Stuck In Global Health

by Raymond Downing

I admit it: I’m stuck in global health – or at least my version of it. My version of global health living where I work, not just visiting; my version is working for the health systems that are here, not introducing new ones.

But it's not just me who is stuck. If major global health conferences are any indication, all of global health is stuck. Though I rarely attend them, I do get the itch every 5-10 years. How is this field changing? What are the current trends? And mostly, what have I been missing? In May 2002, I attended the Global Health Council Annual Conference in Washington DC, expecting to be brought up to date on the latest ideas from academic and government centers. I assumed that after 16 years “in the bush” I would be out of date, and I was looking forward to being challenged.  Instead I found people talking about the same kinds of programs they had been discussing 20 years ago – and it seemed stale. Yet global health has not always been stuck.

My introduction to global health – it was then called international health – was at a MAP International conference and seminar in 1984. MAP, a global Christian health and relief organization, was a strong supporter of the kind of Primary Health Care promoted at Alma Ata in 1978. It was introducing these concepts to people with careers in curative missionary medicine. It was exciting: clinical and public health people were talking with each other, exploring the possibility that rural villagers knew what their health needs were, and that we technical people should listen to them. Their communities, we were taught, should be the hub of any health and development activities; those activities would be most effective when they were “community-based”.

To be sure, there was another approach still very much alive in international health: the “vertical” programs. In contrast to “horizontal” primary care programs, the vertical disease-specific programs were often “donor driven” and run by outsiders. These programs had some remarkable successes, such as small-pox eradication in the late 70s, and some equally striking failures, like malaria eradication in the 60s. What made the mid 1980s such an exciting time for international health is that there was an active debate between the “PHC” people and the more traditional public health and clinical people.

By the 90s a new element entered the conversation. In 1993 the National Council for International Health published Global Learning for Health, an eclectic collection of experiences and thoughts about how we can "bring international health back home". International health workers’ experiences in innovative health programs in the third world began to highlight the deficiencies in western health care systems. These workers – perhaps having learned to listen from their community-based orientation – realized that approaches they were using overseas might work equally well in the “developed” west.

Admittedly, this idea of bringing home approaches that were learned “over there” has not caught on very well – though oral rehydration therapy has become standard of care for diarrhea in US hospitals, and some communities have parish nursing programs that utilize volunteers similar to village health workers. But again, the importance of the ideas behind Global Leaning for Health is that some people were reflecting on their work in light of what they came back home to, and there was the possibility of a debate between the people who had learned from international health, and those who were still trying only to teach it.

With this promising background of listening in local communities, learning there, and bringing what we learned back home, I assumed (or at least hoped) that by 2002, there would be a new “global health”. Having considered the possibility that some communities may know what they needed, and having realized that some of the ways “they” do things may be appropriate even for us, we can truly function as an inter-related global village. “Globalization” is the by-word; the National Council for International Health changed its name to the Global Health Council. Now all of us, representatives from poor and rich countries alike, can sit together at some global table and discuss as equals how to approach global health. That, at least, is the theory. My attendance at the 2002 Global Health Council’s Annual Conference, however, gave me a different picture.

My first impression of the conference was that I was hearing nothing really new. There were new technologies, new statistics, and new jargon, but these were all buttressing old approaches to global health problems. Old approaches are not per se bad; but after having been in the debates about top-down vs bottom-up approaches, and after being convinced that we do need to listen closely to the people we are serving, I was surprised to find very little of this kind of conversation. I heard the results of innumerable studies, and the humanitarian pronouncements of many important people. And at the end, I heard pieces of a passionate debate – but even that debate seemed to miss something. So I went back to my notes to try and understand better what was bothering me.

·      At a panel discussion on “Maternal Mortality: A Human Rights Perspective” one presenter spoke of the need for safe abortions and post-abortion care. I commented that very few if any of the maternal deaths I had seen in 15 years had been related to abortions, either spontaneous or induced. The response was a statistic: 13% of maternal deaths world-wide are due to complications of abortion (meaning 87% were other complications of pregnancy). Yet of the 20 or so conference exhibitors dealing with family planning or women’s health, I could find only 2 mentioning emergency obstetric care (EmOC) in their abstract. The emphases of our women’s health programs don’t seem aimed at the main causes of death.

