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Medical Anthropology: Cross-Cultural Studies in Health and Illness Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gmea20
The Politics and Anti-Politics of Infectious Disease Control a
Ian Harper & Melissa Parker
b
a
Department of Social Anthropology, University of Edinburgh, Edinburgh, UK b
Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK Published online: 24 Apr 2014.
To cite this article: Ian Harper & Melissa Parker (2014) The Politics and Anti-Politics of Infectious Disease Control, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 33:3, 198-205, DOI: 10.1080/01459740.2014.892484 To link to this article: http://dx.doi.org/10.1080/01459740.2014.892484
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Medical Anthropology, 33: 198–205, 2014 Copyright © 2014 Taylor & Francis Group, LLC ISSN: 0145-9740 print/1545-5882 online DOI: 10.1080/01459740.2014.892484
INTRODUCTION
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The Politics and Anti-Politics of Infectious Disease Control Ian Harper Department of Social Anthropology, University of Edinburgh, Edinburgh, UK
Melissa Parker Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
Walking from the courtyard, out of the monsoon rains, into the cool offices of a large and prosperous nongovernmental organization (NGO) in one of Nepal’s sprawling urban cities was a relief. It was the summer of 2013 and research into the politics and expansion of the NGO sector under direct influence of funding from the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM) was underway. We had arranged to meet the director and senior members of the organization to talk about their work on HIV treatment and prevention with intravenous drug users (IDUs). The director was one of a number of high-profile human rights advocates, demanding access to antiretroviral drugs and better services, and the work of these advocates reflected a shift toward a rights-based approach characteristic of the HIV sector in health development work. We were told that the organization had started initially as a loose network of individuals supporting each other in their recovery from drug addiction. Then came the HIV epidemic, and the aid money. IDUs became a risk group, and the target of interventions to prevent the further spread of the HIV virus. ARVs followed, as did a new form of identity politics associated with these transformations. Each member of the team introduced him or herself as a ‘recovering IDU.’ After IAN HARPER is the head of the Department of Social Anthropology at the University of Edinburgh, and a Wellcome Trust Senior Investigator. His research focuses on tuberculosis control, pharmaceuticals, the conduct of research in health development, and healing practices more broadly in the context of South Asia. Address correspondence to Ian Harper, Department of Social Anthropology, University of Edinburgh, Edinburgh, United Kingdom. E-mail: [email protected]. MELISSA PARKER is a reader in Medical Anthropology at the London School of Hygiene and Tropical Medicine. Since the 1980s, she has undertaken anthropological research in Sudan, Ghana, Uganda, Tanzania and the UK on global health issues including female circumcision, HIV/AIDS, neglected tropical diseases, health, and healing in the aftermath of war. Address correspondence to Melissa Parker, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom. E-mail: [email protected]
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receiving several rounds of GFATM funding, they had managed to improve access to diagnostic facilities and treatment by increasing the number of clinics available in the country. The clinic that they had opened on the ground floor of the building they rented for their office was now also being used as a DOTS treatment center, providing antituberculosis drugs too. The GFATM, cognizant of issues around the vertical health policy they had been driving, was becoming more insistent that services be integrated, and had started with tuberculosis (TB) and HIV. Several years earlier, at a regional conference organized by the International Union of Tuberculosis and Lung Disease in Kathmandu—in the sumptuous halls of the five-star hotel, the Yak and Yeti, and next to the equally grand headquarters of the World Bank—HIV activists had greeted the delegates with placards and chanting. ARVs, they shouted, should be available from all DOTS clinics as well. Their voices are gradually being heard, it seems. Yet amidst these successes, the team had criticisms and vulnerabilities. We have low CD4 counts and eat ARVs, said one, but we are all dying of Hepatitis C. This co-epidemic was not being addressed at all. A very high percentage of IDUs have this infectious condition as well, but Nepal does not have adequate laboratory capacities to diagnose it, or the interferon drugs to treat it, or even the physicians trained to manage it. The Global Fund will not provide the necessary funds because it lies outside its remit of providing financial resources for HIV, TB, and Malaria, and deviation from its stated goals and programmatic targets is not possible. It is not the diseases that kill us in Nepal, said the director, it’s the bureaucracy! The last round of funding—round 11 since the annual funding rounds first began—had been cancelled. This was partly due to the global economic recession and a subsequent unwillingness on the part of donors to pay substantial sums into the Fund. Whatever the reason, staff within this NGO were having to rethink their strategies and practice. If the money dries up, where will we be, asked the director and his staff? This small vignette from Nepal draws on Harper’s ongoing Wellcome Trust funded research “Understanding TB control: Technologies, ethics and programs” which highlights some of the complexities of ‘global health.’ A reconfiguration of institutions, technologies, and financial flows has occurred over the past 15 years, generating confusion and concern among anthropologists and others working in this field as to how best to understand and represent these shifts and forces (Biehl and Petryna 2013). As noted previously, for example, we see the conflation of vertical disease programs with new modalities of funding (the Global Fund only came into being in 2001); the rise of NGOs and public–private partnerships (involving a strong ideological push from the Global Fund alongside wider neo-liberal reforms in the health and development sector); the influence and impact of rights-based approaches to health and the identity politics that comes with this (Nguyen 2005, 2010); the maldistribution of resources, and the way in which the issues this presents are simultaneously and centrally related to questions of equity (Farmer 2004); the inability to take into account biological, social, and political issues of co-infection or ‘syndemics’ (see Singer 2009; Singer and Clair 2003); and the need for expansive services that are not fragmented and atomized. These issues are primarily political rather than technical—hence the rationale for the collection of articles in this issue of Medical Anthropology.
