beyond Evidence: The Moral Case for International Mental Health.”
As the title suggests, this article outlines a moral argument for increased attention to be paid to
international mental health. As Patel cites, the global burden of disease attributable to mental,
neurological, and substance use disorders is expected to reach 14.7% in 2020 (from 12.3% in
2000). Despite these shocking figures, “with every new public health challenge, mental health is
once more relegated to the background” (1312). Facing this dire climate, Patel makes four moral
cases for the treatment of mental health in developing countries: 1) That mental disorders are
treatable in developing countries; 2) that mental illnesses, like life-threatening illnesses, must be
removed from the Trade Related Intellectual Property Rights charter preventing the affordable
use of medications developed after 2005; 3) That the brain drain must be reversed in order that
the “people of poor countries should not be paying for the mental health care of those living in
the richer world;” 4) that the human rights of the mentally ill are abused in many countries; 5)
that “mental health problems are not a luxury item on the health agenda of the poor and
marginalized” and must be included in programs promoting physical health (1313). Patel
compares this moral case for international mental health to similar claims made for the right of
persons with HIV/AIDS in developing countries to access antiretroviral drugs, suggesting a 5x10
program to “get 5 million untreated patients into treatment and rehabilitation programs by 2010”
(1314). This reading addresses the need for mental health treatment, suggesting an approach
taken by many of the cases (such as the 3x5 program discussed above). However, the article is
too brief to really compare it to any of these similar initiatives.
Patel: “Poverty and common mental disorders in developing countries”
The authors searched medical journals from 1990 (I assume up until 2003) in order to study the
relationship between poverty and mental health risk in developing countries. They found that
most studies showed an association between poverty and common mental disorders, with the
most constant association being with low levels of education. They believe that there is only
weak evidence to support a specific association with income levels. Factors such as the
experience of insecurity and hopelessness, rapid social change and the risks of violence and
physical ill-health may be one explanation of the poor’s vulnerability to common mental
disorders. The costs of mental ill-health worsen the economic condition, setting up a vicious
cycle. The authors suggest that common mental disorders be looked at with other diseases
associated with poverty by policy-makers and donors. Investment in education and microcredit
may reduce the risk of mental disorders. Strengthening primary care services to work with
mental health may also be effective. By suggesting that poor mental health is associated with
poverty (and particularly with low education levels), the authors provide more evidence that
structural violence can lead to bad health outcomes. The article is notable because often mental
health is left out of discussions of health care for the poor.
World Mental Health Report - Arthur Kleinman
57
Chapter 1 – The Global Context of Well-Being
This chapter sets out to describe the economic and political context of many developing
countries and localities within developing countries. During the 1980s and 1990s, gains in the
economies of developing industrial economies were lost due to economic crises, with health,
education, and other social sector spending being cut from public budgets due to financial
constrictions and austere structural adjustment programs. GNP in many developing countries
has actually declined, and inequality has increased, resulting in a deterioration of living
standards. Much of these negative effects have been due to decisions made by richer economies,
not local economic decision makers. These economic downturns have been exacerbated by
natural disasters and state conflict, both of which are concentrated in poorer countries. Increased
poverty has increased malnutrition, leading to a “breakdown of local moral, social, and economic
structures.” Urbanization has occurred despite low commodity prices and negligible increases
in prosperity due to industrialization. Increased social stratification in countries like Brazil have
been shown to result in greater prevalence of mental illness for the poorer segments. Indeed,
Kleinman’s main argument is that economic prosperity correlates with prevalence of mental
illness, and that impoverished social and economic conditions often does result in greater
prevalence of mental illness. Effective ways to address this involve solutions that are localized
and respectful of local cultural worlds and social contexts.
Chapter 7 – Children and Youth
While health care for children and youth have increased over the years, with UNICEF estimating
that vaccines prevent some 3 million deaths each year, there is still a large gap for children to
access appropriate medical care. Beyond health, school failure rates vary across developing
countries, as do literacy rates. Increasing rates of poverty have turned many children to the street
and prostitution, while state conflict and violence have traumatized thousands of children,
especially refugees. Children increasingly suffer from developmental attrition, or the failure to
reach normal development landmarks physically (height), intellectually, and behaviorally.
Mental retardation has been estimated to be 2 to 8 times more prevalent in developing compared
to developed countries, while epilepsy is 3 to 5 times higher in developing countries. Increased
poverty, limited education, single-parent families, inadequate social safety nets have led to an
increase in adolescent gang membership and aggressive and antisocial behavior among
adolescent males. This author emphasizes that there ought to be preventative measures
emphasized that aim to address nutritional and environmental causes of mental illnesses. This
includes immunization, child safety standards in workplaces, prenatal care, and family planning
measures. Additionally, primary health care should have mental health care as a component to
address secondary and tertiary prevention of mental illnesses. A shared delivery structure of
mental health services can help target people with mental illness and treat symptoms of it more
effectively, in addition to identifying causes.
Rojas, Graciela et al. “Treatment of Postnatal Depression in Low-Income Mothers in
Primary-Care Clinics in Santiago, Chile; A Randomized Controlled Trial.”
This article assesses the effectiveness of a multicomponent intervention in the treatment of
postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile,
comparing it to the usual care. The multicomponent intervention involved a psychoeducational
group, treatment adherence support, and pharmacotherapy, offering a more intense treatment
58
than normally given. As the authors of the study point out, “though prevalence for postnatal
depression varies greatly, it is about twice as high in developing countries as in developed
countries” and, like mental health care in general, remains unaddressed (1629). The
multicomponent intervention designed by the authors suggests that effective care can be given
even in low-income settings where resources are scarce. According to the authors, “a large
number of puerperal women whose depression had not been recognized or treated when
recruiting” for the trial, suggesting a demand for increased treatment and detection of post-natal
depression. The research undertaken by the authors of this article provides an answer (albeit
rather specific) to the calls for mental health interventions that can be affordably and effectively
implemented within resource-poor areas. This article also addresses some of the issues in
providing mental health care within these areas, such as medication compliance and attendance
at group meetings following the initial phase of treatment.
Acland, Sarah. “Mental Health Services in Primary Care: The Case of Nepal”
Acland describes the mental health delivery system as it exists in rural Nepal, one of the world’s
most challenging health care delivery environments. Nepal is one of the world’s poorest
countries and has mountainous geography that makes travel uniquely challenging. With very few
doctors, Nepal’s primary health care system struggles to overcome these challenges with health
care workers and nurses. Mental health work began in Nepal in 1984 with the leadership of the
United Mission to Nepal, a Christian missionary group. UMN drew on the work of the National
Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore for a model community
health system. Mental healthcare in Nepal – as in many other areas – must compete with
traditional healers, who are more widely trusted. UNM has worked to create dialogue with these
healers in Nepal. But it is believed that many mental health patients suffering from disorders that
traditional healers are admittedly unqualified to treat still seek out traditional healers.
