Diarrheal Disease In India’s Ganges River Region

The Ganges River presents a unique insight into the basics of Diarrheal Disease (DD), including symptoms, causes, long-term and short-term impacts and treatment. Further, the interaction between cultural/religious beliefs and biomedical beliefs at the Ganges River illuminates conflicts between culture and public health in the region. Hinduism, the dominant religion in India, requires ceremonial bathing in the polluted Ganges River water and is subsequently increasing the spread of DD. Despite the efforts of global health workers, Hindu ideology in India continues to take precedence over public health advice. While the developed world may have the medical knowledge to alleviate disease, it is important to understand that in some cultures, religious practices overshadow conflicting scientific evidence. There is a tension for global health advocates who strive to reduce mortality rates while respecting people’s cultures.

 

Diarrheal Disease in India’s Ganges River Region

This I Believe…

Rachel Mahoney

This week we read our final piece for course, which is also the closing chapter of Paul Farmer’s Pathologies of Power, entitled “Rethinking Health and Human Rights – Time for a Paradigm Shift.” In it, Farmer drives home the assertion that “public health and access to medical care are social and economic rights” that should be guaranteed to all (217).  The chapter revisits many of the grim realities faced by those who seek to ensure medical access for populations too poor, too disenfranchised, and too discriminated against to receive it.  Farmer also admits the boundaries and limitations of this goal; he writes that bureaucracy and institution will always stand in the way of human welfare as long as there is profit involved with keeping the world’s poor majority subjugated by the world’s rich minority. 

Paul Farmer’s emotive closing statements are echoed in the audio clip called “This I Believe,” which is a recording of Farmer’s recitation of an essay he wrote about the major values and objectives he’s developed while working to ensure health care and human rights to the globe’s most impoverished communities.  Originally recorded and aired on National Public Radio (NPR), the full clip and transcript is available here.

Below is one particularly moving excerpt that calls on us to join the “movement to prevent human suffering”:  

 “I believe in health care as a human right. I’ve worked as a doctor in many places, and I’ve seen where to be poor means to be bereft of rights … Of course such a world is a utopia, and most of us know that we live in a dystopia. But all of us carry somewhere within us the belief that moving away from dystopia moves us towards something better and more humane. I still believe this … We must also call attention to the failures and inadequacy of our own best efforts. The goal of preventing human suffering must be linked to the task of bringing others, many others, into a movement for basic rights.”

I hope these words resonate and stir within you the same impetus they have in me.

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Dr. Paul Farmer is a founding director of Partners In Health, an international organization that provides health care to people living in poverty. Above, Farmer examines a child at a mobile clinic in Haiti.

 

 

 

 

The Paradoxical Co-Existence of Malnourishment & Obesity

Rachel Mahoney

In his piece Culture and the Evolution of Obesity, Professor Peter J. Brown of Emory University’s Global Health Institute explores the social factors that contribute to dangerous diets — specifically obesity.  Brown rejects the traditional view that human predisposition to obesity and fatness are situated solely within the context of biological evolution, in favor of the notion that “the etiology of obesity must account for the social distribution of the condition with regard to gender, ethnicity, social class, and economic modernization … this distribution, which has changed throughout history, undoubtedly involves cultural factors” (Brown 1991: 31).  Brown argues that obesity and hunger are situated instead in a dynamic landscape of networks, institutions, cultural beliefs, and biological evolution, which all fuel the startling rate of obesity in both developed and developing regionsof the globe.

Most countries have extreme numbers of simultaneous underweight and overweight BMIs

ARVs: Surviving VS. Thriving

Rachel Mahoney

The global health community needs to move beyond simply keeping AIDS patients alive, and focus more on improving quality of their lives. A paradox has developed in countries where large proportions of the population are dependent on antiretroviral treatments to survive the virus.  These people claim that though they are being kept alive by the drugs, their “principle complaint” is still gnawing hunger.  Psychiatrtist at the University of Washington, Ippolytos Andreas Kalofonos, examined this connection between ARV disbursement and food disbursement in Mozambique.  Kalofonos asserts that current HIV/AIDS interventions may be procuring peoples’ lives, but they are failing to address these people’s  hunger and ensuing competition over scarce resources.

An additional underlying consequence of 1st world aid disbursal to the 3rd world is that it prolongs post-colonial structures of power by disabling developing countries from independently and internally overcoming health crises.   Plumpy’nut is one example of how 1st world interventions can foster dependence in the 3rd world.  Critics of the “miracle peanut solution” quip “How is [Nutriset, the company that engineered Plumpy’nut] addressing the need for poor people in Haiti not to be dependent on outside intervention in the first place?”

