"Not here": making the spaces and subjects of "global health" in Botswana

Beyond Competence: Efficiency in American Biomedicine

"Competence" is a longstanding value of American biomedicine. One underidentified corollary of competence is efficiency: at once a manifestation of competence, a challenge to competence, and a virtue in its own right. We will explore the social construction of efficiency in US undergraduate medical education through an analysis of its sociocultural and technological landscapes. We present qualitative data from two allopathic medical school field sites in the Midwestern United States, where medical students' careful selection of certain learning resources and overall perspectives on the curriculum underscore their focus on efficiency and pragmatic approaches to knowledge. In the discussion, we consider the ethical implications of physician efficiency, as well as future trajectories for the study of efficiency in the medical social sciences, bioethics, and medical education. We posit that efficiency is at the theoretical heart of US medical practice and education: a finding that has wide-reaching implications for how researchers conceptualize the enterprise of biomedicine across cultural contexts and interpret the lived experiences of physicians, medical students, and other clinicians.

The coloniality of power in Uganda's Nakivale Refugee Settlement: struggling for humanitarian authority amidst the 2018 corruption scandal

This paper addresses the complexity of studying the coloniality of humanitarianism and present-day relationships of power and authority in refugee settings. Building on 13 months of fieldwork, it presents an ethnographic account of the 2018 refugee corruption scandal in Uganda and the Nakivale Refugee Settlement. The core of this paper's argument is based on a grounded analysis of how 'the saga' not only exposed corruptive practices in the country's refugee programme, but also the meanings of being 'human' and what this implies for making claims to humanitarian authority. The paper asserts that the way in which the scandal unravelled in the (inter)national media, and how it affected sociopolitical tensions in the camp, revealed a deeply fraught conception of both human and humanitarian duality, embedded in a coloniality of power. Ultimately, power imbalances, frictions, and conflicts between national, international, and refugee actors highlighted a deep-rooted and historical struggle for humanity and legitimate humanitarian authority.

Intraprofessionalism and Peer-to-Peer Learning in American Medical Education

As previous research has observed, medical students and physicians alike confront vast amounts of knowledge in their education and practice, such that no one clinician can know everything there is to know about biomedicine. Even before clerkships, medical students learn to cope with this impossibility by prioritizing certain information based on its perceived utility for exams and clinical practice. Many factors can shape this process, including teamwork, wherein individual medical students rely on one another to address gaps in knowledge at the level of the group. This paper will draw on qualitative data from two allopathic medical schools in the American Midwest to demonstrate that peer-to-peer learning, a widely utilized pedagogical modality in North American medical schools, is amongst the earliest places where future physicians learn how to rely on their peers in the profession as they make choices about what to know and what not to know about biomedicine: cultivating a culture of "intraprofessionalism" between students with different knowledges and values, as they prepare to enter the same profession. The paper will also consider how differences in the student populations at two field sites impact intraprofessional development. Drawing on scholarship of peer-based learning strategies and the sociology and anthropology of medical education, the authors argue that peer-to-peer learning is a key site in the professional socialization of medical students toward the effective management of medical knowledge.

Pandemics, intellectual property and 'our economy': A worldview analysis of Canada's role in compromising global access to COVID-19 vaccines

Despite self-congratulatory rhetoric, Canada compromised COVID-19 vaccine equity with policies impeding a proposed global waiver of vaccine intellectual property (IP) rules. To learn from Canada's vaccine nationalism we explore the worldview - a coherent textual picture of the world - in a sample of Government of Canada communications regarding global COVID-19 vaccine sharing. Analysed documents portray risks and disparities as unrelated to the dynamics and power relations of the Canadian and international economies. Against this depoliticised backdrop, economic growth fueled by strict IP rules and free trade is advanced as the solution to inequities. Global vaccine access and distribution are pursued via a charity-focused public-private-partnership approach, with proposals to relax international IP rules dismissed as unhelpful. Rather than a puzzling lapse by a good faith 'middle power', Canada's obstruction of global COVID-19 vaccine equity is a logical and deliberate extension of dominant neoliberal economic policy models. Health sector challenges to such models must prioritise equity in global pandemic governance via politically assertive and less conciliatory stances towards national governments and multilateral organisations. Mobilisation for health equity should transform the overall health-damaging macroeconomic model, complementing efforts based on specific individual health determinants or medical technologies.