This case is important for our greater understanding in the course for two reasons. First, it offers
insight into the challenges and necessity of providing mental health care in a developing country.
Creating a system that is effective while also inexpensive enough to operate consistently is a
great challenge. The Nepali program has been able to keep drug costs relatively low by drawing
on the Indian drug market, which is so close by. That option is not always available in other
settings. Second, it provides an excellent example of a health care initiative that is locally
designed and implemented. “The program is note imposed from a foreign design,” Acland
writes. “It has grown up within its own setting” over a period of 25 years, a remarkably long
time.
LECTURE 17
HIV Care in Rwanda Case
This article covers HIV care programs in Rwanda in 2007, focusing on the Rwinkwavu Program,
which was started in May 2005 by Partners In Health at the request of the Rwandan Minister of
Health, Agnes Binagwaho. Rwanda suffered a genocide in 1994, in which Hutu extremists
killed 800,000 Tutsis and politically moderate Hutus, and the health system along with other
infrastructure was destroyed. Since then, the country has been quickly recovering under
President Paul Kagame, and health indices have been improving. The largest cause of morbidity
and mortality is malaria, and HIV prevalence in 2005 was 3.0%. The healthcare system rests on
health centers, which provide a "minimum package of activities" including health promotion,
prevention, and curative activities; district hospitals, which provide prevention, family planning,
more complex curative care, and training; and tertiary hospitals in the cities, Weaknesses include
59
short-staffing, low pay including no pay for animateurs (community health workers), and lack of
services. The Ministry of Health has jurisdiction over the healthcare system, and coordinates the
disbursement of grant money to health-based NGOs in Rwanda. Health care financing is
provided by mutuelles de sante (mutual health insurance), which provides coverage for low
premiums and pays the membership fees for those who cannot afford them. Rwanda received
funding for AIDS treatment programs from the World Bank Multi-Country AIDS Program
(MAP), the Global Fund, and PEPFAR, and had several large NGOs working in country. PIH
established the Rwinkwavu program in the districts of Kayonza and Kirehe, and designed it to
address health systems improvement, the "four pillars" (ART with primary health care, women's
health and PMCTC, TB control, and STI detection and treatment), paid accompagnateurs
(community health workers), and social and economic support. They renovated facilities, sent
teams of PIH and local doctors and staff to each health center and hospital, trained in the PIH
approach to community-based care, and improved communication by providing ambulances to
the health centers. HIV-positive patients were treated with five standard visits if they were
cleared for ART, and treatment was directly observed by an accompagnateur. Early results
indicated that more patients were visiting, 80% of total patients in need of ART were on ART,
only one patient was lost to follow-up, and fewer than 1% needed to be switched to a second-line
drug regimen. The Clinton Foundation made calculations about the cost of scaling up the
Rwinkwavu program to all of Rwanda, and found it to be feasible given a moderate increase in
foreign aid and more recruitment of health workers.
Uvin, Peter. Aiding Violence. Kumarian Press: 1998. (Introduction, Chs. 1-3)
Peter Uvin examines the relationship between the Rwandan genocide of 1994 and the
development system in Rwanda. Rwanda was considered one of the most promising countries in
Africa (“Switzerland of Africa”) at the time, and was one of the most aided countries in the
world, yet it was rife with racism and problems. Uvin concludes that Rwanda is an extreme
example of failure in development aid; the top-down nature lead to further exclusion and
inequality. He outlines his argument and the book in his introduction and then we read chaps 1-3
which go over the history of Rwanda pre-genocide and the image of Rwanda in the development
community. Problems such as racism and inequality are ignored by the development community
because they are considered unsolvable and not the mandate of development agencies. This was
definitely an important reading in many ways and was highly focused on in class (ie I would
probably just go reread it). Uvin was unique in his critique of development as a key player in the
Rwandan genocide. In the larger sense, this reading leads us into the topic of delivery science in
which aid agencies use rigorous analytic methods to determine best outcomes.
Rwandan Rural Health Care Model Scale-Up: District implementation plan
This plan outlines a scheme for the scale-up of the model rural health care programs put in place
by a partnership between Partners in Health, the Clinton Foundation, and the Rwandan
government. The Rwanda rural health care model is founded on the principles of comprehensive
health care available to all, holistic community care beyond the solely clinical, and decentralized,
community-based quality care regardless of the setting. The scale-up detailed requires USD 8.08.4 million per year; the report states that finding sources of financing is a ‘work in progress.’
The minimum package at the level of the health center includes prevention activities including
infant vaccination and vitamin A supplementation, but also provision of ART and chemotherapy
for TB. The plan calls for greater coordination between district hospitals and these health centers
by means of both cellular telephones and radio systems.
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The plan further details a comprehensive supply chain and procurement system for the purpose
of obtaining drugs and diagnostics. It states that patients should be able to access healthcare
without regard to their ability to pay. This ambitious plan reflects the model put forth by Farmer
and Kim. It seeks to remove all financial barriers to care while providing the community-based,
decentralized care that evidence indicates is extremely successful. It includes the production of a
number of rural health care employment opportunities and financial incentives to remain in rural
areas. However, the plan makes it apparent that the funding for the proposed scale-up has not
yet been procured.
LECTURE 15
Pape, “Characteristics of the Acquired Immunodeficiency Syndrome (AIDS) in Haiti”
The purpose of this study was to identify the characteristics of AIDS in Haiti. The authors show
that the types of opportunistic infections and the clinical course in Haitians with Kaposi’s
sarcoma and opportunistic infections were similar in most aspects to those in patients with AIDS
in the United States. The median age of Haitians with Kaposi’s sarcoma and opportunistic
infections was 32 years, and 85% were men. The interval btwn diagnosis and death was 6
months in 80% of the patients. Diarrhea was the most common reason for seeking medical
attnetion. Lymphophenia and skin-test anergy were observed in 85 and 100% of patients.
Potential risk factors (bisexual activity or blood transfusions) were identified in 17% of male and
22% of female patients. Patients belonged to all socioeconomic strata of Haitian society. 33%
of men with opportunistic infections listed a residence in Carrefour, a center of prostitution. This
article was published in 1983, so it’s very interesting to see a discussion of AIDS relatively early
in its history. It mostly provides factual information, but interesting in this article is to see that
85% of the diagnoses were for men; now, AIDS rates have risen dramatically for women. Also,
that 80% of patients died within 6 months suggests the importance of ART.
Farmer P, S Robin, S Ramilus, J Kim. Tuberculosis, poverty, and “compliance”: lessons
from rural Haiti.
TB in Haiti is and has been a huge health issue. TB care around the developing world in
developing settings is poor despite the advent of new short-course therapies. It is the leading
cause of death among individuals 15-49. Proje Veye Sante (PVS) is a community health
program serving the Peligre basin of Haiti’s central plateau (the region displaced by the building
of the hydroelectriv damn). TB care in PVS is poor. Some Community Health Workers attribute
poor outcomes to economic causes; some to widespread false beliefs (caused by sorcery); others
to abandonment once present symptoms are relieved.
