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In the days of the Soviet Union, the powerful Sanitation and Epidemiology Service sought out infectious diseases and stamped them out with compulsory vaccinations….the tactics were brutal—people were often taken from their families and hometowns for months to years—but they were effective. Now, instead, we have human rights. (1)–New York Times, December 5, 2000 This remark illuminates a recurring theme in the history of global health: every emerging global health framework comes with new ideologies that displace previous ones. This article examines six ideologies founded upon differing principles and assumptions that have shaped the state of global health today: colonialism, international health, development, charity, social entrepreneurship, and social justice. These ideologies are useful to understand because the ways in which global health problems are framed can inform the solutions proposed by organizations and policy-makers.
In examining colonial conceptions of global health and contemporary ones, we can see a clear distinction in how health problems are framed. In global health discourse there has been a recent move toward a social justice and human rights framework. In contrast, during the colonial era, subjugation of individuals for profit was the impetus for health interventions. In other words, ‘public health’ served the interests of colonial powers, with improvements in local health a negligible and secondary side-effect.(2) This is because colonialism was based, first and foremost, on the extraction of wealth to benefit the colonizing nation. During the height of European colonialism in the nineteenth century, this wealth took a variety of forms including ivory, slaves, sugar and eventually cotton, rubber, gold, coffee, and tea. The way in which colonialism informed global health can be witness in the construction of Panama Canal in the early 20th century. The Panama Canal was primarily an effort to increase trade. Unfortunately, this effort was at the expense of 21,000 laborers who died in the project before its failure. The failure of the French to build the Panama Canal was due to an epidemic of yellow fever and malaria among workers. Two physicians and leaders in public health, Walter Reed and Carlos Finlay, tried to solve this problem by examining potential causes of the outbreak, such as increased mosquito populations and swamps. While this effort seemed to be a humanitarian endeavor, it was by no means motivated by charity or social justice ideals. Instead, public health interventions were motivated by economic incentive as the poor health of workers was a detriment to commerce and colonial power. International Health The legacy of colonialism left its mark, as public health conceived of and practiced in the United States and Western Europe during the past century has primarily been a state activity and has been closely connected to the protection of the state’s interests. With concerns of an increasingly globalized world, many of the health issues that policy-makers face today remain “international” health issues. One of the key principles of this international conception of global health has been to protect citizens against threats perceived as having an external origin, particularly infectious diseases carried across national borders. “During the 1990s, American scientists, public health officials and defense experts argued that ‘emerging diseases’ presented a threat to American national security, international development and global health. In doing so, they recapitulated the previous century’s dominant logics of international health policy”.(3) Public health has thus been ‘international’, and closely allied with ideologies of national security and international commerce. Furthermore, Western medical research has addressed the needs of the developing world in beneficial ways—by developing quinine as a malarial prophylactic, prevention for yellow fever, etc.—but it has done so with a “West first” attitude consistent with the ethos of colonialism. The advances made in vaccinations, preventions, and treatments were researched almost exclusively because Western nations had military or
Social Entrepreneurship Social entrepreneurship should not be confused with charity. president George Bush in announcing US$15 billion in assistance for HIV/AIDS control described the pledge as a ‘work of mercy’”. and new global initiatives can. A nonprofit that practices social entrepreneurship. Many individuals from wealthier. people respond to human suffering by acting in a virtuous manner based on compassion.”(5) However. the international spread of disease was curbed and the extraction of wealth was preserved. make valued contributions to improving the health of marginalized people in the world. or altruism. “Development aid from many countries should also be welcomed. a referral hospital accepted a donation of oxygen concentrators to help maintain oxygen supplies.23% gross domestic product to the recommended 0. Through prevention and treatment. For example.7% are admirable.S. and recent endeavors to increase aid from the current average of 0. who are not merely driven by compassion. empathy. A study was done to find the reasons for the problem. Philanthropy Traditionally.commercial interest in areas where tropical diseases were prevalent. social entrepreneurship reflects more than the good intentions of its practitioners. charitable organizations survive at the mercy of their donors whose contributions vary with the economic climate. While charity reflects the benefactor’s compassion measured in terms of the generosity of donations to the less fortunate. yet oftentimes these donations are not useful and are given in ways that do not support the local economy. relies less heavily on donor funds because it creates social programs that are meant to be self-sustaining. social entrepreneurship uses its funds to make a lasting social impact. organizations. This would mean that more parents would have jobs and be empowered to take control of their health. investing in social ventures which can then generate their own revenues to sustain themselves. World Health Organization produced guidelines for medical equipment donations to address problems that may be encountered when the majority of global health resources come from charitable donations. but are also compelled by a desire for social change. and is also an important base of public support for official foreign aid. and is increasingly being directed towards emergency humanitarian aid. creating instructional programs which teach the poor how to grow their own food so that they can take care of themselves in the . there are dangers that those who are helped can be placed in a dependent position. The experience of a Gambian hospital provides a case in point. far more money would go into the local economy. while well-intentioned. while charity uses donor funds to buy food to ease the poor’s hunger. treated as victims not agents. Oftentimes. industrial nations feel obligated to donate money or unused items to those less fortunate. on the other hand.