Digging deeper with Dr. Mukherjee

Posted by Victor Roy on December 16, 2008

Imagine an orphaned 9 year old girl caring for her 3 siblings in a village in Rwanda. What are the girl's risk factors for getting HIV/AIDS?

On Tuesday, December 9th, the GlobeMed Network had the great opportunity to engage in such questions with Dr. Joia Mukherjee, the Medical Director from Partners in Health, on a webinar devoted to November and December's globalhealthU theme - Health and Structural Violence. Students from across the country participated, as Dr. Mukherjee used photographs and conversation to reveal the root causes of suffering and disease.

When Dr. Mukherjee asked the question I started this post with, we listed off factors like unsafe sex, promiscuity, and other standard factors. If these are the real factors, then "how come Keith Richards doesn't have AIDS?", Mukherjee asked. Main point: underlying racism triggers a set of "normal" responses, even from socially aware students, that harm our ability to identify the root factors of disease - poverty, inequality, among others. Instead, such assumptions lead to the creation of public health strategies that do little to bring relief and hope to those most vulnerable.

If we're to become effective advocates, then we'll have to understand that health is shaped by deeply embedded social, political, and economic structures which often exclude people from vital resources required for a healthy life. War, poverty, gender inequality, along with racism, are examples of structural violence that Dr. Mukherjee highlighted. Dr. Mukherjee did a great job of asking questions and conversing with students about many examples of structural violence she's seen from her work and experiences in global health.

Two ways, among many others, jumped out to me during the webinar as ways of addressing structural violence.

The first method is a pragmatic global health strategy advocated by many and highlighted by Dr. Mukherjee on Tuesday - employ and train community health workers. CHWs provide dignity and hope, both attacking a community's health problems while also providing a vital source of employment for tens of members in a community. Often, CHWs are healed patients themselves, who then gain a source of income through the job, sustain themselves and their families, and break the cycle of poverty in the process. CHWs are literally foot soldiers fighting structural violence. They're worth atleast several more blog posts (and a ton more funding!).

The second method can be used by all of us all the time, and was at the basis of Mukherjee's presentation: we should question our (often clouded) assumptions about the roots of disease and suffering and ask hard questions about how to act effectively in support of the poorest and most vulnerable. We must recognize how our own contexts and livelihoods (often amidst relative wealth and abundance) might shape initial assumptions that are mistaken and how our efforts can better reflect a clear understanding of structural violence.

Thank you, Dr. Mukherjee, for helping us to dig deeper.

Also, check out Jon Shaffer's (Northwestern chapter) thoughts on the webinar!

Mainstreaming an Understanding of Structural Violence

Posted by Hannah Robbins on December 4, 2008

In his article “Structural Violence and Clinical Medicine,” Paul Farmer declares, “Medical professionals are not trained to make structural interventions.” However, it seems clear to those of us who ascribe to the concept of structural violence that this is an outlook on medical practice that cannot, and should not, be ignored.  How then can we explain the fact that medical professionals, those whose job (and duty) it is to address health problems to the best of their ability, do not employ an understanding of structural violence?  What can be done to conquer the discrepancy that exists between what we know needs to be done to improve the effectiveness of clinical medicine and the nonexistence of a professional position that can fill this void? Perhaps the issue surrounding the concept of structural violence is no longer a decision between a theoretical “yay” or “nay” to the commitment to follow this new, more comprehensive philosophy (which Farmer proves as effective in his description of Partners In Health projects in Baltimore, Haiti and Rwanda), yet how to incorporate this biosocial medical model into mainstream clinical medicine and how to act on this commitment.

In an attempt to answer this provocation, Farmer concludes that we must “link our efforts to those of others committed to initiating virtuous social cycles” and only then can we expect “a future in which medicine attains its noblest goals.”  Though this is a valuable step in putting an understanding of structural violence into effective use, it seems there may be a way to go beyond merely linking medical efforts to social efforts, and instead fully incorporate one within the other.  As Dr. Deborah Claire Stewart (from the UC Davis Medical Center) says, "As we look over the last two decades or so, what's really causing health problems in our society has changed, but we haven't actually changed the focus of our training." So, we must ask, why not?

Though the implementation of a biosocial curriculum within the field of medicine has by no means become the norm, we are certainly beginning to witness a major shift in clinical practice within many individuals and organizations. Yet can we expect this trend to catch on, and how far can we expect this changing perspective to take us?  Will we one day be able to confidently say that medical professionals are trained to make structural interventions? Or if not trained to make structural interventions, are at least educated with a thorough understanding of the pervasiveness of social forces on clinical medicine? 

But of course there are always the potential negatives to take into account. Is it possible that this inclusion of a biosocial philosophy within medicine will prove disastrous and promote the idea that medical professionals should stick to biology and chemistry and stray away from sociology and anthropology?  If we ask the medical field to expand its horizons, what will be the realistic cost of this change?  I don’t have the answers.  But, as Farmer says, “Asking these questions needs to be the beginning of a conversation within medicine and public health, rather than the end of one.”  Let’s not let our fear of uncertainty prevent us from continuing the conversation. 

The Fight Continues

Posted by Victor Roy on December 1, 2008

On December 1st each year, the global health community recognizes World AIDS Day. GlobeMed joins in this day of refection and looking forward. GlobeMed's chapter at UNC is organizing an event this week that highlights this work.

Today is the 20th anniversary since the first WAD - the world community has made a lot of progress over these two decades, but much more work lies ahead. More than 33 million people have AIDS around the world, with the pandemic hitting resource-poor communities the hardest.

Here are a few articles and blog posts from today:

New York Times editorial page

Rick Warren's Civil Forum on Global Health

President-Elect Obama's Message on change.gov

Post more thoughts and links in the comments section.

The Oppression of Altruism

Posted by Divya Mallampati on November 25, 2008

In his book King Leopold's Ghost, Adam Hochschild notes that colonial regimes were effective in carrying out mass violence and oppression by simply believing that those they oppressed were somehow less than human. Colonialism, not just in the case of the Belgian Congo, has subscribed to that philosophy- one that has driven the horrendous acts that we are all too familiar with. After all, inflicting pain is easy when you do not consider the other equal. But what if recognizing the worth of another is also a form of oppression?

The motivations behind colonialism and foreign aid are, of course, very different. Colonialism rested on the dehumanization of people through forced labor, systematic violence, and economic exploitation. Most colonial governments disregarded local traditions and neglected to integrate their economic and political systems with pre-existing cultural and social norms.

On the other hand, the motives behind current foreign aid efforts are presumably altruistic. Major foundations, corporations, and multinational organizations provide billions of dollars each year to fight poverty and malnutrition, provide education, build infrastructures, and promote economic development in the name of equity and humanity. These well-intentioned programs, however, are sometimes dominated by Western discourse and policies that are not attuned to local beliefs or structures- a notion not far from the policies of colonialism that benefited conquering nations. In many cases they create a dependency on aid and can worsen the situation at hand. Altruism, thus, has turned into a source of suffering and pain.

Perhaps it is ambitious to parallel colonialism with foreign aid. I can't argue that both are equally undesirable. One is regarded as unforgivably violent and cruel; the other offers the promise of growth and prosperity. But both point to the importance of truly understanding structural forces. Colonialism has left a legacy of oppression because governments used political and economic means to prevent individuals from leading the lives they wanted. Foreign aid policies, similarly, fail to recognize that communities are embedded in long histories, rich cultures, and complex social, economic, and political systems. If foreign aid is to escape the fate of colonialism, we need to recognize that problems do not exist just for us to solve- that would be too easy. They exist for us to understand, think about, and work together to address.