ANSC-GLBH 148 Final

NOT cumulative, look at the "Final Exam Concepts" posted on Canvas, includes some readings from Weeks 4 and 5

taylor, “explaining difference: culture, structural violence, medical anthropology”

def. structure (in context of social science) & social structure & structural violence

describe relationship between structure and structural violence (3)

structure - continuously observed patterns of collective social interactions that have achieved a degree of permanence

• mostly shown with patterns of social relationships, economy, law, policies, etc.

• & structures are not a material thing, but may have material/physical manifestations (i.e. roads, buildings)

social structure - policies, economic systems, and other institutions that have produced and maintained social inequities and health disparities through the reasoning of social differences (race, class, gender, sexuality, etc.)

structural violence - suffering and injustice embedded into political and economic systems shaped throughout history that are seen as physical manifestations called social structures in order to limit individual agency

• where the same structures that make life easy for some make it hard for others

(aka social structures that put people and groups in harm due to being embedded in political and social systems)

_____

• structures mean stability and comfort for some BUT poverty, insecurity, and violence for others

• structures are not natural, they are the effects of histories of political, economic, and social struggles

• structures are patterns of social collective action & can and should be changed

describe 2 levels of structural interventions: distal and proximal intervention (they work complementary, not competing)

distal (far from underlying cause) = interventions to care for sick patients/treating the body (like bandaid on wound)

• downstream (deal with consequences after they happen)

proximal (close to underlying cause) = prevention and social change/changing policies

• upstream (preventing illness & addressing the root causes, like SDOH, inequality, environment, etc.)

def. structural violence through analytic omission

when we do not discuss history that has created these violent social structures, which enable structural violence (that is most felt by those disproportionately affected by such structures)

def. extreme suffering & structural violence (2nd time defining structural violence)

extreme suffering - premature and painful illnesses, torture and rape, institutionalized racism and gender inequality → all cause great and unjust injury

structural violence - suffering due to structures historically defined and formed, to constrain agency (ability to make choices regarding oneself)

• example: choices (small or large) are limited by racism, sexism, political violence, and extreme persistent poverty

3 difficulties of describing/explaining extreme suffering

• exoticization of suffering

  • suffering of individuals whose struggles remind us of our own move us more than the suffering of individuals distanced/different than us through geography, gender, race, or culture

  • RECOGNITION (recognizing ourself in others) vs. OTHERING (this belief causes people to separate themselves from the suffering of “others”)

• sheer weight of suffering (can’t be quantified/measured)

  • knowing that suffering can’t be expressed in facts and numbers, but reports objectify the suffering of many victims who have little voice and rights

• dynamics and distribution of suffering are still misunderstood

  • to explain an individual’s suffering, have to embed the individual’s biography in the larger context of culture, history, politics, and economy

def. intersectionality

considering gender, race/ethnicity, socioeconomic status (and other social categories) to identify interdependent systems of discrimination/injustice

relation between culture (differences) and suffering/structural violence

culture doesn’t explain fully suffering (b/c it overemphasizes culture as the reason for differences in human behavior BUT neglects biological and individual differences)

→ SO influences thinking that: cultural differences can act as a justification of structural violence

(aka culture fails to acknowledge abuse of power b/c it assumes that the social world is whole)

def. modal suffering (aka modal statistics of suffering)

the most common forms/experiences of suffering within a population OR the dominant pattern of suffering in a society/population that is shaped by culture, politics, and economics

farmer, “on suffering and structural violence”

case study of acephie joseph AIDS

• village of Kay made of refugee peasant farmers that were displaced by Haiti’s dam project that flooded Kay → displaced → poverty

• 19 years old, helped make money for family by walking or on donkey for 1.5 hours to market to sell produce & the road was through the dam and where military were stationed

• soldier sometimes fined or flirted, flirtation welcome b/c poverty, Captain Honorat had wife and children and multiple partners, sexual partners with Acephie for a bit, Honorat got sick and died

• Acephie went to cooking school to become servant, maid, saw new person Blanco, became pregnant, gave birth and diagnosed with AIDS (victim of sorcery OR sexual relations with the soldier)

• Honorat’s first wife had no way to feed her children & Honorat had at least 2 other sexual partners, 1 who was HIV positive

