(C25)
Global health collaborations and alignments
Location FASS Building Meeting Room 2/3
Date and Start Time 25 Jul, 2018 at 13:00
Sessions 2

Convenors

  • Nora Engel (Maastricht University) email
  • Patricia Kingori (The Ethox Centre, University of Oxford) email
  • Salla Sariola (University of Helsinki) email
  • Catherine Montgomery (University of Oxford) email

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Short abstract

The panel asks how and with what implications collaboration and alignment is practiced across the multiple and varied actors, places and practices involved in global health interventions and technologies.

Long abstract

Global health offers analytical scope for STS as global health is characterized by entanglements, alignments and interactions between global and local factors transcending disciplinary, geographical, political, institutional, and sectoral boundaries. Moreover, global health is defined by desire to reduce health inequity in a variety of geographical locations. To reach this aim, considerable emphasis is put on collaborations and technologies including an array of actors, users, practices and settings, which in previous incarnations of global health, such as tropical and colonial medicine, were often peripheral to its focus and design. From community engagement to institutional collaborations with researchers and scientists aimed at knowledge transfer, data sharing and capacity building, numerous ethical, economic and logistical arguments are invoked to support global health encounters.

This panel asks how this complexity is made to align against the historical backdrop of inequity and where the global north and its institutions continue to wield considerable power and resources. We are interested in critical engagements with examples of global health encounters which emphasize what happens in practice, how practices work in ways which reproduce or subvert inequity, and with what effects. We invite papers that examine, but are not limited to:

-different ideas, implicated norms and practices in global health collaborations between scientists, communities, patients, professionals, policymakers, etc.

-how collaboration and alignment matter in development of global health innovations, technologies, institutions, or networks

- relationships between standardization and variability in global health encounters and alignment efforts

- the role of STS scholars in these

This panel is closed to new paper proposals.

Papers

'Built for expansion': conditions of possibility and sites of performance for the WHO's mhGAP diagnostic algorithm

Authors: Eva Hilberg (University of Sheffield) email
China Mills (University of Sheffield) email
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Short abstract

This paper traces how the WHO's mhGAP diagnostic algorithm is the product of strategic collaborations, historical epistemological alignments, and ongoing performative enactments of a particular 'movement' for global mental health that overlooks alternative epistemologies in relation to distress.

Long abstract

Quantifications of mental health and the 'treatment gap' (as conceptualized from a biomedical perspective) have been central in making visible mental health as a global health priority, now named in the UN Sustainable Development Goals. Digital tools support further measurement of both burden and treatment gap, and facilitate task-sharing in countries where there are few mental health professionals. The focus of the paper is the WHO's mhGAP Intervention Guide 2.0 (2016), an algorithmic clinical decision-making tool with protocols for diagnosis and condition management that is currently being implemented in various low- and middle-income countries. We explore how this tool is the product of strategic collaborations, historical epistemological alignments, and ongoing performative enactments of a particular 'movement' for global mental health. In tracing the 'social lives' (the performance and conditions of possibility) of mhGAP, this paper illuminates how its explicit design for global expansion positions mhGAP as only open to questioning from those who are technical 'insiders' (black-boxing mhGAP), and furthermore, sets the epistemological parameters of its own critique. This excludes critiques from different worldviews of distress and promotes a particular techno-scientific imaginary of mental health that also extends to its conception of processes of local adaptation. The paper ends by encouraging the WHO to open the 'black box' of mhGAP development and to be open to alternative epistemological understandings, particularly user/survivor/Mad epistemologies.

Aligning to variable and shifting (user-) settings in developing point-of-care diagnostics for tuberculosis and HIV

Author: Nora Engel (Maastricht University) email
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Short abstract

This paper discusses how developers and implementers of TB and HIV diagnostics align their technologies to the point-of-care and how uncertainty, global standards, and scarce resources cause frictions with the continuous nature of alignment work, impacting access and utilization of technologies.

