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The current debate over the global distribution of COVID-19 vaccines once again highlights the many shortcomings of the modern intellectual property (IP) system, especially when it comes to equitable access to medicines. This essay argues that the (unspoken) conceptual center of struggles over access to new pharmaceuticals rests in the IP system's colonial legacy, which perceives the world as uncharted territory that is ripe for discovery and ownership. This vision of the world as a blank canvas, or terra nullius, sets aside any other models of ownership and devalues other traditional modes of relating to territory and nature. Several examples show the long-lasting exclusionary effects of this hidden legacy of colonial conquest in the field of public health, ranging from the spiraling price of insulin to the distribution of COVID-19 vaccines to the negotiation of sharing mechanisms for virus samples. In all of these cases, the continuing marginalization of other interests by the IP system can lead to exploitation, without either the “sources” of materials, such as those from whom the samples were taken, or the recipients of the eventual product having any say in matters of price and access. This legacy of fundamental exclusion needs to be recognized and addressed in order to arrive at more equitable solutions to public health emergencies such as the current pandemic.
This paper interrogates the depoliticising effects of a seemingly neutral regulatory drive at the heart of the World Health Organization (WHO)'s promotion of traditional medicine. Emerging at WHO in the late 1960s against a political backdrop of decolonisation and pan-Africanism, traditional medicine has continued to be promoted in subsequent decades, culminating in the latest global Traditional Medicine Strategy (2014 to 2023). Yet WHO's promotion and acceptance of traditional medicine have also become increasingly conditional upon its standardisation and regulation – something that appears fundamentally at odds with traditional medicine's heterogeneity. Drawing on insights from critical law and science and technology studies, we suggest that such a process at WHO has done more than simply disqualify the toxic and the dangerous. Rather, it has implicitly and explicitly marginalised and excluded those aspects of traditional medicine that deviate from scientific, biomedical ways of seeing, knowing and organising.
The article de-centres the global history of disease by examining the agency of Eastern European expertise at international organizations and during decolonization. It challenges accounts of anti-malaria policies at the League of Nations Health Organization and at the World Health Organization written from a Western, particularly North American perspective, or on the basis of local reactions to Western interventions. The contribution proposes an analysis of circulations and ideas across multiple cultural, social and political spaces: post-imperial European states, (post)colonial territories and bureaucracies of international organizations. From the 1920s to the 1960s, Eastern European experts played a crucial role in the transformation of malaria from an imperial disease that tested governance over ‘tropical’ peoples into an issue of global health and nation-state building. However, regional representatives reproduced civilizational hierarchies intrinsic to North–South biomedical relations. The global entanglements of Eastern European malariology show that liberation from disease was less about communism or liberalism, and more about national renewal, statehood and world hierarchies.
Health systems that have strong primary health care at their core have overall better patient outcomes. Primary health care is key to achieving Universal Health Coverage and the broader health-related Sustainable Development Goals by 2030. In 2018, at the launch of the Declaration of Astana, the World Health Organization formed the inaugural Primary Health Care Young Leaders’ Network.
This paper aims to demonstrate the scope for young professional-led communities of practice in fostering support systems for young leaders and strengthening the delivery of primary health care at multiple levels.
A description of the Young Leaders' Network community of practice model is presented, with examples of the work the members are doing, individually and collectively, to advance the science and practice of primary health care.
This initiative brought together 21 individuals from across the world, working across disciplines and within an array of socioeconomic contexts to improve primary health care in their respective countries.
This youth-led community of practice is able to share knowledge, evidence and resources to inform clinical and public health activities, policy initiatives, advocacy and research to improve primary health care delivery and health outcomes for communities across the globe.
Antimicrobial resistance is a well-known global health threat that has higher prevalence in the refugee population. Although guidance has been provided by the World Health Organization and Centers for Disease Control and Prevention on implementing antimicrobial stewardship in lower- and middle-income countries, as well as by the United Nations Refugee Agency on other infection prevention and control efforts, no specific guidance exists for implementation of stewardship in this population. We highlight challenges specific to this population, review recent studies of interest within this space, and propose a research agenda to help move stewardship forward in the refugee population. We advocate for the importance of this issue, particularly given recent current events of geopolitical volatility that render this population more vulnerable, in the setting of its already well-known numerous health challenges.