• don’t know if Blanco has it and/or is spreading it to other partners

farmer, “on suffering and structural violence”

case study of Chouchou Louis beating

• Haiti, under dictatorship of Duvaliers who ruled through violence, especially harsh on Haitian poor

• many tried to flee to US who offered economic asylum BUT then Ronald Reagan made agreement with Duvalier to return any caught refugees on sea back to Haiti (many Haitians applied for refugee, 8 accepted only)

• growing pro-democracy Haitian movement, leader of this movement declared candidacy and became present & Chouchou met Chantal

• was overthrown by military

• Chouchou on truck, complain about roads, one passenger was a soldier who took him out and beat him alongside other solders → tried to stay out of jail by avoiding home, fear

• later visiting sister, arrested w/o reason (later said b/c stole bananas), tortured and dumped in ditch to die, family carried him back home at night, serious injuries, 3 days to die

describe structural competency in medicine

5 areas in developing a trainee’s capacity to recognize and respond to: …

relation to structural vulnerability & def. term

• extent that physicians can recognize and respond to health and illness as results of the downstream/top-down/distal effects of social, political, economic structures

____

1. influence of structure on patient health

2. influence of structure on healthcare practices/way of treatment

3. influence of structure in the clinic

4. influence of structure outside the clinic

5. structural humility

can lead to institutionalized transformations of medical hospitals

____

cautions providers against making assumptions about the role of structure in patients’ lives, instead encourages collaboration to understand and respond to structural vulnerability

• structural vulnerability is the risk that an individual experiences due to structural violence & one’s own positionality within socioeconomic hierarchies

  • is not caused or can be fixed solely by individual agency or behaviors

5 ways to address structural competency in global health education

• Describe the role of social structures in producing and maintaining health inequities globally

• Identify the ways that structural inequalities are naturalized within the field of global health

• Discuss the impact of structures on the practice of global health

• Recognize structural interventions for addressing global health inequities, and

• Apply the concept of structural humility in the context of global health.

def. the act of naturalizing inequality

relation to & def. implicit frameworks (what are the 3-4 influences of implicit frameworks)

• sometimes subtle or explicit ways that structural violence is overlooked due to putting blame on cultural differences, behavior, or racial categories (which distracts from the structural causes of harm)

• naturalizing equality is done through implicit frameworks

• (naturalizing inequality is preserving social inequalities)

• (implicit frameworks comes from implicit bias/privileged perspective when understanding health and wellness)

_____

• implicit frameworks focus on the influence of “culture”, individual behavior/choices, and biology/genetics & contextually clueless as an excuse for naturalizing inequality and unjust actions (are assumptions assumed to be true to justify inequality)

6 levels/areas of intervention in medicine (w/ examples)

intrapersonal (structural humility: self-reflection, self-critique)

interpersonal (patient-physician)

clinic (ex: diversity in staff, translator, structural competency training for staff)

community (ex: advocate for affordable housing for community)

research (ex: engage patients in important research goals & research structural factors that affect offered resources for housing, incl. policies and racism)

policies (go beyond advocating for policies by targeting the structural factors that allow for injustices, like media statements and medical education reform)

for Metzl and Hansen “structural competency”:

how do the authors relate structural competency in how to address health disparities and health inequalities?

what’s the problem of cultural competency? how does structural competency improve this

5 concepts of structural competency

basically, healthcare workers need to view healthcare as a -structure & needs to advocate for - -

address health disparities and health inequalities by having physicians be properly trained in cultural sensitivity (understand and respect cultural differences and similarities) & also must understand and intervene in structures that affect patient healthcare and treatment

__

Cultural competency causes physicians to often individualize patient narratives instead of looking at the structural and systemic DOH (determinants of health: political, economic, social). Structural competency trains physicians to recognize and address institutional/structural and social contexts that determine health-related resources in order to fight against stigma

__

1. recognize structures that shape physician-patient interactions (health of patient determined by policies and laws & physicians need to recognize the structural determinants of illness (aka how patient and family perceive and respond to symptoms)

2. redefine structure within medical settings (medicine previously defined by biology BUT needs to incorporate language from interdisciplinary (different knowledge) structures)

3. redefine role of culture in biomedicine (cultural competency often blames culture/cultural differences instead of structural inequalities/violence)

4. address structural intervention (healthcare workers must be trained in systemic solutions that work towards systemic equality)

5. develop structural humility (life-long/continuous self-reflection and self-critique where you recognize your own biases and limits that allows for active learning and respecting cultural differences)

(basically similar to a previous slide about role of social structures in health disparities, how structural inequalities are naturalized, role of social structures in global health, structural interventions, structural humility)

__

basically, healthcare workers need to view healthcare as a sociopolitical structure & needs to advocate for systemic change

for harvey “structural competency and global health education”:

what is the discussed pedagogical (teaching) shift in relation to global health programs?