Global health wars: a rhetorical review of global health critique

The critique of global health is a longstanding tradition in the global health humanities (GHH). Typically, this critique takes an expected tack: critics take a slice of global health, identify its rhetoric, expose its power, and elucidate its unanticipated consequences. Here, I subject global health critique to its own approach-conducting a 'rhetorical review' of global health critique in order to ascertain whether it has rhetoric, power and unanticipated consequences of its own. Following this review, I find that global health critique has a rhetoric, and that this rhetoric can be organised into three types: (1) 'global health as mere rhetoric', (2) 'splitting global health', and (3) 'figuring global health war.' Ultimately, I argue that the rhetoric of GHH critique, like the rhetoric of global health, is a rhetoric of consequence-and a rhetoric worth revisiting.

Epidemic confusions: On irony and decolonisation in global health

The movement to decolonise global health is gathering pace. In its concern with the fundamental, distal causes of inequality and its call for social justice, the decolonisation movement forces us to question how global health works, for whom, where it is located, its funding practices, power asymmetries, cultures of collaboration and publication. This paper uses a new book by Harvard-based physician-anthropologist Eugene T. Richardson, Epidemic Illusions, as a point of departure for a broader analysis of the nature of global health knowledge, science, authorship, research and practice. Written in a 'carnivalesque' style, the book proceeds through a series of 'ironic (re)descriptions' to argue that global public health is an 'apparatus of coloniality'. In so doing, the book is generative of four ironic turns that we explore through the themes of guilt, humility, privilege and ambiguity. In locating these ironic turns within the broader landscape of global health, we reflect on whether the means of such a book achieve the ends of decolonisation.

Assessing how global health partnerships function: an equity-informed critical interpretive synthesis

Background

Global health partnerships (GHPs) are situated in complex political and economic relationships and involve partners with different needs and interests (e.g., government agencies, non-governmental organizations, corporations, universities, professional associations, philanthropic organizations and communities). As part of a mixed methods study designed to develop an equity-sensitive tool to support more equity-centred North-South GHPs, this critical interpretive synthesis examined reported assessments of GHPs.

Results

We examined 30 peer-reviewed articles for power dynamics, equity and inequities, and contradictions or challenges encountered in North-South partnerships. Among articles reviewed, authors most often situated GHPs around a topical focus on research, capacity-building, clinical, or health services issues, with the ‘work’ of the partnership aiming to foster skills or respond to community needs.

The specific features of GHPs that were assessed varied widely, with consistently-reported elements including the early phases of partnering; governance issues; the day-to-day work of partnerships; the performance, impacts and benefits of GHPs; and issues of inclusion. Articles shared a general interest in partnering processes and often touched briefly on issues of equity; but they rarely accounted for the complexity of sociopolitical and historical contexts shaping issues of equity in GHPs. Further, assessments of GHPs were often reported without inclusion of voices from all partners or named beneficiaries.

GHPs were frequently portrayed as inherently beneficial for Southern partners, without attention to power dynamics and inequities (North-South, South-South). Though historical and political dynamics of the Global North and South were inconsistently examined as influential forces in GHPs, such dynamics were frequently portrayed as complex and characterized by asymmetries in power and resources. Generally, assessments of GHPs paid little attention to the macroeconomic forces in the power and resource dynamics of GHPs highlights the importance of considering the broader political. Our findings suggest that GHPs can serve to entrench both inequitable relationships and unfair distributions of power, resources, and wealth within and between countries (and partners) if inequitable power relationships are left unmitigated.

Conclusions

We argue that specific practices could enhance GHPs’ contributions to equity, both in their processes and outcomes. Enhancing partnering practices to focus on inclusion, responsiveness to North-South and South-South inequities, and recognition of GHPs as situated in a broader (and inequitable) political economy. A relational and equity-centred approach to assessing GHPs would place social justice, humility and mutual benefits as central practices—that is, regular, routine things that partners involved in partnering do intentionally to make GHPs function well. Practicing equity in GHPs requires continuous efforts to explicitly acknowledge and examine the equity implications of all aspects of partnering.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00726-z.

Defining global health: findings from a systematic review and thematic analysis of the literature

INTRODUCTION

Debate around a common definition of global health has seen extensive scholarly interest within the last two decades; however, consensus around a precise definition remains elusive. The objective of this study was to systematically review definitions of global health in the literature and offer grounded theoretical insights into what might be seen as relevant for establishing a common definition of global health.

METHOD

A systematic review was conducted with qualitative synthesis of findings using peer-reviewed literature from key databases. Publications were identified by the keywords of 'global health' and 'define' or 'definition' or 'defining'. Coding methods were used for qualitative analysis to identify recurring themes in definitions of global health published between 2009 and 2019.

