The Dark Heart of Global Health?

Guest post by Johanna Crane, a medical anthropologist and assistant professor at the University of Washington and author of “Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science.”

Researchers collecting genetic data from Khomani Bushmen community in southern Africa.
Researchers collecting genetic data from Khomani Bushmen community in southern Africa.
Stanford

Global poverty isn’t just a tragedy. For the biomedical research community, it’s also an opportunity.

Last week, two of my students approached me wanting advice about how to get experience “doing” global health.  This happens to me all the time.  I teach classes on bioethics, science and society, the history of AIDS, and medicine across cultures.

Many of my students want to become doctors.  Some of them care deeply about global health inequalities, while others are primarily concerned with how to get accepted to medical school. Either way, they’re already figuring out what so many North American universities have figured out in the last decade:

Global health is a hot commodity. That is both good and bad news.

I began working in HIV research in the late 1990s, shortly after the first effective HIV medicines transformed the disease in the U.S. and people with AIDS stopped dying, and starting living.  I lived in San Francisco at the time, and I remember the week in 1998 when the Bay Area Reporter, the local gay newspaper, celebrated the fact that they had received no death notices for the first time since the epidemic began in 1981.

To folks who had come of age during the AIDS era, it seemed like nothing short of a miracle.  Unfortunately, it would take nearly a decade before the hardest-hit parts of the world, mostly in Africa, would see much benefit from this discovery.

Back then, Americans weren’t scrambling to go to Africa and “do” global health the way they are now.  Rather, African countries were ignorantly written off as places where people “didn’t understand Western time” and wouldn’t take the drugs properly – a view backed by the multinational pharmaceutical industry because it let them off the hook for pricing their products too high for poor countries.

And despite really important early studies done by African researchers in Congo, Uganda, and elsewhere, AIDS science was seen as something that happened in the U.S. and Europe, not Africa.

Johanna Crane cover Scrambling for AfricaToday, the landscape of AIDS research is dramatically different.  As I describe in my new book, Scrambling for Africa, African countries such as Uganda that were once ignored by all but a handful of American researchers have now become sought-after “partners” by some of the most prestigious research universities in the world.

Why?  Because over the last decade there has been an explosion of interest and investment in “global health” in this country, and when Americans—like my students—say they want to “do” global health, what they usually mean is that they want to go to Africa.

The benefit of this transformation is the fact that Western funders (the U.S. in particular) stopped stonewalling and began funding HIV treatment in poor countries.   This actually happened a decade ago, when then-President George W. Bush announced his $15 billion PEPFAR program back in 2003.

While it may pain liberals to admit this, it was Bush who actually took the bold step of putting big money behind HIV treatment in Africa.  Bill Clinton, on the other hand, sided with the pharmaceutical companies for much of his administration.

Around the same time, American HIV researchers started looking for ways to help curb the epidemic in less wealthy parts of the world.  Many of them turned towards English-speaking countries in sub-Saharan Africa, where the epidemic had hit hardest and a common language smoothed efforts to collaborate.

The fact that HIV treatment was coming to the continent made it a more attractive place to do research.  The large numbers of untreated and newly-treated patients represented a research population that was simply unavailable in the U.S.

As one American HIV researcher who shifted his work to Uganda told me, Africa had become “in vogue.”  As time passed, what started as an interest in HIV expanded to include other infectious diseases, especially malaria and tuberculosis, and, more recently, “non-communicable diseases” or “NCDs” like cancer.

This shift has brought a great deal of resources to some African clinics and hospitals.  For example, my book describes the transformation of one Ugandan HIV clinic from a two-room facility run out of a donated shipping container into a multi-building, state-of-the-art HIV treatment and international research center. One Ugandan researcher explained it to me like this:

“HIV,” he said, “opened Uganda’s doors to a lot of international organizations.”  AIDS, he went on, “is a bad thing that happened to Uganda, but it has also exposed the country to certain things maybe we would never have seen.”

So what’s bad here?  Why would anyone want to criticize this outpouring of attention and funding to health care and health research in poor countries? In part, for exactly that reason – because it seems beyond criticism, and that should make us nervous.

