‘Reimagining Global Health: An Introduction’ by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico (University of California Press, 2013).
Global health as a focus of study has rapidly gained popularity across university campuses over the past five years, but it is a nascent discipline and ‘Reimagining Global Health’ aims to fill a gap in the current literature by providing an introductory textbook to the field. This pioneering book originates from a Harvard College class, first taught in 2008, entitled ‘Case Studies in Global Health: Biosocial Perspectives’ and additionally draws on training materials from the ‘Global Health Delivery’ courses at the Harvard School of Public Health and ‘Introduction to Social Medicine’, a required course at Harvard Medical School (p.xviii, p.10). The volume’s contributors include course faculty, guest lecturers, teaching fellows and former Harvard undergraduate students. Indeed, 33 of the 34 contributors have studied or worked at Harvard University, Harvard Medical School or the Harvard-affiliated Brigham and Women’s Hospital. The remaining contributor, Ophelia Dahl, co-founded the NGO Partners in Health with the book’s editors Paul Farmer and Jim Yong Kim. The book aims to ‘reimagine’ global health by taking a distinct biosocial approach and combines what Farmer terms the ‘resocializing disciplines’ of anthropology, sociology, history and political economy with epidemiology, demography, clinical practice, molecular biology and economics to build a new field and vision of global health equity (p.xiv).
Three of the book’s editors are eminent anthropologists as well as practising physicians, and the volume aims to critique prevailing global health discourses using the theoretical and methodological approaches of anthropology, sociology, history and the political economy of health (p.3). The editors posit that clinical medicine and public health must utilise these ‘resocializing disciplines’ to best address the biosocial nature of global health problems (p.9). The book is written for undergraduates, students of medicine, nursing and public health, NGO and global health practitioners, as well as anyone seeking to better understand global health equity (pp. xiii-xvii). Some sections of the book appear more focused towards current practitioners, while other chapters speak more to current students and the students that the book imagines are future global health practitioners. This focus coupled with a focus on healthcare delivery shapes the ways in which the book imagines, examines and critiques global health problems.
The volume is organized into twelve chapters and is intended to be used as a “toolkit” by global health practitioners (p.xvi), especially chapter two which explores relevant theoretical frameworks and explains the work of Peter Berger, Thomas Luckmann, Robert Merton, Max Weber, Michel Foucault, Arthur Kleinman, Veena Das, Margaret Lock and Paul Farmer. Chapters three-five discuss and contextualize global health within the historical periods of colonial medicine, the rise and fall of the primary healthcare movement in the 1970s and 1980s, and global health in a time of AIDS. Chapters six-eight examine key issues in global health delivery by providing case studies from Haiti and Rwanda, an exploration of the science of global health delivery, and a critique of the quantitative instruments of global health, cost effectiveness analysis and the disability-adjusted life year (DALY). Chapter nine discusses the moral dimensions of global health work. Chapters ten, eleven and twelve discuss the current landscape and possible future of global health through an examination of aid delivery, global health priorities, and global health advocacy. Chapter twelve includes an advocate’s toolkit of activist strategies to better enable readers to act on the book’s objective of achieving greater equity in global health.
‘Reimagining Global Health’ is impressive in its breadth of material covered and disciplines incorporated. It is not necessarily clear, however, how well the book functions as a toolkit for current and future global health practitioners. The toolkit of social theories is intended to highlight relationships that shape social actions and so promote critical self-reflection and aid in the development of practical solutions to health problems (p.31). The book starts from the position that most global health practitioners are focused on “action” and have limited exposure to or patience for social theory (p.15). The theoretical toolkit includes, for example, an explanation of Foucault’s concept of biopower and readers are meant to use this to critically examine processes of global health interventions in which biopower may operate (pp. 25-30). Brief nods to biopower are peppered throughout the book (see p.33, p.46, p.224), but it is not apparent that these references, largely limited in context and analysis, are sufficient for a reader to competently engage with the concept of biopower.
Furthermore, the concept of biopower is presented without a background explanation of Foucault’s particular understanding of power. The theories of Weber and Foucault are explained and used as if both shared the same definition of ‘power’, but Weber conceptualized power as hierarchical and concentrated in particular agents, while Foucault conceptualized power as produced and undermined from one moment to the next in relations between people. This distinction has implications for the ways in which agency and power relations are understood in global health discourse.
