Midterm Review

Question 1

Biomedical

Answer 1

1. individual and biological → body as a machine
2. health = absence of disease
3. magic bullets
4. commodification of health

Question 2

Behavioral/Lifestyle

Answer 2

1. behavior and beliefs
2. regulation and modification of personal conduct and attitudes (education, counseling, incentives)
3. the lifestyle model: personal responsibility to make healthy choices; poor health results from bad decisions of laziness

Question 3

Political Economy

Answer 3

1. societal structures (political and economic practices, policies and institutions)
2. health reflects and derives from social, political and economic structures and relations that limit personal and collective agency
   
   1. limited access to health care, recreation, housing, education, nutrition

Question 4

Social Medicine

Answer 4

Rudolf Virchow: Prussia typhus report 1848
- disease has social causes, treatment needs to be structural and sociopolitical; recommended democracy to treat typhus)
- “Medicine is a social science, politics is medicine on a larger scale”
- Black Panther Party: free clinics and community health
- Jack Geiger and John Hatch: US community Health centers (affordable, community-oriented)

Question 5

Biosocial model of health

Answer 5

• Bridget Hanna and Arthur Kleinman EMPHASIZED
• biological and social are “mutually constitutive and inherently intertwined parts of a complex whole”
• success and failure interventions are both social and biological factors

Question 6

Unintended consequences of purposive social action

Answer 6

• Robert Merton, sociologist
• Causes:
  
  • complex social realities
  • limitations of knowledge
  • blind spots, myopias and bias (imperious immediacy of interest)
  • rigidity of habit (in individuals and organizations)
• Effects:
  
  • radiate into other spheres
  • affect the conceptual terrain
• Examples
  
  • ARVs in Mozambique

Question 7

Medicalization

Answer 7

• Hanna & Kleinman; Berger and Luckmann social construction of reality (sociology of knowledge); Irving Zola
• “to make medical”: applying medical knowledge to behaviors that are not self-evidently medical or biological
• example of the social construction of knowledge, shows how social, cultural, historical factors influence definitions of interventions upon illness/disease
• Examples
  
  • according to DSM-5 a person is considered clinically depressed if they still feel grief after two weeks

Question 8

Modes of Authority

Answer 8

• Max Weber, German sociologist, 1864-1920
• Traditional Authority:
  
  • patriarchs, feudal lords, royalty
• Charismatic Authority:
  
  • extraordinary leaders; ex. Mahatma Gandhi, Nelson Mandela, Jesus, Trump
• Rational : Legal Authority
  
  • authority derives from laws and rules; vested in institutions, not individuals
  • institutions become more powerful than individuals; wield power over individuals/populations
  • associated with modernity, standardization, quantification, calculation, technologization
  • most common in bureaucracy

Question 9

Bureaucratic/Technical authority

Answer 9

• rationalization of everyday life- transforms the mystical and mysterious (or socially complex) into laws, rules, and regulations
• advantages: less biased, more efficient, quantifiable, “scalable”
• disadvantages: “iron cage of rationality”
  
  • stuck in own categories, dehumanization (no emotion, tradition, spontaneity), anti-innovation, anti-localization
• Examples: Center for Disability Accommodations, health insurance (assign diagnostic labels)

Question 10

Local moral worlds/ethical complexity

Answer 10

• Arthur Kleinman, Physician-Anthropologist, Harvard
  
  • “local moral worlds are settings of moral experience which express what is most at stake for people in their local networks of relationships in communities”
  • helps understand how global health interventions are taken up, how people act the way they do
  • Example: spirit ambulance

Question 11

Social Suffering

Answer 11

• Arthur Kleinman, Veena Das, Margaret Lock (1977)
• social and health problems are intermixed
• suffering caused by social forces (born into poverty, discrimination, abusive households)
• suffering is interpersonal, not individual (chronic illness— exacerbate social and health problems)
• interventions/”solutions” often cause or worsen suffering (indifference and/or unintended consequences)

Question 12

Structural Violence

Answer 12

• Johan Galtung 1969 (popularized by Paul Farmer)
• a form of violence wherein some social structure or institution may harm people by preventing them from meeting their basic needs… “avoidable impairment of fundamental human needs”
• arrangements are structural because embedded in political and economic organization (”social structures”)
  
  • violent because they cause injury to people
  • seem natural in our way of understanding the world— invisible
• Examples: differential access to resources, political power, education, health care, legal counsel, incarceration