THE NEW LANDSCAPE OF GLOBAL HEALTH AND INFECTIOUS DISEASE Since 2000, we have witnessed significant discursive shifts around ‘global health.’ A range of forces, both economic and political, have resulted in a reconfiguration of how we understand and
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approach health at the global level. As Fidler (2009) has pointed out, this re-conceptualization has been associated with a substantial increase in finances and resources, and includes the following shifts: the framing of health as a security issue (cf. Ingram 2005); the emergence of new international governance regimes, such as the World Health Organization’s International Health Regulations; new assemblages of organizations dealing with certain infective threats, like the GFATM; leading economic powers tabling health issues at global summits and meetings; shifting geopolitical relations, both around states (such as China’s ascendancy), NGOs (such as Médecins Sans Frontières, see Redfield 2005, 2013; Fassin 2009; Fassin and Rechtman 2009) and Partners in Health (Farmer 2003); and the rise of the Bill and Melinda Gates Foundation, which has invested substantially in health (Birn 2005). In addition, one of the consequences of the Millennium Development Goals (MDGs) is that development interventions have become more weighted toward health oriented targets (Nayar and Razum 2006). MDGs Four, Five, and Six, in particular, are to ‘reduce child mortality,’ ‘improve maternal health,’ and ‘combat HIV/AIDS, malaria, and other diseases,’ respectively. In macroeconomic terms, development assistance for health (that is, all flows into health from public and private institutions by those providing ‘development assistance to low-income and middle-income countries’) has increased from $5.6 billion in 1990 to $21.8 billion in 2007 (Ravishankar et al. 2009). Many of the interventions funded with this money have focused on controlling infectious diseases. For those of us immersed in health and development work, whether as practitioners or researchers, it has been necessary to try and keep abreast of, and understand, these shifts and their implications. Some have tried to categorize the shifts involved. Lakoff (2010), for example, argues that they revolve around the poles of managing pathogens and the emergence of humanitarian medicine. Others point to the underlying pharmaceutical determinism as increasingly central to interventions (Biehl 2007; Harper 2002; Petryna 2009), in part as a reaction to the shifting patterns of global trade and their associated patent debates in the wake of HIV (McGoey, Reiss, and Wahlberg 2011). However we try to define the forces and discourses at work as these issues unfold around us (and to some extent this can only ever be done in hindsight), we adhere to the view—as a recent volume on critical studies in global health so richly attests (Biehl and Petryna 2013)—that ethnographic research has a vital role to play. It allows for problematizing issues, and provides critical commentary and counternarratives to quick fix theoretical and technical proposals for change. In this special issue, we explore the implications of these institutional and discursive shifts and provide further ethnographic engagement with infectious disease programs. Building on James Ferguson’s anti-politics thesis (Ferguson 1990) in particular, the articles highlight the politics and anti-politics of infectious disease control. In brief, Ferguson’s line of argument, drawing on Foucauldian analytical ideas applied to World Bank reports on Lesotho between 1975 and 1984, is that ‘development’ discourse generates particular forms of knowledge around which interventions are organized. In this sense, the pictures created by these bureaucracies both marginalize other political framings (ones that cannot be acted upon by these organizations) and simultaneously perform the unacknowledged political work of expanding and embedding bureaucratic and state interventions. While the authors of each of the articles in this collection in Medical Anthropology draw on Ferguson’s central idea, they are also cognizant of the limits of his approach—notably, an over-reliance on textual analysis and a tendency to overstate the effects of certain reports; a lack of attention to the nuance of development workers’ own engagements and interactions in policy work; and of how certain narratives come to justify and drive pathways
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of intervention. (The critique is most clearly developed in Parker and Allen’s contribution.) The authors of all articles analyze the politics and anti-politics of infectious disease control at multiple levels and across scales. Taylor and Harper’s article explores the issues occurring at a countrywide level, between ministries, bilateral agencies, and other aid organizations. Parker and Allen move upstream in their article to highlight the way in which anti-political rhetoric is deployed at an international level for political and strategic reasons. They show how this approach has enabled difficulties arising with vertical programs seeking to control neglected tropical diseases (NTDs), through mass drug administration, to be set to one side. Leach and Tadros, by contrast, reveal how political narratives of infection outbreak in ‘international’ forums are taken up by communities and NGOs, and highlight the implications that this has had in specific social and political milieu. The emergence of the Global Fund has revitalized the resources available for international attempts to control TB, malaria, and HIV. For those of us involved in TB control activities prior to its emergence (Harper worked in TB control in the early 1990s in Nepal), this injection of resources energized TB control from the resource barren years that came before. Central to debates around the Fund has been one between vertical health care delivery (focusing on one specific issue) and more comprehensive care. In 2007, the Global Fund took on board a number of criticisms of its modus operandum and decided to consider more comprehensive country investments. This decision was greeted with a warning not to throw the vertical programmatic babies out with the bathwater (Ooms et al. 2008). It was part of an ideological debate around the benefits of vertical versus more comprehensive