Global Health Exam 2

Partners in Health (PIH)

A nonprofit GH organization that was founded on the moral that healthcare is a human right and not a priviledge. They wanted to provide high quality medical care to poor and marginalized communities. Its approach combines modern medical treatment with social support and advocacy to address the underlying causes of poor health. The five co-founders were Dr. Paul Farmer, Dr. Jim Yong Kim, Ophelia Dahl, Todd McCormack, and Thomas J. White; their work began in Haiti in 1983, and PIH was formally founded in 1987.

What diseases for PIH?

PIH initially focused on tuberculosis (TB), multidrug-resistant tuberculosis (MDR-TB), and HIV/AIDS, particularly in communities that lacked access to effective treatment. Its early work centered on rural Haiti, followed by Peru, where it treated MDR-TB, and Russia, where it addressed TB outbreaks in prisons and surrounding communities; it later expanded HIV/AIDS treatment in Haiti and other countries, including Rwanda and Lesotho. By the mid-2010s, PIH had expanded into additional countries and broader health issues, but TB and HIV/AIDS remained central to its history.

Why were the diseases not addressed?

These diseases were neglected because of poverty, unequal access to health care, weak health infrastructure, and discrimination against marginalized populations. Many international health experts believed that treating complex illnesses such as MDR-TB and HIV/AIDS in poor communities was too expensive or impractical because patients needed lengthy treatments, expensive medications, and consistent follow-up. Instead of addressing these barriers, health systems often treated poverty as a reason to withhold treatment, allowing preventable suffering and deaths to continue.

How does PIH show structural violence and social suffering?

The film shows how poverty, inadequate health care, unsafe living conditions, and global inequality made people in Haiti and Peru more vulnerable to disease and death; for example, patients could be unable to complete TB treatment because they lacked food, transportation, or money. Their suffering was not simply the result of biological illness but also of social systems that denied them resources and opportunities available to wealthier people.

What was a community health worker? Innovative?

A community health worker (CHW) was a local person trained to help patients follow treatment plans, take medications, recognize health problems, and access medical services. Because CHWs lived in or near the communities they served, they could visit patients at home, provide emotional support, and help address practical barriers such as hunger and transportation. This was innovative because traditional medical systems often expected patients to travel to clinics and manage complicated treatments alone; PIH instead brought care directly to patients and treated social support as an essential part of effective medicine. EX: PIH's TB programs combined medication with food assistance and regular visits from community health workers. This helped patients complete lengthy treatments and demonstrated that even people living in extreme poverty could successfully recover when given appropriate medical and social support.

Barriers in PIH

PIH faced resistance from medical experts, international health organizations, and policymakers who argued that treating MDR-TB and HIV/AIDS in impoverished communities was too expensive, too complicated, or unsustainable. Some experts favored directing limited resources toward prevention or less expensive public health interventions rather than providing costly, comprehensive treatment to individual patients. PIH challenged these assumptions by demonstrating that patients in places such as Haiti and Peru could recover with proper medication, community-based care, and social support; its successful MDR-TB programs helped influence the World Health Organization to revise its treatment recommendations

Social construction of reality theory

Culture creates a social world, and the social world is reality for members of that group. Norms and values created through culture- what matters, how to be a “good person”, sense of right and wrong. What we pay attention to- what is legitimized in society- is decided on by one’s culture and social world. This includes science, health, illness, disease- these also shaped by social forces. EX: Gender reveals (colors have nothing to do with gender, but culture made an association).  rebellion/nonconformity defined by culture because that is showing there is a culture to rebel against, Gender roles, values, practices change with age/other social categorization, Defines how those groups are supposed to think, act, and relate one to another.

Social construction of Reality medicalization

subjective or personal life experiences redefined as disease, taken on by medical system as something to be “managed”. EX: PTSD, people used to have to just deal with it, but now it is a disease with medication

Culture

• The set of ideas, beliefs, values, and practices, remaining the same for an extended period of time that are shared between a group and learned through interactions with other members of that group.

•  Not just what you do, but how you think about what you do. Culture can change, but for the most part it stays the same.