Long abstract

Social science literature has criticized simplified ideas of technology transfer underlying much technology design for global health. Healthcare technologies should be attuned to particular contexts-of-use to be effective. This paper uses the development of point-of-care (POC) diagnostics - promised to be designed to fit users outside laboratories or in resource constrained settings- to study what developers and implementers do to align diagnostic technologies to the POC. Fieldwork among global health actors involved in diagnostic development including manufacturers, donors, industry consultants, international organisations, policymakers, regulators and researchers is combined with fieldwork among users of diagnostics in India, including decision-makers, NGOs, program officers, laboratory technicians and nurses. Adding to STS theory of alignment, doability and user interaction, several points are put forward: The setting and user to which developers and implementers of global health diagnostics align are multiple, varied, emerging, keep shifting and go well beyond the imagined characteristics of a local user setting. They include multiple -engaged and imagined- user settings, but also those of developers, of global intermediaries, competitors, and diseases/bugs. The results reveal how a shifting complexity of actors, settings, scales and moments in time is invoked and made to collaborate. This alignment work is continuous and has consequences for access and utilization of the technology. Alignment work is characterized by uncertainty as to what is to be aligned, at the same time as standardizing elements, politics and scarce resources cause frictions with the continuous nature of (re-)aligning and over what constitutes a well-aligned diagnostic and for whom.

Indigenous epistemologies in global health: WHO regulation of traditional medicine since Alma Ata 1978

Authors: Francesco Salvini (University of Kent) email
Emilie Cloatre (University of Kent) email
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Short abstract

The paper examines the WHO's engagement with traditional medicine, and interrogates the regulatory shaping of indigenous epistemologies in global health. This history offers important insights to address how alternative epistemologies of care have been mobilised in global health since 1970s.

Long abstract

The paper examines the history of the WHO's engagement with traditional medicine. It argues that this history offers important insights in understanding both how alternative epistemologies of care have been mobilised or side-lined in global health over the last 40 years, and the influence of neoliberal ideologies on the regulation of non-biomedical resources in healthcare.

The paper critically reads the key WHO documents, practices and institutions that have engaged with traditional healing, since the discussions leading to the 1978 Alma Ata declaration. In turn, it argues that an effect of these discourses and regulatory strategies is to erase the alterity of indigenous knowledges through an acceptance that is conditional on their subordination. An effect is the effacement of the political boldness of indigenous alternatives.

Such process is part of a longer history of appropriation, exclusion, transformation and conditioning that has surrounded indigenous knowledges since the colonial era. In those movements, notions of tradition and modernity have come to categorise what epistemological arrangements could be considered as legitimate participants in contemporary healthcare. The paper engages with these issues by resignifying the traditional, as a practice that stands before (not only as "previous to", but also as "in front of") modernity, allowing us to replace traditional epistemologies of healing and caring as a matter of the contemporary. In doing so, the paper exposes the tensions between appropriation and regulation surrounding indigenous epistemologies, contributing to the decolonisation of global governance of healthcare.

Living-with microbes in the era of antimicrobial resistance

Authors: Salla Sariola (University of Helsinki) email
Elina Oinas (University of Helsinki) email
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Short abstract

This paper explores collaborations to tackle the global increase of antimicrobial resistance (AMR) and focuses on human-microbial encounters in a vaccine trial set in Benin, West-Africa.

Long abstract

This paper explores encounters generated by the global increase of antimicrobial resistance (AMR). As antibiotics are becoming redundant due to drug resistance, modern medicine is at risk of being turned back by a century. The focus of this paper is a collaborative vaccine trial in Benin, West Africa, that aims to prevent bacteria-borne diarrhoea and development of drug resistant strains.

