Paper short abstract:

This qualitative study explores epistemological power in the debate about the meanings of global health and international health. Four positions are mapped against a decolonial framework that reveals their epistemological foundations and entailed power relations in global health governance.

Paper long abstract:

The COVID-19 pandemic has spiraled contestations of epistemological power in the sphere of health research and governance. Positions of power become visible through dominating concepts that have guided the governance of the pandemic. To explore such power dynamics, we employ a qualitative study of the debate about Global Health and International Health and the meanings and uses of both concepts. We conducted a literature review and in-depth interviews with selected experts who have published on this debate to critically analyze different conceptual positions. Results were integrated into a decolonial theoretical framework based on decolonial literature. As a result, we map four different conceptions of Global and International Health: International Health, liberal Global Health, critical Global Health, and decolonial Global Health. While International Health is referred to as part of between-states diplomacy, critical and decolonial Global Health occur mostly in academic and activist debates, and liberal Global Health dominates global governance. Our critical framework reveals that historical Western hegemony continues to reproduce power asymmetries in global governance through exerting epistemological power in health research and governance. This contributed to the global inequalities highlighted by the COVID-19 pandemic, in which unequal vaccine distribution represents an example of liberal Global Health policy. Mapping different conceptions of Global and International Health and their functions in health governance enhances an understanding of the power relations they entail. By exposing contemporary health governance as rooted in colonial power relations, we promote further development of emancipatory conceptions of health that address global inequalities and envision epistemic diversity.

Paper short abstract:

Using an ethnolinguistic analysis of the language of disease, and more specifically of the stomach, this presentation highlights how this language can be conflated with other languages (those of the body, illnesses, pain, anxiety, and hopelessness) influencing the treatment regimen and trajectory.

Paper long abstract:

Health epistemology in Africa has suffered hostility from western medicine, with the former classified as primitive, savage, and based on ‘traditional’ systems. African disease aetiologies have been devoid of scientific insights and epistemological assessment, while colonialist patterns centred on Euro-Western knowledge systems have shaped the language and response to health and illness. The current global health ecosystem, which ‘upholds the supremacy of the white saviour’ by devaluing the epistemic contributions of the so-called traditional or indigenous societies, is thus ill-equipped to fully address the latter’s health challenges, resulting in adverse health outcomes, such as missed diagnosis, wrong treatment, and preventable deaths.

This paper is motivated by the argument that health is critical for human well-being, yet folk dimensions of health knowledge are largely unknown. While it is generally acknowledged that believing, saying, and doing do not always synchronise, synergies nevertheless exist between thought, utterance, and behaviour. Health practitioners often base their decisions on what is said and how it is said.

Using an ethnolinguistic analysis of the language of disease, and more specifically of the stomach, this presentation highlights how this language can be conflated with other languages, such as those of the body, illnesses, pain, anxiety and hopelessness, etc. influencing the treatment regimen and trajectory.

Data for this presentation is drawn from a larger project which comprised the systemic collection and analyses of folk terminologies, coinages, idioms, phrases and lexemes relating to illnesses among three indigenous groups in Ghana: the Ga, Asante, and Kasena, using ethnographic approaches.

Paper short abstract:

This paper offers a critical perspective on the unintended consequences of Global Health activities through two examples: WHO's announcement of Disease X and the mass distribution of antibiotics as part of the Global Elimination of Trachoma program.

Paper long abstract:

As the messages and materials related to global health activities circulate, negotiations of meaning occur at their centers and margins. This paper uses ethnographic data collected through traditional in-person fieldwork and social media analysis online to examine the (mis) alignments between pandemic preparedness messages, neglected tropical disease elimination programs and the priorities of populations targeted by these global health activities.

I draw comparisons between messages shared on Twitter in reaction to the World Health Organization’s announcement of its addition of Disease X to the agency’s R&D Blueprint with the meaning-making that occurred in a Global Elimination of Trachoma target village in eastern Niger following an annual mass distribution round of antibiotics. Online discourse and in-person interviews reveal how inequities are highlighted through these actions and transformed into understandings of risk, power, and resistance. This paper offers a critical perspective on the unintended consequences of Global Health activities more broadly through these two examples, and recommends ways that medical anthropology can contribute to programs that better address the social and political aspects of infectious disease.

Paper short abstract:

Drawing from an ethnography of sex work and HIV/AIDS policies in Mali, this presentation highlights how structural dimensions of global health policies – projectification, scale-up and metrics – embed, and how these entanglements result in coercion, overtesting, and the absence of linkage to care.