Unanticipated consequences of purposive action

• Purposive action involves motives

• Purposive action results from making a choice among alternatives/options for action

• Actions have a goal (what outcome will be) and a process (how we get there) 

• Purposive actions might not actually achieve the intended goal

• Purposive actions might have unwanted, unintended, and unexpected outcomes

This can lead to problems: If the issue is not understood (If it is a new virus, many might not know how it was transmitted, but then realize the real reason), If interventions come from a different place than where the issue is occurring and culture, language, other biosocial/contextual factors not taken into account. Values or expectations of governing bodies in global health can also create obstacles to anticipating effects of action (issues might be so big and take a lot of time to figure out) From making a plan to taking action can take time, so what is happening in an area of need might be different from the original situation. (maybe within the issue, or a conflict has broken out within the area, or other factors that may change the context if people were going to help). EX: military launched campaigns to identify and treat people with “sleeping sickness” spread by tsetse fly. Involuntarily injected which led to bad side effects and now the consequence is people having higher mistrust in medicine

Social Suffering and Structural Violence

“harm caused by the way society is organized”. Historical, political, economically driven processes that cause inequity and make life more difficult for disadvantaged groups. The results of structural violence; what is caused by the impact of social forces. Results from what political, economic, and institutional power does to people. But ALSO- shapes responses to social problems. In other words, the people in power (who are at an advantage) decide whether to help others when an issue occurs. What effect people in power have on those who are at a disadvantage. Brings us back to the old question- Why do people get sick and die from treatable conditions? Disadvantaged groups have fewer avenues to get needed resources AND less power to influence those who might distribute resources. Agency (ability to take action) constrained by systems and institutions that work in the favor of those with more societal power. 

Rationalization and Bureaurcracy

refers to how modern institutions use rules, laws, procedures, and organized systems to make decisions and manage people and resources. Authority comes from a person's position within an organization rather than their individual qualities, like it might with a king or religious leader. Bureaucracies, such as governments, corporations, schools, and nonprofit organizations, create hierarchies with specific roles, responsibilities, and rules so that systems can operate efficiently and predictably, even when individuals leave and are replaced. This can be beneficial because it standardizes processes, promotes consistency, and helps distribute resources in an organized way, including in global health delivery. However, too much rationalization can limit creativity, flexibility, and individual choice, creating what sociologist Max Weber called the “iron cage,” where people become trapped by rules and procedures that prioritize efficiency over human needs. For example, a university website may provide students with all the information they need, but navigating the system can be frustrating when they need to speak with a real person to resolve a specific problem.

Beuracracy

creates hierarchy, organization, defined roles with specific responsibilities (and rewards). Any one within these roles are replaceable with things like shifts and such

rational authority

Power comes from laws, rules, and official positions. Example: A university professor has authority over grades because of their official role and university policies.

Charismatic authority

Power comes from a person's personality, charm, or ability to inspire others. Example: A leader gains followers because people admire and believe in them.

Religous authority

Power comes from religious beliefs, traditions, or a person's recognized spiritual position. Example: A priest or religious leader has authority within their religious community.

Biopower and Discipline

refers to the ways institutions use biological and medical information to define, count, categorize, organize, and control groups of people. Institutions, such as schools, governments, and health care systems, establish rules and norms that shape human behavior and organize society. They use surveillance, recordkeeping, and data collection to monitor people, establish standards for what is considered normal, and influence how individuals behave. Over time, people may internalize these expectations and begin monitoring and controlling their own behavior, even when no one is directly watching them. This is connected to discipline, which involves establishing rules and practices that encourage people to behave in specific ways, using both external punishment and self-control to maintain order. Biopower operates through systems and institutions rather than just through individual people. It can have positive effects, such as tracking diseases, understanding population health, and preventing illness, but it can also reinforce inequality by categorizing people, limiting their access to resources, or treating certain groups as abnormal or less deserving. For example, elementary school teaches children basic skills such as reading, writing, and math, but it also teaches them to follow rules, raise their hands, sit still, and control their behavior. Children learn to regulate themselves to meet institutional expectations, demonstrating how institutions shape both what people know and how they behave.

Primary health care

Integrating biomedical with local approaches, community participation, “health by the people” to create healthy populations, strengthen overall immunity

Alma-Ata

134 countries, 67 international organizations. Commitment to achieving universal primary healthcare by the year 2000. Health care for all! Declaration of Alma-Ata. Accessible to everyone, community based, cost effective, affordable, scientifically sound, governments responsible for health of people, linking social, economic sectors to health.

