Dr. Paul Farmer, global health and human rights activist, founder of the nonprofit Partners in Health, and a Harvard anthropologist and medical professor, was recently in Seattle and took time out for a two-hour open Q&A session with UW students that centered on equity as the key to global health.
In celebration of Black History Month, Farmer opened the discussion by asking students to think about what case fatality rates tell us about equity. Farmer asked students to reflect on the ill effects of centuries of events and processes that have stacked the odds against large groups of people – in terms of risk of being exposed to a disease and what happens after a person gets sick – and the roles that racism and inequality play. He challenged students to widen their “lenses” by thinking about the global political economy – and how we can undo centuries of racism and gender disparity that is literally making us sick.
“If we keep erasing history we will always be lost, and not know what reparative actions are required to make the world a more equitable place,” said Farmer. Farmer emphasized that a key aspect of global health is to restore history – by recovering counter colonial histories that have been erased and developing correctives. He conveyed that at Harvard, medical students are required to study social medicine in the course Essentials of Medicine, though pointing out that the content is not included in Medical Board exams.
The discussion was facilitated by Dr. Rachel Chapman, UW professor of Global Health and Anthropology, who asked students in the room to consider the unequal race-gender dynamics of a classroom space, and to favor more equity by self-ordering their questions so that people with less social power ask their questions first.
Farmer and Chapman started the discussion by asking students “What questions should we be taking up in global health?” Students responded to the opportunity with an eye-opening discussion that included university global health curricula, humility, colonialism, epistemology and the erasure of knowledge, global health career paths in international development, and respect.
Q: How can we avoid reproducing colonial systems when donors fund INGOs instead of funding National Ministries of Health?
A: The erasure of history is a critical part of the neo-liberalization of global health. Even today propaganda around colonialism lives on, for example, when people say that there were better medical systems under colonialism. This propaganda is entirely false. Colonial health systems were guided by the idea of “control over care” and focused (and failed) on disease control. They failed to provided care, failed to establish health systems, and epidemics exploded under colonialism – they failed on the public health and clinical fronts, and yet propaganda succeeded in a narrative that says that after independence it was somehow worse. We need to ask what happened after decolonization. We need to learn about history and why things are the way they are, or we won’t get the staff, stuff, space and systems we need.
Q: Can you expand on epistemological humility? How can we encourage global health practitioners and medical anthropologists to be more humble about what they do, and to listen to people in the global south as people who have something to teach?
A: There are gifted people in this room, and I do not suggest that anyone abandons their passions. But what do we do in privileged spaces - where epistemological humility, cultural humility, any kind humility - is not rewarded? Humility is worth cultivating more consciously. Desocialized/psychological ways are not brave enough. How can we address arrogance that is systemic? Some fields are particularly prone to a lack of epistemological humility, for example, development economics. We must understand that everyone is part of an epistemological system that is different from one’s own. Our problem is the idea of being culturally competent, and people thinking they know things they can’t possibly know. When I work in places, I spend a lot of time on top of my clinical duties asking people about things, asking questions like “Where were you born? Tell me about your family?” Not everyone is interested in epistemology, but we should be. We are weak in laying down new knowledge in global health, public health and medicine, but we don’t have to be. I’m glad when historians and anthropologists go into global health equity – and go into deep inquiry.
Q: How do you envision decolonizing research in medical practices in global health? If we go into working with a community, did the community ask us to be there? What is that driving force for us to go there and be “saviors” if we are using our Western views to validate our mission there?
A: Cultural humility, respect, and restoration of history fit into this equation. These are also safeguards against romanticizing all epistemologies and ignoring important findings that could be replicated with different meanings. How can we respect and learn, but not be extractive about knowledge? We’ll struggle with this question. We have to build universities in places where there are “university deserts.” There are also new possibilities with new technologies. In Canada, a place where colonial propaganda has been very successful, indigenous people have been split into 632 groups. Do we want 632 groups? No universalizing language? I think this would fail IPs, but to make their knowledge different from other epistemologies is a trap where they could lose out on knowledge from other universities like Oxford, Cambridge, and UW. In some countries it is expected that you work with local colleagues or you won’t get through national review boards unless you do it their way, and I agree with that. That is a corrective – in response to something that went down the drain of history. That is called respect.