As interest in and funding for global health exploded, American universities have seen a proliferation of programs, institutes, and departments dedicated to “global health.” Hundreds of U.S. (not to mention Canadian) institutions are now competing for research and training sites in low-income countries, especially in Africa.

Ugandans waiting for care at a local clinic.
Ugandans waiting for care at a local clinic.
Wikipedia

In some ways, these efforts bring helpful resources to underfunded health care systems, but at the same time they generate a “scramble” for desirable—read: poor—research and clinical sites where Americans can go to “do” global health.  In short, global health needs inequality, even values it, in a way that deeply troubles the field’s defining goal of redressing global health disparities.  This is the potential “dark heart” that global health would rather not confront.

In an effort to promote collaboration and avoid appearances of parasitism, American institutions often use the language of “partnership” to describe their relationships with African clinics and universities.  The promotion of collaboration is all well and good, but too often global health boosters overlook they ways in which these programs are designed by and for American, not African, faculty and students.  American research money funds studies designed by American researchers; African researchers are often brought in after the fact to facilitate ethical approval and patient recruitment.

In Uganda, many aspiring health researchers must fund their studies out of their own pockets; it is only if they become “attached to someone” (as one Ugandan physician told me) that they might acquire foreign funding, and then only if their research question is of interest to the international funder.

Doctors at Donka
Doctors at Donka

Moreover, despite the language of “partnership,” American global health programs tend to set up their own, independent funding streams in Africa—often through “shell” NGOs—rather than work with existing administrative infrastructures, which are seen as “too difficult.”  Difficult they may be, but that is also a convenient excuse for keeping the purse strings tightly in American hands.

At the Ugandan clinic I studied, international funding has introduced new inequalities in employment as doctors and health care workers with American-backed paychecks often make much more than those working on government health salaries.  One clinic doctor I interviewed put it quite bluntly when he told me, “HIV money and research money has somehow killed our health system.”

Global health research and training programs depend on poor countries’ surfeit of undertreated patients in order to survive.  People don’t go to Japan or Sweden or Qatar to “do” global health because these places do not offer these kinds of “opportunities.”

As one Ugandan researcher I spoke with put it, “We have loads and loads of patients.  Other people don’t have patients.  They are training doctors under video – I saw it in Norway.  They have never touched patients!”  As a recent article in the Chronicle of Higher Ed noted, this desire and opportunity to “touch” patients is deeply troubling when it comes to untrained American undergraduate students (such as the ones who often approach me in search of programs that will allow them to do just that).

So, what do I tell the students who come to me looking for advice about getting into global health?  I affirm their desire to fight poverty and inequality, but I also ask them to consider the ethics of global health exchanges. Sometimes tell them things they don’t want to hear:

  • Going to Africa is going to primarily benefit you, not African patients.
  • People in Africa do not need you to educate them about HIV.
  • You are more likely to burden, rather than help, local health care providers.

Ultimately, the problem isn’t with these individual students, or with well-meaning global health researchers.  The problem is that very few people are willing to challenge the heroic narrative of global health and the “white savior complex” that puts good intentions beyond reproach.  This narrative obscures the ways in which global health needs and seeks out global poverty, even in its efforts to redress it.  Instead, it allows us to bask in a sentimentalism that lets us pat ourselves on the back for simultaneously cultivating global citizens and fighting health inequalities.

This is especially evident in Seattle, where global health is a full-fledged “sector” of our economy, and an increasing motivator of local technological entrepreneurship.  In this heroic narrative, U.S. global health efforts are framed as humanitarian and altruistic, even when they benefit American careers first and foremost.


Johanna Crane
Johanna Crane

Johanna Crane is an assistant professor at the University of Washington-Bothell in Interdisciplinary Arts and Sciences. A medical anthropologist, Crane teaches a variety of courses on the complex workings of power in relation to medicine, science, and technology. Her book Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science (Cornell University Press, 2013) is based on Crane’s fieldwork conducted in the U.S. and Uganda focused on how much of Africa has moved from being largely excluded from medical advances to becoming a key locus of knowledge production in global health and HIV research.

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