Alma-Ata themes

“Appropriate technology” Use of low cost, sustainable, tools for resource poor areas and including community input. Critique of “medical elitism” Professionals not readily available in all areas, acknowledging the rural/urban divide, health as avenue for social and economic development, expand access to primary care to improve education and nutrition, creating a healthier workplace, logic of free market creeeping in- not just health for health’s sake so people can live how they want, but for health economic development

Bellagio (Selective primary health care)

Rockefeller Foundation Belaggio center, Italy. Group of wealthy nations met intending to talk about population growth impact on global health. However, researches published a article critiquing the primary health care “health for all” movement and proposed a different approach. Cost-effective analysis of specific health interventions- what would be the best ‘high return in lives saved per dollar’. Referred to “an age of diminishing resources” and gave SPHC as an “interim strategy” until a time when more funds available for GH delivery.

GOBI for the Bellagio proposal

Growth monitoring

Oral rehydration therapy (developed 1960s)

Breastfeeding

Immunizations

Easy to monitor and measure which appealed to donors, scientists, economists at the time. SPHC was pitched as “interim strategy” meant to complement Alma-Ata declaration.. but was different. “Band aid or ROI?'“ GOBI left out some leading causes of death and didn’t address struggling healthcare systems.

Horizontal approach

focuses on strengthening the overall health care system and providing comprehensive, ongoing care for a wide range of health problems. For example, a community clinic might provide vaccinations, prenatal care, treatment for infections, and routine checkups rather than focusing on just one disease. This approach is important because it improves long-term access to health care, strengthens local medical infrastructure, and addresses multiple health needs within a community.

Vertical approach

targets a specific disease. Horizontal programs can provide more comprehensive, sustainable care, whereas vertical programs can be effective at controlling urgent health problems. However, vertical programs may neglect other health needs, while horizontal approaches can require more time and resources to develop. Some organizations, such as Partners In Health (PIH), combine both approaches by targeting diseases such as tuberculosis while also providing food assistance, community health workers, and broader health care services. This demonstrates how combining the approaches can treat specific diseases while addressing the underlying barriers that affect overall health.

What were the major goals and policies that came out of the Alma-Ata conference, and how did they change the direction of global health delivery?

organized by the World Health Organization (WHO) and UNICEF, promoted Primary Health Care (PHC) and the goal of “Health for All” by the year 2000. It argued that health care was a human right and that governments should provide accessible, affordable, comprehensive care to everyone, with community participation and an emphasis on preventing disease rather than only treating it. The conference promoted addressing social determinants of health, such as poverty, nutrition, clean water, sanitation, and education, alongside medical treatment. This changed the direction of global health by encouraging countries to build community-based health systems that addressed the overall health of populations rather than focusing only on hospitals, specialists, and individual diseases.

What was meant by “appropriate technology,” and what was different about this approach from previous ideas about how medicine should be delivered in global health?

means using health care methods, tools, and treatments that are scientifically sound, affordable, practical, and suited to the needs and resources of the local community. For example, training community health workers to provide basic treatments, vaccinations, and maternal care can be more practical in a rural area than relying entirely on expensive hospitals and specialist doctors located far away. This differed from approaches that emphasized advanced Western medical technology, expensive equipment, and highly trained specialists. Appropriate technology emphasized that effective health care did not always require the most sophisticated equipment; it required solutions that communities could access, maintain, and use successfully.

What were the major goals and policies that came out of the Bellagio conference, and how did they differ from Alma-Ata?

helped promote Selective Primary Health Care (SPHC) as a more targeted and affordable alternative to the comprehensive approach outlined at Alma-Ata. Rather than attempting to improve all aspects of health and society at once, SPHC focused limited resources on a small number of interventions expected to save the most lives at the lowest cost. This approach became associated with GOBI: growth monitoring, oral rehydration therapy, breastfeeding promotion, and immunization. The key difference was that Alma-Ata advocated comprehensive primary health care addressing broad social and economic conditions, while the Bellagio approach prioritized specific, measurable health interventions that could be implemented quickly with limited funding.