resourcing policies (see Garrett and Farmer’s 2007 exchange in Foreign Affairs for an example of this in relation to the benefits of the Global Fund’s investment strategy, Garrett 2007; Farmer 2007). A number of unintended consequences have occurred with this new modality of intervention. The Global Fund is primarily a financial disbursement mechanism. It is unique in the health development field, primarily because funds are released in response to performance, and performance is assessed by reaching targets and indicators set in-country. This way of working is presented as simple and straight-forward. Ministerial staff are asked to present a case to do ‘x’; a plan is agreed (in consultation with staff from the Fund); the resources are provided; once the projects have been successfully completed, further money is released to develop the work. New forms of managerialism have been developed to enable this ‘simple’ approach to work. In the case of TB control, for example, countless managerial mechanisms, including procedures to track monies and strict monitoring and evaluation protocols, have been put in place to help monitor whether or not TB targets are being met. Transparency is one of the Fund’s clarion calls and, as a glance at its extensive website reveals, there is a sustained commitment to transparency (http://www.theglobalfund.org/en/). The organization also prides itself on values of efficiency borrowed from the private sector; given the sheer volume of resources dispersed, it is remarkable that it attempts to do this without an in-country presence. However, there are consequences to this modality of engagement. These are usefully captured through ethnographic research on the ground—in the offices and meeting places of the actors, who are attempting to bring in these resources, while adhering to the protocols and stipulations demanded by staff based at the Global Fund’s headquarters in Geneva. Taylor and Harper, in this issue, demonstrate this by describing the unintended consequences of this new public–private partnership in Uganda. Since its introduction there, the partnerships demanded by the Global Fund not only involved bypassing existing relationships that were already in place but also drove
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up the associated costs and involvement from partners beyond what was envisaged. By focusing on the processes and practices of applying for a new round of funds from this mechanism, Taylor and Harper highlight two new costs for Uganda: the expenses involved in hiring expensive consultants, and the time and direct costs of ensuring broad stakeholder participation. The World Health Organization also went beyond its mandate to provide support and stability for the emergent institutional form that developed. Taylor and Harper draw attention to the increased bureaucratization and the political and economic issues arising at this particular institutional level. The Global Fund’s attempts to “ensure the accountability, efficiency and effectiveness of programs being funded” (http://www.theglobalfund.org/en/performancebasedfunding/) has thus had significant unintended consequences at the country level. This has stimulated debate at another political register, with some arguing that a proportion of allocated funds should be given to other biomedical interventions. Shortly after the Global Fund was established, for example, it was argued that significant reductions in overall child mortality and morbidity could be achieved, if relatively small proportions of public health finance allocated toward the control of HIV/AIDS, tuberculosis, and malaria were re-directed toward the integrated control of neglected parasitic diseases (Molyneux, Hotez, and Fenwick 2005). Molyneux and colleagues went on to argue in this article that controlling Africa’s neglected diseases was one of “the most convincing ways to make poverty history” (106); a few years later, the same authors (Hotez et al. 2008) presented the case for establishing a ‘new Global Fund’ on NTDs. This has not happened, although considerable resources are now directed toward the control of these diseases. In 2012, for example, US funding for research and development on NTDs had reached $3.05 billion (Policy Cures 2012). It is important and interesting to note that the term ‘neglected tropical diseases’ was constructed in the aftermath of the Millennium Development Goals. The sixth MDG aims to combat ‘HIV/AIDS, malaria, and other diseases,’ with the residual category ‘other diseases’ essentially captured, after intense lobbying, by those promoting the control of NTDs through the magic bullet approach of mass drug administration for adults and children living in endemic areas. The approach appeals to governments and organizations such as the Bill and Melinda Gates Foundation, not least because they are committing aid to achieve the MDGs in ‘cost-effective’ ways. Parker and Allen conducted their research against this background. In their article, they draw attention to politics at two registers. Drawing on village-based fieldwork undertaken in Uganda and Tanzania, they show that the mass distribution of drugs for the treatment of two NTDs, schistosomiasis, and lymphatic filariasis was less effective than suggested in the biomedical literature. At several sites, it failed, with a complex array of social, economic, political, and historical issues explaining the reluctance to receive, let alone consume, free medicines at a local level. Parker and Allen highlight the limits to a top-down, vertical approach in the absence of broader primary health care service provision. At an international level, their findings received a mixed reception, stimulating heated and, at times, acrimonious reactions (usefully summarized by Reisz 2013). This is partly because they called into question the way in which first-world universities and their global health departments control the flow of resources for tropical disease control programs. In their article in this issue, by detailing the strategies deployed to set aside discomforting evidence and silence dissenting voices, Parker and Allen show how a moral discourse advocating the ‘right to health’ is effectively used to trump research evidence pointing to the mixed impact, unintended or otherwise, of NTD control programs at a local level.
