University of California Press, 2013, 478 pages
This textbook was written for an undergraduate course on global health at Harvard University, compulsory for those enrolled at Harvard Medical School. It aims to introduce ethical, social, economic, and political theories and methods to medics in order to critically inform their analyses of the frameworks used to build and justify global health movements. As such, the emphasis is on giving the reader the capacity to do the analysis him/herself rather than laying out the full exegesis in the book, which focuses more on outlining theories with brief illustrative examples and case studies.
It is edited by eminent physician-anthropologists Paul Farmer, Arthur Kleinman and Jim Yong Kim, the last of whom is now president of the World Bank. Refreshingly, and perhaps indicative of the optimistic tone of the book, the final editor has not yet finished his graduate studies. He is global health activist and joint MD-PhD student, Matthew Basilico. So they are all (or will be) doctors who are also trained in what they refer to as the “resocializing disciplines – anthropology, sociology, history, political economy” (p.3). One key thesis of the text is that the practice of medicine and the theorising of these other disciplines inform one another; both are required to forge the new multidisciplinary global health practice that they advocate. They propose “biosocial analysis” (p.xix) as a means of developing global health to become “more than just a hobby” (p.xvi), using this book as a “toolkit of global hope” (p.xvi). These quotations from the preface immediately set the tone for a text that is frequently stirring and emotionally charged, while mostly remaining balanced and lucid, as we have come to expect from Farmer and Kleinman. (I cannot comment on Yong Kim and Basilico’s previous work as I am not familiar with it).
There are 12 chapters and 478 pages; I do not propose to describe and analyse all of them. They cover a broad range of topics: unpacking the meaning(s) and history of health and global health, exploring the ethical and political claims for and against health for all, exploring how aid does and doesn’t work, as well as examining healthcare delivery models. Instead, I seek to elucidate the key theses, using two chapters to evaluate the arguments and case studies used in the book to support them in order to produce a broad assessment of the successes of the book.
The authors describe the first decade of the 21st century as a “golden age of global health” (p.302). They trace the history of public health from colonial medicine to international health, to Alma-Ata and the primary healthcare movement, to selective primary healthcare, to the neoliberal era and finally to this golden age (which appears to be at risk of ending with the global financial crisis). So what do they mean by this emotive term? In the fifth chapter, Luke Messac and Krishna Prabhu use the example of AIDS to show how technoscience, biosocial analysis, community activism and political will combined to redefine the possible, leading to a massive increase in global health funding. Worldwide development assistance for health rose from $5.6bn in 1990 to $8.7bn in 1998, and then to $23.8bn in 2007. Likewise, in 2000 the USA funded antiretroviral therapy for a few hundred people around the world. By 2009, the President’s Emergency Plan for Aids Relief (PEPFAR) supported 2.5m people in 24 nations for antiretroviral treatment, as well as funding 539,800 interventions for pregnant women who were HIV positive.
What happened? Global health practitioners, previously “socialized for scarcity” (p.115) had been trying to modify use of what little resources they had, i.e. to optimise “use of a tiny resource pie” (p.115). But now they refocused their efforts on expanding the size of that pie. At the same time, activists mobilised political will to take on the pharmaceutical companies through various methods of struggle: legal, journalistic, public protest, etc. They succeeded in forcing the industry to dramatically reduce prices. In other words, rather than starting from a ‘realist’ or prudential standpoint of knowing what resources and funds were available and working within that remit, global health practitioners and activists started from the ethical standpoint that every person suffering with AIDS deserved treatment, wherever they were and whatever their financial and social circumstances. If resources and funds did not allow that, then they had to figure out a way to change that, i.e. they had to reimagine the possible.
So when we move on from AIDS and think of health more generally, how do we figure out what our ethical starting point should be? Another key chapter, written by Basilico and Kleinman as well as several others, examines the moral roots of global health work. It briefly surveys the contribution of utilitarianism, particularly with regard to cost-effectiveness analysis and disability-adjusted life years (DALYs), before moving on to cosmopolitan models such as human rights and Amartya Sen and Martha Nussbaum’s capabilities approaches. By this point, the authors of previous chapters have already laid their cards on the table in stating their belief that health is a human right. However, this chapter demonstrates how the editors have not let dogma cloud their judgement. They recognise the problems of the human rights model: including the various interpretations of human rights discourses co-opted by opposite sides of the Cold War and the prioritisation of civil and political rights over social and economic rights after the end of the Cold War. Human rights theory’s reference to the individual rather than the community is discussed. This model’s promotion of small interventions rather than broad-based social change is mentioned, with reference to Alain Badiou. Finally, the one-size-fits-all universalism of all cosmopolitan models is discussed.
Here the chapter demonstrates one of the shortfalls of the book, inevitable in a text of this nature. The brief but lucid outlines of theory whet the appetite for a more sustained critical analysis that never materialises. In this case, I would have appreciated a discussion of how the supposed universalism of the human rights approach interacts with the actual diversity of interpretations and implementations, perhaps illustrated with ethnographic evidence. Of course this would have led to a bloated textbook, rather than the concise and readable one that we have. And it is somewhat pointless to chide the authors for what is left out of an already pretty heavy tome. This book does not aim to be exhaustive. It is an introduction, with a recommended reading section at the end of each chapter for those who want to probe further. This chapter finishes by stating its aim to be a “springboard to deeper consideration of the moral roots of engagement in this work” (p.285). A more sustained critical engagement with any topic would also likely lose its balance, which is undesirable in an introductory textbook. The authors have clearly made huge efforts not to unduly favour particular schools of thought. In fact their efforts at balance sometimes tip into what appears to be effortful palliation. The discussion of the failures of structural adjustment with regard to improving the health of developing nations is a case in point.
So the authors start from the ethical standpoint of health equity, health as a human right for all. From here they seek to reimagine the practice of global health. They use the example of AIDS throughout the book to illustrate how this has been done in the past, and so can be done in the future. AIDS is analysed through the prism of healthcare delivery models (especially Partners in Health, set up by Paul Farmer and Jim Yong Kim), of funding, of activism, and importantly, through case studies of those suffering with AIDS. The driving thrust of all this is that “the limited vision of what is currently defined as possible… is not immutable” (p.340), i.e. we should not be constrained by it.
This use of AIDS neatly ties the book together, lending coherence to its narrative, a difficult task in a textbook of this size. It also falls on the right side of the fine balance between perseverative redundancy and passionate reiteration of an important point. However, the lack of other examples of how the possible has been reimagined in global health work did lead me to wonder whether AIDS was being used to link the chapters in this way, or was features simply because the authors could not think of any other examples. The construction of the British NHS and Mexican Seguro Popular are both briefly mentioned, but with little critical engagement, and there are no other examples given from the “golden age of global health”.
Overall though, this is a superb, inspiring book introducing the critical tools of social theory to undergraduates. It has much to offer to postgraduates as well, particularly its revision of concepts. When was the last time I saw the Foucaultian concepts of biopower and governmentality explained in four pages with such clarity? Never. Owing to its breadth of scope, I would also recommend this book to general readers and activists. This kind of balanced analysis combined with an openly partisan normative claim for global health equity is a rare thing that should be read beyond the realms of academia. The authors finish with the simple plea for the “pursuit of a more just, fair society that allows our children, wherever they are born, a decent shot at a decent life” (p.353). If this is how medicine is taught at Harvard I wish I had studied there.