Paper long abstract:

A defining feature of global health – understood as the set of institutions and policies aiming at intervening “into the lives of other peoples” (Packard 2016) as it emerged since the 1990s – is projectification (Hubmann 2021). The hegemonic form of global health policies is indeed the project, i.e. policies designed and implemented according to temporally bounded and linear frames. Although this trend goes much beyond global health, the way projectification affects the outcome of health policies is particularly striking in countries with weak infrastructures and public services, where it entails that whole sectors are subject to pause or sudden interruption (McKay 2018). Another dimension of global health that received particular scholarly attention in the last decade is the rise of metrics (Adams 2016). Drawing from an ethnography of sex work and HIV/AIDS policies targeting sex workers in Bamako in the early 2010s, this presentation highlights how these trends unfold in a period marked by the scaling-up of the fight against HIV/AIDS. I will describe how the rapid and exponential rise of funds dedicated to key populations intertwines with projectification and metrics, and scrutinize how these entanglements play out and shape everyday activities of HIV/AIDS programs that aim to test sex workers for HIV. This analysis unveils how larger trends and a specific temporal regime embed in a specific context, and how this leads to unintended consequences such as coercion in care, overtesting, and the absence of linkage to care for HIV positive sex workers, thus exacerbating preexisting vulnerabilities and increasing inequalities.

Paper short abstract:

Evidence from the field is presented on the humanitarian response to the ongoing epidemic in Mozambique where anthropology emerges as a key tool for understanding behaviors and working on prevention and reduction of risk factors with the communities involved in an effective and conscious way

Paper long abstract:

In Mozambique, a cholera epidemic has been underway since February 2023 involving almost all the provinces of the country, further aggravated by Cyclone Freddy which devastated the province of Zambezia. Doctors with Africa CUAMM in collaboration with the local government and with the support of Unicef operates in the humanitarian response which aims to identify cases, create sanitary cordons, sanitisation and prevention activities.

For all this to be effective, my experience as an anthropologist in working with communities, local committees and village leaders allows us to understand the social and cultural determinants and to co-design response strategies and resilience mechanisms compatible and embodied by the population.

Investigating the social structure as well as community decision-making processes, gender and generational relations leads to grasp the social watermark that determines the response of communities to the interventions proposed by the NGO and the health system.

Analysing together with the communities the imaginary that the quantitative data on epidemics tell about the communities was also an essential exercise to problematize the statistical-centric approach of humanitarian interventions to grasp local perspectives, logics and adaptations.

Working across 4 provinces, around 25 districts, hundreds of villages and thousands of interlocutors, the anthropological perspective becomes a grammar of listening and for coordinating the response on the various levels involved.

In strategic terms, the ongoing experience becomes a relevant case study for rethinking the quantitative epistemology of the "Global Health mind-set” in favour of more focused attention to the assumptions that medical anthropology suggests

Paper short abstract:

The piece we write about is but a sub-data of an ethnographic study on young women’s reproductive future in the wake of the COVID-19 vaccination rollout in Khwisero, Kenya. The ethnographic thoughts and stories portray how untimely state healthcare financing changes can do to vaccination discourse.

Paper long abstract:

Following independence in 1963, the Kenyan post-colonial government made free health care a key policy goal. This was an attempt to abolish the health care user fees (out of pocket) implemented by the colonialists. However, around 1989, following pressure from the World Bank and IMF, user fee was reintroduced. The reintroduced fees were again suspended in 1990 and reintroduced in phases in 1991. From 1991 onwards, several abolishment and reintroductions of user fees on different healthcare levels have continued to disorganize and stagnate the access and utilization of state care in Kenya. The continuity of these colonial and post-colonial public health histories of shifty, divisive user fees within care contributed to the discord between the Khwisero women and state healthcare systems in the region. Drawing on 8-month ethnographic work, I invite the audience to explore through stories embedded in photo ethnography, a mini-dynamics series on how state care engulfed in "user fee" policies fractured and reproduced vaccine hesitancy among women in the Khwisero. The health facility in this paper was not only a hospital premise but housed the history of care - of the women's idea of justice, inclusion and fairness. prior to July 2022- before the COVID-19 pandemic, care was administered free in the hospital premises, but with the introduction of the healthcare user fee, the hospital became a hotbed of politics- injustice- doubtful hope- vaccination rumours and hesitancy, and multiple dysfunctionalities. I situate my COVID-19 vaccination work within this plurality and complexities of women's vaccination hesitancy and care fees.

Paper short abstract:

Morphine, an ‘essential’ analgesic, is rarely prescribed in many regions. Analysing its use in an Indian hospital, this paper displays the historical, social, and clinical stakes that complicate the 'demand' implicit to Global Health literatures that posit this problem as primarily one of ‘access’.

Paper long abstract:

The use of opioid drugs has become a key concern for global health communities. Typically, this has taken the form of research into ‘overuse’, often focussing on the USA. Yet there has also been a concerted effort to increase the visibility of the opposite problem; the absence and inaccessibility of strong opioid pain relief elsewhere in the world, most pressingly the analgesic morphine in many low and middle-income countries. As a heuristic device, ‘access’ has been the dominant way through which global health literatures have understood and tried to address this latter concern. Articles covering regions such as the Pacific, Mexico, India, Zimbabwe, and Sub-Saharan Africa more broadly use this relatively uncomplicated framing to describe the plight of patients in healthcare settings where morphine is not commonly prescribed. Indeed, even when authors draw attention to the imbalances in opioid research (92% conducted into ‘misuse’ and ‘abuse’ and only 8% into opioid ‘access’) it is this terminology that demarcates the problem. Yet behind a lack of ‘access’ lie a multitude of factors that disrupt the assumed demand implicit therein. For, as the anthropology of drugs has displayed, these are objects inconsistent between diverse geographical, temporal, or institutional settings. Analgesics and their representations are conditioned by historical and legislative trajectories, public and professional narratives, clinical and lay practices of pain and relief. In this paper, I draw on ethnographic fieldwork undertaken in a north-Indian cancer hospital to display the complexities so often collapsed within global health into the simple terminology of ‘access’.