·      There were a few places where Africans did question our assumptions - but very quietly, “in between the lines”. At the launching of the African Council for Sustainable Health Development (ACOSHED), one African health official was asked, “Why do all Africans say they are helpless? Why don’t you do a better job coordinating donors?” His response was eloquent: “You cannot coordinate donors when you have your own vision.” Do we realize the strain we put on African health systems when there are so many of us to coordinate? Do we spend any time listening to what that African vision is?

·      And at the panel on “Tuberculosis and AIDS: The Critical but Ignored Linkage”, the African presenter was Dr. Francis Omaswa from the Ugandan Ministry of Health. He addressed his given topic well – and then, just before sitting down, said “Our number one killer still remains malaria.” We could have a statistical debate, but malaria still remains foremost in the minds of many Africans. Yet of all the conference panels and roundtables, 21 were on HIV/AIDS, and only 4 were on malaria; and there were ten booths in the exhibition hall dealing wholly or partly with AIDS, but none dedicated solely to malaria. Have we listened to Africa’s priorities?

·      Finally, I heard quoted yet again the proverb about giving a man fish, and he will eat today; teach him how to fish, and he will eat every day. The proverb does address the “relief to development” question – but are we still assuming the fellow doesn’t know how to fish? Since this is a global village, perhaps he has no fish because his river is polluted from other “development” efforts; perhaps he has fish to sell, but no market. The metaphor still works, as long as we remember that we are part of his economy, not just his savior.

·      I did not hear the controversy around Thabo Mbeki mentioned at any of the discussions on AIDS I attended, unless I raised it. Yet he is an important voice in the AIDS debate in Africa, and his views deserve to be examined, even if we don’t agree with them. The press has crucified him, but at this prestigious international health meeting we did worse: we ignored him. Do we think the western approach to AIDS is really completely appropriate in Africa? The one passionate debate at the end of the conference was about whether we work with drug companies to get anti-retrovirals into Africa, or instead pressure the companies to lower their prices and in the meantime find generic drugs made in other countries. Yet the assumption on both sides was that anti-retrovirals must be a cornerstone of AIDS care in Africa. A larger question, according to Mbeki, is the validity of that assumption – but it’s not a question we asked.

·      We heard a presentation by Edward Green at the pre-conference retreat of the Christian Connections for International Health (CCIH). He presented the findings of his research into why the incidence of AIDS is falling in Uganda, suggesting that a main reason for the decline is changes in sexual practices, not condom use. However, he had difficulty publishing his findings – one journal even telling him that his work was “dangerous” because people might stop using condoms as a result. He was listening to what the people of Uganda had been saying – and listening to his own findings – but the academic community didn’t want to hear them.

In reviewing these reasons for my discomfort at the Global Health Conference, I found a single theme running through all of them: are we listening? Community-based health care taught us that we should listen to poor people in the village – but that is a long difficult process. It is no surprise that I heard once in a workshop in East Africa that as we facilitate development discussions in villages, sometimes we need to “facipulate”: appear to facilitate, but really manipulate. Have we done the same thing with African NGOs and Ministries of Health? Why are we so sure of our own agendas? One discussant in a maternal mortality workshop was concerned that as conservative anti-abortion policies in Washington influence funding for women’s health care, the programs would become “donor-driven” – seemingly unaware that her own pro-abortion programs were equally donor-driven.

And what has happened to Global Learning For Health? The ultimate result of listening to people is learning from them: we let what they tell us influence us and the way we function at home. True globalization means that we need to learn as much as teach, and receive as much as give; true globalization means we no longer control the agenda of how this happens. But I don’t hear this need to listen and to learn articulated any more.