RESULTS

The search resulted in 1363 publications, of which 78 were included. Qualitative analysis of the data generated four theoretical categories and associated subthemes delineating key aspects of global health. These included: (1) global health is a multiplex approach to worldwide health improvement taught and pursued at research institutions; (2) global health is an ethically oriented initiative that is guided by justice principles; (3) global health is a mode of governance that yields influence through problem identification, political decision-making, as well as the allocation and exchange of resources across borders and (4) global health is a vague yet versatile concept with multiple meanings, historical antecedents and an emergent future.

CONCLUSION

Extant definitions of global health can be categorised thematically to designate areas of importance for stakeholders and to organise future debates on its definition. Future contributions to this debate may consider shifting from questioning the abstract 'what' of global health towards more pragmatic and reflexive questions about 'who' defines global health and towards what ends.

"Not from home": Cancer screening avoidance and the safety of distance in Eswatini

This paper shows how travel and distance make cervical cancer screening safer for women in Eswatini. It is based on three months of original ethnographic research conducted in a semi-urban town in Eswatini from September to December 2014, involving daily participant observation and semi-structured, in-depth interviews with 20 women and 7 health workers. Results of the research show how women use travel to create safer clinical spaces and encounters in the context of cancer screening. Specifically, the research found that in the cervical cancer screening clinic, women's bodies are negatively judged and talked about. This creates fear - of judgment, verbal violence and gossip - all of which are intensified in hospitals and with nurses who are close to home. It is a fearful, laborious and difficult clinical encounter which causes a medical migration, where women seek screening in distant hospitals and with nurses who are "not from home." Distance provides anonymity and minimizes pathways of gossip, thus mitigating fear and making cervical cancer screening safer for women. The social rationale around distance shows how travel can create or recreate clinical spaces and experiences of care in the context of local medical migration. It also upsets culturalist assumptions about women's avoidance of cervical screening. Improving cancer screening programs in Eswatini calls for an approach sensitive to the clinical and social realities that create fear and constrain women's choices.

Global Health Education and Mediatization of Care in Costa Rica

Costa Rica has become a destination for global health education courses, while funding for global health has increased dramatically over the past thirty years. An examination of one Costa Rican group's efforts to market humanitarian discourses, focusing on website design, provides a window into the workings of global health education and details the sometimes-uncomfortable position of non-US health professionals in educational programming. This contributes to theorizations of the intersection of mediatization and care, and suggests links between the legitimation of global health as a discipline, on the one hand, and the reproduction of inequities, on the other.

Finding "What Works": Theory of Change, Contingent Universals, and Virtuous Failure in Global Mental Health

Global Mental Health has developed interventions that strive to work across great difference-variously conceptualized as cultural, socio-economic, geographic, or pertaining to the characteristics of health systems. This article discusses how the evaluation framework Theory of Change (ToC) facilitates the production of 'global' knowledge across such differences. Drawing on 14 months of multi-sited fieldwork among Global Mental Health actors in Europe, North America and South Africa, it traces the differential use of ToC in GMH interventions. While much critical scholarship of Global Health metrics holds that techniques of quantification rely on universals that necessarily betray the "real world", ToC unsettles these critiques. It comes into view as an epistemic and relational device that produces 'contingent universals'-concepts that are true and measurable until they stop working in the field, or until the parameters of 'what works' shift to a new iteration. As such, Theory of Change produces actionable-rather than true-knowledge attuned to open-ended change, both desirable (impact) and unforeseen (adaptation). Its effects, however, are ambiguous. ToC presents us with a horizoning technique that enables what I call "virtuous failure" within the evidence-based paradigm. It may equally harbor the potential to disrupt distinctions such as bricolage (tinkering) and design (planning) and their respective politics, as it may tie neatly into audit cultures, depending on its use. The article analyzes the novel stakes of reflexive evaluation techniques and calls on anthropology and critical Global Health for renewed empirical engagement.

Whose Global, Which Health? Unsettling Collaboration with Careful Equivocation

The recent push for multidisciplinary collaboration confronts anthropologists with a long‐standing ethnographic problem. The terms we have to talk about what we do are very often the same as the terms used by those with whom we work, and yet we are often doing very different things with these terms. I draw on over a decade of “awkward collaboration” with scientists working in highland Guatemala to explore how challenges of equivocation play out in research focused on improving maternal/child nutrition. In the interactions I describe, epidemiologists undertake ethnography, anthropologists study scientists, and a Mam–Spanish translator works for projects organized around English‐language funding structures and aspirations. I detail situations in which methods, interests, and goals coalesce and diverge to argue for the importance of careful equivocation, a research technique attuned to unsettling binaries that does not result in sameness or unity. I offer suggestions for how this technique might productively reshape the emerging global health imperative to work together. [global health, controlled equivocation, co‐laboring, material‐semiotics, Guatemala]