4 pillars of structural competent global health education

away from viewing health as charity or aid through humanitarian work → towards using structural competency & structural humility to look at how structural power dynamics globally & current global health training approaches may reproduce global inequalities

• global health programs come from biomedical humanitarianism (where students from high-income countries go to low and middle-income countries to help) & these students are often underprepared in how to understand and properly address these structural issues despite good intentions

• this reinforces colonial relationships like in the past

__

1. training includes critical history that looks at power and social inequalities

2. students self-reflect about their own positionalities & emphasize reflexivity (self-aware of how own actions affect local communities)

3. away from models of charity towards models of solidarity partnerships (working together with the local community & long-term engagement)

4. imagine and advocate for structural interventions that address root causes of global health disparities

(recognize that the global north benefits off the structures that enforce health inequalities in the global south)

OPTIONAL READING

for metzel and dorothy “structural competency meets structural racism”:

what is the main argument (aka connect to structural competency and structural racism in biomedicine)

biomedicine must recognize both structures that shape health (structural competency) AND how racism is structurally produced, maintained, and reproduced in structures, which include biomedicine

• historically and still today, medical knowledge has structurally created racial categories that justify race-based health disparities

• race is a social construct & has been used a reason to justify race as a biological risk factor (STRUCTURAL RACISM)

students must understand power, not just diversity in medicine

def. de facto apartheid

system of oppression and domination over one race enacted by another racial group (aka institutionalized racial segregation) that was done in practice, but wasn’t formally recognized

def. bad faith

relation to position of higher up workers

individuals knowingly/purposefully deceive themselves (self-deception) in order to avoid acknowledging realities disturbing to them & still actively engage/are part in and reproduce these systems despite their own values and possible good intentions

__

• acknowledge that bosses don’t have complete control & each individual worker has their own agency/freedom, which continues to reproduce inequality

• understand management as humans trying to have ethical, comfortable lives while in the midst of an unequal, harsh system

• how everyone is stuck in a particular system, even those who want to do good & it is what actions they take that determine the transformation OR reproduction of the system

def. gray zones

how do we break away from these cycles?

sometimes, is when the need to survive is greater than the ethical problem (aka when people are forced to make terrible decisions)

• where even ethical workers are forced by the harsh market to participate in a system of labor that perpetuates suffering

• is like placing person vs person, when both are trying to survive and make the best of their situation (maybe in the same or in different ways)

__

constant self-reflection (why do i think the way i do? what choices do i have?) AND collective action that is proactive towards the gradual shifting of doing collective good

describe clinical gaze

it limits suffering to (2)

how does it relate to naturalizing inequality

physicians treat patients more like an object/body & view them as a subject isolated from the social contexts in which they live

• focus on the words and symptoms of the patient after cadaver dissection & focus on the isolated diseased organs

limited to 2 lenses: suffering is caused by biology or behavior

• blames biology and physical factors, instead of the political decisions related to structural causes

it decontextualizes a person, which contributes to naturalizing inequality

• basically physicians project a form of violence onto the bodies of patients

def. symbolic violence & misrecognition

how do the 2 relate?

symbolic violence - naturalization/internalization of dominant social and cultural norms by imposing them onto others without them knowing

misrecognition - where unequal/dominating relations of power stay hidden b/c people recognize them as objective and natural, instead of recognizing them as power struggles and forms of domination

__

• what we recognize as a form a equality is actually misrecognized b/c it is actually a form of inequality (due to the fact that we perceive the world through the lens of a dominant social world)

• this causes us to start believing it ourselves and internalize these systems that we and others belong in these social positions