Efforts to govern health globally have broadened considerably since the 1850s in terms of the subjects, goals, participants, and instruments of governance efforts. Originating in a thin, limited set of rules formally agreed by states, the contemporary global health system has evolved into a complex, dense, yet fragmented network involving governance processes both within and outside the health sector, engaging hundreds of state and non-state actors across all countries. Broader global trends shaped health governance, but key features of the current system also owe much to the particularities of specific events: the HIV/AIDS pandemic, West African Ebola crisis, and most recently Covid-19. Can contemporary networked governance processes can add up to a coherent, functional system for protecting global public health, or is more hierarchy needed? The World Health Organization is a central convenor, legitimator, adviser, and political arena in a fragmented system, but has not yet been empowered to assume the role of a directive coordinator. The extent to which major powers will construct a more hierarchical system is an open question in a world that is not yet post-Westphalian nor truly multipolar.
From nearly any perspective and metric, the effects of malaria on the African continent have been persistent and deep. By focusing on the malady of malaria and the last century of biomedical interventions, Graboyes and Alidina raise critical historical, ethical, and scientific questions related to truth telling, African autonomy, and the obligations of foreign researchers. They provide a condensed history of malaria activities on the continent over the past 120 years, highlighting the overall history of failures to eliminate or control the disease. A case study of the risks of rebound malaria illustrates the practical and moral problems that abound when historical knowledge is ignored. In light of current calls for renewed global eradication efforts, Graboyes and Alidina provide evidence for why historical knowledge must be better integrated into global health epistemic realms.
The substantial strain that women are facing during the COVID-19 pandemic can affect their menstrual cycle and further impair their quality of life. In low- and middle-income countries, this strain is exacerbated by: cultural taboos and poor education related to menstruation; ‘period poverty’; unavailability of menstrual hygiene products; and poor hygiene facilities. We suggest actions that governments, healthcare professionals and individuals can take to address these factors and minimise the psychological impact of COVID-19 on women's physical and mental health.
This article moves past high politics and the most prominent activists to explore the daily, intimate practice of international movement building by mid-level fieldworkers within the International Planned Parenthood Federation (IPPF) during its first decade of existence (1952–62). It illustrates how fieldworkers and the IPPF’s practitioner-oriented newsletter Around the World attempted to bridge the ideological and geographic diversity of the family planning movement and connect with advocates around the world through an emotive narrative of suffering, love, and global humanity, reinforced by affective bonds and women’s volunteerism. The story of global family planning must thus be seen not only as part of the history of eugenics, population control, and feminism, but also as part of the longer trajectory of maternalist humanitarianism. This mid-twentieth century version of maternalist humanitarianism built on earlier traditions but also incorporated concepts of human rights, critiques of dominant gender and sexual norms, and an official commitment to local self-determination in the context of decolonization movements. Still, the organization was plagued by the problems that shape humanitarianism more broadly, including the difficulty of moving past colonialist discourses, deeply rooted feelings of racial superiority, and the contradictions inherent in attempts to impose an impossible ideal of political neutrality in a politically complex world. Looking at the history of global family planning from this perspective thus helps us understand how the different traditions, intimate relationships, and practical experiences mid-level actors bring to their work shape the broader process of international movement building, beyond high-level political and ideological activism.
Given the demonstrated success of programs that bolster informal Emergency Medical Service (EMS) systems in other low- and middle-income counties (LMICs), this study aimed to explore formal and informal systems, practices, customs, and structures for emergency response and medical transport in Colca Valley, Perú while identifying possible opportunities for future intervention.
Twenty-two interviews with first responders and community members were conducted in three mountain villages throughout rural Andean Colca Valley of Perú. Subjects were recruited based on profession and experience with medical emergencies in the area. Transcripts were entered into Dedoose, coded, and analyzed to identify themes.
Providers and community members shared similar perceptions on the most common barriers to emergency care and transport. Challenges experienced equally by both groups were identified as “structural problems,” such as lack of infrastructure, lack of structured care delivery, and unclear protocols.
Incongruities of responses between groups emerged with regard to certain barriers to care. Providers perceived baseline health education and use of home remedies as significant barriers to seeking care, which was not proportionally corroborated by community members. In contrast, 86% of community members cited lack of trust in health providers as a major barrier.
Community members often noted witnessing a high frequency of emergency events, their personal experiences of helping, and the formal utilization of lay providers. When specifically questioned on their willingness to engage in first aid training, all participants were in agreement.
While structural changes such as increased infrastructure would likely be the most durable improvement, future interventions focused on both empowering community members and improving the relationship between the health center and the community would be beneficial in this community. Additionally, these interview data suggest that a layperson first aid training program would be feasible and well-received.