Create new program where residents in sector 1 get free-care, money, nutritional supplement,
travel expenses, monthly reminders, and physician visits for no shows. Sector 2 didn’t. Surprise
surprise sector 1 had great results (even though it wasn’t using a short course but was using the
old standard multidrug therapy). Given high costs of hospitalization this sector 1 package may
be less expensive.
Conclusions: 1. ID and treatment of contagious patients should be top priority. 2. Hunger and
poverty are prime culprits of treatment failure. 3. Cultural, political and economic factors are not
all equal and vary per setting (here economics are most imp). Patient dependent failure should
only be evoked after poor program design can be excluded. 4. Coordinate aids prevention and tb
control programs 5.Haiti TB will spread to America so industrialized nations should help. THE
POINT: economic factors were more important than all else.
LECTURE 16
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Mukherjee, J, et al. The PIH Guide to the Community-Based Treatment of HIV in
Resource-Poor Settings.
Chapter 1
Zanmi Lasant first did VCT (before the days of ART). Most declined these services and stigma
remained high. Once PMTC and ARVs became available people starting getting tests and using
VCT. They had adherence rates observed in US HIV not high like they had with TB. They
decided to use accompagnatuers who would deliver meds with DOT. No lab tests so used
clinical algorithms to do triage. This led to high cure rates, however skeptics still cited high cost
of ART and lack of infrastructure, however accompagnatuers showed that they could fill this
infrastructure gap. With advent of the Global Fund ZL decided to expand to the public sector for
scale up, started in Lascahobas clinic-showed that AIDs money can improve primary health care.
NGO public sector partnership results in a flow of money, drugs, personnel, ect
Chapter 2
Four Pillars of HIV prev. and care: 1. HIV prev and care in the context pf PHC-reduce stigma
because of context (test done there, same day). Provider initiated care. 2. TB detection and
treatment. 3. Women’s health, family planning 4. STI detection and treatment. These are also
entry points for case detection
Integrate VCT and primary care so the PT doesn’t have to make multiple trips. Have ongoing
support. Special attention to discordant couples-encourage disclosure and condom usage
(distribute for free). Manage TB coinfection. Women’s health, PMTCT, Family planning, and
STIs.
Community-based approaches to HIV treatment in resource-poor settings
The authors carried out a pilot project in order to gauge the feasibility of successful HAART in
resource poor-settings. Their HIV Equity initiative treated 60 HIV positive patients in the
Central Plateau in rural Haiti. The central argument is that if effective HAART is possible in
Haiti, the poorest country in the Western hemisphere, claims that HAART cannot be
implemented in resource-poor settings are untenable. There are two main objections to HAART
in resource-poor settings: drugs are too expensive, and these settings lack infrastructure to
deliver medications. In response to these objections, the authors state that drug costs are
artificially high, and describe a simplified regimen that would not require experts to deliver it.
Also, they claim minor modifications could improve local capacities to deliver HAART. This
reading contests common challenges to the provision of health care services in resource-poor
settings. While the majority of our readings emphasize the difficulty of implementing successful
interventions in such settings, this reading illustrates the feasibility of improving health outcomes
in Haiti, one of the poorest areas in the world.
LECTURE 18
Peru National TB Program Case
This article details Pedro Suarez’s work as the Director of Peru’s Tuberculosis (TB) Control
Program, which received recognition as a model TB program from the World Health
Organization (WHO) in 1994. His work is significant as he established a strong TB program in
Peru during a time of great economic struggles and reform. Following a brief overview of the
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land, people, and history of Peru, the article details the Ministry of Health in Peru, the regulatory
entity of the health sector, EsSalud, the public health care sector. In the initial stages of TB
treatment, short-course regimens were first and foremost. By 1989, the World Bank became the
largest source of funding for TB control programs in developing countries and DOTS (Directly
Observed Therapy Short-course) came to the forefront in 1994. TB treatment in Peru began in
1930 and by 1940 the government established the National Anti-TB service. Pedro Suarez,
trained professionally in medicine and public health, took charge of the national TB control
program in 1990 after enlisting as an adviser to candidate Alberto Fujimori who went on to win
the election. Suarez led the effort to develop the first set of National TB Control Program
Guidelines along with the Pan-American Health Organization. The TB program emphasized
local strategies and training. It eventually became very well respected and impacting. In 1997,
the WHO made revisions to TB treatment guidelines with updated regimens. Soon, the national
TB program became more complex and mired in issues of overlooking certain poorer
populations and drug-resistant forms of TB. This case study provides a general overview of a
successful TB control program that can be useful in understanding how TB could be best
controlled. There are various sociological factors that play into the program such as the
formation of bureaucracy that eventually hinders the movement of the program and unintended
consequences of multi-drug resistance. Suarez can also be analyzed under the framework of hero
and anti-hero.
Peru MDRTB
Ethnographic story of the woman who develops MDRTB, is treated with regular DOTs which
does not help her. She changes her name and moves to receive DOTs (regimen 1 and 2)
somewhere else when they stop treating her, even though she knows it will not help her. She
feels guilty when her loved ones fall sick.
WHO said that it is not a priority to treat MDRTB and that MDRTB PTs would most likely die
anyway. A strong TB program is the solution to resistance. Peru developed a strong DOTs
program and retreated those who failed, but case failures were not recorded in regional
notification reports, and 100% cure rate were the goal. Promotions depended on cure rates.
Socios en Salud was started. They screened for resistant cases and brought to Boston to test.
Bayona and Farmer worked to get MINSA to agree to let them treat 10 patients, Tom White gave
funding. Used Health promoters to administer. Socioeconomic support including food, bus fare,
ect. As word spread they continued to get more and more PT, treatment was its own evidence.
Kept detailed metrics used along with passionate letter to secure money from Soros and OSI.
Farmer gave a speech at a conference saying that Saurez and the policy is killing PTs, this
international pressure along with a report showing the prevalence of resistance pushed Suarez to
update guidelines and critically examine resistance in the NTP. HMS and SES convened a
meeting with WHO and other players in which SES argued that taking on MDRTB could lead to
an expansion of resources for the problem and long term change. Everyone at the meeting
agreed that all people with TB regardless of resistance have a right to treatment. The Green light
committee managed to get prices lowered for TB meds by having them added to the WHO
Model List of Essential Drugs (increase demand and competition).