Why were SPHC and the GOBI approach attractive to major global health organizations and many countries?

organizations such as UNICEF, governments, and international donors because they offered relatively inexpensive, practical, and measurable ways to reduce child illness and death. For example, oral rehydration therapy could prevent deaths from dehydration caused by diarrhea without requiring expensive hospital equipment, while immunization could protect large numbers of children against infectious diseases. These interventions were easier to fund, implement, and evaluate than comprehensive reforms addressing poverty, inequality, sanitation, and health care infrastructure. They were especially attractive during periods of economic crisis and limited government budgets, although critics argued that concentrating on a few interventions could neglect broader health needs and the structural causes of poor health.

What was neoliberalism in the 1980s, and what impact did it have on global health delivery?

an economic and political approach that emphasizes free markets, privatization, competition, reduced government spending, and a smaller role for the state in providing services. During the 1980s, international financial institutions and many governments promoted these policies as ways to address economic crises and improve efficiency. In global health, neoliberalism encouraged governments to reduce public spending, increase private-sector involvement, and focus on cost-effective health interventions rather than providing comprehensive public health care. As a result, health care could become more difficult to access for poor populations when governments reduced services or introduced fees, although supporters argued that market-based reforms could improve efficiency and control costs.

What were structural adjustment programs, and how did they affect health care and global health delivery?

economic reform packages promoted by institutions such as the International Monetary Fund (IMF) and the World Bank, particularly during the 1980s and 1990s, often as conditions for loans to countries experiencing debt or economic crises. These programs commonly required governments to reduce public spending, limit budget deficits, privatize state-owned enterprises, and implement market-oriented reforms. In many countries, cuts to public budgets and health services, hiring restrictions, and the introduction of user fees made medical care less accessible, especially for poor families. These policies also encouraged a shift toward selective, low-cost health interventions rather than comprehensive public health systems. Critics argue that structural adjustment programs worsened health inequalities by placing economic goals ahead of social welfare, although their specific effects varied across countries.

What are some ways the AIDS pandemic “invented” contemporary global health?

The HIV/AIDS pandemic helped transform global health by showing that infectious diseases were not just medical problems but also issues of human rights, economic inequality, politics, and access to medicines. During the crisis, activists, scientists, nonprofit organizations, governments, and international institutions worked across national borders to demand treatment for people who could not afford it. The fight for affordable antiretroviral drugs (ARVs) helped expand the role of organizations such as Doctors Without Borders and treatment-access movements, and encouraged new international funding programs, including the Global Fund and PEPFAR. The pandemic also challenged the assumption that advanced treatments were too complicated or expensive to provide in low-income countries.

What were some barriers to global health interventions against HIV/AIDS?

Major barriers included the high cost of medicines, pharmaceutical patents, international trade rules, inadequate health infrastructure, stigma, and political resistance. Patents allowed pharmaceutical companies to control the production and sale of brand-name ARVs, keeping prices unaffordable for many people in low-income countries. Some policymakers and pharmaceutical companies also argued that poor countries lacked the resources, medical supervision, or infrastructure necessary to distribute complicated treatments effectively. These barriers meant that people in wealthy countries increasingly had access to life-saving medication while millions of people in Africa and other low-income regions died without treatment.

What major change occurred in 1996 that changed the outlook for people diagnosed with HIV/AIDS?

In 1996, combination antiretroviral therapy (ART) became a major breakthrough in HIV treatment, often called the advent of highly active antiretroviral therapy (HAART). Instead of relying on a single drug, patients could take combinations of medications that suppressed HIV replication, reduced viral levels, and dramatically lowered the risk of progressing to AIDS. HIV was no longer necessarily a death sentence for people who could access treatment; it increasingly became a manageable chronic condition. However, these medicines were initially extremely expensive, so many people in Africa and other low-income regions could not benefit from the breakthrough.

Why weren't ARVs accessible to people living with HIV/AIDS in South Africa in the 1990s and early 2000s?

ARVs were largely inaccessible because brand-name medicines were protected by patents and sold at prices far beyond what most patients and many African governments could afford. Pharmaceutical companies controlled production and pricing, while international trade rules and pressure from wealthy countries made it difficult for countries to import or produce cheaper generic versions. In South Africa, the government also faced political controversy over its response to HIV/AIDS, including under President Thabo Mbeki, whose administration questioned aspects of the scientific consensus on HIV and delayed effective treatment policies. As a result, millions of people who could have benefited from treatment remained untreated, despite the availability of effective drugs.

Why did pharmaceutical companies refuse to relax patents for Africa, even though Africa represented a small share of potential sales?