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Leach and Tadros explore the implications of narratives around another infectious agent, H1N1 influenza (‘swine flu’). The fears of viral zoonoses going airborne and wreaking havoc globally have stimulated narratives of infection with politically significant ramifications. Those that accompanied H1N1 were channeled in particular to those around global health security. Associated with this was the almost inevitable geographies of blame as disease sources are located in particular countries or populations (as seen with HIV, SARS, Ebola, and plague, among others) and seen as a threat to more distant climes, particularly in the first world. Focusing on the politics of knowledge production, Leach and Tadros compliment the article by Parker and Allen. In Egypt, particular narratives around the outbreak of H1N1 influenza had significant effects. The government responded in a draconian way as the disease outbreak was narrated as emerging from a particular geographical space. It moved beyond the WHO’s position, and driven by ideological and religious intent, instigated a policy of culling pigs. Using the qualifier ‘swine’—the ‘pig issue’—allowed forceful bio-political interventions into the Christian Coptic communities (the Zabaleen). The government announced the plan to cull pigs, and used the WHO declaration as its justification. Scientific and religious claims merged here, as pigs are unclean in Islamic religious discourse, and linked with anti-Christian sentiments—as became clear in significant media outlets. The forces were aligned against a group that already had a long history of social and political marginalization. The authors’ own political impetus is to put into circulation other narratives of those stigmatized and affected by the policies placed around them. The Zabaleen counternarrative highlighted that the pigs were significant consumers of organic waste, that their demise would have counter public health implications, and that this was just another affront in a long history of marginalization. These accounts barely registered in the local media. In documenting this, Leach and Tadros offer an excellent example of research that explores the relationships between popular representations of the disease, trust in government programs and the media, and the power relations that this reflects (cf. Nichter 2008). The authors point to how we need to understand these issues across scales: international narratives of outbreaks, once adopted in Egypt, cannot be separated from the Islamic state building history and its current manifestations. These three articles demonstrate the power of ethnographic engagement in the realm of infectious disease control. They should not be dismissed as “anecdotal, nongeneralizable, and inherently impractical,” even if they are deemed not to fit with the urgency of policy prescriptions or lack obvious utility (Biehl and Petryna 2013:20). On the contrary, by highlighting the political and apolitical dimensions of infectious disease control, they demonstrate the value of analyses that link our research and institutional politics, with international and national responses to disease outbreaks, to the communities most affected by these policies.
REFERENCES Biehl, J. 2007 Pharmaceuticalization: AIDS treatment and global health politics. Anthropological Quarterly 80(4):1083–1126. Biehl, J. and A. Petryna 2013 Critical global health. In When People Come First: Critical Studies in Global Health. J. Biehl and A. Petryna, eds. Pp. 1–20. Princeton, NJ and Oxford, UK: Princeton University Press. Birn, A. 2005 Gate’s grandest challenge: Transcending technology as public health ideology. Lancet 366:514–519.
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Farmer, P. 2004 Rethinking medical ethics: A view from below. Developing World Bioethics 4(1):17–41. ———. 2007 From “marvellous momentum” to health care for all: Success is possible with the right programs. Foreign Affairs, April 1, 2007. Fassin, D. 2009 Another politics of life is possible. Theory, Culture and Society 26(5):44–60. Fassin, D. and R. Rechtman 2009 The Empire of Trauma: An Enquiry into the Condition of Victimhood. Princeton, NJ and Oxford, UK: Princeton University Press. Ferguson, J. 1990 The Anti-Politics Machine: ‘Development,’ Depoliticization and Bureaucratic Power in Lesotho. Cambridge, UK: Cambridge University Press. Fidler, D. 2009 After the revolution: Global health politics in a time of economic crisis and threatening future trends. Global Health Governance 2(2). http://www.ghgj.org/Fidler_After%20the%20Revolution.pdf. Garrett, L. 2007 The challenge of global health. Foreign Affairs, January 1, 2007. http://www.foreignaffairs.com/articles/62268/ laurie-garrett/the-challenge-of-global-health. Harper, I. 2002 Capsular promise as public health: A critique of the Nepal National Vitamin A Programme. Studies in Nepali History and Society 7(1):137–173. Hotez, P., D. Molyneux, A. Fenwick, L. Savioli, and T. Takeuchi 2008 A Global Fund to fight neglected tropical diseases: Is the G8 Hokkaido Toyako 2008 summit ready? PLoS Neglected Tropical Diseases 2(3):e220. Ingram, A. 2005 The new geopolitics of disease: Between global health and global security. Geopolitics 10(3):522–545. Lakoff, A. 2010 Two regimes of global health. Humanity: An International Journal of Human Rights, Humanitarianism and Development 1(1):59–79. McGoey, L., J. Reiss, and A. Wahlberg 2011 The global health complex. BioSocieties advance online publication, February 7, 2011. doi:10.1057/biosoc. 2010.45. Molyneux, D., P. Hotez, and A. Fenwick 2005 Rapid impact interventions: How a policy of integrated control for Africa’s neglected tropical diseases could benefit the poor. PloS Med 2(11):e336. Nayar, K. and O. Razum 2006 Millennium Development Goals and health: Another selective development? International Studies 43(3):317–322. Nguyen, V. 2005 Antiretroviral globalism, biopolitics and therapeutic citizenship. In Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems. A. Ong and S. Collier, eds. Pp. 124–144, Malden, MA, Oxford, UK, and Carlton, Australia: Blackwell. ———. 2010 The Republic of Therapy: Triage and Sovereignty in West Africa’s Time of AIDS, Durham, NC and London: Duke University Press. Nichter, M. 2008 Global Health: Why Cultural Perceptions, Social Representations, and Biopolitics Matter. Tucson: University of Arizona Press. Ooms, G., W. Van Damme, B. Baker, P. Zeitz, and T Schrecker 2008 The ‘diagonal’ approach to Global Fund financing: A cure for the broader malaise of health systems? Globalization and Health 4(6). http://www.globalizationandhealth.com/content/4/1/6.
