The moral economy of universal public healthcare. On healthcare activism in austerity Spain

Spain has a national health service, universal in access and free at the point of use. The global economic crisis of 2008, with its subsequent austerity policies, has put the universality of public healthcare at risk. This has led to an increase in healthcare activism, whose aim is to fight healthcare cuts and privatization to safeguard the national health service for all. This article addresses such healthcare activism. Drawing on long-term fieldwork with a heterogeneous set of actors ranging from individual activists and unions to ad hoc activist collectives, I will analyze the moral economy of healthcare activists in Madrid, to understand why and in which terms they defend universal healthcare as a common good and challenge its marketization. In Spain, since the democratic transition, struggles around what constitutes a common weal have been highly politicized and affect-laden. The national health system stands as one example here, as it is closely linked to the emergence of the democratic welfare state in the late 1970s, following decades of Franco's dictatorship. This makes Spain a particularly interesting case, as the widely acknowledged understanding of public healthcare as a public and social good is intimately linked to democratization and welfare. Therefore, struggles over the nature of health systems are also struggles over the political, moral and economic organization of society, over (il)legitimate forms of power and over ways of caring for each other. In such struggles, visions of the public, the state and the political economy come to the fore. In Spain, there is ambivalence about the state's role as both protector and provider of the public good, but also as facilitator of capitalism, which this article will address.

Bodies in peril: Healthcare workers on the frontlines of global maternal health interventions

Drawing on long-term ethnographic fieldwork in maternity settings in Tanzania and Pakistan, we argue that 'bodywork' condenses all politically and practically at stake for maternal healthcare providers. Our research confronts how global health programmes expect paramedical providers working on the frontlines of obstetrics to implement interventions without also attending to violent everyday realities of providing care amidst structural constraint and precarity. We demonstrate this approach's dire aftermaths. Healthcare workers' bodies evidence risks and injuries not only attendant on care in lower-resource settings, but which unfold specifically from their efforts to meet the onerous demands of global health systems. Toxic hospital environments represent a paradox of care - medicine exposes patients and providers to greater risks than if medicine were not involved - but this inherent riskiness barely registers. Elisions of healthcare providers' experiences of harm are telling; they reveal global health's neglect of occupational risk and a racialised under-attention and under-valuing of the risks carried by bodies of colour, and women especially. We trace and corroborate providers' experiences of threats to their wellbeing while enacting global health agendas. We conclude with a provocation that social scientists' bedside witnessing must result in actionable evidence if a more sustainable global health is to prevail.

Toward resourcefulness: pathways for community positive health

Communities are powerful and necessary agents for defining and pursuing their health, but outside organizations often adopt community health promotion approaches that are patronizing and top-down. Conversely, bottom-up approaches that build on and mobilize community health assets are often critiqued for tasking the most vulnerable and marginalized communities to use their own limited resources without real opportunities for change. Taking into consideration these community health promotion shortcomings, this article asks how communities may be most effectively and appropriately supported in pursuing their health. This article reviews how community health is understood, moving from negative to positive conceptualizations; how it is determined, moving from a risk-factor orientation to social determination; and how it is promoted, moving from top-down to bottom-up approaches. Building on these understandings, we offer the concept of 'resourcefulness' as an approach to strengthen positive health for communities, and we discuss how it engages with three interrelated tensions in community health promotion: resources and sustainability, interdependence and autonomy, and community diversity and inclusion. We make practical suggestions for outside organizations to apply resourcefulness as a process-based, place-based, and relational approach to community health promotion, arguing that resourcefulness can forge new pathways to sustainable and self-sustaining community positive health.

A Stalled Revolution? Misoprostol and the Pharmaceuticalization of Reproductive Health in Francophone Africa

Misoprostol entered the global market under the name Cytotec in the mid-1980s for the treatment of gastric ulcers. Decades of research have since demonstrated the safety and effectiveness of off-label use of misoprostol as a uterotonic in pregnant women to prevent and treat post-partum hemorrhage, treat incomplete abortion, or terminate first-trimester pregnancy. Global health experts emphasize misoprostol's potential to revolutionize access to reproductive health care in developing countries. Misoprostol does not require refrigeration, can be self-administered or with the aid of a non-physician, and is relatively inexpensive. It holds particular promise for improving reproductive health in sub-Saharan Africa, where most global maternal mortality related to post-partum hemorrhage and unsafe abortion occurs. Although misoprostol has been widely recognized as an essential obstetric medication, its application remains highly contested precisely because it disrupts medical and legal authority over pregnancy, delivery, and abortion. I draw on fieldwork in Francophone Africa to explore how global health organizations have negotiated misoprostol's abortifacient qualities in their reproductive health work. I focus on this region not only because it has some of the world's highest rates of maternal mortality, but also fertility, thereby situating misoprostol in a longer history of family planning programs in a region designated as a zone of overpopulation since the 1980s. Findings suggest that stakeholders adopt strategies that directly address safe abortion on the one hand, and integrate misoprostol into existing clinical protocols and pharmaceutical supply systems for legal obstetric indications on the other. Although misoprostol has generated important partnerships among regional stakeholders invested in reducing fertility and maternal mortality, the stigma of abortion stalls its integration into routine obstetric care and availability to the public. I demonstrate the promises and pitfalls of pharmaceuticalizing reproductive health: despite the availability of misoprostol in some health facilities and pharmacies, low-income and rural women continue to lack access not only to the drug, but to quality reproductive health care more generally.