 

Pro-Plumpy'nut advertisement from UNICEF.

Humanitarian Aid: not so humanitarian, after all

Rachel Mahoney

Through her anecdotal representation of Tanzanians during the 2006 East African Food Crisis, Kristin Phillips illustrates some of the ways food and humanitarian aid can be disruptive and destructive to receiving communities in the developing world.  Phillips writes that the flawed system food aid distribution in Tanzania — which was “funneled too narrowly to the very poorest citizens”— created new socio-economic stratifications that bred social tension and discontent (Phillips, 24).   Additionally, food aid undermined traditional Tanzanian values and beliefs surrounding gift giving.  One man Phillips interviewed explained how anonymous food do not allow Tanzanians to thank their donors, a vital feature of Tanzanian exchange practices:

“Tell us to whom we are indebted. We must know whom to thank … The gift is therefore at one and the same time what should be done, what should be received, and yet what is dangerous to take. This is because the thing that is given itself forges a bilateral, irrevocable bond, above all when it consists of food.” People were unwilling not to know to whom they were bound and beholden (Phillips, 40)

Phillip’s account of Tanzanian food aid is not unlike Erica Bornstein’s critique of World Vision, a Christian child sponsorship organization that isolates poor African children and connects them to American sponsors.  Bornstein summates the irony of this system: “In effect, new perceptions of economic disparity are produced by the very humanitarian efforts that strive to overcome them” (Bornstein, 595).  She continues to describe the post-colonial “ulterior motives” of many humanitarian aid missions, which effectively fracture and disenfranchise members of developing societies instead of providing solutions for long-term economic development and independence.

An advertisement taken from worldvision.org.

Ironies of Inequality: The Ethics of Treating Diarrheal Disease

Rachel Mahoney

In his text Pathologies of Power, Paul Farmer discusses the “ironies of inequality” pertaining to global health standards.  Farmer criticizes the way first world medical research efforts “ditch” medical ethics codes as soon as research begins in poor and underdeveloped countries: “In arguing the health care is a human right, one signs on to a lifetime of work dedicated to erasing double standards for rich and poor … without a social justice component, medical ethics risks becoming yet another strategy for managing inequality” (Farmer 201).

The global crusade to end diarrheal disease is not spared from these double standards, as  “global control of diarrheal disease has always been highly political” (Pollard et al., 165).  In the 1980s the WHO founded several organizations to combat diarrheal disease.  But because most of the funding for these campaigns came from US corporations (pharmaceutical and the like) that stood to gain from vaccine proliferation in the third world, WHO’ anti-diarrheal disease efforts downplayed structural approaches for treating and preventing diarrhea in favor of pharmaceutical ones.  These agenda-minded corporations eventually obscured the importance of diarrheal disease on the global health stage, as efforts to improve general “childhood illness” made diarrheal disease “invisible” (Pollard et al., 165).   Breastfeeding is critical to both the prevention and treatment of diarrhoea. Infants who are exclusively breastfed for the first six months of life and continue to be breastfed until two years of age and beyond develop fewer infections and have less severe illnesses, including diarrhoea.  Even though this information is widely accepted by the international health community, companies like Nestle are still allowed to infiltrate developing markets with less-nourishing infant formula.

Pollard and his colleagues connect these features of diarrheal disease to Farmer’s sentiments about the risks of medical ethics being divorced from social justice:  

“Death from diarrheal disease is equivalent to death from failure to access the most basic form of primary health care.  Thus, the risk of death is very heterogeneous and concentrated among communities that lack access to care, either for geographical, social, or economic reasons.  Even in a country with good vaccination program, those communities are the last to get access to vaccines, especially expensive, new vaccines”  further contending that, “countries must come to see rotavirus vaccines as one of a range of possible strategies available to help combat the problem of diarrheal disease mortality rather than as a standalone intervention” (Polland et al., 166-167).

Causes of child deaths in low-income countries Source: WHO, World Health Statistics 2011

The fruits of peace can be gathered from the tree of suffering

Rachel Mahoney

In her piece When Wounds and Corpses Fail to Speak: Narratives of Violence and Rape in Congo (DRC), Ngwarsungu Chiwengo dissects the inadequacies of human rights discourses at conveying suffering.  She uses the Congolese genocide as a case study of how the international community pushed pain “further into invisibility.” Chiwengo explains how the west’s post-colonial constructions of Africa are transmitted through the language used to communicate suffering or violence.