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Petryna, A. 2009 When Experiments Travel: Clinical Trials and the Global Search for Human Subjects. Princeton, NJ and Oxford, UK: Princeton University Press. Ravishankar, N., P. Gubbins, R. Cooley, K. Leach-Kemon, C. Michaud, D. Jamison, and C Murray 2009 Financing of global health: Tracking development assistance for health from 1990 to 2007. Lancet 373:2113–2124. Redfield. P. 2005 Doctors, borders and life in crisis. Cultural Anthropology 20(3):328–361. ———. 2013 Life in Crisis: The Ethical Journey of Doctors Without Borders. Berkeley: University of California Press. Reisz, M. 2013 Unwanted side-effects. Times Higher Education, May 30:32–37. Singer, M. 2009 Introduction to Syndemics: A Critical Systems Approach to Public and Community Health. San Francisco: Jossey Bass. Singer, M. and S. Clair 2003 Syndemics and public health: Reconceptualizing disease in bio-social context. Medical Anthropology Quarterly 17(4):423–441.
Medical Anthropology: Cross-Cultural Studies in Health and Illness Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gmea20
The Politics and Anti-Politics of Infectious Disease Control a
Ian Harper & Melissa Parker
b
a
Department of Social Anthropology, University of Edinburgh, Edinburgh, UK b
Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK Published online: 24 Apr 2014.
To cite this article: Ian Harper & Melissa Parker (2014) The Politics and Anti-Politics of Infectious Disease Control, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 33:3, 198-205, DOI: 10.1080/01459740.2014.892484 To link to this article: http://dx.doi.org/10.1080/01459740.2014.892484
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Medical Anthropology, 33: 198–205, 2014 Copyright © 2014 Taylor & Francis Group, LLC ISSN: 0145-9740 print/1545-5882 online DOI: 10.1080/01459740.2014.892484
INTRODUCTION
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The Politics and Anti-Politics of Infectious Disease Control Ian Harper Department of Social Anthropology, University of Edinburgh, Edinburgh, UK
Melissa Parker Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
Walking from the courtyard, out of the monsoon rains, into the cool offices of a large and prosperous nongovernmental organization (NGO) in one of Nepal’s sprawling urban cities was a relief. It was the summer of 2013 and research into the politics and expansion of the NGO sector under direct influence of funding from the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM) was underway. We had arranged to meet the director and senior members of the organization to talk about their work on HIV treatment and prevention with intravenous drug users (IDUs). The director was one of a number of high-profile human rights advocates, demanding access to antiretroviral drugs and better services, and the work of these advocates reflected a shift toward a rights-based approach characteristic of the HIV sector in health development work. We were told that the organization had started initially as a loose network of individuals supporting each other in their recovery from drug addiction. Then came the HIV epidemic, and the aid money. IDUs became a risk group, and the target of interventions to prevent the further spread of the HIV virus. ARVs followed, as did a new form of identity politics associated with these transformations. Each member of the team introduced him or herself as a ‘recovering IDU.’ After IAN HARPER is the head of the Department of Social Anthropology at the University of Edinburgh, and a Wellcome Trust Senior Investigator. His research focuses on tuberculosis control, pharmaceuticals, the conduct of research in health development, and healing practices more broadly in the context of South Asia. Address correspondence to Ian Harper, Department of Social Anthropology, University of Edinburgh, Edinburgh, United Kingdom. E-mail: [email protected]. MELISSA PARKER is a reader in Medical Anthropology at the London School of Hygiene and Tropical Medicine. Since the 1980s, she has undertaken anthropological research in Sudan, Ghana, Uganda, Tanzania and the UK on global health issues including female circumcision, HIV/AIDS, neglected tropical diseases, health, and healing in the aftermath of war. Address correspondence to Melissa Parker, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom. E-mail: [email protected]
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receiving several rounds of GFATM funding, they had managed to improve access to diagnostic facilities and treatment by increasing the number of clinics available in the country. The clinic that they had opened on the ground floor of the building they rented for their office was now also being used as a DOTS treatment center, providing antituberculosis drugs too. The GFATM, cognizant of issues around the vertical health policy they had been driving, was becoming more insistent that services be integrated, and had started with tuberculosis (TB) and HIV. Several years earlier, at a regional conference organized by the International Union of Tuberculosis and Lung Disease in Kathmandu—in the sumptuous halls of the five-star hotel, the Yak and Yeti, and next to the equally grand headquarters of the World Bank—HIV activists had greeted the delegates with placards and chanting. ARVs, they shouted, should be available from all DOTS clinics as well. Their voices are gradually being heard, it seems. Yet amidst these successes, the team had criticisms and vulnerabilities. We have low CD4 counts and eat ARVs, said one, but we are all dying of Hepatitis C. This co-epidemic was not being addressed at all. A very high percentage of IDUs have this infectious condition as well, but Nepal does not have adequate laboratory capacities to diagnose it, or the interferon drugs to treat it, or even the physicians trained to manage it. The Global Fund will not provide the necessary funds because it lies outside its remit of providing financial resources for HIV, TB, and Malaria, and deviation from its stated goals and programmatic targets is not possible. It is not the diseases that kill us in Nepal, said the director, it’s the bureaucracy! The last round of funding—round 11 since the annual funding rounds first began—had been cancelled. This was partly due to the global economic recession and a subsequent unwillingness on the part of donors to pay substantial sums into the Fund. Whatever the reason, staff within this NGO were having to rethink their strategies and practice. If the money dries up, where will we be, asked the director and his staff? This small vignette from Nepal draws on Harper’s ongoing Wellcome Trust funded research “Understanding TB control: Technologies, ethics and programs” which highlights some of the complexities of ‘global health.’ A reconfiguration of institutions, technologies, and financial flows has occurred over the past 15 years, generating confusion and concern among anthropologists and others working in this field as to how best to understand and represent these shifts and forces (Biehl and Petryna 2013). As noted previously, for example, we see the conflation of vertical disease programs with new modalities of funding (the Global Fund only came into being in 2001); the rise of NGOs and public–private partnerships (involving a strong ideological push from the Global Fund alongside wider neo-liberal reforms in the health and development sector); the influence and impact of rights-based approaches to health and the identity politics that comes with this (Nguyen 2005, 2010); the maldistribution of resources, and the way in which the issues this presents are simultaneously and centrally related to questions of equity (Farmer 2004); the inability to take into account biological, social, and political issues of co-infection or ‘syndemics’ (see Singer 2009; Singer and Clair 2003); and the need for expansive services that are not fragmented and atomized. These issues are primarily political rather than technical—hence the rationale for the collection of articles in this issue of Medical Anthropology.
THE NEW LANDSCAPE OF GLOBAL HEALTH AND INFECTIOUS DISEASE Since 2000, we have witnessed significant discursive shifts around ‘global health.’ A range of forces, both economic and political, have resulted in a reconfiguration of how we understand and
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approach health at the global level. As Fidler (2009) has pointed out, this re-conceptualization has been associated with a substantial increase in finances and resources, and includes the following shifts: the framing of health as a security issue (cf. Ingram 2005); the emergence of new international governance regimes, such as the World Health Organization’s International Health Regulations; new assemblages of organizations dealing with certain infective threats, like the GFATM; leading economic powers tabling health issues at global summits and meetings; shifting geopolitical relations, both around states (such as China’s ascendancy), NGOs (such as Médecins Sans Frontières, see Redfield 2005, 2013; Fassin 2009; Fassin and Rechtman 2009) and Partners in Health (Farmer 2003); and the rise of the Bill and Melinda Gates Foundation, which has invested substantially in health (Birn 2005). In addition, one of the consequences of the Millennium Development Goals (MDGs) is that development interventions have become more weighted toward health oriented targets (Nayar and Razum 2006). MDGs Four, Five, and Six, in particular, are to ‘reduce child mortality,’ ‘improve maternal health,’ and ‘combat HIV/AIDS, malaria, and other diseases,’ respectively. In macroeconomic terms, development assistance for health (that is, all flows into health from public and private institutions by those providing ‘development assistance to low-income and middle-income countries’) has increased from $5.6 billion in 1990 to $21.8 billion in 2007 (Ravishankar et al. 2009). Many of the interventions funded with this money have focused on controlling infectious diseases. For those of us immersed in health and development work, whether as practitioners or researchers, it has been necessary to try and keep abreast of, and understand, these shifts and their implications. Some have tried to categorize the shifts involved. Lakoff (2010), for example, argues that they revolve around the poles of managing pathogens and the emergence of humanitarian medicine. Others point to the underlying pharmaceutical determinism as increasingly central to interventions (Biehl 2007; Harper 2002; Petryna 2009), in part as a reaction to the shifting patterns of global trade and their associated patent debates in the wake of HIV (McGoey, Reiss, and Wahlberg 2011). However we try to define the forces and discourses at work as these issues unfold around us (and to some extent this can only ever be done in hindsight), we adhere to the view—as a recent volume on critical studies in global health so richly attests (Biehl and Petryna 2013)—that ethnographic research has a vital role to play. It allows for problematizing issues, and provides critical commentary and counternarratives to quick fix theoretical and technical proposals for change. In this special issue, we explore the implications of these institutional and discursive shifts and provide further ethnographic engagement with infectious disease programs. Building on James Ferguson’s anti-politics thesis (Ferguson 1990) in particular, the articles highlight the politics and anti-politics of infectious disease control. In brief, Ferguson’s line of argument, drawing on Foucauldian analytical ideas applied to World Bank reports on Lesotho between 1975 and 1984, is that ‘development’ discourse generates particular forms of knowledge around which interventions are organized. In this sense, the pictures created by these bureaucracies both marginalize other political framings (ones that cannot be acted upon by these organizations) and simultaneously perform the unacknowledged political work of expanding and embedding bureaucratic and state interventions. While the authors of each of the articles in this collection in Medical Anthropology draw on Ferguson’s central idea, they are also cognizant of the limits of his approach—notably, an over-reliance on textual analysis and a tendency to overstate the effects of certain reports; a lack of attention to the nuance of development workers’ own engagements and interactions in policy work; and of how certain narratives come to justify and drive pathways