• it reproduces implicit frameworks → that lead to naturalizing inequality

• what is recognized as pride should be recognized as forms of domination

• they don’t recognize that they are participating in/enforcing a form of domination that involves dominating themselves

for holmes “oaxacans like to work bent over”:

details about Triqui workers

Holmes lived and worked alongside indigenous farmworkers, documenting and observing firsthand how exploitation is justified by physicians, farmers, and workers

Tanaka farm

• de facto apartheid w/ race, citizenship, and class → reinforces larger inequalities

• hierarchy of suffering

  • much of self-destructive suffering of Triqui migrants is socially-structured

• Triqui strawberry workers

• workers bare the physical marks of structural violence (injuries, pain, exhaustion)

• farms and migrant clinics are examples of gray zones b/c workers seeking their own survival will be complicit with a system of violence against others & physicians are under difficult conditions and have limited resources to work with

• Triqui people internalize their social position through a form a ethnic pride in their bodily differences that help them endure their working conditions BUT this also aids in the naturalization and reproduction of structures that exploit them

  • which also depoliticizes their suffering & protects exploitive systems from critique

  • aid in their own subjugation

all of this causes systemic injustice to seem invisible

(indigenous people couldn’t sell goods through their local market b/c of the US-Dominican Republic-Central American Free Trade Agreement → made them come to the US → faced forms of discrimination)

REVIEW

for singer and erikson, ch.1 “global health and anthropological paradigm”:

• reasoning for tropical/colonial medicine used for indigenous people

• health disparity vs health inequity

• def. acute vs chronic stressors

• def. cultural inconsonance

• 3 ways of using anthropological lens as an approach to global health

• only helped the indigenous people as it would impact how much wealth is profited through colonialism (resource extraction) and exploitation of the indigenous peoples & also as a way to prevent themselves/the colonizers from getting sick or dying from these local diseases

__

health disparity - differences in health that are not due to social inequalities and health inequities

health inequity - inherently unfair and unjust differences in health due to social inequalities & structural violence (shaped by colonialism and post-colonial structures) (has unequal access to healthcare)

__

socioeconomic factors that disproportionately affect marginalized people/groups who, as a result, face:

• acute (sudden, unexpected events that greatly burden daily life)

• chronic (ongoing problems/stressors where one is unable to achieve emotional satisfaction and unable to fulfill major social roles that are important to their identity)

__

cultural inconsonance - stress stemming from one’s social and cultural expectations contradicting each other and negatively impacting their health

__

1. EMIC (focus on knowledge from people who posses it), not ETIC (from higher powers that project analysis onto people it concerns)

2. view daily life in different settings

3. situate local into global contexts

for singer and erikson, ch.1 “global health and anthropological paradigm”:

explain the historical roots of global health throughout history (list and summarize, starting with colonial and tropical medicine & ending with increased advocation to a right to health and away from commodification of health)

• colonialism, colonial and tropical medicine

• international health

• cold war

• league of nations → united nations & WHO

• international monetary fund (IMF) and world bank (WB)

  • favored neoliberalism b/c of cold war politics

• shift from relationship between countries to issues that cross transnational borders

• World Bank gained power → privatization, deregulation, reduce government involvement/power (neoliberalism) in 1970-1980s

• rise of NGOs (non-governmental organizations), humanitarian organizations, relief groups, etc.

• increased advocation for right to health: to recognize health as a human right & propose shift away from commodification of health (focus on social & structural determinants)

def. neoliberalism & describe

def: a political and economic response to socialism, communism, and fascism

• focuses on a ‘free market’ with limited government/state interference

• became a dominant framework

w/o gov. influence, the market’s supply and demand can lead to efficient allocation of resources

trust in that individuals understand the market & will make correct informed decisions

BUT

criticisms in that neoliberalism creates subject to act in certain ways & state exists to protects rights but not to provide social services

what are the 3 policy pillars of neoliberalism

def. SAPs & what caused the rise of SAPs

3 effects of SAPs

1. privatization of public sphere (private markets)

2. deregulation of corporate sector (less government intervention)

3. lowering of income and corporate taxes from cuts to public spending (less government services)

aka privatization, liberalization, stabilization

__

SAPs (structural adjustment policies) are economic reforms that low-income countries can implement under the control of the IMF/WB (world bank) to stabilize the economy, reduce government intervention, and promote market-oriented economies

