Global Health and Philosophy

The Problem of Global Health

To many, the problem of global health is fairly obvious – millions of human beings die preventable deaths every year.  And millions more suffer from physical pain, functional impairments and knock-on consequences of preventable or treatable morbidity.

With this in mind a very understandable approach to teaching global health is to present the major causes of ill-health and mortality across countries, teach the epidemiological pathways of these major causes, and the possible means of prevention, treatment and mitigation.

The core problem of global health, then, is understood as largely one of implementationof identifying at-risk individuals, of providing medical care to those who need it, adherence to prevention or treatment, and so forth.

To put it simply, the problem is of getting goods and services to the people who need them.  As one global health expert and a hero of mine, Paul Farmer, recently put it in relation to the Ebola epidemic in West Africa, “we need staff, stuff, space, and systems.

Such a view is undeniably true, and much can be accomplished towards improving the health of people if we did manage to get more goods and services to people who need them.

In the graduate programme, Global Health and Social Justice that I run, we present a different approach – this approach is inclusive of the view above but goes much beyond.

 

An Alternative Approach

Our interdisciplinary approach can be described as having three principles.

  1. First, the availability, provision, and management of healthcare is more than just a scientific or technical matter.
  2. Second, human health is about more than just access to healthcare and involves social conditions from conception to death and from the local to the global.
  3. Third, identifying what we ought to do about ill health and health inequalities within and across societies involves ethical reasoning at the individual, social, and global levels.

While I have been teaching this approach at King’s College London to graduate and undergraduates for the past few years, it was recently put to another kind of test recently in Mexico.

I was invited to teach a week-long course at the Medical School of UNAM, the largest and most prestigious university in Mexico.  The basic test was whether this approach to teaching about global health would be coherent and relevant to people who are the ‘subjects of the global health?

I began the first session with an interactive chart (click here to access chart tool). This heat map chart was created by the Institute of Health Metrics at the University of Washington and presents a ranking of the largest causes of morbidity and mortality in the world as the whole, and according to sub-regions.

It is a fascinating chart full of information that, indeed, could be the centrepiece of a week long course.  However, I used it as a starting off point to argue that it presents certain information as being important, excludes other information, and has some implicit ethical values. 

Here is an example showing the death per 100,000 by region and cause:

screenshot-2

Source: Institute for Health Metrics and Evaluation   

To be more precise, this chart presents the view that the right thing to do would be to address the largest causes of morbidity and mortality first, and to do that through addressing the causes of the morbidity and mortality at the individual level. 

 

3 Principles in Action

Given that the majority of Mexican citizens do not have sufficient access to healthcare (if at all), the students recognised that the provision of healthcare is not simply a technical or scientific issue. 

The availability and distribution of healthcare is a political and ethical issue as well as technical and economic.  Moreover, there is much debate still in Mexico about the roles of the government and private sector in healthcare.  Who should provide, who should pay, and how healthcare should be financed are decisions that are enmeshed in both political battles, economic frameworks, and various kinds of social and political values.

The second principle that health is something that is affected by things much beyond access to healthcare was also uncontroversial.

Every medical graduate in Mexico is required to do one year of rural service, partly in return for the free medical education.  Like many other who work and live in developing countries, it is fairly easy to recognise that material poverty is a social condition that determines ill-health and mortality.

However, what the students were surprised to learn was the research on the social gradient in health that came out from the Whitehall studies on the health of British civil servants.  They were also surprised to learn about socio-psycho-biological pathways to ill-health.

Until recently, aspects such as stress and control and the social gradient in health were thought to be largely concerns for industrialised countries.  But, as the Mexican students learned, the link between social inequalities and health inequalities is a matter for developing countries as well.  And the students had very little difficulty in seeing that health of individuals is not longer just a domestic issue but affected by factors—biological, economic, political, et cetera—that happen in far away places.

It is perhaps regarding the third principle about the pervasive role of ethics that the students felt less certain.

Medical students and faculty may be some of the most value driven individuals, but they are not likely to receive very much training in ethics or dialectical reasoning.  Some of the students were able to regurgitate the famous principles of bioethics – autonomy, beneficence, non-maleficence, and justice.  But they struggled to explain what these principles meant and why they were important to realise in the clinical encounter.

We went through the bioethics principles, the historical events that produced them, and the ethical foundations for each.  We then moved on to how concerns about population health, social determinants of health and health inequalities, globalisation and health, and global health inequalities requires drawing on political philosophy and theories of social justice in contrast to moral philosophy in bioethics.

 

Final Note

On the final day of the course, I asked for feedback on the week and one thing that each of them would improve.  Repeatedly, it was expressed that they would have like to see more information and data that was directly relevant to Mexico and Latin America.  This is completely understandable but also brings an important aspect of global health into relief.

Much of the literature on health issues in Mexico and the region is not available in English.  This raises the problem both that students and teachers of global health outside Latin American are not able to fully grasp the issues facing that region.  But this is even more crucial when it comes to ethical literature.  As it was pointed out to many throughout the week, there are number of ethical approaches to addressing social inequalities and health inequalities within Latin America such as ‘critical epidemiology,’ ‘epistemologies of the South,’ ‘liberation theology,’ ‘solidarity’ and so forth.  While the students recognised that lack of full knowledge of these approaches reflects the language barrier, one student pointed out that it is partly my responsibility to learn Spanish to learn these ideas as much as it is their responsibility to translate these works into English.

The week in Mexico among some of the brightest medical students and professionals reaffirmed the three principles of inter-disciplinary global health teaching.  But it also reaffirmed what I have been discovering throughout my travels.  Whether in central European countries such as Germany and Austria, or in South Africa and India, and now in Mexico, there exist a rich and diverse ethical approaches to understanding the value of health and ethical reasoning about the right social responses.

The prevailing view in global health circles that the right thing to do is to start at the top of the list of the leading causes or most cost-efficient treatments is likely to be the ethics of one group of people from a particular region or professional expertise.

It is my hope that as more and more individuals learn about global health, from an inter-disciplinary perspective, that includes a heavy dose of philosophy, there is going to be a much richer understanding of the causes of ill-health and mortality in the world, and how we should respond at the local, national and global levels.

At the least, more people will begin to understand the fuller picture about human health beyond its biological and medical aspects.

Sridhar Venkatapuram


Sridhar Venkatapuram is a Lecturer in Global Health & Philosophy at King’s College London and Senior Research Associate at University of Johannesburg. He is the creator and Director of the MSc in Global Health & Social Justice.  His first book is called Health Justice. An Argument from the Capabilities Approach and he recently did a TEDx talk on the human right to health at TEDxLSHTM. 

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