(8) The concentrators broke down and were put into storage. can often be misguided. “Humanitarianism provides the primary ethical basis of voluntary action undertaken by non-governmental organizations (NGOs). Social entrepreneurs manage donor contributions in an effective manner. Subsequently a hospital donations committee was established to oversee the donations process. and that the hospital did not have the expertise to assess or maintain the equipment. much of global health today comprises donated goods and unsustainable one-time initiatives. U. if aid agencies were to purchase goods locally and hire local health workers instead of bringing in foreign staff. development aid has been progressively reduced in recent years. In 2002. Furthermore. Interviews confirmed technical problems with the equipment and revealed that the donation process was flawed.(4) It must be acknowledged that generous philanthropy from concerned individuals and many foundations. Thus. and do. similar guidelines should be publicized and used to inform well-intentioned donors. When it comes to the intersection of charity and global health. Instead. (6). rather than towards sustainable development. the underlying societal rules and structures that generate the social ills are not addressed.(7) This trend has occurred because philanthropy. In a humanitarian approach. In 2000. In other words. global health has been tied to philanthropic ideals and religious notions of charity.
old social institutions have to disintegrate.(13) While the development agenda still continues. In other words. Encountering Development. but ultimately the quality of life for all would improve. global health activities have been increasingly framed within the context of social justice and human rights. In his book. rapid growth of material production and living standards. bonds of caste. deregulation. I’d like to see a fundamental change in ethics or culture around that. the high-tech pioneers of Silicon Valley. for instance. such as the World Bank and the International Monetary Fund. the development discourse of the past revolved around conceptions of the “third world”. (2) health as a key factor of sound business practice and social responsibility. Within this doctrine. or indirectly in choosing to support programs and organizations and individuals that have had impact. which honors people for their sacrifice—how much they give and the purity of their motives. Ancient philosophies have to be scrapped. and promoted neoliberal policies. The goals of this economic dream were echoed in one of the most influential documents of this period. and determination commonly associated with. decreased public sector spending. modernization of agriculture. We still have the lingering effect of a culture of charity.(10) Dees elaborates on the ideology of social entrepreneurship: “In society. I’d love to see an ethics change. not just for how much they give or how generous they are. and the widespread adoption of modern education and cultural values. creating value in business so that consumers are willing to pay for the goods and services.”(11) Development There are two broad frameworks in the contemporary global health discourse: one motivated by social justice and the other by economic development principles. rational producers and consumers whose decisions were motivated primarily by economic concerns. social entrepreneurship “combines the passion of a social mission with an image of business-like discipline. Furthermore. Arturo Escobar argues that this discourse created the construct of the third world in which the legitimating forces of the “first world” served the interests of the powerful rather than the powerless. from the start of the development movement it was predicted that inequalities would worsen as a result of market-based policies. prepared by a group convened by the United Nations: “There is a sense in which rapid economic progress is impossible without painful adjustments. individuals in a society were viewed as autonomous. Social Justice and Human Rights In the past decade. Today. and (3) the ethical principle of health as global citizenship. and large numbers of persons who cannot keep up with progress have to have their expectations of a comfortable life frustrated. Very few communities are willing to pay the full price of economic progress. innovation.”(9) The social entrepreneur’s philanthropic energies are channeled into business ventures. neoliberal structural adjustment policies have been curbed and the importance of cultural sensitivity and the pitfall of ethnocentrism have been recognized. and by doing so. the social entrepreneur earns a profit which is invested in the social ventures. so that we honor people for the impact they’ve had directly. Several key principles of this framework include: (1) health as a global public good. I’d like to see more value placed on social impact and success than on good intentions or effective marketing or the severity of the need you’re claiming to serve.”(12) The propagation of these early ideologies and the debt crisis of the 1980s ushered in a new set of programs around “development”. According to J. These programs were supported by the major financial institutions. the goals of the development movement remain ambitious—high levels of industrialization and urbanization.long run. and privatization. creed and race have to burst.(14) . Development ideology centers on the idea that increasing development is an economic incentive for the whole world— that “a rising tide lifts all boats” despite the inequalities that may result. Gregory Dees. later termed “structural adjustment policies” emphasized the market allocation of resources. Such policies.