AMPATH Rural Case - Park, Bhatt, Rhatigan, Kim
This case study examines the development of the Academic Model for the Prevention and
Treatment of HIV/AIDS (AMPATH), an organization in Kenya committed to distributing ARTs
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and providing healthcare services (including social and economic services) through grassroots
community work. AMPATH started in the late 1990s; they began a pilot treatment program that
was successful and expanded through entrepreneurial leadership. AMPATH was not concerned
with the success of individual projects but with overall structural change: to integrate HIV care
into the broader, national primary care agenda.. The organization was self-sustainable, employed
mostly locals (98% Kenyan), gave performance-based incentives on salaries to encourage
innovation, and had good visibility on the ground (local workers and doctors monitored
administration of ART to patients). Still, 85% of the population was not showing up for testing
because of social, structural, and psychological barriers, so in 2007 they piloted Home-Based
Counseling and Testing (HCT)—they go door-to-door testing people. The program is desirable
because it directly targets constituent population, but it may be a strain on organization
resources, especially because PEPFAR pays for home-based testing but not community health
worker salaries.
Putting the case in context, it is a good example of innovation dissemination (explained by
Berwick) and health system building (advocated by Kim). AMPATH showed that ART
provision on a large scale in a resource poor setting such as Western Kenya was a possibility.
The HCT model, though, is harder to scale up because of the large cost in time and resources and
is also harder to translate into a community where AMPATH has not already built patientcounselor relationships of trust that come from the longevity and past actions of the organization.
LECTURE 20
Berwick DM. Disseminating innovations in health care.
Berwick's article describes guidelines to achieve a successful spread of innovations in health
care, based off observations of different approaches towards innovation, encouraging
communication, and giving flexibility to adopters. Important factors in the rate of spread of
innovation include benefit, compatibility, simplicity, trialability, and observability. Adopters fit
into five categories based on innovativeness: innovators, early adopters, early majority, late
majority, and laggards, which differ in timing and willingness to adopt new technologies.
Innovators are adventurous and tolerate risk, and they should be allowed room to experiment,
and should be offered tolerance for failures and response to successes. Contextual factors
include organizational support for innovation, which should focus on innovators, early adopters,
and the interface between early adopters and the early majority. It is important to find sound
innovations, perhaps by having people assigned to look for them, to find and support innovators,
to invest in early adopters with meetings and casual interactions, make early adopter activity
observable through social channels, to be open to reinvention of innovations, to create slack for
change, and to lead by example.
Implementation science strategies described in this article have been slowly spreading to
different health systems. Don Berwick has not been fully accepted into academia, but he has
many devotees, including Professors Kim, Farmer and Kleinman. Some examples of good use
of Berwick's strategies include Peru's National TB program, which used face-to-face meetings,
conferences, and national sharing of data to ensure that innovations in TB care spread quickly
and well.
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From a Declaration of Values to the Creation of Value in Global Health - Kim, Rhatigan,
Jain, Porter
In this document, the author suggest that to achieve the value of universal access to health care
put forth in the WHO mission statement and the Alma-Ata Declaration of “Health for All by the
Year 2000,” the delivery of health care services in resource-poor settings must be realized. To do
this, global health programs have to move beyond “projects” to become health care delivery
organizations. Successful innovations need to be captured and spread to practitioners on the
ground. This does not happen by policy but by design and management of health care delivery
system. The Global Health Delivery (GHD) Project, a partnership between HMS and HBS, was
formed in 2006 to systematize the study of global health care delivery and improve health care
delivery in resource poor settings. There needs to be a strategic perspective—the equitable and
just creation of value (“long-term health outcomes achieved per dollar spent”) for customers and
stakeholders (patients). A focus on solely implementation is incomplete because it does not
question if the goals, service, scope, system design, and organizational structure are in place.
The starting point is recognizing that value for the patient is generated by the overall set of
interventions in treating a medical condition. A care delivery value chain maps all activities that
contribute to patient’s medical conditional outcome (including costs and effects), and it helps
determine the configuration, sequence, and interdependence of key steps where value is added.
In resource poor settings value is increased through shared delivery infrastructures in which the
care of multiple medical conditions is coordinated and integrated for 2 reasons: 1) allows
investments in better quality/more efficient personnel and facilities and 2) harnesses synergies in
care across medical conditions.
Obviously, global health care delivery has inevitable complexities of local cultures, politics,
economics, and history that must be understood to design and manage systems, so the GHD
project seeks only principles that will guide health care system design in any location (the details
will vary with setting). The principles are found in ethnographic case studies of delivery systems
that embody lessons and identify important questions. The ultimate goal is to make the science of
health care delivery a rigorous field of study that encourages collaboration among scientists,
medical practitioners, business scholars, and social scientists.
Grimshaw and Eccles, “Is evidence-based implementation of evidence-based care
possible?”
Dissemination of new research knowledge into healthcare systems has largely been reliant on
publication in peer-reviewed journals, but this approach is ineffective: studies in the US indicate
that 30-40% of patients do not receive care complying with current scientific evidence. This
reading detailed the results of a systematic review of 235studies of guideline dissemination and
implementation strategies. Most dissemination and implementation strategies produce small to
moderate improvements in care, and multifaceted interventions are not more effective in single
interventions in producing favorable health outcomes. The impact of this review was hindered
by the lack of a theoretical base for understanding the behavior of healthcare providers. The
main idea of this reading is that current dissemination and implementation strategies are not as
effective as they could be. It is accordingly necessary to develop a theoretical framework to
understand how dissemination works in the context of health care. This reading thus provides
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support Jim Kim’s global health delivery project, and his call for a novel field of delivery
science.
Sanders, David, and Andy Haines. "Implementation Research Is Needed to Achieve
International Health Goals."
Sanders and Haines argue that health research needs to focus on the “implementation gap” (or
the gap between knowledge of disease and knowledge of implementation, especially in poor
countries). Optimal implement requires infrastructure, equipment, supplies, competent personnel,
and “intersectoral actions.” The main topic of the article is on health systems research (HSR).
First the authors give an overview of the crisis in health, health systems, and HSR in low-income
countries. Then they address how to correct the “knowledge-implementation gap.” Lastly, they
suggest actions for increasing the quantity and quality of HSR. There is a widening gap in infant
mortality and life expectancy between rich and poor countries, and thus policies must be
implemented to decrease the gap. However, research in how to implement these policies has
been largely neglected. Suggested measures include building capacity through training and
resources. Moreover, greater advocacy is encouraged. This essay is largely relevant to the
debate on the dissemination of innovations in health care. As discussed in class, there are a great
number of treatments, models, and technology that could instigate revolutionary change in global
health. However, implementation of these policies and advancements is extremely poor and
needs improvement. HSR could be an integral part of disseminating knowledge effectively.
