Module 3: Pitfalls in Global Health Work

A primary misconception in global health work is the idea that any action is better than inaction. The desire to “do something” comes from what many experience as an ethical call-to-action when faced with the knowledge of poverty and destitution. This “primacy of the ethical” can lead to interventions that are poorly researched and ineffectively implemented.(1)

“The failure to subject this problem to such thorough-going investigation has perhaps been due in part to its having been linked historically with transcendental and ethical considerations.”(2)

Despite good intentions, global health work that does not follow best practice principles can be wasteful, unethical, and harmful. Worst practices can create serious public health concerns that introduce new barriers to patient care, which can reinforce and perpetuate health disparities and cyclical poverty. Documented here are several pitfalls in global health work that have confounded public health interventions and prevented the realization of intended goals.

Pitfall 1: Top-Down Approach

When global health organizations aim to effect change abroad through foreign bureaucratic institutions or attempt to orchestrate transnational public interventions, aid rarely reaches those who need it most. This top-down approach to implementing programs has repeatedly been shown to be wasteful and ineffective when compared to community-based, bottom-up approaches.(3) Consider the case of the Péligre Dam, a project funded by what was the precursor of the World Bank.

Pitfall Case Study: Péligre Dam, Haiti

Haiti is known as the poorest country in the Americas with a gross national product of about $400 per person per year. From the accounts of peasant farmers in Haiti’s Central Plateau, they were cash-poor but had enough to eat, because they had land.(4) For the people farming near the upper Artibonite River, all this changed in 1956 as a “poverty-reduction program” funded the construction of a modern hydroelectric dam in the Péligre valley.

“All sorts of ironies abound in development work: the World Bank has become, interestingly enough, the leading funder of tuberculosis control in the world, replacing the World Health Organization as the major funder behind many interventions.(5)  And yet the building of this dam, a product of development ideologies, undoubtedly increased rates of tuberculosis in this area of Haiti.”(6)

Flooding of the fertile valley caused wide scale land loss. Peasant farmers, not even aware of the construction of this dam, were driven up to the arid hills above the area in which the dam was built.(7) The families who lost their livelihoods and homes to the hydroelectric dam were not compensated or resettled. This led to immense poverty in the region, high TB rates, and increased risk for HIV infection. Thus, the top-down implementation of this development project without consideration of its local impacts led to poor health outcomes for the very people that it intended to aid.

“People often ask how they survive. The answer is that they often do not. Mortality rates were appalling in the decades after the valley was flooded.”(8)  

Pitfall 2: No Community Involvement

Health programs must involve community members at all levels of assessment, design, implementation, and evaluation in order to be effective in a local environment. One way in which this can be achieved is by employing health workers from the community. Community health workers (CHWs) may be family members, friends, or even patients who provide health education, refer people who are ill to a clinic, or deliver medicines and social support to patients in their homes. While they do not supplant the work of doctors or nurses, they are a vital interface between the clinic and the community and should be paid for their work.(9) Above all, CHWs are crucial to the success of global health efforts because of their unique understanding of local problems. Their close community ties allow them to identify areas of need and to effectively navigate potential barriers that others may not be positioned to understand.

Positive Program Case Study: Community Health Workers in Zambia

According to recent estimates, 1.2 million out of a total population of 10 million Zambians were infected with HIV by 2005. But like most African countries, there were not enough health workers to provide HIV counseling and testing services. In order to relieve the burden on the already overstrained health workers, community health workers were trained as lay counselors who could provide these services.

“Lay counselors, when provided with the approved and appropriate training, can play a key role in HIV counseling services. While they can support the provision of good-quality counseling and testing services to relieve overburdened health care workers, they will require ongoing supervision to further enhance their performance. In order to make this strategy sustainable, efforts must be made to mainstream their activities and formalize their relationship with the health facilities.”(10)

A study of this intervention indicates that the services of CHWs are well-received at health facilities and that they now provide up to 70% of the services.(11) The study also reveals that the lay counselors are highly competent and that their error rate is lower than that of health care workers themselves. Moreover, the quality of their counseling services is high, causing them to be indispensable in resource-limited facilities.