• caused by low-income countries needing loans after the 1970s economic crash BUT IMF would only lend money to countries if they agreed to SAPs

__

1. reduce public services & increase user fees

2. shift from economic growth to economic failure

3. which causes naturalization of neoliberalism to be both the framework & the solution

effect of SAPs in low-income and independent countries (4 “steps”)

gained independence, need loans reconstruct/reform

→ SAPs given to provide support, but came with strict guidelines for SAP that mainly benefit HICs (high income countries)

→ social services eroded as a result of SAP (is seen as needing aid from HICs)

→ aid is given in name of “helping the poor”, SAPs continue, with strings attached

(these adjustment programs foster problems of legitimacy for sub-Saharan African states & erode their political capacity to govern)

for Keshavjee “free-market orthodoxy infiltrated the international aid movement”:

relationship between Bretton Woods Agreement, IMF and WB, war, neoliberalism, governmentality (def.), Bamako Initiative in sub-Subsaharan African countries

• Bretton Woods Agreement established a postwar international monetary system w/ convertible currencies, fixed exchanged rates, and free trade → became the ISF (that became the IMF) & IBRD (that became the WB)

• end of 2nd world war

• lead to rise of neoliberalism, stating that state intervention should leave the market alone so it could work efficiently b/c gov. intervention led to market failures

• As soviet influence grew, US provided loans to poor countries → IDA program → IDA and IBRD became the WB (world bank)

  • IDA required regular funding, which gave the US gov. (largest donor) a lot of influence over recipient countries and the WB

• rise of socialism and fascism in 1930s → saw free market as an economic form of political democracy

  • no gov. interference would be to equilibrium (resources allocated efficiently)

  • individuals always made choices that were rational

  • individuals have full knowledge of the market and will make correct informed decisions

• neoliberalism became a form of governmentality (subjects are formed & their individual behaviors influenced by the creating of certain structures and norms aka power)

• OPPOSING:

  • consumers won’t always make sensible choices

  • too may external factors associated with disease that doesn’t justify individuals to make rational decisions

  • healthcare is more public utility than private good

  • maldistribution of income limits ability of poor to get access to healthcare through the market

• SAPs

• Accelerated Development in Sub-Saharan Africa: A Plan for Action & Bamako Initiative

  • initial growth rate → into growing decline in economic growth

  • Bamako Initiative was supported & implemented BUT relieved governments of responsibility of looking after poorest citizens, instead put burden on individuals regardless of their ability to pay for services

for Watkins and Swidler “AIDS industry”:

def. working misunderstandings

what is the logic of donors vs. brokers vs. villagers

consequences of such working misunderstandings

working misunderstandings - continuous communication and collaboration despite fundamental misunderstandings between donors, brokers, and villagers

• allow program to continue BUT aren’t really effective

• where each actor (donor, broker, villager) interprets language, goals, and results differently BUT have a surface-level agreement to continue the system

__

donors are result-oriented (require measurable/quantifiable outcomes aka metrics), assume AIDS are caused by individual behaviors & promote individual responsibility, lack cultural understanding

brokers (NGOs and gov. officials) mediate between donors and villagers, but are limited by need to appeal to donors b/c need to maintain funding. are compliant to donors b/c their livelihood depends on it, despite knowing limited effectiveness.

• because brokers serve own interests of maintaining funding, they shape reports to fit expectations of donors WHICH lead to misrepresentation of villagers’ needs

villagers (aka intended beneficiaries) engage with NGOs/brokers out of economic necessity or obligation, but often misinterpret health messages b/c of villagers’ deeply embedded belief that it centers around family, poverty, gender, spirituality & may not internalize health messages (aka may not prioritize AIDS intervention in the same way). have limited agency

(aka donors have most power, brokers depend on donor funding so they reproduce donor language and priorities, villagers are least powerful and most vulnerable)

__

results in wasted resources that don’t address the structural causes of HIV, frustration in all actors (see e/o as noncompliant or exploitative), illusion of success w/o actual major effective change

examples of rituals of global health for ritual spaces, ritual objects, and ritual activities