“How Physicians Can Change the Future of Healthcare” - Porter, Michael
The preoccupation with cost reduction undermines physicians and patients. Health care reform
should instead focus on improving health and health care value for patients. This reform must be
led by physicians. Competition stimulates innovation and drives value, but the health care system
currently has the wrong kind of competition (ex. physicians are pressured to improve
productivity by shortening time with patients) where players in a system gain not by increasing
value for the patient, but by taking value away from someone else. The right kind of competition
is positive-sum competition, which is about creating and improving value—more customer
benefit per dollar (enhancing quality and efficiency)—and produces multiple winners (patient,
doctor, and society). A value-based system is grounded in three principles: 1) goal is value for
patients, 2) care delivery is organized around medical conditions and care cycles, and 3) results
are measured. The effects of a value-based system are: 1) it encourages the pursuit of excellence
in service line choices, 2) it leads to greater cooperation among physicians, 3) it includes patients
as engaged participants who act responsibly, 4) it means fewer malpractice suits, 5) it results in
less administrator and insurer intervention in medical practice (supportive health plans), and 6) it
makes reimbursements based on care cycles not discrete services. Today’s most popular health
care reform proposals are flawed such as 1) single payer, which stifles innovation, 2) consumerdriven health care, which increases patient responsibility when patient may not be informed, 3)
pay for performance, which requires compliance with process guidelines not results, and 4)
integrated payer-provider systems, which eliminate competition where it is most important,
support substandard care in particular areas, and have incentives to minimize costs. To create a
health care system that works, the focus must be on value, measured by health outcomes per
dollar spent, because it is a shared goal from which everyone, including physicians can benefit.
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This strategy for reform is market based but physician led as we come to understand that the best
way to control future costs is to encourage and reward quality and value.
This article comes into our study of global health systems, for these strategies of focusing on
value, organizing care delivery by cycles and conditions, and keeping measurement records can
be applied to global health delivery in addition to physician’s hospital health care delivery.
Advocating for a value-based system ensures that we see results that benefit everyone, and these
are principles that can be brought to the developing world as well.
LECTURE 21
World Health Organization. Everybody’s Business: Strengthening Health Systems to
Improve Health Outcomes: WHO’s Framework for Action.
How the WHO secretariat can provide more effective support to Member States and partners. 4
pillars to WHO’s response:
1. A single framework with six building blocks. It is essential to have a clear definition of what
a health system is and what constitutes health systems strengthening. The building blocks show
desirable attributes, define priorities, and are a means for identifying gaps, but must be
understood as the simplification they are. They are as follows: Service delivery, health
workforce, health information, medical products, vaccines and technologies, financing, and
leadership and governance.
2. Health systems and health outcome programs: getting results. WHO must attempt to have a
more systematic and sustained response rather than fragmented advice on specific conditions.
Bring together program and systems expertise as has been done with costing and health
resources. Extend existing interactions, better communication and awareness on addressing
health system processes, and greater consistency and quality of data reporting.
3. A more effective role for WHO at country level. Countries have different needs from WHO.
Some have specific policy requests, other want international exposure, but it tends to be lower
income countries that want more direct involvement. WHO must improve ability to diagnose
systems, seek consistent and active engagement, try and build national capacity for analysis and
management, and tracking trends should be for national decision making.
4. Role of WHO in international health systems agenda. Produce global norms, standards and
guidance including concepts, metrics, best practices, and future scenarios. Building and shaping
international systems for outbreaks and emergencies. Work with other international partners.
Rethinking the Institutional Architecture for Global Health - Frenk, Julio
In this speech, Frenk argues that the best way to close the knowledge-action gap in global health
is by improving the performance of health systems, not just at the national level but also by
giving shape to a global health system.
First, he redefines global health so it provides a more useful guide to action. Global health should
refer to those health conditions that affect most countries as a result of their interdependence.
The notion that best reflects this is the global transfer of health risks caused by 1) the rise of
global environmental threats (climate change), 2) the movement of people across national
boundaries, 3) the adoption of risky lifestyles across cultures, 4) variance among countries in
safety standards, 5) trade in harmful products, 6) spread of medical technologies, and 7) flows of
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human and financial resources. The solution to the vertical/horizontal debate is a “diagonal”
approach, whereby explicit intervention priorities are used to drive improvements into the health
system.
Second, he dispels common misconceptions about health systems. There are three common
misconceptions to health systems: 1) that it’s a “black box”—things are too complicated, so let’s
put in inputs and outputs will work themselves out, 2) that it’s a “black hole”—no amount of
money will suffice to achieve the desired results, 3) that it’s a “laundry list”—it’s a list of
different organizations or persons that participate in producing health services (without
integration). He suggests four directions for a comprehensive framework: 1) think in terms of
interrelations, 2) include people/population in the health system, 3) realize that its goals include
distribution (equity is important), and 4) expand our view of health system’s enabling functions:
stewardship, financing, service provision, and resource generation. It is important to realize, too,
that there are wide variations in performance by different health systems (even at same income
and expenditure levels) because of differences in leadership, institutions, systems, and
technologies.
Finally, he draws concrete suggestions for success in improvement of national health systems in
the 21st century. There are two key aspects: global governance and global ethics. Global
governance must solve the sovereignty paradox (health continues to be a national responsibility
even though determinants of health and the means to fulfill that responsibility are increasingly
global), and the dissonance paradox (think of a global health system as a structured set of
relationships among actors that perform different functions, not as organizational entity—up till
now the broad variety of actors hasn’t been able to develop an effective capacity for concerted
action). Global governance involves performing functions of international collective action:
production of global public goods and the mobilization of global solidarity. This requires a firm
ethical foundation (ideals): for every human being to have the same opportunity to achieve
potential, global ethics must solve the accountability paradox (be accountable to the people,
whose universal rights we must uphold, not the national governments). A rights-based approach
to health mobilizes global solidarity. The level and distribution of health serves to assess the
performance of society as a whole.
Frenk, Julio, “Bridging the Divide: Global Lessons From Evidence-Based Health Policy in
Mexico”
A review of changes Julio Frenk made to the Mexican health system as Minister of Health during
the period of 2000-2006. As a middle-income country, Mexico suffers from a double burden of
disease in which the problems of both developed (chronic, non-communicable disease) and
developing countries (infectious diseases, malnutrition and reproductive health) come together.
PROGRESA, later renamed Oportunidades, creates incentives for families to invest in their
children through cash transfer system; Frenk saw the success this program was having and scaled
it up. He also created a system of Suguro Popular (popular health insurance) in order to help deal
with the half of Mexico’s population that was uninsured. In his work, Frenk casts aside the old
horizontal/vertical debate in favor of the “diagonal- a strategy in which explicit intervention
priorities are used to drive necessary improvements into the health system.”
This reading is a part of the science of delivery and health systems strengthening portion of the
course. Frenk’s work was highlighted in class as a rare example of a minister of health who
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actually did something and who went about it in a scientific way. That is, Frenk examined all the
evidence that was out there, looked at what other countries were doing, looked at his own
country, saw what worked and what didn’t and went from there. Frenk is adamant that sharing of
success stories is an extremely important part of the process of building better health systems
internationally. He describes datasets of health in various countries as global public goods. It is
this type of rigorous study that is necessary.
Roberts, Mark, William Hsiao, Peter Berman and Michael Reich. Getting Health Reform
Right.