The Binds of Global Health Partnership: Working out Working Together in Sierra Leone

Global health partnerships (GHPs) are the conceptual cousin of partnerships in the development sphere. Since their emergence in the 1990s, the GHP mode of working and funding has mainly been applied to single-disease, vertical interventions. However, GHPs are increasingly being used to enact Health Systems Strengthening and to address the global health worker shortage. In contrast to other critical explorations of GHPs, we explore in this article how the fact, act, and aspiration of binding different actors together around the ideology and modes of partnership working produces the perpetual state of being in a bind. This is an original analytical framework drawing on research in Sierra Leone and London. We offer new insights into the ways in which GHPs function and are experienced, showing that along with the successes of partnership work, such arrangements are often and unavoidably tense, uncomfortable, and a source of frustration and angst.

Stuck in the Clinic: Vernacular Healing and Medical Anthropology in Contemporary sub-Saharan Africa

While vernacular therapeutics had long been a topic of interest to many writing about medicine and healing in Africa, with a few exceptions most recent anthropological writings on medicine in Africa are focused on biomedicine. In this article, I trace this shift back to the turn of the millennium and the convergence of three events: the emergence of global health, the accession of the occult economies paradigm, and critiques of culturalism in medical anthropology. I argue that these three shifts led to research projects and priorities that looked different from those defined and undertaken as late as the late 1990s. While seeking to avoid the errors that could come with writing about vernacular therapeutic traditions in Africa as bounded comprehensive systems, I argue that there are empirical, political, and practical reasons why medical anthropologists may want to reconsider our collective research priorities.

Temporality and Positive Living in the Age of HIV/AIDS--A Multi-Sited Ethnography

Drawing on comparative ethnographic fieldwork conducted in urban Mozambique, United States, and Sierra Leone, the article is broadly concerned with the globalization of temporal logics and how specific ideologies of time and temporality accompany health interventions like those for HIV/AIDS. More specifically, we explore how HIV-positive individuals have been increasingly encouraged to pursue healthier and more fulfilling lives through a set of moral, physical, and social practices called "positive living" since the advent of antiretroviral therapies. We describe how positive living, a feature of HIV/AIDS programs throughout the world, has taken root across varied political, social and economic contexts and how temporal rationalities, which have largely been under-examined in the HIV/AIDS literature, shape communities' responses and interpretations of positive living. Our approach is ethnographic and comparative, with implications for how anthropologists might think about collaboration and its analytical possibilities.

'Worse than HIV': The logics of cancer screening avoidance in Swaziland

This article shows the consequences of competing global health agendas within differential clinical and social worlds. Specifically, it examines how HIV's prominence in local clinical programming in Swaziland influences cervical cancer screening rates. Drawing on 2014 ethnographic research conducted in a semi-urban town in Swaziland, the interview and participant observation data show the relative scarcity of cervical cancer care and the consequences of HIV/AIDS funding and programming dominance. 20 women and 7 health workers were interviewed in homes, clinics and small businesses. Data were analysed using frameworks of medicoscapes and therapeutic citizenship. Results show that women's patterns of screening avoidance were based on lengthy diagnostic procedures, treatment expense, therapeutic travel to neighbouring South Africa, and frequent therapeutic failure. In sum, avoidance of cervical screening in Swaziland has structural components, and is a product of organisational and political choices at local and global levels. This study challenges culturalist assumptions about African women's avoidance of cervical cancer screening. In the future, delivering successful cervical cancer screening in Swaziland will depend on expanding cancer screening and treatment, which should be informed by perceptions of clinical care held by the very women public health practitioners aim to keep healthy.

Global Health, Geographical Contingency, and Contingent Geographies

Health geography has emerged from under the "shadow of the medical" to become one of the most vibrant of all the subdisciplines. Yet, this success has also meant that health research has become increasingly siloed within this subdisciplinary domain. As this article explores, this represents a potential lost opportunity with regard to the study of global health, which has instead come to be dominated by anthropology and political science. Chief among the former's concerns are exploring the gap between the programmatic intentions of global health and the unintended or unanticipated consequences of their deployment. This article asserts that recent work on contingency within geography offers significant conceptual potential for examining this gap. It therefore uses the example of alcohol taxation in Botswana, an emergent global health target and tool, to explore how geographical contingency and the emergent, contingent geographies that result might help counter the prevailing tendency for geography to be side-stepped within critical studies of global health. At the very least, then, this intervention aims to encourage reflection by geographers on how to make explicit the all-too-often implicit links between their research and global health debates located outside the discipline.

