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Global Health's Anti-Politics - honors thesis presentation by Dalton Price '20
Posted on November 20, 2020 By Cornell Anthropology
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DALTON PRICE: Hello, my name is Dalton, and I did my thesis. It's titled Global Health's (Anti)politics, A Comparative Ethnography of the World Health Organization and Partners in Health. Now, the starting point my thesis is that global health is this fast emerging yet ill-defined architecture sometimes referred to as one big problem. Other times, it's an open source anarchy where a number of actors can just flood in with very low barriers to entry. And it's fast changing, which I think is an important part. Now, in my thesis, I hone in on one particular change, the fall of the use of the term "international health" and the coupled rise of the term "global health" starting in the later 20th century. Now, international health versus global health. International health implies an attachment to nations at the most basic level, whereas the global transcends nations. And this connotes important differences in the logic, ethics, and practices among these actors. And what I would suggest, is that it has fundamentally changed health governance and how global health or health humanitarianism is carried out. Now, focusing more specifically on this desire to be global. First, it comes in the wave of neoliberal reforms and the gutting of public sectors that we've seen over the years, where we see this new endowed legitimacy to non-state actors, NGOs, humanitarian organizations who have severed their ties with the state. We can track this through financing, through expectations, and so on. And the other is this growing sensitization to suffering or this moral attention to suffering that's been described by Didier Fassin and other anthropologists but also the new types of responses we have to the suffering, which I think is important. And so, this fractured relationship with the state that the global implies is really no coincidence. It's born out of this surge of neoliberalism as well as a new moral economy focus on suffering, the two of which I analyze as interconnected phenomena gaining traction in this, again, mid to late 20th century. Now, in my research, specifically, I look at how these changes in global health as they happen embed at the level of the institution and ethnographically dissect the WHO and partners in health. In looking at them, I'm focusing specifically on how these two groups differentially engage in politics. That's kind of the particular aspect I'm focusing on here and how this political calculus of neutrality that is quite known to the humanitarian sector for being neutral, apolitical, and so on, how this political calculus factors into their decisions. And so, from the outset of my thesis, I introduce the idea of anti-politics because at the WHO, it's not a matter of whether people are being political or apolitical. Same thing, the Partners in Health, it isn't political or apolitical. It is instead, what I would suggest, is anti-political or an anti-politics because it's not a mere binary. It's an active aversion to politics. This anti-politics term first comes up in Ferguson's work in Lesotho, looking at the development industry there, and obviously maps onto other parts of the humanitarian and social impact sectors. Now, in particular, I show in this thesis how politics is systematized at both of these agencies and how they do and really do not address the structural determinants of health. I chose the WHO because the WHO identifies as this international organization tied to its member states. It also claims to be a neutral apolitical organization. Partners in Health, on the other hand, was founded 40 years later and is kind of valorized as this beacon for the future of global health. This organization identifies as a global social justice organization. And then, we'll unpack that a bit. But I think these two organizations provide-- though the thesis is about these two organizations in particular, it really introduces a nice comparison of thinking through international versus global health and how these changes are happening. And so, I use my ethnographic data from these experiences to bear on these broader shifts and changes happening in global health shaped by these new moral economies to focus on suffering as well as neoliberal reforms and so on. This research is based on several months of interviews and participant observation at the WHO's Eastern Mediterranean regional office in Cairo, Egypt, as well as their country office in Amman, Jordan, as well as some other minor projects throughout the Middle East and North Africa or the Eastern Mediterranean region as defined by the WHO. On the other hand, I continued-- I carried out two months additional on the ground research with Partners in Health in their branch in Lima, Peru as well as, throughout all of this, going through an array of archival materials that can help me better understand what is happening within the walls of these institutions and what shapes what happens. And so, I began this presentation with focusing on my work with the WHO and then compare to Partners in Health. Now, at the WHO, there were politics was this unaddressed but not unacknowledged part of their work. People always say the WHO doesn't talk about politics. It's neutral, apolitical. That's not the case. WHO staff are very aware of politics, and conflict, and civil unrest, protests, dissidents, and so on. Dissensions, excuse me. But politics is quite literally a daily point of discussion, which I saw in my own experience there working in an emergency briefing room where every morning a list of all the political events in our region were listed out. But the difference is that they're not addressed. We discuss them. We acknowledge them. But they're not used to tailor interventions strategically. And that's an important detail. So, as we think through this, first, it's important to acknowledge the WHO's history. The earliest conversations about an international health organization like the WHO happened in these war time conditions of the mid-twentieth century and wholly shaped the WHO's modern or contemporary practices. So, that's something important to think about, and I discuss it in my thesis. But also, it's very clear that rendering technical process that Tanya Marie Lee talks about, which is quite characteristic of biomedicine and public health practice. She describes it as an arena of intervention that is bounded, dissected, and devised using corrective measures