Globally, South Asia has the highest proportion of disabling hearing loss. There is a paucity of data exploring the associated hearing loss and disability caused by chronic middle-ear disease in South Asia in the setting of surgical outreach. This study aimed to measure disability using the World Health Organization Disability Assessment Schedule 2.0 in patients undergoing ear surgery for chronic middle-ear disease in an ear hospital in Nepal.
The World Health Organization Disability Assessment Schedule 2.0 was translated into Nepali and administered by interview to patients before ear surgery, and results were correlated with pre-operative audiograms.
Out of a total of 106 patients with a mean age of 23 years, the mean World Health Organization Disability Assessment Schedule 2.0 score was 17.7, and the highest domain scores were for domain 6 ‘participation in society’ at a score of 34. There was a positive correlation of World Health Organization Disability Assessment Schedule 2 score with hearing level (r = 0.46).
Patients with ear disease in Nepal have had their disability measured using the World Health Organization Disability Assessment Schedule 2.0. Our study demonstrated a correlation between impaired hearing and disability in a surgical outreach context, which was an expected but not previously reported finding.
Trust between actors is vital to delivering positive health outcomes, while relationships of power determine health agendas, whose voices are heard and who benefits from global health initiatives. However, the relationship between trust and power has been neglected in the literatures on both international politics and global health. We examine this relationship through a study of relations between faith based organisations (FBO) and donors in Malawi and Zambia, drawing on 66 key informant interviews with actors central to delivering health care. From these two cases we develop an understanding of ‘trust as belonging’, which we define as the exercise of discretion accompanied by the expression of shared identities. Trust as belonging interacts with power in what we term the ‘power-trust cycle’, in which various forms of power undergird trust, and trust augments these forms of power. The power-trust cycle has a critical bearing on global health outcomes, affecting the space within which both local and international actors jockey to influence the ideologies that underpin global health, and the distribution of crucial resources. We illustrate how the power-trust cycle can work in both positive and negative ways to affect possible cooperation, with significant implications for collective responses to global health challenges.
Here, I give an account of what it means for an institution to be trusted and be trustworthy in the context of global health research. I employ the example of data sharing to illustrate the importance and value of trustworthiness as an institutional moral characteristic. I use the term ‘institution’ to refer to groups or collectives that actively undertake research, such as universities and research centres. I conclude that trust is important in global health research collaboration because of the power imbalance between partners that often characterises such collaborations. In order to promote trust, institutions need to focus on being trustworthy by developing a behaviour that corresponds to the aims, principles and values they profess to uphold, and by demonstrating that they have incorporated into their functions, rules and regulations the particular needs of their partners and collaborators.
While human rights law has evolved to provide guidance to governments in realizing human rights in public health emergencies, the COVID-19 pandemic has challenged the foundations of human rights in global health governance. Public health responses to the pandemic have undermined international human rights obligations to realize (1) the rights to health and life, (2) human rights that underlie public health, and (3) international assistance and cooperation. As governments prepare for revisions of global health law, new opportunities are presented to harmonize global health law and human rights law, strengthening rights-based governance to respond to future threats.
The COVID-19 pandemic has given rise to the massive development and use of health indicators. Drawing on the history of international public health and of the management of infectious disease, this paper attempts to show that the normative power acquired by metrics during the pandemic can be understood in light of two rationales: epidemiological surveillance and performance assessment. On the one hand, indicators are established to evaluate and rank countries’ responses to the outbreak; on the other, the evolution of indicators has a direct influence on the content of public health policies. Although quantitative data are an absolute necessity for coping with such disasters, it is critical to bear in mind the inherent partiality and precarity of the information provided by health indicators. Given the growing importance of normative quantitative devices during the pandemic, and assuming that their influence is unlikely to decrease in the future, they call for close scrutiny.
Frailty prevalence is higher in low- and middle-income countries (LMICs) compared with high-income countries when measured by biomedical frailty models, the most widely used being the frailty phenotype. Frailty in older people is becoming of global public health interest as a means of promoting health in old age in LMICs. As yet, little work has been done to establish to what extent the concept of frailty, as conceived according to ‘western’ biomedicine, has cross-cultural resonance for a low-income rural African setting. This study aimed to investigate the meaning of frailty contextually, using the biomedical concept of the frailty phenotype as a framework. Qualitative interviews were conducted with a purposive sample of older adults, their care-givers and community representatives in rural northern Tanzania. Thirty interview transcripts were transcribed, translated from Kiswahili to English and thematically analysed. Results reveal that despite superficial similarities in the understanding of frailty, to a great extent the physical changes highlighted by the frailty phenotype were naturalised, except when these were felt to be due to a scarcity of resources. Frailty was conceptualised as less of a physical problem of the individual, but rather, as a social problem of the community, suggesting that the frailty construct may be usefully applied cross-culturally when taking a social equity focus to the health of older people in LMICs.