What's in the 'treatment gap'? Ethnographic perspectives on addiction and global mental health from China, Russia, and the United States

Recent years have seen the emergence of a 'global mental health' agenda, focused on providing evidence-based interventions for mental illnesses in low- and middle-income countries. Anthropologists and cultural psychiatrists have engaged in vigorous debates about the appropriateness of this agenda. In this article, we reflect on these debates, drawing on ethnographic fieldwork on the management of substance use disorders in China, Russia, and the United States. We argue that the logic of 'treatment gaps,' which guides much research and intervention under the rubric of global mental health, partially obscures the complex assemblages of institutions, therapeutics, knowledges, and actors framing and managing addiction (as well as other mental health issues) in any particular setting.

Cultural conundrums: the ethics of epidemiology and the problems of population in implementing pre-exposure prophylaxis

The impending implementation of pre-exposure prophylaxis (PrEP) has prompted complicated bioethical and public health ethics concerns regarding the moral distribution of antiretroviral medications (ARVs) to ostensibly healthy populations as a form of HIV prevention when millions of HIV-positive people still lack access to ARVs globally. This manuscript argues that these questions are, in part, concerns over the ethics of the knowledge production practices of epidemiology. Questions of distribution, and their attendant cost-benefit calculations, will rely on a number of presupposed, and therefore, normatively cultural assumptions within the science of epidemiology specifically regarding the ability of epidemiologic surveillance to produce accurate maps of HIV throughout national populations. Specifically, ethical questions around PrEP will focus on who should receive ARVs given the fact that global demand will far exceed supply. Given that sexual transmission is one of the main modes of HIV transmission, these questions of 'who' are inextricably linked to knowledge about sexual personhood. As a result, the ethics of epidemiology, and how the epidemiology of HIV in particular conceives, classifies and constructs sexual populations will become a critical point of reflection and contestation for bioethicists, health activists, physicians, nurses, and researchers in the multi-disciplinary field of global health. This paper examines how cultural conundrums within the fields of bioethics and public health ethics are directly implicated within the ethics of PrEP, by analyzing the problems of population inaugurated by the construction of the men who have sex with men (MSM) epidemiologic category in the specific national context of South Africa.

Epidemiology and 'developing countries': writing pesticides, poverty and political engagement in Latin America

The growth of the field of global health has prompted renewed interest in discursive aspects of North-South biomedical encounters, but analysis of the role of disciplinary identities and writing conventions remains scarce. In this article, I examine ways of framing pesticide problems in 88 peer-reviewed epidemiology papers produced by Northerners and their collaborators studying pesticide-related health impacts in Latin America. I identify prominent geographic frames in which truncated and selective histories of Latin America are used to justify research projects in specific research sites, which nevertheless function rhetorically as generic 'developing country' settings. These frames legitimize health sector interventions as solutions to pesticide-related health problems, largely avoiding more politically charged possibilities. In contrast, some epidemiologists appear to be actively pushing the bounds of epidemiology's traditional journal article genre by engaging with considerations of political power, especially that of the international pesticide industry. I therefore employ a finer-grained analysis to a subsample of 20 papers to explore how the writing conventions of epidemiology interact with portrayals of poverty and pesticides in Latin America. Through analysis of a minor scientific controversy, authorial presence in epidemiology articles, and variance of framing strategies across genres, I show how the tension between 'objectivity' and 'advocacy' observed in Northern epidemiology and public health is expressed in North-South interaction. I end by discussing implications for postcolonial and socially engaged approaches to science and technology studies, as well as their relevance to the actual practice of global health research. In particular, the complicated interaction of the conflicted traditions of Northern epidemiology with Latin American settings on paper hints at a far more complex interaction in the form of public health programming involving researchers and research participants who differ by nationality, ethnicity, gender, profession, and class.

Behind the scenes of a research and training collaboration: power, privilege, and the hidden transcript of race

This paper examines a federally funded research and training collaboration between an Ivy League psychiatric research center and a historically Black university and medical center. This collaboration focuses on issues of psychiatric recovery and rehabilitation among African Americans. In addition, this multidisciplinary collaboration aims to build the research capacity at both institutions and to contribute to the tradition of research in culture and mental health within the medical social sciences and cultural psychiatry. This article provides a window into the complex, often messy, dynamics of a collaboration that cross cuts institutional, disciplinary, and demographic boundaries. Taking an auto-ethnographic approach, we intend to illustrate how collaborative relationships unfold and are constructed through ongoing reciprocal flows of knowledge and experience. Central to this aim is a consideration of how issues of power, privilege, and the hidden transcript of race shape the nature of our research and training efforts.