&

explain the process for training

spaces: rural motels, city conference centers, community 3rd spaces

objects: cash rewards for attendance, snacks, whiteboards and markers

activities: participation and interactive activities, following pre-established social hierarchies of education and social position (I.E. facilitator leads session by following a manual)

__

training is the most sustainable & is the most likely intervention to get funding

→ organization needs a committee and bank account to do more ritual activities

→ upholds invisible guidelines that profit wealthier countries aka HICs

→ group must be made into a CBO (community-based organization) or faith-based

cycles back where money from private donors to this mission-oriented organization will be allocated to specific project by the group/org

for hickel “aid in reverse: how poor countries develop rich countries”:

describe the contradiction to the prevailing narrative of HICs as generous donors that aid lower income countries

3 proposed solutions to this

lower income countries often pay much more in debt than they receive in aid overall → leads to greater dependence on global aid

HICs extract resources from these countries back home to get more profit

__

1. debt cancellation/forgive debts (eliminate excessive debt, so the money from donors goes to country’s efforts and not interest)

2. tax haven reforms (stop and penalize extreme debt and interest/illicit outflows)

3. global tax policies (global minimum tax on corporate income to prevent HICs from profiting off resources of lower income countries)

OPTIONAL TEXT

for Ferguson “the anti politics machine”:

case study with ‘development’ in Lesotho

• Lesotho: low income country that received assistance from 27 countries and 72 orgs that resulted in “no change”

1. created country in need of intervention (with ethnocentric and inaccurate history that leaves out structural contexts)

2. take ‘politics’ out of ‘development’ (which essentialize ‘the people’ as undifferentiated who need to be educated)

3. implement ‘technical’ projects (so any failure is technical, not political)

4. produce ‘side effects’ (including more bureaucracy)

5. create ‘anti-politics machine’ that turns political responsibility and questions into technical ones

for Pfeiffer “are NGOs undermining health systems in Mozambique”:

4 negative consequences of NGOs in Mozambique

&

recommendations on how to solve this (4)

• NGOs led to fragmented health system b/c NGOs aren’t fully integrated in the national health system, which leads to multiple of the same services → inefficient

• health officials in public sectors go to NGOs b/c of the salaries, which weakens the public health system & limits government’s ability to provide consistent quality care (self-interest of salary)

• NGOs have their own priorities over national health priorities → reduced accountability in health sector b/c lack of agreement between NGOs and national health strategies

• greater social inequality to healthcare access b/c NGOs may not include certain communities or health issues → unequal access to healthcare services

__

• integrated services, where NGOs aligned with national/global health strategies

• invest in training to strengthen national health system

• better coordination between NGOs and government sectors to avoid duplication & fragmented health system

• encourage donors to support long-term in public health structures instead of in short-term projects

for Hobbs “stop trying to save the world”:

critiques about the international health development sector

argues for 2 things: humility and incrementalism (def. latter term)

• the sector values large-scale projects that promise rapid and significant impact, which gain popularity due to this BUT they often overlook the complex structures and lives of the communities (aka local contexts) WHICH may expand existing problems

• lack of accountability/continuous evaluation of these projects done by these sectors (difficult to know their true impact) → may allow ineffective or harmful initiatives to continue

• pressure to show fast results causes these sectors to prioritize short-term achievements over long-term solutions → doesn’t do effective developmental changes

it’s not that development is broken, it’s just slow

need to constantly test these models (before, after, and constantly)

__

argues for humility & incrementalism (slower expansion aka small step-by-step adjustments, instead of large promising changes)

for Hobbs “stop trying to save the world”:

2 case studies: PlayPump & Kremer’s trial of textbooks → into Deworm the World

playpump (merry-go-round hooked up to a water pump)

• issues: not used, in need of repair, pumps were reliant on child labor

• many of the villagers weren’t even asked if they wanted a PlayPump, they just got one & sometimes, it replaced the handpumps they already had

• reflects common pattern:

  exciting new development idea → huge impact in one location → influx of donor dollars → quick expansion → failure

textbooks and deworm the world:

• in Kenya, Kremer wanted to test if giving kids textbooks made them better students

• split schools into groups, gave some textbooks and some nothing, 4 years, no conclusive result

• 3 years, with medication to get rid of stomach worms, made kids physically better off and healthier