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of intervention. (The critique is most clearly developed in Parker and Allen’s contribution.) The authors of all articles analyze the politics and anti-politics of infectious disease control at multiple levels and across scales. Taylor and Harper’s article explores the issues occurring at a countrywide level, between ministries, bilateral agencies, and other aid organizations. Parker and Allen move upstream in their article to highlight the way in which anti-political rhetoric is deployed at an international level for political and strategic reasons. They show how this approach has enabled difficulties arising with vertical programs seeking to control neglected tropical diseases (NTDs), through mass drug administration, to be set to one side. Leach and Tadros, by contrast, reveal how political narratives of infection outbreak in ‘international’ forums are taken up by communities and NGOs, and highlight the implications that this has had in specific social and political milieu. The emergence of the Global Fund has revitalized the resources available for international attempts to control TB, malaria, and HIV. For those of us involved in TB control activities prior to its emergence (Harper worked in TB control in the early 1990s in Nepal), this injection of resources energized TB control from the resource barren years that came before. Central to debates around the Fund has been one between vertical health care delivery (focusing on one specific issue) and more comprehensive care. In 2007, the Global Fund took on board a number of criticisms of its modus operandum and decided to consider more comprehensive country investments. This decision was greeted with a warning not to throw the vertical programmatic babies out with the bathwater (Ooms et al. 2008). It was part of an ideological debate around the benefits of vertical versus more comprehensive resourcing policies (see Garrett and Farmer’s 2007 exchange in Foreign Affairs for an example of this in relation to the benefits of the Global Fund’s investment strategy, Garrett 2007; Farmer 2007). A number of unintended consequences have occurred with this new modality of intervention. The Global Fund is primarily a financial disbursement mechanism. It is unique in the health development field, primarily because funds are released in response to performance, and performance is assessed by reaching targets and indicators set in-country. This way of working is presented as simple and straight-forward. Ministerial staff are asked to present a case to do ‘x’; a plan is agreed (in consultation with staff from the Fund); the resources are provided; once the projects have been successfully completed, further money is released to develop the work. New forms of managerialism have been developed to enable this ‘simple’ approach to work. In the case of TB control, for example, countless managerial mechanisms, including procedures to track monies and strict monitoring and evaluation protocols, have been put in place to help monitor whether or not TB targets are being met. Transparency is one of the Fund’s clarion calls and, as a glance at its extensive website reveals, there is a sustained commitment to transparency (http://www.theglobalfund.org/en/). The organization also prides itself on values of efficiency borrowed from the private sector; given the sheer volume of resources dispersed, it is remarkable that it attempts to do this without an in-country presence. However, there are consequences to this modality of engagement. These are usefully captured through ethnographic research on the ground—in the offices and meeting places of the actors, who are attempting to bring in these resources, while adhering to the protocols and stipulations demanded by staff based at the Global Fund’s headquarters in Geneva. Taylor and Harper, in this issue, demonstrate this by describing the unintended consequences of this new public–private partnership in Uganda. Since its introduction there, the partnerships demanded by the Global Fund not only involved bypassing existing relationships that were already in place but also drove
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up the associated costs and involvement from partners beyond what was envisaged. By focusing on the processes and practices of applying for a new round of funds from this mechanism, Taylor and Harper highlight two new costs for Uganda: the expenses involved in hiring expensive consultants, and the time and direct costs of ensuring broad stakeholder participation. The World Health Organization also went beyond its mandate to provide support and stability for the emergent institutional form that developed. Taylor and Harper draw attention to the increased bureaucratization and the political and economic issues arising at this particular institutional level. The Global Fund’s attempts to “ensure the accountability, efficiency and effectiveness of programs being funded” (http://www.theglobalfund.org/en/performancebasedfunding/) has thus had significant unintended consequences at the country level. This has stimulated debate at another political register, with some arguing that a proportion of allocated funds should be given to other biomedical interventions. Shortly after the Global Fund was established, for example, it was argued that significant reductions in overall child mortality and morbidity could be achieved, if relatively small proportions of public health finance allocated toward the control of HIV/AIDS, tuberculosis, and malaria were re-directed toward the integrated control of neglected parasitic diseases (Molyneux, Hotez, and Fenwick 2005). Molyneux and colleagues went on to argue in this article that controlling Africa’s neglected diseases was one of “the most convincing ways to make poverty history” (106); a few years later, the same authors (Hotez et al. 2008) presented the case for establishing a ‘new Global Fund’ on NTDs. This has not happened, although considerable resources are now directed toward the control of these diseases. In 2012, for example, US funding for research and development on NTDs had reached $3.05 billion (Policy Cures 2012). It is important and interesting to note that the term ‘neglected