It seems instead that we think we know what the world needs. We speak a new “global” language, but often only dress up old neo-colonial ideas with new technologies. In our shrinking world we feel more intensely the weight of the world’s disease burden, and declare without irony (as the conference program cover did) “when it comes to global health, there is no them, only us” – never realizing the double meaning of the phrase. The intention, of course, is to affirm a global interconnected “us”, but the conference instead seemed to affirm a western “us” trying to help a poor “them” – a “them” whose agenda seems not to exist.

Is it too late to start listening again?

***

Perhaps it is. In March 2015 I tried again to update myself – this time at the annual meeting of the Consortium of Universities for Global Health in Boston. To me, it seemed that global health was really losing its way. Or possibly, it was simply becoming up-to-date, in sync with the latest advances of biomedicine and public health. In either case it appeared that listening was no longer necessary in global health, that global health answers would be coming from well-conducted studies, from applications of the latest technology, but certainly not from the people being served. 

For me, the best part of the conference, by far, was the student essay contest. The students were alive, fresh, honest, passionate; their stories raw, full of wonder, fear, anger, pity and compassion. One student was robbed; another had her first experience watching children die; a third described mapping health facilities in a Haitian village that was leveled four months later by an earthquake.

In comparison, the rest of the presentations were careful, plodding, and self-assured. Like all good science, they were accurate, considering all possible variables, cautiously hopeful based on the evidence. They were about “platforms”, “systems,” “value chains”, and “apps”; about capacity, scale-up, determinants, and assessment. Politics and culture were factored in, but only as “context”. As usual, these scientific presentations decided what the question was, and then proceeded to thoroughly answer the question they just asked. But was it the right question?

To me, what was missing was the connection between the students’ experiences and the academic answers.

Would it be possible to have a conference where the student essays were first, were in fact the introductory plenary? Students, as the main drivers of university global health programs, deserve a larger role than just an essay contest. Why are they studying global health? What do they want? Perhaps we could begin with their experiences, their impressions, their questions. The entire conference could be an ongoing dialogue, or dance, or sometimes even duel, between raw experience and careful science.

Both are necessary. Student interest is only one driver of global health growth; the other is, of course, careful science, and the technological solutions it produces. These solutions from the industry, together with government desire for global health security, provide the technology, and the necessary funds, for the massive growth of global health [1].

A conference that seeks to be a conscious live dialogue between those with fresh experience of the problems and those actively involved in seeking responses would itself be a unique contribution to this still burgeoning field of global health. And such a dialogue could prepare the way for the far more fundamental dialogue that still needs to happen: between global health scholars and activists in the West, and those in the receiving countries.

Low and middle income country scholars know where the money, the technical expertise, and the high paying jobs are; they increasingly know how to access these resources. But what do they really want? What are their visions for global health? Opening the essay contest to narrative essays by citizens of middle and low income countries would be a way to begin hearing voices we are not used to.

But this was not the conference I experienced in 2002, or in 2015.

This piece was originally published in the collection "Global Health Means Listening".

Raymond Downing is an American medical doctor. After medical school and internship in New York City, he studied Family Medicine in Knoxville, Tennessee. Then he and his wife, Janice Armstrong, also a Family Doctor, opened a government-funded Family Practice clinic in a rural Appalachian county north of Knoxville. After seven years there, they and their family of two children moved to Eastern Sudan to work in primary care in a refugee settlement for three years. Following that they spent four years at a Mennonite mission hospital in Tanzania, and in 1993 they moved to Kenya. Downing worked for a year as Medical Coordinator in the New Sudan Council of Churches, with frequent travel to Southern Sudan. In 1995 he and Jan moved to western Kenya to work in a Quaker mission hospital. In 2001 they returned to the U.S. to work with the Indian Health Service on the Navajo reservation. They returned to western Kenya in 2004 to serve as Lecturers in Family Medicine at Moi University School of Medicine in Eldoret, helping to establish the first Family Medicine program in Kenya. They both continue to work there.

References

[1] Lakoff, A, “Two Regimes of Global Health,” Humanity: An International Journal of Human Rights, Humanitarianism, and Development, Volume 1, Number 1, Fall 2010, pp. 59-79.