Pitfall 3: Lack of Knowledge Regarding Political and Historical Forces

In order for global health interventions to be successful, implementers must have an accurate understanding of both the immediate environmental and broader historical factors which have shaped the target community. In the Péligre Dam case-study, the history of Haiti as a slave colony was a fundamental underlying factor which perpetuated cyclical poverty in the Central Plateau.(12) The failure of development activities in Rwanda similarly illustrates the pitfalls that occur when global health workers lack knowledge about broad political and historical realities.

Pitfall Case Study: Rwandan Genocide

The Rwandan genocide was a surprise to nearly all of the aid workers in the country. Rwanda was seen as a well-developing country and was a model for other African nations to follow. Yet today, Rwanda is a prime example of the failures of the development industry which attempted to increase development while ignoring historical tensions within the country. Such ignorance of the impending genocide is highlighted by Peter Uvin:

“The pauperization was omnipresent, the racist discourse loud; fear was visible in people’s eyes, and militarization was evident—but that was none of my business, for I was there for another Rwanda, the development model.”(13)

In fact, up to the last minute, thousands of workers and foreign experts were building roads, extending credit, training farmers, and distributing food. What caused the development community to be so blind-sided? In his book “Aiding Violence,” Uvin argues that the development community posited an apolitical image of Rwanda as a generic developing country. Such a simple and false conception allowed Rwanda to be constructed as a “development problem” that could be controlled. This false pretense was important to development agencies in order for them to construct a positive organization identity, or what Uvin calls a “logo” in the development market. The realities of inequality, racism, and oppressive governing were not allowed into this equation as it disrupted the “solvable problem” that development agencies desired. Thus, the development community saw themselves working above and outside of the social and political realm, preventing themselves from having to make political and ethical decisions.

The obliviousness on the part of foreigners, particularly the development community, to the impending genocide illustrates how easily historical knowledge can be contorted and confused in order to serve the (often well-intended) purposes of the powerful. Tensions in Rwanda were exacerbated by the top-down, external nature of the development model, which interacted with the forces of racism and oppression that eventually spawned the genocide.

“I have no difficulty in accepting an emphasis on the significant role of the elites in inflaming and manipulating ethnic hatreds.  But I would add that they were harnessing real social forces, embedded in the structure of the society and in the perceptions of many of its members.”(14)

Pitfall 4: Ignoring Barriers to Care

Fighting disease in impoverished settings also means fighting the poverty which is at the root of poor health. In order to achieve this, global health workers must attend to peoples’ social and economic needs. If organizations fail to improve access to food, shelter, clean water, sanitation, education, and economic opportunities, their activities will not be likely to result in improved health. This is because health care in the Global South is often difficult for the poorest people to access due to hidden costs that make even "free" clinics and treatment out of reach. These hidden barriers to care may include culturally instilled fears, transportation fees, and childcare.

For example, although blindness in the Global South is usually curable, most patients do not receive medical attention. Why is it that visually impaired people do not seek eye care services even when care is available? The answer to this question is multifold, and it is important to note that lack of awareness about treatment availability and benefits is not the primary problem.(15) Rather, patients face a variety of barriers that combine to prevent them from seeking proper medical attention. One study in a rural Indian village found that the leading reasons for not seeking care were monetary constraints (18.8%), transport difficulty (17.4%), lack of awareness about cataract in the eyes (17.4%), and lack of escort (14.5%).(16)

Positive Program Case Study: POSER

POSER, or Program on Social and Economic Rights, is a series of initiatives attached to Partners in Health in Rwanda, Haiti, and Peru which are meant to address the economic barriers that prevent patients from accessing health care. For example, in Haiti, transportation and telecommunications infrastructure are minimal, as is access to other facilities. With no structured or subsidized public transportation system, most Haitians travel by foot, by animal, and in informal trucks and buses.(17) Such transportation difficulties are an impediment to seeking medical care. POSER was founded on the belief that meeting patients’ social needs was just as important as meeting their medical needs. The program’s key projects included providing patients with nutritional support, building homes for those patients who were most in need, paying school fees for patients’ families who were unable to do so, and building well caps or filtration systems for communities to ensure access to clean drinking water.