This chapter provides background on the need for health system reform and introduces a
framework for effective analysis. The authors see four forces driving health reform (11). First,
rising costs caused by aging populations, infectious diseases, chronic diseases, fee-for-service
payment systems, and expensive technologies create a financial problem. Second, as countries
develop, and see pictures of the quality of life in the modern west, they have higher expectations
about what kinds of health care they deserve. Third, cash-strapped governments cannot pay for
the required extensions as a result of caps on social sector spending and (for poor countries)
dependence on the volatility of the global market. Finally, an ideological shift toward marketbased solutions is encouraging adoption of private health sector expansions. Interestingly, the
authors note that health-sector reform has a periodic character and often rides the wave of
political or economic shock (a point that gives this article particular relevance today) (5). Finally,
they introduce the concept of the “control knob” to indicate particular health systems
adjustments that governments can make to improve performance. They argue that this differs
from traditional approaches, which each rely on imperfect health and system-functioning
indicators.
This reading fits into the context of the course as a part of the shift toward “health system”
literature in the past 10 years. They mention the need for context-dependent social analysis, and
are wary of policy suggestions that don’t consider outcomes and performance (e.g. the IMF
focusing on decreasing social sector spending as a means, without looking at the ends
themselves). Finally, it fits into the question of what should happen given the context of the
financial downturn, noting the importance of crises for spurring action.
LECTURE 22
Kleinman, Arthur. Cleveringa lecture.
In the Cleveringa lecture, Kleinman discusses the issue of a lack of caregiving in modern
healthcare. Caregiving is related to actions that “enable life” such as affirmation, assistance,
responsibility, solidarity, and acknowledgement. Kleinman argues that caregiving has become
largely a matter for friends and close relations rather than medical professionals. In fact, most
caregivers are women. He thus asks the question: “Are medicine and caregiving incompatible to
the point of divorce” (1646)? To discuss caregiving, Kleinman brings up the notion of antiheroism and going “against the tide of values and sentiments” (1648) by living morally (in this
case, caregiving) despite the patterns of the world. He suggests various ways to integrate
caregiving into medicine such as preparing students cognitively, affectively, and morally to
relate to patients and their networks. He promotes the idea of critical self-reflection, and
emphasized the need to promote individual care as much as population prevention.
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Kleinman’s lecture introduces his basic and essential arguments for caregiving in medicine. He
brings in the ideas of moral worlds and the anti-heroic to support his case for caregiving. This
concept and act of caregiving relates back to the themes of social suffering and structural
violence, which focus on the individual and his or her illness narrative. Focusing on the
individual rather than using broad measures such as cost-effectiveness analysis is crucial, as
extrapolated from Kleinman’s points.
Kleinman, Arthur. “Catastrophe and Caregiving: the Failure of Medicine as an Art.”
In this Lancet article, Kleinman discusses caregiving as an essential part of the “art of medicine.”
He discusses how caregiving involves skilled nursing, competent social work, rehabilitation
efforts with therapists, and the home healthcare aides. Yet, unfortunately, caregiving is largely
relegated to the patient’s family and friends. It has been suggested that the art of medicine might
be separate from the technical and scientific aspects of diagnosis and treatment. By allowing
physicians to focus solely on the latter, could the medical system be more efficient?
Unfortunately, Kleinman argues, “the art and science of medicine don’t peel off from each other
in clean and intact wholes” (1656). The experience is as important as the technical assessment.
Kleinman suggests various ways to emphasize the art aspect of medicine. His ultimate hope is
that the doctor affirms the patient as a suffering individual and creates specific “responses” rather
than prescribed regimens. Much of this training in caregiving could start at medical schools,
hospitals, and educational institutions.
Kleinman, as in the Cleveringa lecture, discusses caregiving as a lost art in medicine. He
encourages medical professionals to become actively involved in practicing and promoting
caregiving. Referencing Walsh McDermott, he discusses the two sides of medicine—the art and
the technical. The two are not mutually exclusive, a reminder that individual care should be
given even in context of global health in which populations and broad swaths of prescriptions are
the norm.
Walsh McDermott, Kurt W. Deuschle and Clifford R. Barnett, “Healthcare Experiment at
Many Farms”
This paper talks about a study talks about a program designed and implemented in a Navajo
community to test the limits of purely biomedical treatment. They brought in first rate
technological care to this community with a relatively high mortality rate and relatively high
burden from so-called “preventable” conditions. After 6 years of work, these authors concluded
that they had made some differences in the incidences and burdens from specific diseases. But
they had made no measurable impact on the biggest killer – pneumonia/diarrhea during infancy.
This they concluded occurred because “the effectiveness of contemporary medical technologies
is dependent on the socioeconomic circumstances of the recipient in the case of the infant.” Thus
the importance of addressing social conditions is clear.
LECTURE 22
Kleinman, Arthur. The Illness Narratives: Suffering, Healing and the Human Condition.
In Chapters 1 and 2, Professor Kleinman outlines what he describes as the four most important
meanings of the illness experience. Illness (the innately human experience of symptoms and
suffering) is fundamentally different from disease which is related to specific biological
pathology. These have important implications for how medical care should be thought about:
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Symptom as Meaning: The symptoms and complaints from a sick person vary depending on
culture and social group within a culture. “Social experience is embodied in the way we feel and
experience our bodily states and appear to others.” Thus different people may respond to
different illnesses differently based on their individual experiences. Understanding who a patient
is can be essential to knowing how to interpret that person’s complaints. Kleinman argues that
typical practitioners are not trained to interpret these experiences as they relate to social context
and can reduce or dehumanize patients by relating everything back to biology.
Cultural Significance as Meaning: Cultural values and stigma can have tremendous implications
for how diseases present themselves (or do not do so) in different societies. Noncompliance, too,
must be related to specific cultural meanings and values. Kleinman believes that different
cultural presentations require sensitive evaluations from practitioners. Ethnography, biography,
history, and psychotherapy are the appropriate search methods to create knowledge about the
personal world of suffering.
Life World as Meaning: In the context of a chronic disorder, an illness can become embodied in
a particular life trajectory. Only through the detailed context of a lengthy case description can the
personal and social meanings of illness be fully appreciated. It is the role of the health
professional to help address the deeply private significance of illness. For example, it is
important for the practitioner to help the chronically ill and those around them come to terms
with these significances and master them when possible. Thus a disheartened patient can be
educated to escape feelings of guilt and jealousy towards people free of a disorder.
Explanation and Emotion as Meaning: One of the important tasks of effective medical care of
the chronically ill is to affirm the patient’s experience of illness as constituted by lay explanatory
models and to negotiate, using the specific terms of those models, a specific therapeutic
approach. Another core clinical task is the empathetic interpretation of a life story that makes
over the illness into the subject matter of a biography. To fully appreciate the sick person’s and
the family’s experience, the clinician must first piece together the illness narrative as it emerges
from the patient’s and the family’s complaints and explanatory models; then he or she must
interpret it in light of the different modes of illness meaning—symptom symbols, culturally
salient illnesses, personal and social contexts.