Q: I see global health as becoming an industry – multilaterals, bilaterals, and NGOs are a dime a dozen. I am fearful of ending up on a path where I can join an organization, have a nice job, travel to places I want to go, and have a lot of personal gain, but not contribute to global health equity. Are there any underlying principles to keep in mind or experiences to pursue that would allow me to be as useful as possible in this field?
A: Chapman: How do you keep from being part of racial capitalism in creating a need for an expertise in which your benefit and capital will grow exponentially because you’re filling a place because your existence creates a need for the place? There might be expertise on the ground but you’re fitting yourself into an economy where you may be perpetuating the inequities. Some NGOs, like HAI, funnel resources to the only sustainable sector – the public sector – rather than allocating resources to an American NGO, which would use them much quicker. To me the best thing is to get yourself out of a job, and not be in a job to stay in it. Ask who are my local counterparts that can do this, and how can I move resources to them in sustainable ways? Lack of individual cultural humility that makes people believe they are experts and can do something better than a local person with experience working in a war in their own country, for example, is breaking something in people and institutions. The need for you to be an expert to go somewhere is an institutional creation here – there, it’s expected that these inexperienced “experts” will come so that a national institution can get funding for their own health system so they can run maternal health or get vaccinations, for example. Universities require medical school applicants to have global experience – but that means inexperienced people in resource poor conditions get access to people’s bodies. We need to think about these institutional imbalances.
A: Farmer: This question merits regular elevation. NGOs like HAI or Partners in Health would say what Rachel Chapman just said. In Haiti, after the 2010 earthquake, most training centers for doctors and dentists were destroyed - if ever there were a time to avoid the neoliberal logic that public sectors can never do anything it would be then. We built a medical center but it is public property with the Ministry – a public good. In the development world in the 80s, people said Africa needs to develop primary education, not tertiary education. That’s high formalism of colonialism. Can you find either a university or group like HAI? One student related working with a well-funded NGO that glorified external experts, doing “primitive, non-helpful” projects. She said the NGO was making no efforts to have the work done by local counterparts. So she left and found another more effective organization. She recognized her own privilege. You will be faced with these challenges – and sometimes you can change the organization, but incentives are set up in the way that you fear. We want to bring talent back to social justice organizations. You have to be discerning and will make mistakes – but learn how to do things better. If you’re part of a system that siphons money from the public sector, part of a system that does not create opportunities to exploit local talent, a system that does not think about poor people – these are the safeguards I keep in mind. Preferential opportunities for the poor, accompaniment, and structural violence – these are three ideas that keep me out of trouble.
Q I read the book AIDS and Accusation – in Nigeria there is stigma against HIV, is there a way for legislation to help?
A: I’ve never been in northern Nigeria. So I’m going to share experiences from other places. The biggest trap you’re facing is: structural barriers are not always readily seen. Nigeria doesn’t even put 2% of its GDP in health care. In the past, I’ve made the mistake to assume that psychological, cognitive, or cultural barriers were the problem. But it’s a structural problem. If there are cultural problems, I’m more suspicious of us, the caregivers. Our job is to diagnose the flaws of the system serving poor people, not the flaws of the people we’re meant to serve. We misdiagnose system failure as patient failure. Always assume there are structural impediments you can’t see – make a list of 10 possibilities and put them in order. If we’re talking about poor people, we often blame the patient and misdiagnose the barriers as psychological, cognitive, or cultural – but actually it’s structural barriers. The majority of legislation in Nigeria was punitive (fines, isolation, quarantine) – but there is the possibility of progressive legislation. For example, opt-out tests for pediatric HIV. Legislation to force people to do things in clinical “deserts” usually fail. Something other than just legislation is required. I recommend everyone doing a global health degree to look at the cases in Putting People First – critiques of the tyranny of the empirical.
For a video (accessible to UW students) of the full talk, see: https://mediasite.hs.washington.edu/Mediasite/Play/55158717239b490c887a8cd75fa50a6d1d (Part 1) and https://mediasite.hs.washington.edu/Mediasite/Play/d67e3ae47f04455291f615252f02519c1d (Part 2)