Last mile research: a conceptual map

Background: The term 'last mile' has been used across disciplines to refer to populations who are farthest away, most difficult to reach, or last to benefit from a program or service. However, last mile research lacks a shared understanding around its conceptualization.Objectives: This project used a concept mapping process to answer the questions: what is last mile research in global health and, how can it be used to make positive change for health equity in the last mile?Methods: Between July and December 2019, a five-stage concept mapping exercise was undertaken using online concept mapping software and an in-person consensus meeting. The stages were: establishment of an expert group and focus prompt; idea generation; sorting and rating; initial analysis and final consensus meeting.Results: A group of 15 health researchers with experience working with populations in last mile contexts and who were based at the Matariki Network institutions of Queen's University, CAN and Dartmouth College, USA took part. The resulting concept map had 64 unique idea statements and the process resulted in a map with five clusters. These included: (1) Last mile populations; (2) Research methods and approaches; (3) Structural and systemic factors; (4) Health system factors, and (5) Broader environmental factors. Central to the map were the ideas of equity, human rights, health systems, and contextual sensitivity.Conclusion: This is the first time 'last mile research' has been the focus of a formal concept mapping exercise. The resulting map showed consensus about who last mile populations are, how research should be undertaken in the last mile and why last mile health disparities exist. The map can be used to inform research training programs, however, repeating this process with researchers and members from different last mile populations would also add further insight.

Fundamentally uncaring: The differential multi-scalar impacts of COVID-19 in the U.S

2020 in the United States was marked by two converging crises—the COVID-19 pandemic and the large-scale uprisings in support of Black lives. These crises were met with both a counterproductive and inadequate response from the federal government. We examine these converging crises at the individual, social, and political scales. The biological realities of COVID-19 impact different populations in widely varied ways—the poor, the elderly, Black, Indigenous, and people of color, and those living with comorbidities get sick and die at the highest rates. Social distancing guidelines shifted millions of people to work-from-home and millions more lost their jobs, even as care laborers, preponderantly women, Black, Indigenous, and people of color, were asked to put their and their loved ones' lives on the line for the continuation of all of our lives. These biological, social, and economic crises have been punctuated by civil unrest, as millions took to the streets for racial justice, noting the unequal impacts of the pandemic. These converging crises have laid bare decades of neoliberal and neoconservative policies and ideologies, undergirded as they have been by racial capitalism, for their fundamental uncaringness. In this paper, we argue that this pandemic not only made a wider population more acutely aware of the necessity and importance of the need to care and for caring labors, but also that we stand at the precipice of potentiality--of producing a more caring society. To frame our argument, we draw on Nancy Scheper-Hughes and Margaret Lock's (1987) framework of three bodies—individual, social, and political—to unpack the multi-scalar entanglements in the differential impacts of COVID-19, questions of care, and their articulation in the current political-economic context.

Worlds in a bottle

In this article, I call for an object-centered ethnography to illuminate the ontological multiplicity that marks the worlds of health and healing that people inhabit. Focusing on a sports-drink bottle filled with a remedy from a faith healer in rural South Africa, I explore the ‘partial connections’ that link the world of global health and the world of traditional healing through objects and bodies. Drawing on medical anthropology focused on global health and medical pluralism as well as scholarship from the ontological turn, I argue that global health programs are limited by their failure to recognize the ontological multiplicity their target populations inhabit.

A qualitative approach to examining health care access in rural South Africa

Using a combination of documentary analysis, a household survey, and in-depth interviews, we examine instances when people access healthcare outside of the standard, government protocol in Harry Gwala District, KwaZulu-Natal to better understand barriers to access. South Africa's healthcare system is organized according to a spatial hierarchy, where specialty care is concentrated in urban areas and basic care is disbursed throughout the country. Livelihoods and family life are shaped by South Africa's political and economic history and current day. The tensions between everyday life and national healthcare policy are evident when people access care outside of official policy. Our research reveals that resource scarcity, transportation, and kinship networks, all rooted in South Africa's economy and long history of racial segregation, have the biggest influence on access. This finding adds to scholarly literature by bringing in the experiences of rural residents to reveal that the healthcare system is inextricably linked to the country's political-economy and that access models focused on distance break down when faced with poverty, transportation, and family networks in rural areas. Further, by focusing on examples of access outside of the prescribed pathways, we examine in depth what is happening on-the-ground. At the same time, we examine the broader political and economic context that has shaped both the healthcare system and the people who access it. As a result of this qualitative research, we open up possibilities for improving access to the healthcare system by highlighting factors outside of the system.

"Blame it on the weeds": politics, poverty, and ecology in the new South Africa

In January of 2000, spectacular fires burned in the natural veld of Cape Town, South Africa. As the fire-fighting effort finished, a theory emerged: invasive alien species, trees from other countries, such as Australia and the United States, were to blame for the fires. While the invasive alien hypothesis captured the attention of media and policy makers alike, there was little ecological evidence to support it. This article places the fires of 2000 in a longer history of post-apartheid policy and science surrounding invasive alien floral species, arguing that the fires allowed for a synergy between concerns over poverty relief, nature conservation, and scientific research. The most visible example of this synergy was an increased commitment to the Working for Water programme on the Cape Peninsula, a large-scale employment programme utilising unskilled labour to clear invasive alien species in order to conserve South African water resources. In addition to providing employment for South Africa's poorest citizens, Working for Water provided funding for ecological research about invasive alien species. The studies that resulted from this funding focused on gathering information to make practical suggestions for invasive species control. Although the focus of these studies was on management, the science used was itself as rigorous as it had ever been. In the post-apartheid era, as poverty relief and nature conservation came together, scientists ensured that they would continue to play a role in nature conservation by making their research relevant to both invasive species control and to poverty relief.