to produce desirable results. That's kind of how she understands this idea of rendering technical, which she uses to describe what she saw in her field work among Indonesian development experts. Now, in my time with the division, I focused specifically on antimicrobial resistance, AMR. It's a particular infectious disease similar to antibiotic resistance but kind of more inclusive of a term. And so, it was very clear the WHO's framing of AMR was all around the antibiotic itself, a pill. Too much of the pill was bad. And that seemingly simple conclusion is what drove much of our work on AMR while I was there. This pill is in circulation. It becomes a currency with three main actors being implicated in its economy. You have the patients who take up the medicine. You have the doctors who prescribe the medicine. Sometimes it depends on the country. And pharmacists who dispense. And again, in my field work, this was reflective not only in our team's composition, which is mostly doctors, and pharmacists, and then microbiologists, but also every single intervention we designed. The patient, doctor, and the pharmacist were all at the core of the WHO's understandings of AMR and circumscribed their interventions. According to the WHO logics, these individuals-- patients, doctors, and pharmacists-- were the locus of problematic behavior. Those were where the interventions need to be focused. And this is important for thinking about how the organization thinks about politics because these organizations-- not these organizations. These individuals are often seen as separate from their political lives. For example, in Egypt, despite people-- well documented the work of Shireen Hamdi and so on, how Egyptians rationalized their health through politics or political failings by the government, the national government. That is not taken into account to the WHO level where everything is rendered technical. The second main part that I noticed that shapes this anti-politics is how the WHO with these universalist framings that I call them that necessitate a standardized mode of intervention across the world, across the geographies in which the WHO works. And so, what do I mean by that? In short, the WHO's anti-politics is in part a function of geography. For my time, I think, working in the Middle East and North Africa, there was an indisputable political precarity that comes with working there, where politics is talked about in a very different sort of way than, for example, in the Western context where I come from. And this precarity is something that was very different, again, from my experience in Peru, where people would talk openly and publicly about politics. In the Middle East and North Africa, I was told about how you could get penalized for it, and researchers have in the past. And so, for the WHO, especially in this region, politics was something that felt very off the table and something that was not just messy but also dangerous. And so, since the WTO works in a very standardized mode across the regions that it works in, which are all regions, one sets the stage for all. In this case, the Middle East, North African context and the political opportunity that is associated with that region maps onto the work that they do elsewhere, which is, again, also shaped by this rendering technical process and so on. And so, returning to the words of Steven Hoffman, a journalist. He said the WHO is, quote, expected to manage the complicated global politics that emerge while also being a world class public health agency. In this, they're expected to respect national sovereignty and all of that. And there's so high expectations. But it's also a near unachievable duality and an unfair expectation of this agency to navigate both the complicated politics while also being this world class public health agency. Now, the last part that I noticed and focus on, at least in my thesis, that shapes the politics of the WHO is this diplomatic culture given its position vis a vis national governments and identity as an international organization. The WTO is composed of 194 nation states that provide funds to finance all of their programs and all of their staff. And so, they're very much so connected. And the WTO is born out of a treaty. And it's really more in the international affairs sector than necessarily a humanitarian sector or health care services sector. And so, at the WTO, there there's also this really strong institutional memory of what goes wrong when sovereignty is violated for nations. We saw it with the Indonesian context of when the WTO took viral samples and shared them. And there were many issues that I talk about in my thesis there. But this is all to say that diplomacy at the WTO is this balancing act between WHO's institutional interests, in this case, safeguarding populations from the threat of AMR, but also being a team player with its member states and avoiding sovereign encroachment as they've been accused of in the past. So, this diplomacy, again, the balancing act right there, is what shapes their anti-politics as well. Now, after thinking through the anti-politics of the WHO, also need to focus on Partners in Health. Now looking at Partners in Health. Partners in Health really reflects this more kind of global organization that I'm talking about as compared to the international that I associate with the WHO. But an analysis of this kind of global aspiration, again, shows that it really is really aspirational and in some instances can devolve into these neocolonial realities that limit the national offices of Partners in Health and localize blame and responsibility to those national offices and not necessarily the Boston headquarters that dictates what happens, in this instance, in the Lima, Peru office. And so, Partners in Health really claims to carry out this biosocial care of bridging the gap between the biological sciences and biomedicine and the more social sciences like anthropology given, again, it's founded by many physician anthropologists and others who straddle the two disciplines. So, it claims to engage in these sort of acts of biosocial care while also addressing structural violence. However, in my fieldwork, I saw that there was a very clear disconnect between what they claim to do and what they actually do. And so, when Paul Farmer, the founder, a physician anthropologist, when he created Partners in Health among scientists, alongside his founders, he created an NGO that has great ideas, promotes innovative programs, and really does challenge long held assumptions in this space. And they've been applauded for these efforts by