This language has effectively muted the voices and erased narratives of individual Africans peoples because it “supports a particular conception of rights and acts to mask power relations and stifles the possibility of engaging critiques.”  Further, international acknowledgement and discussion of human rights abuses is marked by the residue of western imperialism, so the representation of African events in western literature, media, and human rights discourse are limited by the underlying power relations between the two regions. “Colonization, religion, and European contact have led to the construction of an African identity of alterity.”  Thus, even when the international community acknowledge and discuss human rights atrocities committed in Africa, colonial constructions of African identity permeate those discussions—further broadening the “veil of silence” covering the dead.

The global health crises caused by diarrheal disease also represent a salient example of the suffering of some is silenced by those in power, who control the language used to express pain and decide whose plights will be spoken of and whose will be overlooked.  The silence surrounding diarrheal disease reflects the colonial notion that “human life in Africa isn’t worth the same as man’s life any where is.”  One article about diarrheal disease calls the completely preventable disease “The Silent Killer” of children worldwide; silent because its victims—who suffer no political agency and extreme poverty—have no voice on the global stage.  It is time to give these children a voice.

Here is a still image from a video campaign created by the Centers for Disease Control and Prevention (CDC) that encourages people to speak-out against violence instead of succumbing to the silence that propagates it worldwide.

The Coca-Colonization of Global Health and Human Rights

Rachel Mahoney

“The history of trade follows that of larger world orders.  Following years of exploiting their former colonies, rich countries ordered trade to their own advantage and have maintained unequal orders ever since.  Although they no longer extract mineral, oil, and timber with the barrel of a gun, they now use tariffs, subsidies, and import quotas.  One order of exploitation has given way to a subtler but equally lethal version” (O’neil, 149)

One salient example of subtle contemporary imperialism is the coca-colonization of many developing economies.  Coca-colonization, a term coined as the result of rising neoliberalism, occurs when powerful multi-national corporations (Coca-Cola) and lending institutions (International Monetary Fund) take steps to “modernize” and “integrate” indigenous agricultural economies, instead spurning these markets to ineffective peripheral positions in the global balance of power  (Leatherman & Goodman, Coca-colonization of diets in the Yucatan).  

As students of public health and human rights — and more importantly, as active global citizens — it is our duty to consider each angle of the claims made about global health; we must understand the complex and dynamic ways institutions, governments, and corporations around the world affect the health and status of everyone.  Joyce A. Millen, former Director of the Institute for Health and Social Justice at Partners In Health and professor of Social Medicine at Harvard Medical School, echoes this need for critical skepticism of health statistics: “…many of the significant health improvements made over the last 50 years are marred by growing health disparities between the world’s wealthy and the world’s poor” … “the ‘winners’ and ‘losers’ amidst the global balance of power and wealth.  Millen goes on to caution that “aggregate statistics mask” the unevenness of health improvements worldwide, by failing to mention that “equally dramatic losses” of many development strategies (Millen et al., 4 and 5).

Included in the “equally dramatic losses” alluded to above, are the 10 million children under five-years-old who died in 2007.  What is more, is that 97% of these children died in developing countries that lack the resources to treat and prevent their predominantly preventable deaths. How different might the fates of these children be if they had won the proverbial “birth lottery”?  Alas, they, along with billions more babies, are born in countries with infant mortality rates sixteen times higher than the Global North (Millen et al., 5).

Millen and her colleagues make clear the disparities that prevent raw economic growth from benefitting everyone equally.  A myriad of intersecting factors like colonialism, political and structural violence, malnourishment, and corporation-dominated global financial flows have only worsened the lives of the world’s poorest citizens: “specific growth-oriented policies have not only failed to improve the living standards and health outcomes among the poor, but also have inflicted additional suffering on disenfranchised and vulnerable populations” (Millen et al., 7).

An anti-neoliberalism cartoon symbolizing the corporate imperialism it perpetuates around the world.

Clean the (Developed) World

Rachel Mahoney

Kleinfeld categorizes preventable diabetes-related obesity in children as an “extension of [diabetes] to the young where health care professionals feel society and public policy have most glaringly failed. Diabetes, they say, should never have gotten there” (8).