• founded NGO: Deworm the World

• but just b/c it worked in Kenya, doesn’t mean it will work across Africa or in India

• stopped conducting these trials and just implemented the treatment & ALSO stopped doing continuous evaluations of the effectiveness of the project

• argues that development projects success depends on specific dynamics of the place where they’re applied

OPTIONAL READING

for Illich “to hell with good intentions”:

critique about American do-gooders

for Conference on InterAmerican Student Projects (CIASP) in Mexico

• argues for removal of all North American “do-gooders” in Latin American (people who want to help w/ good intentions but do so in impractical ways where they fail to recognize structural factors and the needs of the communities)

  • the people are often untrained, so why not spend that money to train people who will have to meet the volunteers

Universal measurements reinvented by economists into financial systems that turned former colonies into future recipients of aid

how does this ^ relate to metrics?

argues that metrics will help improve the politics of health in that there will be reduced state/gov. intervention & increased role of NGOs and the private sector

def. QALY, DALY

how are these ^ problematic?

QALY (quality-adjusted life year) - quality of life gained in relation to an intervention

• counting the cost of keeping people alive (where that can be afforded) (aka focuses on what you get)

DALY (disability-adjusted life year) - calculates loss of productivity due to death or disability

• justifies interventions to reduce morbidity and mortality (in areas where those are assumed) (aka focus on what you lose)

__

it reduces life to economic logics and value/usefulness

def. RCT (randomized controlled trials)

an experimental measure of impact evaluation where the population receiving a program or policy intervention is chosen at random from a population, and a control group is also chosen at random from the same population

• this method of research as intervention creates a dependence on measurable outcomes

  • enrolling in clinical trials becomes the only access to healthcare

for adams, “introduction to metrics: what counts in global health”:

critique of metrics in global health

it advocates for…

• reduces health to numbers, which ignores the social, cultural, and political contexts that have influenced health outcomes → cause interventions that misalign with experiences of communities

• metrics aligns health with market, where success is measured by cost-effectiveness and investment instead of well-being → can shift funding towards easily quantified programs and away from programs for less measurable but equally important health factors

• may lead to data manipulation (numbers or manipulation/redefining language terms) to meet certain indicators of success and funding

• ignores unquantifiable factors, like mental health → causing incomplete health strategies

• prioritize short-term projects over long-term sustainable health improvements

advocates for combining quantitative data with qualitative knowledge to get a better understanding on how to approach global health initiatives

describe how metrics turn health data into a source of capital and how metrics equates to power

• turn intervention into research, then commercialize it

• if you make profits on health investments, then profits can become more important than health

• but good numbers are hard to get, and lacking data is as important as lacking health (may lead to manipulation of data)

• metrics is the source of power and decision making

  • continues to bypass the nation-state and health politics with neoliberal, technical solutions

for oni-orisan “counting in complicated”:

example of Blessing

example of Funmi

relate metrics to maternal mortality in Nigeria

• in Nigeria, woman named Blessing died soon after being transferred to the hospital for uncontrolled bleeding after delivering a healthy child

  • the death wasn’t counted b/c even though she was declared dead when arriving at the hospital, officially declared her dead before she entered the hospital B/C the hospital is politically motivated and she would’ve been an unnecessary death that would’ve negatively impacted the hospital’s data in reached the expected results

• ethnography of Healthy Mothers Healthy Babies (HMHB) program, showed Nigeria was behind on MDGs (interventions to address hunger, poverty, disease, illiteracy, discrimination against women, etc.)

__

• Funmi needed to be urgently seen at the hospital b/c sutures from C-section opened up, was told to go back to emergency room and that nurses would help, nurses didn’t help and doctor led Funmi into a makeshift examination “room” (later known that nurses weren’t told by Funmi about how her insides had broken through the open suture in her skin)

__

• severe maternal health issues in Nigeria & data on maternal mortality is used to secure international funding, which can shift focus away from addressing systemic issues towards meeting donor expectations of results

• pressure to get successful data can lead to data manipulation or overlooking qualitative/unquantifiable factors of maternal health (like the mother’s experience/narrative and quality of care received)

• metrics isn’t neutral b/c influenced by who decides what to count, how to count, and why