anthropologists and public health practitioners alike. But still, at the end of the day, categorically, it is a global health NGO that is-- the core of its programming depends on these biomedical and public health toolkits. And so, Partners in Health can push the boundaries of intervention or what frameworks need to be used in this space. But it does not fall outside of these boundaries. And that's really important because, as they claim to employ these biosocial theories for handling structural violence and so on, we really see that these claims are instead institutionalized and therefore refracted, the result being an organization whose modes of intervention align with a set of rules for how health promotion is to be conducted. And in this way, it really is a paradox woven into the organization. And again, return to the work of Fassin. He talks about how there is a state of contradiction that's inherent to these humanitarian governments, thereby declaring this paradox that suggests itself. Or the paradox itself is a product of the institutionalization of Farmer's ideas in the form of a humanitarian actor. Or, in other words, the paradox that I describe in Partners in Health does not typify Partners in Health but rather global health and humanitarian governments at large, which is something important to consider here, again, in thinking about what shapes their anti-politics and how does it manifest in their work. And so, in claiming to be this progressive organization, this local good discourse of going beyond what the expectations are and doing biosocial approaches, which in some respects, they do-- in their tuberculosis program, they'll provide food baskets, and some financial assistance, and so on. Those are programs that they do, not necessarily at the scale of, say, the biomedicine centric programs like providing medicines or guiding people to care. Those do happen. It is present. However, Partners in Health staff spoke about their very comprehensive, integrated approach to tuberculosis with a sense of completion in some ways as if they considered all relevant perspectives. And so, when I asked, one person told me, we have thought about this-- this being tuberculosis-- ever since I entered Partners in Health, how to look at health for people in a different way and from different points of view. So, that's what someone on the tuberculosis team told me. But rhetorically, but not actually, the programs they executed each day are embodied or already embodied the multidisciplinary perspectives they sought. And so, as a result, that's what they felt. And so, as a result, these other structural determinants of health are often obscured and considered. What I mean by that is they consider a lot about the socioeconomic factors. For example, we see the agency engaging some of those things but not necessarily the political side, or how politics shapes socioeconomics, or how certain forms of corruption that I heard quite a bit about, again, shape the work that they're doing because of this barrier between their work and the political world in Peru. So, that was something really important to consider. And then also, we see this a fragile yet tense relationship between the Partners in Health Peru office and the Peruvian national government. And again, I suggest that this is one of the relationships that ground the organization's anti-politics. And so, this relationship is essentially that Partners in Health is inextricable from the Peruvian government. Their Peru office is inextricable from the Peruvian government. And that when Partners in Health Peru devises programs, they carry out pilot programs and then work with the Peruvian government to carry those out at scale in Peru, in the nation. And so, the grounding of Partners in Health Peru's work is indeed a scaling process. They depend on the Peruvian government to carry out their mission. And so, if that relationship is broken, then Partners in Health Peru can no longer carry out its mission. It can no longer do what it wants to do. And so, it introduces this very fragile relationship between the Peruvian government and Partners in Health Peru. When we talked about politics, that was something that was always mentioned. We aren't able to get political because of this fragile and oftentimes tense relationship they have with the Peruvian government. I was told about this countlessly throughout my fieldwork. And so, I'm thinking about what can be done about this. We must really be thinking about who designed, who set up this. Or, who's orchestrating this relationship between the Peruvian government and Partners in Health Peru? And, really, its global North actors. Partners in Health, despite being this organization that claims to focus on community engagement-- again, all of those decisions were made in Boston, where the organization is founded and where the headquarters still remain. And so, in thinking through politics and what can be done in this context about this fragile relationship, it's essential that I reorient my analysis towards Partners in Health's Boston-based headquarters. And so, in this way, because they're wholly dependent on the state to carry out their mission, there is such a danger of getting political that it would risk everything. And so, I actually associate this with the idea of going global and how, in this idea of global health as compared to international health, we claim to be getting away from governments but in reality, it's just that the relationship with these governments is being reorganized and, in this case, into much more fragile configurations that make it much more difficult to even get political. That is kind of the main part that shapes Partners in Health's anti-politics. In thinking through all of these different factors, I conclude my thesis with several questions about how we move forward on this and what types of organizations we're producing in public health but also the types of organizations we should be producing and how politics fits into this narrative. And really thinks through more broader sociopolitical changes or disruptions of the established order in global health but also more broadly. So, thank you so much. And that's my presentation.
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Anthropology major Dalton Price presents the results of his honors thesis, "Global Health's Anti-Politics: A Comparative Ethnography of the World Health Organization and Partners in Health"
Major in Anthropology
Anthropology minor for pre-health students
50 Years of Excellence: Travelers Summer Research Fellowship
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