In the post-antibiotic era, we argue, it is vital to gain a granular view of the various practices of relation-making between humans and microbes, and how they are changed by the threat AMR. The paper analyses encounters between Northern European tourists, who double-act as participants in the vaccine trial, with local populations of Grand Popo. As part of the vaccine trial, tourist-cum-research volunteers spend two weeks in the region chosen for its moderate levels of infectious diseases and antimicrobial resistance as well as historical, cultural significance. While visiting Benin, these study participants become exposed to various new bacteria; some fall ill with diarrhoea, while others don't. In this encounter, social and microbial cultures meet and mingle.

Based on ethnographic research from 2017-2018, this paper seeks to understand how all those involved in the trial understand microbes and anti-microbial resistance. We discuss the shifting ways tourists embody and discuss their bodily contours and assumed embodied integrity and fragility in relation to the local environment, for example via the experience of diarrhoea. Their experiences reveal the different modes of discussing, embodying, embracing, and resisting encounters with the local, both human and microbial.

Lords of the fly: tracing tsetse control networks and the social proximity of sleeping sickness interventions in Uganda

Author: Shona Jane Lee (University of Edinburgh) email
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Short abstract

Novel tsetse fly control tools play a key role in the 'one health' approach to eliminating sleeping sickness. Tracing their implementation across Uganda, I reveal fractured collaborations underpinning local tsetse control networks, and the importance of social proximity in sustaining interventions

Long abstract

A decline of the vector borne disease Human African Trypanosomiasis (HAT), or 'sleeping sickness', in recent years has paved a roadmap for its elimination as a public health problem by 2020. Galvanised by this agenda, and driven by technology-oriented Public Private Partnerships, focus has shifted from reactive outbreak response to sustaining vigilant diagnostic surveillance and tsetse fly suppression 'to the last mile'. While cost-effectiveness is positioned centrally to sustainability, less emphasis is placed on the socio-technical relationships that shape the long-term legacy of interventions. How are commitments to community engagement and in-country collaboration from global health research and policy discourse enacted through local networks at community level? I present findings from ethnographic research in Uganda on the implementation of 'emerging technologies' in tsetse control, tracing the collaborative networks of researchers, entomologists, veterinarians, and health workers in their endeavour to integrate vertical programmes into fragile local human-tsetse assemblages. This reveals fissures in the 'one health' framework at ground level, where decentralised and under-resourced district offices struggle to maintain operational cohesion in precarious socio-technical ecosystems, while authoritative claims on expertise and power still firmly reside in hands of donors and research institutions in the global north. Structural gaps in infrastructure and epistemological inequity cannot be circumnavigated with technologies alone. Relatively modest, socially embedded technologies have endured where comparatively aloof, vertical mass spraying campaigns have come and gone at great expense with no long-term impact. Sustainability is shaped by the social proximity of interventions, promoting longevity through community buy-in and ownership.

Managing superbugs and desire to belong in Latvia

Author: Zane Linde-Ozola (University of Leeds) email
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Short abstract

This paper explores how Latvian health specialists engage with globalized forms of governmentality in managing growing antibiotic resistance epidemic.

Long abstract

Drawing on ethnographic work in Latvia, this paper explores how Latvian health specialists engage with globalized forms of governmentality in managing growing antibiotic resistance epidemic. For these specialists the international audits, practice algorithms, quality and safety indicators, surveillance systems operate not only as disciplinary technologies but also as instruments with discursive and materialized potentiality of relationships with various effects. These health professionals mobilize their work and themselves as governable entities as an attempt to establish presence and sense of belonging to imagined and institutionalized state, Europe and beyond. At the same time, engagement with these governance technologies allows to actively cultivate distance and detachment from other relationships (e.g., the Soviet past). Cutting undesired relationships and setting boundaries operate as another attempt to obtain presence in Europe's health arena and to move from category of 'almost-but-not-quite-European' into much desired category of 'fully-European'. Paradoxically, Latvian health professionals' desire to belong reproduces the coloniality of power between West and East Europe's spaces and subjects.

This panel is closed to new paper proposals.