Paper short abstract:

The PrEP pill, intended to prevent HIV, also puts users at risk of different types of stigmatization related to gender, promiscuity and HIV. Social anthropology enables us to examine global health critically, explore the users' lived experiences, and understand what stigma means to PrEP users.

Paper long abstract:

Based on 11 months of ethnographic fieldwork following a Pre-exposure prophylaxis (PrEP) study for men who have sex with men and transgender women in Dar es Salaam, this study observed how the PrEP pill, intended to prevent HIV, also put users at risk of experiencing several types of social stigmatization. Anthropological perspectives and methods enable us to examine global health interventions critically, explore the users' lived experiences and employ theory to make sense of what, in this example, stigma means to PrEP users. Stigma was, above all, related to social exclusion when living with HIV, and being identified as a PrEP user might be (mis)read by the users' social environment to indicate HIV positivity. In this respect, PrEP use was mistaken for the use of ARVs. While neither PrEP use nor living with HIV was mainly linked to homosexuality, men who have sex with men were targets for PrEP interventions; PrEP users ran the risk of being stigmatized as "homosexual" or "gay". Lastly, for persons assigned male gender at birth who did sex work, PrEP became an important HIV preventative measure and enabled safer sex and more partners. However, the social risk of exposing PrEP use to clients was, for some, a constant concern, as their status as PrEP users could mark them off as promiscuous and as living with HIV. These findings show that HIV stigma persists and that interventions aimed at biomedically preventing HIV transmission may have the somewhat paradoxical effect of triggering different forms of stigmatization.

Paper short abstract:

This paper analyzes events following HPV and Covid-19 immunization, exploring the role of intersectional dynamics and epistemic injustice in pharmacovigilance (PV) evidence and practice, and concluding how anthropology can enhance vaccine safety.

Paper long abstract:

Vaccine pharmacovigilance refers to the science and activities concerned with the detection, assessment, understanding, prevention and communication of events following immunization. It is part of the broader field of pharmacovigilance (PV), which with the neo-liberalization of drug regulation has acquired an increasing role in drugs access and safety. Amongst the range of activities of pharmacovigilance, this paper focuses on the process through which post-vaccination symptoms are identified and categorized as vaccine 'side effects’. Drawing on a 'Patchwork Ethnography' conducted in Colombia, Italy, and the Netherlands from 2019 to 2023, our analysis delves into intersectionality and epistemic injustice in vaccine’s safety. The events that developed in 2014 in El Carmen de Bolivar, a town on the Colombian Atlantic coast, where girls reported mysterious symptoms post HPV vaccination, dismissed as Mass Psychogenic Illness, connects with global experiences following covid-19 vaccines. When in 2022 thousands of people who menstruate(d) reported menstrual irregularities following COVID-19 vaccines, these were initially attributed to pandemic stress. By comparing these cases with responses to other vaccines, we highlight the influence of epistemic injustice and historical bias on pharmacovigilance research, shaping the evidence produced. This paper advocates for a transdisciplinary approach to pharmacovigilance, where anthropological methods and questions enhance global health.

Paper short abstract:

Global health discourse champions the importance of 'choice' in reproductive rights. Yet, this shows how medical workers in Timor-Leste confront and challenge the concept of 'reproductive choice' by highlighting structural inequalities in health and the biomedical approach to reproduction.

Paper long abstract:

Global health discourses champion the importance of 'choice' and freedom in sexual health and reproductive health. However such discourses legitimise Western biomedical science over local knowledge and obfuscate lived experiences and past and present health inequalities.

During the Indonesian occupation, Timor-Leste experienced a state family planning programme that was implicated in claims of genocide. Since independence, however, reproductive rights have been promoted as part of national development. This paper, based on 18 months of ethnographic fieldwork presents how local medical workers challenge global health education on Family Planning over a ten-day family planning training course. Here, whilst facilitators reinforced the importance of client 'choice', the medical trainees highlighted contradictions in the course material, challenging the lived reality of individual choice in reproductive health.

Feminist scholars have labelled the discourse of choice ‘a fantasy’ (Crist 2020) or ‘a magic wand’ (Mol 2008) which disguises a wider range of structural inequalities. This has been particularly highlighted through a reproductive justice framework (Ross and Solinger 2017). This article shows how local medics shatter the ‘illusion’ of choice in the face of structural inequalities and health that extend beyond individual bodies. Simultaneously, throughout the training, the contradictions which this discourse ensued deepened scepticism towards biomedicine, perpetuating inequalities and even reproducing forms of coercion.

What this shows, I argue, is not that choice is undesirable in this context. Rather as a discourse which promises, and fails to deliver, reproductive freedom, the promotion of choice fails within a current neoliberal, neocolonial, biomedical model of global health.