Chapter 7 is about the importance of practitioners listening to patient and support network
explanatory models. Understanding the cultural and social context of a patient’s explanatory
model can be essential to being able to negotiate with that patient. Practitioners need to recognize
that the patient can contribute as an equal to his or her diagnosis and treatment. However, all too
often the voice of medicine drowns out the voice of the life world, often in ways that seem
disrespectful, even intolerant, of the patient’s perspective.
Chapters 14-16 are about building a new framework from which to understand medicine and
health care. Chapter 14 looks at several medical professional perspectives on the state of care in
the US. Some have become demoralized and cynical… but others are more hopeful and want to
find ways around the bureaucratic barriers to real psychosocial care. Some of the best caregiving
healers had illness experiences which led them to their role. Medicine, Kleinman argues, cannot
be separated from society. Additionally training should work not just to develop the technical
skills of treatment but also the humane side of care.
Chapter 15 presents a method of care for the chronically ill. The goal is to turn the patient-doctor
relationship into a collaboration and not a hierarchy. Kleinman believes that the practitioner
should be trained to take a “mini-ethnography” of the patient and that patient’s social context.
Nothing is irrelevant here and the goal is empathetic listening and an attempt at understanding.
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The practitioner should also take a brief life history in which the illness is placed in the context
of life. This can both not dehumanize the patient and keep the practitioner actively interested in
the case. From these pictures, the practitioner should interpret what the patient thinks and try to
understand the patient’s explanatory model. Then the goal is to negotiate with that patient within
the context of this explanatory model – the idea is to engage the patient and family in a way that
both empowers the patient and helps to educate the patient about the care that should be given.
But it is not a one-sided relationship and the doctor, too, learns from and listens to the patient.
Then the practitioner must critically self-reflect on the case and think about how his or her own
biases played into the case and are affected by the case. Practitioners finally must work to
remoralize the patient and the patient’s support group when necessary. This involves looking at
the illness narrative and coming up with effective interventions to improve problems: referrals to
psychotherapy or counseling, listening deeply to a patient, etc.
In Chapter 16, Kleinman argues that medical education and practice needs to fundamentally
change. This reform should place the illness as well as the disease at the center of the purpose for
practice and care. Kleinman believes the evaluation of patient care must be extended from
limited cost-effectiveness analysis to an assessment of how the care treats problems in the
experience and meaning of illness. He also believes that more resources should be available for
the “popular sector” of care – families and patients themselves, who actually do most of the
caregiving. Finally he argues that medical research currently avoids the human side of disorders
and, in doing so, restricts total medical knowledge. Here is the great last line of the book:
“Against the commercialized self-images of our age, which corrode altruism and convert
decency into merely a professional gesture, the experience of the healer can be a quest for a kind
of human wisdom, a model of forbearance and courage, a form of goodness, a lesson in the
essentials of humanity.”
Kleinman, Arthur. What Really Matters: Living a Moral Life Amidst Uncertainty and
Danger.
Idi Bosquet-Remarque was Professor Kleinman’s friend and mentee. He met her while she was
doing her senior Honors Thesis in college. She was very focused on humanitarian assistance in
the mid 1970s when the effects of structural adjustment were becoming clear and there was
much violence and conflict throughout Africa. She was both extremely skeptical of the way
development had been done and also extremely drawn to living and working among the poor.
Some of her ideas were very much related to what Professor Farmer has called “pragmatic
solidarity.” Idi believed it was “ethically unacceptable to study those in distress without first
providing practical assistance to alleviate their suffering.” She also worried that aid workers
often do not allow disadvantaged groups to represent themselves and often misrepresenting
them. She worried about the design of international aid since projects are driven and run by
outsiders rather than local people. She began working in East Africa and set up safe homes for
battered women, worked to bring water, food, and basic health services to the most
disadvantaged, and was involved in all sorts of assistance work. The people she helped felt
comfortable with her – she lived with them, tried to speak their language, and listened to them.
She kept an open mind and recognized the complexity of everything around her – the local
official who “stole” a bit to help his family was not nearly as corrupt as the right higher-up who
robbed millions. She believed in the importance of a combination of local voices and external
power – that is she used her status as a foreigner to help local people be heard. Philosophically,
Idi drew from liberation theology and other ethical theorists. Then, in 1997, in the middle of
horrible violence and terrible instability, Idi came to Harvard to talk with Professor Kleinman
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about everything. She was despairing about everything she had seen, her programs destroyed,
people she loved and worked with raped, murdered or sent away. Yet, despite all of this suffering
she decided to return to Africa. To Idi what mattered most was commitment – commitment to be
there for and with others when their need is greatest. The combination of real solidarity with
practical assistance and true commitment to causes that make one’s life more difficult and
volatile than otherwise is what really mattered to Idi and what gave her life such “moral beauty.”
Peabody FW. Landmark article March 19, 1927: The care of the patient.
Medical school teaches you the diagnosis and treatment of disease, but the practice of medicine
is actually an art that includes the whole relationship of the physician with the patient. One
barrier to teaching the "art" in medical school is that while medicine is a personal matter,
students are taught in hospitals—impersonal, dehumanized machines that remove the patient
from his accustomed environment and strip the patient of his personal identity. Oglesby
describes the large group of patients who do not show organic pathological conditions, but
instead have a functional disorder, which may be caused by nervous or emotional influences.
These patients are often told that they have "nothing the matter" with them, and though their
symptoms are rarely fatal, their lives are often miserable as a result. After a while, the symptom
occupies the center of the picture for the patient, and causative factors (emotional, nervous) fade
into the background, making the causes hard to discern. The successful diagnosis and treatment
of these patients depends on establishing a personal relationship between physician and patient.
The hospital might even enhance the patient's confidence in the physician, and its distance from
the home can make it easier to treat functional disturbances. These cases illustrate the importance
of personal relationships, since in all humans disease "at once affects and is affected by what we
call the emotional life." This reading is connected to Professor Kleinman's lecture on caregiving.
In our society, this type of caregiving is rarely done by medical professionals. Instead it's done
by families and wider social networks (despite the fact that they are at the bottom of the status
hierarchy of health).
LECTURE 23
Kidder, Tracy “The Good Doctor: Paul Farmer Set Out Twenty Years Ago to Heal the
World; He Still Thinks He Can”
Kidder describes a month he spent traveling with Professor Farmer – from Boston to Cange,
Haiti to Paris to Moscow. Kidder shows the power of Farmer’s liberation theology in motivating
his actions. We are familiar from the rest of this course with PIH’s work in Cange, Lima, and
Russia. Kidder here outlines the DOTS- Plus saga, the work required to get funding for Russia’s
prisons, and Farmer and Kim’s Robin-Hood-esque stealing from Brigham and Women’s
hospital. This reading highlights the issues of heroism that have run through this course.