tropical diseases’ was constructed in the aftermath of the Millennium Development Goals. The sixth MDG aims to combat ‘HIV/AIDS, malaria, and other diseases,’ with the residual category ‘other diseases’ essentially captured, after intense lobbying, by those promoting the control of NTDs through the magic bullet approach of mass drug administration for adults and children living in endemic areas. The approach appeals to governments and organizations such as the Bill and Melinda Gates Foundation, not least because they are committing aid to achieve the MDGs in ‘cost-effective’ ways. Parker and Allen conducted their research against this background. In their article, they draw attention to politics at two registers. Drawing on village-based fieldwork undertaken in Uganda and Tanzania, they show that the mass distribution of drugs for the treatment of two NTDs, schistosomiasis, and lymphatic filariasis was less effective than suggested in the biomedical literature. At several sites, it failed, with a complex array of social, economic, political, and historical issues explaining the reluctance to receive, let alone consume, free medicines at a local level. Parker and Allen highlight the limits to a top-down, vertical approach in the absence of broader primary health care service provision. At an international level, their findings received a mixed reception, stimulating heated and, at times, acrimonious reactions (usefully summarized by Reisz 2013). This is partly because they called into question the way in which first-world universities and their global health departments control the flow of resources for tropical disease control programs. In their article in this issue, by detailing the strategies deployed to set aside discomforting evidence and silence dissenting voices, Parker and Allen show how a moral discourse advocating the ‘right to health’ is effectively used to trump research evidence pointing to the mixed impact, unintended or otherwise, of NTD control programs at a local level.
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Leach and Tadros explore the implications of narratives around another infectious agent, H1N1 influenza (‘swine flu’). The fears of viral zoonoses going airborne and wreaking havoc globally have stimulated narratives of infection with politically significant ramifications. Those that accompanied H1N1 were channeled in particular to those around global health security. Associated with this was the almost inevitable geographies of blame as disease sources are located in particular countries or populations (as seen with HIV, SARS, Ebola, and plague, among others) and seen as a threat to more distant climes, particularly in the first world. Focusing on the politics of knowledge production, Leach and Tadros compliment the article by Parker and Allen. In Egypt, particular narratives around the outbreak of H1N1 influenza had significant effects. The government responded in a draconian way as the disease outbreak was narrated as emerging from a particular geographical space. It moved beyond the WHO’s position, and driven by ideological and religious intent, instigated a policy of culling pigs. Using the qualifier ‘swine’—the ‘pig issue’—allowed forceful bio-political interventions into the Christian Coptic communities (the Zabaleen). The government announced the plan to cull pigs, and used the WHO declaration as its justification. Scientific and religious claims merged here, as pigs are unclean in Islamic religious discourse, and linked with anti-Christian sentiments—as became clear in significant media outlets. The forces were aligned against a group that already had a long history of social and political marginalization. The authors’ own political impetus is to put into circulation other narratives of those stigmatized and affected by the policies placed around them. The Zabaleen counternarrative highlighted that the pigs were significant consumers of organic waste, that their demise would have counter public health implications, and that this was just another affront in a long history of marginalization. These accounts barely registered in the local media. In documenting this, Leach and Tadros offer an excellent example of research that explores the relationships between popular representations of the disease, trust in government programs and the media, and the power relations that this reflects (cf. Nichter 2008). The authors point to how we need to understand these issues across scales: international narratives of outbreaks, once adopted in Egypt, cannot be separated from the Islamic state building history and its current manifestations. These three articles demonstrate the power of ethnographic engagement in the realm of infectious disease control. They should not be dismissed as “anecdotal, nongeneralizable, and inherently impractical,” even if they are deemed not to fit with the urgency of policy prescriptions or lack obvious utility (Biehl and Petryna 2013:20). On the contrary, by highlighting the political and apolitical dimensions of infectious disease control, they demonstrate the value of analyses that link our research and institutional politics, with international and national responses to disease outbreaks, to the communities most affected by these policies.
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Petryna, A. 2009 When Experiments Travel: Clinical Trials and the Global Search for Human Subjects. Princeton, NJ and Oxford, UK: Princeton University Press. Ravishankar, N., P. Gubbins, R. Cooley, K. Leach-Kemon, C. Michaud, D. Jamison, and C Murray 2009 Financing of global health: Tracking development assistance for health from 1990 to 2007. Lancet 373:2113–2124. Redfield. P. 2005 Doctors, borders and life in crisis. Cultural Anthropology 20(3):328–361. ———. 2013 Life in Crisis: The Ethical Journey of Doctors Without Borders. Berkeley: University of California Press. Reisz, M. 2013 Unwanted side-effects. Times Higher Education, May 30:32–37. Singer, M. 2009 Introduction to Syndemics: A Critical Systems Approach to Public and Community Health. San Francisco: Jossey Bass. Singer, M. and S. Clair 2003 Syndemics and public health: Reconceptualizing disease in bio-social context. Medical Anthropology Quarterly 17(4):423–441.