One reason for the spread of 100% preventable illness like diabetes and diarrheal disease is social apathy amongst the world’s privileged who believe they are immune to the diseases and disparities of the poor.  Judith Hall writes that people tend to see themselves as individuals foremost, and as members of a connected population only secondarily.  According to Hall, this sociopathic apathy perpetuates misconceptions about health—particularly by providing a rationalization for the preventable suffering of the disconnected ‘other’:

Our modern world tends to emphasize the individual person. We are less inclined to think of ourselves as part of a species, as part of evolution. We rarely reflect on transgenerational effects, in other words that many biologic mechanisms are adaptations for survival of the species rather than survival of individual persons (Hall, 234)

Breaking away from this social disconnect is non-profit founder Shawn Seipler.  In 2008, the well-to-do business executive founded a organization called Clean the World, which recycles millions of bars of complementary soap from hotels to the developing world.  So far, Seipler’s organization has distributed nearly 10 million bars to nearly 50 nations worldwide.  Seipler claims that he “… stumbled on research saying millions of children could be saved each year across the globe if only they used soap and water to wash their hands. In particular, one study found that the top two killers of children younger than 5 — acute respiratory illness and diarrheal disease — could be cut by 60 percent if kids had regular access to soap” (Santich).  Imagine the lives that could be saved if everyone in the west harbored Seipler’s same values of connectedness and social responsibility.

Global Health Statistics Major Causes of Death in Neonates & Children Under Five in the World

Similar to the life years lost because of endemic diarrheal disease in the developing world, diabetes is rapidly the west’s 21st century plague of the ages: “Here, then, was the price of diabetes, not just the dollars and cents but the high cost in quality of life” (Kleinfeld, 2).  Maybe it will take a terrifying health crisis like diabetes in the developed world to finally do away with “first world” and “third world,” and create one world.

Statistics from CleanTheWorld.org

“A loving smile is counted as charitable offering”

Rachel Mahoney 

In Islam, there is an entire pillar dedicated to the importance of Muslim charity and alms for the poor which states:

“Filled with the gratitude of La ilaha Ilallah, we long to share with all beings the bounties bestowed on us by the Generous One. This is manifested by sharing a portion of lawfully earned income with those in need, zakat. Beyond this is the continuous flow of generous actions, thoughts and gestures. The Prophet of Allah has enjoined that we offer charity constantly through every limb of our body. A loving smile is counted as charitable offering.

Though it was recorded in the 5th century and has been the subject of much controversy in recent decades, the Qu’ran advocates for the same human rights many contemporary global health workers believe and strive for. In her analysis of HIV/AIDS in China, Yanqiu Rachel Zhou explains how AIDS patients in China (and in many other parts of the world), are viewed as, “morally problematic others” for which foreign aid workers and missionaries are solely responsible (Zhou 293).  These people experience widespread discrimination and social and familial abandonment because of the “general ignorance and misconceptions” surrounding their disease.  Like Chinese HIV-positive individuals, AIDS patients worldwide suffer incredible mistreatment because they are written off as promiscuous, drug-addicted, and entirely responsible for their poor health statuses.  According to Farmer, this sub-human treatment is a form of structural violence, or “institutionalized offenses of human dignity: extreme and relative poverty, social inequalities … and more spectacular forms of violence that are un-contestedly human rights abuses” (Farmer: Pathologies of Power, 8).

In many countries where HIV/AIDS is prevalent, ignorance and myths about the virus contribute to its proliferation, especially amongst poor and voiceless women.  For instance, the false notions that AIDS is a men’s disease and heterosexual AIDS “won’t happen” have robbed many HIV-positive women of their voices, rendering them almost totally invisible from modern scientific and popular commentary about AIDS (Farmer, 62).  Farmer claims that these women have not been silent about their plights, but have “simply been unheard” as forces of structural violence, sexism, and poverty rob women of agency over their bodies and their health.

Poverty, social inequity, and low self-esteem amongst poor women are considered major co-factors in leading women to feel powerless and engage in high-risk sexual behavior. Farmer elaborates on this connection: “AIDS has transformed many women’s survival strategies into death strategies” and he cites rising trends of poor young women using sex at the behest their families to generate income in impoverished communities (Farmer, 79).

In these ways we can see how diseases like HIV/AIDS and cholera are intersectional, and how the people who are enduring them can be mapped amongst a landscape of interacting social structures.  Scholars like Famer and Zhou make clear that the solutions to healing people cut-off from their communities because of false stigma need not be elaborate or expensive.  If these people were simply viewed as human beings, that would be a fine start toward their recovery. Paralleling the pillar of Islamic charity, Zhou writes how one Chinese AIDS patient reported feeling markedly better about his health status after receiving “just a smile or warm eye contact from others” (Zhou 294).

Image of malnourished AIDS patient in China