Module 2: Unintended Consequences of Global Health Endeavors

This article applies social theory to global health endeavors in order to illuminate the unintended consequences and pitfalls that often accompany such interventions. This theoretical framework is then applied to the emergence of multi-drug resistant tuberculosis in order to highlight the importance of best practices and illustrate the dichotomy between good intentions and poor outcomes.

“…with the complex interaction which constitutes society, action ramifies, its consequences are not restricted to the specific area in which they were initially intended to center, they occur in interrelated fields explicitly ignored at the time of action. Yet it is because these fields are in fact interrelated that the further consequences in adjacent areas tend to react upon the fundamental value-system.”(1)

In his essay “The Unanticipated Consequences of Purposive Social Action,” social theorist Robert Merton outlines several explanations for how the outcomes of any action—policy, program, or other—can deviate from the intended purpose. Ignorance, he argues, is the first and most obvious limitation to a correct anticipation of the consequences of action. In global health, ignorance may be due to a gap in the existing state of knowledge or the failure of the implementer to gather all relevant information. In a time when global health is increasingly tied to the complexities of political economy, culture, and history, it is more important than ever for entrepreneurs and NGOs to understand the many local and dynamic factors which may determine the outcome of a given intervention.

“Precisely because a particular action is not carried out in a psychological or social vacuum, its effects will ramify into other spheres of value and interest. This process may in part be due to the fact that when a system of basic values enjoins certain specific actions, adherents are not concerned with the objective consequences of these actions but only with the subjective satisfaction of duty well performed.”(2)

Second, a global health intervention may lead to unintended and undesired consequences due to “error” on the part of the implementer. This is often due to the assumption that actions which have in the past led to the desired outcome will continue to do so. Such an assumption is often “fixed in the mechanism of habit and it there finds pragmatic justification, for habitual action does in fact often, even usually, meet with success.”(3)

“We have here the paradox that whereas past experience is the sole guide to our expectations on the assumption that certain past, present and future acts are sufficiently alike to be grouped in the same category, these experiences are in fact different. To the extent that these differences are pertinent to the outcome of the action and appropriate corrections for these differences are not adopted, the actual results will differ from the expected.”(4)

For example, this fallacy may occur when a well-intentioned global health organization implements an established program in a new location, with the assumption that because the intervention was successful in one location, it will be successful in another. As the French mathematician, Henri Poincare, has put it, "... small differences in the initial conditions produce very great ones in the final phenomena…and prediction becomes impossible."(5)

Case Study: The Emergence of Multi-Drug Resistant Tuberculosis

Almost a third of the world’s population is infected with Mycobacterium tuberculosis, the organism that causes TB.(6) Most of those infected never fall ill, but individuals who do can recover if they have access to effective therapies. The administration of such therapies in the richer, western countries effectively eliminated the threat of TB in the Global North. While a positive development, this had two unintended, deleterious effects: western governments and pharmaceutical companies alike turned their interest away from TB control and treatment, and with the development of drugs came new problems associated with their misuse. In fact, “inadequate therapy allowed mutant M. tuberculosis organisms to develop and spread a reservoir of bacteria resistant to first-line drugs.”(7)

This “inadequate therapy” refers to the widespread application of Directly Observed Treatment, Short-course (DOTS), a program for the treatment of TB. While DOTS is highly effective at treating pan-susceptible TB, it has a mere 5% cure rate for patients with multi-drug resistant tuberculosis (MDR-TB).(8) Despite the unambiguous evidence demonstrating the clinical failure of DOTS in cases of MDR-TB, it was recommended that physicians “treat all patients with first-line drugs only.”(9) From the perspective of social theory, global health organizations erred when they failed to “recognize that procedures [treatment protocols] which have been successful in certain circumstances need not be so under all conditions.” In addition, DOTS can sometimes amplify preexisting resistance. “This is not a theoretical model. We know patients who present with drug-resistant disease, receive DOTS, acquire more resistance to more drugs, then get the officially recommended re-treatment regimen, only to pick up resistance to a fourth or fifth drug.”(10)

“Just as rigidities in social organization often balk and block the satisfaction of new wants, so rigidities in individual behavior may block the satisfaction of old wants in a changing social environment.”(11)

Caught in the wheels of bureaucracy, many organizations continued to abide by “principled rejection of doing business from case to case”(12)—even though “the organism had been updated genetically” but the policy had not.(13) From the perspective of global health initiatives, the widespread application of DOTS in the Global South was an easier strategy than considering the subtleties of each case. The simplicity and efficacy of DOTS for treating the majority of TB cases meant managerial success for these organizations, but it also meant clinical failure for individuals with MDR-TB.

“One would not want to use short-course chemotherapy for patients who are resistant to the two main drugs in the treatment regimen, this is precisely what may happen when DOTS is pushed as the sole TB treatment strategy. A five % cure rate means that most of the remaining patients either died or remained sick – and infectious. For most people- patients, family members, doctors, nurses, and others – managerial success is not the ultimate goal of clinical practice. Clinical success is.”(14)

The failure of the global health community to anticipate the emergence of multi-drug resistant tuberculosis and the incorrect assumption that the DOTS program would be equally effective in all local worlds illustrates the pitfalls of “ignorance and error” as described by Merton. Thus, the emergence and failure to treat MDR-TB exemplifies the unfortunate and unintended consequences not only of scientific progress, but also the failure of bureaucratic policies to adapt to the varying biosocial realities of the countries in which they operate.

As a result, we now live in a world in which several different standards of care may be advocated for the same disease. For those with chronic infectious diseases, including tuberculosis and AIDS, these standards include excellent treatment for some; ineffective treatment for others; and no treatment for most.(15)

Footnotes

(1) Merton, R.K. "The Unanticipated Consequences of Purposive Social Action." American Sociological Review, 1 (1936): 894-904.

(2) Ibid.

(3) Ibid.

(4) Ibid.

(5) Poincare, H. Calcul Des Probabilites. Paris, Gauthier-Villars, 1912, archive.org/details/calculdeprobabil00poinrich/page/n13/mode/2up.

(6) Kim, J. Y., Shakow, A., Mate, K., Vanderwarker, C., Gupta, R., & Farmer, P. (2005). Limited good and limited vision: multidrug-resistant tuberculosis and global health policy. Social Science & Medicine, 61(4), 847-859.

(7) Ibid.

(8) Farmer, Paul. “Social medicine and the challenge of biosocial research. In: Innovative Structures in Basic Research: Ringberg-Symposium 4-7 October 2000.” Munich, Germany: Generalverwaltung der Max-Planck-Gesellschaft, Referat Press- und Õffentlichkeitsarbeit; 2002. p. 55-73.

(9) Ibid.

(10) Merton, Robert K. "The Unanticipated Consequences of Purposive Social Action." American Sociological Review, 1 (1936): 894-904.

(11) Ibid.

(12) Weber, Max. “On Bureaucracy” in From Max Weber: Essays in Sociology. New York: OUP, 1946. pp.196-204; 224-244.

(13) Farmer, Paul. “Social medicine and the challenge of biosocial research. In: Innovative Structures in Basic Research: Ringberg-Symposium 4-7 October 2000.” Munich, Germany: Generalverwaltung der Max-Planck-Gesellschaft, Referat Press- und Õffentlichkeitsarbeit; 2002. p. 55-73.

(14) Ibid.

(15) Ibid.