The expansive breadth of the volume leaves the coverage of many topics rather unsatisfying. For example, the explanation of biopower in the social theory toolkit usefully mentions anthropologist Adriana Petryna, but would have additionally benefited from including the work of other leading contemporary academics on biopower such as anthropologist Paul Rabinow and sociologist Nikolas Rose (e.g. Rabinow and Rose 2006). It feels like a missed opportunity that the book, focused on issues such as health delivery, biopower and AIDS, does not include the work of anthropologist and practising physician Vinh-Kim Nguyen (2010), whose monograph ‘The Republic of Therapy: Triage and Sovereignty in West Africa’s Time of AIDS’ beautifully and thoughtfully handles all of these issues. Additionally, the volume’s historical chapters would benefit from further critical reflection and analysis. Chapter four’s description of the 80 percent threshold for child vaccination in the developing world (p.98), for example, could have been critically examined by including the anthropologist Veena Das’ biosocial analysis of vaccine delivery in India and the process of producing political documents for international global health organizations (Das 1999:106-109). Given the book’s emphasis on using ‘resocializing disciplines’ to understand problems of global health equity, and given that three of the book’s four editors are anthropologists, the book could have engaged far more with the wealth of relevant anthropological literature.
The importance of local knowledge and lived experience is reiterated throughout the book and in its role as a toolkit the book points to the anthropological methodology of ethnography as a central starting point for global health delivery (p.141, p.224, and pp.274-275). It is argued that practitioners should conduct ethnographic research to best adapt programs to local contexts, but the text does not describe potential ethnographic methodological considerations for global health practitioners or include a detailed description of what ethnography is (pp.187-188). It would be useful for the book to include a discussion of what this form of ethnography and its potential ethical issues would look like for global health practitioners.
The volume ends with a call for people of all levels of training and experience to become involved in the movement for global health equity (p.352). In this vein, the book includes inspiring stories of individuals’ achievements in the promotion of global health, such as Yale University law student Amy Kapczynski’s campaign to improve treatment access for HIV/AIDS in South Africa (p.124). Throughout the book, however, individuals from outside North America and Europe working on global health issues as practitioners, researchers and activists feel largely invisible, and inclusions of their contributions are limited to a discussion of the work of Zackie Achmat and Mark Heywood, founders of the Treatment Action Campaign (TAC) in South Africa (p.276, pp.344-345). The influential Ugandan physician, academic and HIV/AIDS activist Peter Mugyenyi is mentioned in the description of a photograph in chapter five but is not referenced in the actual chapter (p.128). A discussion of Mugyenyi’s work to make antiretroviral medication more accessible in Sub-Saharan Africa, his role in the formation of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) program, or his book ‘Genocide by Denial: How Profiteering from HIV/AIDS Killed Millions’ (2008) would be a very useful addition to chapter five’s discussion of the process and work of increasing antiretroviral access in Sub-Saharan Africa, by people such as Amy Kapczynski, President George W. Bush and the musician Bono.
Chapter nine includes a noteworthy biosocial error, where it is stated that Kikuyu women’s practise of female genital cutting in Kenya often leads to fistula (p.262). The reference given for this statement, note 81, does not even mention the practice (Feierman et al. 2010), and the form of female genital cutting (that was) practised by Kikuyu women (Type I and Type II), while associated with various potential serious health consequences among other issues, has not been linked to an increased risk of fistulae (see Browning et al. 2010; Peterman and Johnson 2009; Morison et al. 2001). This minor error highlights a message that runs throughout ‘Reimagining Global Health’: it is importance for global health practitioners to be knowledgeable of the cultural, social and historical context of health issues faced by specific communities.
‘Reimagining Global Health’ is an ambitious textbook with an inspiring message of social justice and global health equity that avoids both unreflective activism and informed scepticism. It often feels as though ‘Reimagining Global Health’ does not go far enough in its use of the ‘resocializing disciplines’, but it still provides an important biosocial perspective to a complex set of problems. This well-written and accessible introduction to problems of global health will shape the developing discipline’s future and bring attention to the pressing need for global health equity.
Reviewed by Mary-Anne Decatur, a PhD candidate in Anthropology at the School of Oriental and African Studies, University of London. Mary-Anne is currently researching female genital cutting and male circumcision in the Kilimanjaro Region of Tanzania, and is also the editor of Popular Anthropology Magazine.
Correspondence to Mary-Anne Decatur.
References
Das, Veena.1999. Public good, ethics, and everyday life: Beyond the boundaries of bioethics. Daedalus, 128(4): 99-133.
Browning, Andrew, et al. 2010. The relationship between female genital cutting and obstetric fistulae. Obstetrics &Gynecology, 115(3): 578-583.
Feierman, Steven, et al. 2010. Anthropology, knowledge-flows and global health.Global Public Health, 5(2): 122-128.
Morison, Linda et al. 2001. The long-term reproductive health consequences of female genital cutting in rural Gambia: a community-based survey. Tropical Medicine and International Health, 6(8): 643-653.
Nguyen, Vinh-Kim. 2010. The Republic of Therapy: Triage and Sovereignty in West Africa’s Time of AIDS. Durham: Duke University Press.
Peterman, Amber, and Kiersten Johnson. 2009. Incontinence and trauma: Sexual violence, female genital cutting and proxy measures of gynecological fistula. Social Science & Medicine, 68: 971–979.
Rabinow, Paul; Nikolas Rose. 2006. Biopower Today. Biosocieties, 1(2): 195-217.