Wednesday, October 15, 2014

Has global health become medicalised?

Many people have heard of ‘global health’. In fact, it is hard to get away from it, particularly on the medical side of college campuses, in health policy discussions, or the media when a newsworthy epidemic breaks out somewhere. Global health is generally code for (unfair) health disparities and the unhappy tendency of health crises walk or fly across national borders. Perhaps less familiar is the concept of ‘medicalization’. Roughly speaking, it is the process by which human problems are understood as (or ‘reduced to’) medical problems. For example, one could view diabetes as a purely medical problem, for which better treatments are needed, rather than (say) a condition implicating a host of social, political and economic factors, such as the low-cost of processed food, changes in work conditions and the structure of built environments. So what happens when you put ‘global health’ and ‘medicalization’ together?

Jocalyn Clark has written some intriguing exploratory pieces on the links between medicalization and global health in the online journal Global Health Action. Do global health initiatives tend to medicalize the problems that they set out to tackle? And if so, what effects does this process of medicalization then have? Certainly there is a tendency to seek technological (‘innovative’) solutions to health problems in developing countries, often with mixed results. To the extent that the determinants of poor and better health are social, political and economic, purely medical interventions are likely to have superficial impact. I wonder if there is also something else at play: not just medicalization, but the allure of objectivity and neutrality – think Red Cross -- associated with Western medicine. Coming into a developing country with medical interventions seems far less politically fraught than proposing large-scale changes to ways of life. So there is a tension between a major tenet of global health (that health is socially determined) and the political implications of trying to improve health globally. The tendency towards medicalization may paradoxically reflect a need to look for a ‘safe space’ for global health practice.

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Friday, October 10, 2014

Responsibility for collateral ebola damage

I guess that as far as bioethics and Ebola goes, resistance is futile. As someone interested in bioethics, right now you apparently have three choices: ignore that the Ebola epidemic is happening, join the noisy crowd of disease control bioethicists clamouring for attention, or point out ethical issues that are neglected or lie on the margins of the mayhem. The first option seems irresponsible. The second option seems superfluous: how much of that do we need, really? The third option, on the other hand, might have something to it. So in that vein ...

Those infected by an infectious disease during an epidemic are the object of immediate concern. Those they expose to infection are an important, secondary concern. But there are further knock-on effects that may be less obvious than (say) the overall economic impact. The Ebola epidemic raising havoc with the older, chronic, HIV epidemic in West Africa. Reliable access to HIV treatment has always been a struggle, but now HIV-positive persons in places like Liberia need to travel to get their drugs. Since only some of those in rural areas have the time/money to do that, treatment interruption and its consequences (viral rebound, etc.) are inevitable. In this way, Ebola leads to death by HIV. But it is not just HIV. Ebola in these regions is compromising health systems that were very fragile to begin with, a reversal of hard-won achievements may be faced on many fronts: malaria, diarrhoea, maternal and child mortality.

So the ethics question: when international and local agencies are engaged to control Ebola in West Africa, should they concentrate on Ebola alone, or do they also have some responsibility to deal with the collateral damage that Ebola has caused?

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Saturday, October 04, 2014

A raging epidemic of bioethical commentary

I don't think I have seen so much bioethics commentary about a single topic -- in such a short span of time -- since I got interested in the field. Talk about Ebola is spreading and multiplying far faster and wider than the virus. It is definitely flavour of the month, and as for how many infectious disease bioethicists there are out there, who knew?  Even the ones I thought were more into enhancement or face transplants or some other shiny object of bioethical curiosity are getting in on the action. Decent analyses are being written, it's not that. It is more about where they all were for the last decades, or even in the last years, when cholera, ebola, dengue, malaria and other (neglected) disease threats have been popping up all around developing countries. Does it really have to (frankly) affect a couple white folks from the North before it gets hot and happening? I already knew that Western media outlets are self-absorbed ambulance chasers but ...

OK, I am being overly harsh. I just hope there is more to the bioethics coverage than what-measures-are-appropriate-to-combat-spread-of-terrifying-disease-or-stop-it-from-getting-to-our-shores. The ethics of urgency, Ethics 911. Ebola's rise and spread in Western Africa is a symptom of what kind of shape those countries are in, not just their health care systems but the social and political circumstances in which those systems are embedded. Ebola can only thrive in messed up places. My prediction is that once Ebola has been contained, attention to the driving forces of poor health in developing countries will get as much attention from bioethicists as it generally gets. Plus ca change.

P.S. Now this is more like it ...

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