In order to evaluate the efficacy of these interventions, a randomized research study was conducted.(18) Members of one group of patients with active TB were given free medical care; members of a second group were given free care as well as financial aid incentives to attend a monthly clinic and aggressive home follow-up by trained village health workers. When patients were given economic support in addition to just medication, their TB cure rates and compliance increased dramatically. Comparing the two groups showed significant differences in mortality, sputum positivity after 6 months of treatment, persistent pulmonary symptoms after 1 year of treatment, average amount of weight gained, ability to return to work, and cure rate. Based on these data, the authors concluded that high cure rates can be achieved if the primacy of economic causes of TB is acknowledged and addressed. Thus, effective medical care is not just about providing medication, but rather about providing a system which takes care of patients holistically and includes the provision of economic opportunities.

“The experience of Proje Veye Sante suggests that hunger and poverty are the prime culprits in treatment failure, just as they are so often responsible for the reactivation of endogenous infection. The hoary truth that poverty and TB are greater than the sum of their parts is once again supported by the data.”(19)

Footnotes

(1) Levinas E. “Totality and infinity”. A Lingis, translator. Duquesne (PA): Duquesne University Press; (1969):79.

(2) Merton, R. K. (1936). The unanticipated consequences of purposive social action. American sociological review, 1(6), 894-904.

(3) Ramsey, K. M., & Weijer, C. (2007). Ethics of surgical training in developing countries. World journal of surgery, 31(11), 2067-2069.

(4) Farmer, P. AIDS and Accusation: Haiti, Haitians and the Geography of Blame. University of California Press, 2006. JSTOR, www.jstor.org/stable/10.1525/j.ctt1pp3p4.

(5) "Tuberculosis." The World Bank, 19 Aug. 2013, www.worldbank.org/en/topic/health/brief/tuberculosis-control.

(6) Farmer, P. “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): 55-73.

(7) Farmer, P. AIDS and Accusation: Haiti, Haitians and the Geography of Blame. University of California Press, 2006. JSTOR, www.jstor.org/stable/10.1525/j.ctt1pp3p4.

(8) Ibid.

(9) Walton, D. A., Farmer, P. E., Lambert, W., Leandre, F., Koenig, S. P., & Mukherjee, J. S. (2004). Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti. Journal of public health policy, 25(2), 137-158.

(10) Mwangala, Sheila, et al. “Task-Shifting and Quality of HIV Testing Services: Experiences from a National Reference Hospital in Zambia.”Plos One, vol. 10, no. 11, 25 Nov. 2015, doi:10.1371/journal.pone.014307.

(11) Ibid.

(12) J. Leyburn“The Haitian People” Caribbean Transformations, Baltimore: Johns Hopkins University Press; (1974).

(13) Uvin, P. “Aiding violence. The development enterprise in Rwanda”. West Hartford: Kumarian Press; (1998).

(14) Kuper, L., “The Pity of It All: Polarization of Racial and Ethnic Relations”. London: Duckworth; (1977).

(15) Donoghue, M. “People Who Don’t Use Eye Services: ‘Making the Invisible Visible.” Journal of Community Eye Health. 12.31 (1999): 36-38.

(16) Malhotra R et al. “Increasing access to cataract surgery in a rural area--a support strategy.” Indian J Public Health. 2005 Apr-Jun;49(2):63-7.

(17) Walton, D. A., Farmer, P. E., Lambert, W., Leandre, F., Koenig, S. P., & Mukherjee, J. S. (2004). Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti. Journal of public health policy, 25(2), 137-158. 

(18) Farmer P, S Robin, S Ramilus, J Kim. “Tuberculosis, poverty, and “compliance”: lessons from rural Haiti.” Seminars in Respirator Infections (1991);6(4):254-60.

(19) Ibid.