Pharmaceutical companies argued that patents were necessary to protect intellectual property, recover research and development costs, reward innovation, and fund the discovery of future medicines. They also worried that allowing inexpensive generic drugs into African markets could lead to price erosion, parallel imports, or re-exportation into wealthier markets, where the drugs could otherwise be sold at higher prices. Critics argued that this reasoning prioritized commercial interests over human lives, particularly because many people dying from AIDS could not afford the patented medicines. The film highlights the moral conflict between protecting drug-company profits and making life-saving treatment available to people regardless of income

According to the film, how does pharmaceutical R&D occur, and who pays for it?

The film challenges the pharmaceutical industry's argument that high drug prices are necessary to recover research and development (R&D) costs. It emphasizes that a substantial amount of drug research is funded by public money, including government grants, university research, and publicly supported scientific discoveries, before private companies develop, test, patent, and market medicines. Taxpayers therefore help fund the scientific foundations of many treatments, while pharmaceutical companies can obtain patents that give them exclusive rights to sell the resulting products. The film questions whether it is fair for companies to charge prices that exclude millions of people from medicines when public funding helped make those medicines possible. This does not mean all R&D is publicly funded; private companies also invest in clinical trials, regulatory approval, and drug development.

What role did the U.S. anthrax scare play in the debate about generic drugs in Africa?

After the 2001 anthrax attacks in the United States, there was concern that the antibiotic ciprofloxacin (Cipro) would be too expensive or unavailable in sufficient quantities to protect Americans. The U.S. government threatened to use its authority to override the patent or obtain cheaper generic supplies if the manufacturer did not lower its price. The film uses this event to highlight what it portrays as a double standard: when Americans faced a public health emergency, the government considered overriding patent protections, but African countries faced strong pressure and potential trade-related consequences when they sought similar flexibility to obtain affordable HIV medicines. The episode strengthened activists' arguments that governments should be able to prioritize public health over patent protections during emergencies.

What is PEPFAR? Who initiated it, who opposed its original mission, and how did its drug sources change?

stands for the President's Emergency Plan for AIDS Relief, a U.S. government initiative launched by President George W. Bush in 2003, with major treatment funding beginning in 2004. It was designed to expand HIV prevention, testing, and treatment, especially in heavily affected countries in sub-Saharan Africa. Its development faced concerns and resistance from some fiscal conservatives, critics of large foreign-aid programs, and advocates who disagreed with aspects of its original prevention priorities, including its emphasis on abstinence and faith-based approaches. Drug access was central to its success: initially, brand-name medicines were important sources of treatment, but the program increasingly procured lower-cost generic ARVs that met U.S. Food and Drug Administration quality standards. This change helped PEPFAR stretch its funding to treat many more people and demonstrated that generic medicines could be both affordable and safe.

What is the status of PEPFAR today?

As of October 2026, PEPFAR still exists, but its operations have been significantly disrupted by U.S. foreign-aid freezes, funding cuts, and program cancellations beginning in 2025. Before these disruptions, PEPFAR had supported antiretroviral treatment for more than 20 million people worldwide. An independent study published in July 2026 reported that at least 1,700 HIV service sites had closed following terminated or delayed payments, demonstrating the potential consequences for treatment and prevention. Some life-saving services have continued under limited authorizations, but the program's funding and operations have changed substantially

Key concepts of Fire in the Blood

• 1996: Combination antiretroviral therapy transformed HIV from a frequently fatal disease into a manageable chronic condition for people who could access treatment.

• Patents: Give pharmaceutical companies exclusive rights to sell patented drugs, which can keep prices high and limit access.

• Generic drugs: Lower-cost versions of medicines that can greatly expand access when they meet appropriate quality standards.

• Publicly funded research: Government and university research often contributes to the scientific discoveries behind new medicines, alongside private investment.

• Anthrax scare: The U.S. government's willingness to consider overriding a patent for Cipro highlighted the unequal treatment of public health emergencies in wealthy and poorer countries.

• PEPFAR: A major U.S. HIV/AIDS initiative launched by President George W. Bush in 2003 that greatly expanded access to treatment worldwide.

• Central message of Fire in the Blood: Access to life-saving medicines depends not only on scientific discoveries but also on economic systems, patent laws, political decisions, and the willingness to prioritize human lives over commercial interests.