• advocates for balanced approach that recognizes metrics & also recognizes the complex realities that these numbers aim to represent (AKA evidence-based and culturally sensitive approaches)

for farmer “accompaniment as policy”:

def. accompaniment

how to implement accompaniment as policy?

how should accompaniment be seen as?

describe situation in Haiti

accompaniment - commitment to support others until they achieve their goals which is decided by them when the task is complete, not by others

• it doesn’t privilege technical expertise over solidarity, compassion, or willingness to tackle seemingly impossible challenges

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• provide financial support and help in development to strengthen public sector

• train local individuals to serve as health advocates and providers in their own communities → for culturally appropriate and accessible care

• commit to sustained partnerships that respect the timelines and needs of communities, instead of imposing outside agendas

(encourages people to reimagine their roles as committed partners working towards health equity)

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should be seen as a central framework for effective governance, NOT as a side factor of policy

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in Haiti

• worked with community health workers to address social determinants and medical care improved outcomes, started with programs

• realized they also needed to change policies

  • Sachs & Global Fund to Fight AIDS, TB, and Malaria (2002)

  • US President’s Emergency Plan for AIDS Relief (2003)

• 2010 earthquake in Haiti

  • out of $2.4 billion in aid, only 1% went to the Haitian government

  • rest of the money went into agencies and programs that forced Haiti to become dependent on these donor nations (reproduce the same colonial relationships that have been happening throughout history)

regarding Max Weber’s “iron cage”:

def. bureaucracy

def. the “iron cage”

consequences of the iron cage

bureaucracy - system based on formal rules and laws

• have a hierarchical structure, technical competence, etc.

• aims for efficiency, predictability, calculability (like rationalism)

iron cage - the dehumanizing effects of excessive rationalization from bureaucracy

• individuals become trapped by strict rules and procedures

• leads to loss of individual freedom/agency, creativity, and spontaneity

• absolves culpability (AKA relieves government of responsibility for wrongdoing/fault)

• prioritizes means (rules) over ends (human values)

consequences:

• alienation and disenchantment (disappointment about something you previously respected) for individuals

• difficulty in adapting to change due to rigid adherence to rules

• potential for irrational outcomes despite rational design

(doesn’t allow for what we think are rational decisions despite the bureaucracy being described as a rational institution)

(want individuals to be engaged, NOT FROM OBLIGATION, in forming social relationships)

2 types of failure of accompaniment, describe

failure of implementation

• is not the fault of the program/program design, BUT how they implement the program due to failure in understanding and recognizing how these programs/interventions will play out on the ground in real social, political, and economic contexts

failure of imagination

• don’t have people there who can shape and implement these programs in

• is the failure to be creative & to go against the already prescribed system that has created these norms and these iron cages that become impossible to break

def. pragmatic solidarity

3 factors of pragmatic solidarity, describe

encourages us to join the struggles of the oppressed, instead of working solely as disconnected experts

where solidarity by itself isn’t enough, you need solidarity AND a pragmatic/realistic approach

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1. immediate action while addressing root causes (take immediate practical steps to alleviate suffering, while simultaneously addressing underlying social, economic, and political injustices that cause this structural violence)

2. preference for the poor (dedicated to those suffering the most, not just those who are easiest to reach or those most politically convenient)

3. led by those most affected (working WITH affected communities to allow their needs and priorities to guide interventions and solutions)

(demonstrates that we stand WITH those in need, not just in spirit, but with our resources and relentless pursuit of justice)

def. hermeneutics of generosity (vs. hermeneutics of suspicion)

5 factors of hermeneutics of generosity

hermeneutics of generosity - giving people the benefit of the doubt, encourages an initial approach of trust and understanding

(hermeneutics of suspicion is assuming people are self-interested or even malicious)

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1. presuming good intentions (seek to understanding underlying reasons, presuming they are good instead of immediately getting critical or offended)

2. curiosity and seeking truth (why someone might be acting a certain way → leads to deeper understanding)

3. strengthening relationships (also fosters cooperation)

4. applied in various contexts (distinguishes b/w unjust structures that deserve hermeneutics of suspicion & the individuals within these unjust structures who often deserve hermeneutics of generosity)

5. empathy and compassion (recognizes that everyone has a story and reasons for their behavior)

similar to cultural relativism