Neonatal mortality is one of the leading causes of under-five mortality globally, with the majority of these deaths occurring in low- and middle-income countries. In Ghana, there is a belief in an array of newborn conditions, called Asram, that are thought to have a spiritual, rather than physical, cause. These conditions are predominantly managed by traditional healers as they are considered unable to be treated by allopathic medical providers. Through a series of semi-structured qualitative interviews of medical providers in Kumasi, Ghana, conducted in July–August 2018, this study sought to elucidate perspectives of allopathic medical providers about Asram, including the perceived implications of traditional newborn care patterns on newborn health and higher-level neonatal care. Twenty health care providers participated and represented a tertiary care hospital and a district hospital. Medical providers were universally aware of Asram but varied on the latitude they gave this belief system within the arena of newborn care. Some providers rationalized the existence of Asram in the backdrop of high neonatal mortality rates and long-standing belief systems. Others highlighted their frustration with Asram, citing delays in care and complications due to traditional medical treatments. Providers utilized varying approaches to bridge culture gaps with families in their care and emphasized the importance of open communication with the shared goal of improved newborn health and survival. This study describes the importance of providers being aware of socio-cultural constructs within which pregnant women operate and suggests a focus on the shared goal of timely and effective newborn care in Ghana.
Female genital mutilation (FGM) is very pervasive in Africa, with significant regional variations in the prevalence of this traditional practice. This study examined the linkages between FGM and multiple sexual partnership in Mali and Sierra Leone – two African countries with a high prevalence of FGM. Data were from the 2018 Mali and 2013 Sierra Leone Demographic and Health Surveys, and the study sample comprised 4750 women from Mali and 16,614 from Sierra Leone. Multilevel logistic regression was used for the data analysis, with reported adjusted odds ratios (aOR) and associated 95% confidence intervals. In Mali, women who had not undergone FGM were less likely to have multiple sexual partners (aOR=0.60, CI=0.38–0.96) compared with those who had undergone FGM. In Sierra Leone, women who had undergone FGM (aOR=1.15, CI=1.02–1.30) were more likely to have multiple sexual partners compared with those who had not undergone FGM. Age, level of education, wealth quintile, sex of household head, community socioeconomic status, mass media exposure, and community literacy level were found to be associated with the likelihood of multiple sexual partnership among women in Mali and Sierra Leone. Comprehensive, age-group-based risk-reduction strategies, such as abstinence education and decision-making skills (assertiveness) training, are needed to reduce girls’ and young women’s engagement in multiple sexual partnerships. Policy interventions, such as anti-FGM legislation and initiatives like the ‘Schooling for the Female Child’ initiative aimed at reducing social inequality among girls and women, might help decrease FGM and the likelihood of health-compromising behaviours like multiple sexual partnership.
Sometimes referred to as hidden hunger, micronutrient deficiencies persist on a global scale. For some micronutrients this appears to be due to inadequate intake, for others intake may not match increased requirements. However, for most micronutrient deficiencies there is uncertainty as to the dominant driver, and the question about the contribution of malabsorption is open. Environmental enteropathy (EE), formerly referred to as tropical enteropathy and also referred to as environmental enteric dysfunction, is an asymptomatic disorder of small intestinal structure and function which is very highly prevalent in many disadvantaged populations. Recent studies of the pathology and microbiology of this disorder suggest that it is driven by very high pathogen burdens in children and adults living in insanitary environments and is characterised by major derangements of the epithelial cells of the intestinal mucosa. Transcriptomic data suggest that it may lead to impaired digestion and absorption of macronutrients. Given the very high prevalence of EE, marginal malabsorption could have large impacts at population scales. However, the relative contributions of inadequate soil and crop micronutrient contents, inadequate intake, malabsorption and increased requirements are unknown. Malabsorption may compromise attempts to improve micronutrient status, but with the exception of zinc there is currently little evidence to confirm that malabsorption contributes to micronutrient deficiency. Much further research is required to understand the role of malabsorption in hidden hunger, especially in very disadvantaged populations where these deficiencies are most prevalent.
There has been growing consensus to develop relevant guidance to improve the ethical review of global health policy and systems research (HPSR) and address the current absence of formal ethics guidance.