‘Introduction: Disease. charitable notions. Today. whether or not we avert our gaze. citizenship. The process. The Declaration of Alma-Ata was adopted at the International Conference on Primary Health Care and expressed the need for urgent action by all governments to protect the health of all the people. housing.there are historical precedents for enshrining social and economic rights in official human rights declarations. at least on a small scale and almost surely on a much larger one. Paul Farmer is one individual champion for the use of a human rights discourse in global health. (3) King NB. Medicine. initially within the context of the constitution of the nation state.org/resources/publications/dialogue/2_01/articles/602. sickness. . and the right to security in the event of unemployment. in Arnold (1988b): 1–26. 2002.…”(16) Conclusion The ideologies of global health presented here are a simplistic outline of the more complex and dynamic frameworks around which global activities have been justified. In order to tackle the challenges of global health today. Lastly. Carnegie Council on Ethics and International Affairs. Articles 25 and 27 of the 1948 Universal Declaration of Human Rights were particularly revolutionary because they revealed a new focus on social and economic rights. while a human rights framework may be better suited to scale-up interventions through the public sector. the most important of which is the principle of health as a fundamental human right.html (2) Arnold (1988a)David Arnold. if we find the rhetorical tools necessary to bring the privileged on board as we build a movement to promote the rights of the poor. disease. For example. clothing.Article 25 states that everyone has the right to a standard of living adequate for the health and well-being of him or herself and of his or her family. these ideologies exist in various forms and continue to validate interventions and motivate funding. old age or in circumstances beyond control.”(15) An example of this move toward a social justice framework is the Alma-Ata declaration. development frameworks. and a global contract. He advocates for a life in which one has the opportunity to pursue one’s aspirations. concerns of national security. These rights include food. These frameworks are not mutually exclusive and each possesses unique strengths and weaknesses. and that this idea should be used as the basis of a social justice movement in global health: “Whether or not we see these horrible deaths [from disease and poverty]. Furthermore. it is important to understand the limitations of each ideology as the assumptions upon which global health work is founded have implications for the solutions proposed. and human rights discourses form the hodgepodge of motivations for global health work. Colonial sentiments. One need only read the Universal Declaration of Human Rights: articles 25 and 27 seem to speak directly to the issue and are infused with the human values advanced in this lecture… And these articles are actionable. necessary social services.cceia. they are happening…. Dr.” Human Rights Dialogue: Human Rihts for All? The Problem of the Human Rights Box. the strengths of these ideologies must be utilized in order to gather attention and resources. business models. commerce: ideologies of postcolonial global health. http://www. Winter 2000: 2(I). today needs to go global as a key dimension of global justice. an entrepreneurial framework may allow for greater innovation. widowhood. the key to progressive movement lies in unraveling the faults of the past with the hope of a better future. Global health needs to move out of the charity mode of bilateral aid and philanthropy into the realm of rights. Security. disability. Specifically.“It was one of the characteristics of modernity to take health out of the confines of religion and charity and make it a key element of action of the state and the rights of citizenship. While the field of global health may never be devoid of prejudice and new mistakes to be made. Footnotes (1) Chidi. medical care. “Why more Africans don’t use human rights language. Social Studies of Science 32:763–89. The declaration contained ten main points. and Empire’. Anselm Odinkalu.
Washington (D. 2005.C. Ilona. (9) Dees. Beyond good intentions: lessons on equipment donation from an African hospital. (6) Lancaster C. 2000. (8) Howie S. (5) Birdsall N. Transforming foreign aid: United States assistance in the 21st century.org/documents/dees_sedef. Int Aff. (11) Dees. . 1995. The shifting politics of foreign aid. Foreign Aff.84:136–152.org/documents/deesinterview. Lancet 2004.” The Tanner Lectures on Human Values. 2008.1069-1074. Personal interview.caseatduke. 8 June 2009 <http://www. (7) Woods N. Peel D. http://www. Encountering Development.(4) Alkire S. 1951. Department of Social and Economic Affairs. 108 pp.skollfoundation.364.58:630–631." Stanford Social Innovation Review (2007): 28-39. Princeton: Princeton University Press. Delivered at University of Utah.pdf (8 June 2009). Hill PC. .86(1):52–6. J Epidemiol Community Health 2004.org/media/skoll_docs/2007SP_feature_martinosberg. (12) United Nations. Global health and moral values. Gregory. Chen L.pdf (8 June 2009). Bull World Health Organ. J. March 30. (16) Paul Farmer. Arturo. "The Meaning of "Social Entrepreneurship". Sammeh M.caseatduke. (10) Martin.1. “Never Again?: Reflections on Human Values and Human Rights. Roger L. (13) Escobar. How to help poor countries. From charity to rights: proposal for five action areas of global health. (14) Kickbusch. 2005.): Institute for International Economics. 2005. "Social Entrepreneurship: The Case for Definition.pdf>. Measures for the Economic Development of Underdeveloped Countries. Hill SE. Njie M.Gregory.” http://www.81:393–409. (15) Ibid. and Sally Osberg. 34-35. et al. J..
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