Kleinman, Farmer and Kim have spoken extensively about the fact that the vast majority of
people in global health will never be heroes – non-heroic work is also necessary and admirable.
But here, we see what that rare heroism looks like. Professor Farmer’s dedication is almost
other-worldly in Kidder’s description. We are meant to take this not as a call to follow in Paul’s
steps exactly, I don’t think, but rather as an inspiring story of what one heroic individual has
been able to do.
Griffin, Tom. “Calling the Shots.” (Profile of Dr. William Foege)
Bill Foege (pronounced FAY-gy) was the key architect of the “surveillance/containment”
approach to combating epidemics, a strategy that was ultimately credited with bringing about the
eradication of smallpox. He pioneered the idea under unusual circumstances while a medical
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missionary in Nigeria in 1966. With a shipment of smallpox vaccine still months away, Foege
received a report that a nearby village had a case of smallpox. After verifying the case, he
“resorted to military tactics,” using a radio network of missionaries to ID all cases of smallpox
and using his limited supplies of vaccine to immunize villages and markets near where the
infected were living. This allowed him to stop the spread of the disease with <50% vaccination
rates, rather than the 80-100% previously thought. “Surveillance/ containment” was a hard sell at
first, but it eventually became part of the global smallpox strategy.
After returning from his mission, Foege rejoined the CDC, where he had worked briefly before,
working his way up to head of the Smallpox Eradication Program. Then, from 1977 to 1983,
Foege was head of CDC. His major accomplishments there include reorganizing the agency,
directing more resources to preventative medicine, and quickly IDing the sources of two health
crises: toxic shock syndrome and Reye’s syndrome. Later, Foege was one of five nominees to
succeed Jim Grant as Executive Director of UNICEF. (Not in the article: Carol Belamy, then
Director of the Peace Corps, was chosen instead.) More recently, Foege has worked to combat
polio, river blindness, and Guinea worm, and he currently advises the Global Health Program at
the Gates Foundation. Professor Kleinman has referred to Bill Foege as an original “maverick,”
back before “maverick” carried the political connotation it now does.
Lowry, Elizabeth. “Strong Medicine.” Columns: The University of Washington (Profile of
Christopher Murray)
Christopher Murray, one of the world’s foremost health economists, was a medical school
classmate and fellow resident of Paul Farmer and Jim Kim’s, though he chose to focus on
economics while they studied medical anthropology. Until Summer 2007, when he was hired
away by the University of Washington to found and lead the new Institute for Health Metrics and
Evaluation there (funded in part by UW, in part by the Washington state government, and in part
by a $105 million gift from the Gates Foundation), Murray was a professor at Harvard and
Director of the Harvard Initiative for Global Health (HIGH). Both Farmer and Kim consider
their good friend’s move to UW, which was spurred in part by the falling through of Harvard
funding for a similar institute here, a great catch for UW and quite a blow to Harvard.
Murray’s work seeks to see the “big picture” of global health efforts – for example,
understanding how to deal with the fact that different countries face different health challenges
and have different amounts of money to invest. He believes that the broader you go in global
health, the less work is going on, and he sees a role for a “super-generalist” looking broadly at
what has worked and what hasn’t. Murray is also known as someone who speaks his mind and
lays out the facts in a straightforward way, even when that is unpopular. While working at the
WHO, Murray was closely involved in the writing of the World Health Report 2000, which
ranked the world’s health-care systems by comparing expenditures with results (the US was #37)
– a move that angered many at the time but that has also been credited with getting some
countries to invest more in health programs and to work to improve those programs. He’s also
been widely quoted in the press as saying that while child-mortality rates are at an all-time low,
they are not falling fast enough. Murray is married to Emmanuela Gakidou, a fellow professor
at UW medical school. They met while he was a professor and she and undergraduate at
Harvard. His sister, Megan Murray, is a Professor of Epidemiology at the Harvard School of
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Public Health.
LECTURE 24
Odinkalu, Chidi. "Why more Africans don't use human rights language."
This article criticizes the gap between the ideals articulated in the Universal Declaration of
Human Rights and the realities of human rights organizations in Africa. Odinkalu states that
most Africans are acutely aware of infringements on their rights, and would like to change them.
However, unlike the leaders of the successful anti-colonialist and anti-apartheid movements,
Western-based human rights campaigns in Africa have not made the effort to build a broad base
of support and reach out to the people upon whom injustice is inflicted. Instead, they are
divorced from the realities of African people; they function as watchdog organizations that report
on injustices from safe offices in capital cities and are both supported by and cater to Western
audiences. Odinkalu urges human rights organizations to be more inclusive and strive for
popular mobilization, in order to unite and help people who are already struggling for their
rights. Odinkalu's article fits into the course by providing a scathing criticism of human rights
organizations and, by extension, many NGOs, by arguing for more inclusive, locally-based
initiatives. This fits in with the professors' general insistence on inclusiveness, appropriate social
strategy, and building a real movement by empowering people. For example, PIH is responsive
to local needs by involve local people in leadership, and strives to turn over its operations to
government ministries of health.
Farmer, Paul. Never Again?: Reflections on Human Values and Human Rights. The
Tanner Lectures on Human Values.
In this Tanner Lecture, Paul Farmer talks with moral outrage about inequality in the world, his
experiences with Partners In Health, and about our obligation to treat the world's poor. He
addresses these issues through the lens of regarding the pain of others through photography,
which he argues can personalize suffering and help us realize that we all share the same world,
although he recognizes that such images can lose their shock value, can foster pessimism about
the inevitability of suffering, and may not nourish more durable emotions. He argues for the
importance of considering poverty and inequality as human rights offenses, and explains how
structural violence ties in to inequality, epidemic disease, and globalization. He talks about the
opposition between human values such as compassion, pity, mercy, solidarity, and empathy, and
selfishness, resignation, and lack of imagination, and how it is important to work through the
public sector (because of scale and rights, of course). He talks about the failure to recognize the
complicity of the West in setting up the background for and failing to intervene in genocides in
Rwanda and Darfur, and mentions that "bearing witness" is not enough without political action.
Paul Farmer then talks about the history of injustice in Haiti, as it developed from "the first state
in the western hemisphere to put into practice the modern notion of rights" to a place where most
citizens' rights are routinely violated, and how much of Haiti's current situation has resulted from
US involvement. He speaks of the right to health care and deplores the commodification of
health insurance, and the inequality of differences in the distribution of care. Social movements
and how to build them are the next topic, including the importance of mixing scholarship and
activism, the failures of relativism, the usefulness of human rights, and the hope to build a
movement that improves health systems around the world, including the American one. Paul
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Farmer closes with a statement that photographs can be an effective form of testimony if linked
to historically and geographically wide analyses.
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