Question 13

Biopower

Answer 13

• Michel Foucault, French philosopher/historian of science
• goal of maximizing life- governments increasingly exerted their power through the control of populations and individual bodies
• diffuse: does not operate through clear/obvious visible agents of power. operates through expertise, technologies, strategies of quantification, etc.
• productive: produces particular behaviors, fields of intervention, etc.
• demonstrates how concern for life and health can be used for political ends
• two poles: individual(self-discipline) and population (longevity of population)

Question 14

Philanthrocapitalism

Answer 14

• Matthew Bishop and Michael Green (2008)— Birn readings (2014)
• Definition:
  
  • guided by principles and practices of for-profit enterprise
  • demonstrates capitalism’s (and capitalist’s) benevolent potential
  • depends on profits amasses from exploitation and inequities:
    
    • financial speculation, tax shelters, monopolistic pricing, exploitation of workers and subsistence agriculturalists, and destruction of natural resources

Question 15

Colonial Medicine

Answer 15

• medicine core to colonial mission → colonies as a laboratory for health innovation
• frailty of ‘savage’ bodies vs European → racial hierarchies based on biological differences
• increased movement of goods and bodies → colonies became permanent outposts of production lead to tropical medicine
• isolation of quinine, Niger River expeditions failed (1841)

Question 16

Tropical Medicine

Answer 16

• global trade expanded, colonies more permanent resources
• medicine is the core of the labor force
• focused on epidemics (bulk loss of population/labor force, not individual suffering
• “black body” is resilient to tropical disease and and better for labor in hot climates (justify slavery); darker bodies are vectors of disease (poor hygiene)
• first lead sustained international epidemiological investigations
• germ theory developed (1880s)

Question 17

International Health

Answer 17

• first inter-nation health organizations emerged from 19th century cholera pandemics and Panama Canal
• focused on solving easily fixable problems, ignoring those related to SES inequality
• vertical approach, magic bullet, single disease
• Panama Canal→ US took over constructed, PAHO created
• Rockefeller Foundation (1913)→ motives were “scientific philanthropy, improving public image, econ growth, expanding global capitalism (philanthrocap.)
• International Bureau of Health/PAHO created early 1900s
• UN created after WW2

Question 18

Missionary Medicine

Answer 18

• focus on individual minds, individual lives
• purpose of conversion; sin and contamination are cause of illness

Question 19

Cholera

Answer 19

• high mortality untreated, antibiotic treatment
  
  • John Snow (1854) in London discovered the cause was in water pumps
• Philippines 1902 (US Cholera War)
  
  • unhygienic behavior → immune bodies of Filipinos = insurrectors
  • razes villages, forced medications, burned corpses
• 1870-1900 “International Sanitary Conferences” to solve cholera’s effect on international trade; trade= solution for cholera and mosquito diseases
• Panama Canal 1881-1889 (France)
  
  • thousands of workers died of cholera, malaria, yellow fever
  • Africans imported, died at same rate so project abandoned and US took over for France

Question 20

HIV/AIDS

Answer 20

• “the first neoliberal pandemic” → low spending led to death from AIDS and a decimated workforce; 1990 Zambia teachers and nurses dying faster than trained
• biosocially: RNA virus targetting immune cells; targets marginalized populations
  
  • affects stigmatized populations, spread and lack of treatment can be attributed to colonial legacies: structural adjustment, lack of healthcare infrastructures, medication too expensive, race ideas about cultural barriers to treatment adherence
• led to change in global health
  
  • global funding increased, increase focus on treatment and prevention, activists and community organization importance, role of private foundations and philanthrocapitalism, activism sped up FDA approval processes

Question 21

Yellow Fever

Answer 21

• RNA virus, from mosquitoes, black vomit (GI bleed)
• Water Reed, Cuba (1891): experiments determined mosquito was cause of yellow fever
• US Panama Canal (1902): began with mosquito eradication, quinine, protected worker dwellings, lay new sewage pipes; eliminated 1905
  
  • required institutional and international support
  • creation of International Sanitary Bureau → Pan American Health Organization (PAHO)
  • Panama model applied to other diseases

Question 22

Malaria 1955

Answer 22

• biological factors:
  
  • parasite, complex life cycle, anemia, liver failure
  • treatment: anti-parasites, develops resistance
  • moves back and forth between mosquitoes and humans
• WHO tried to eradicate with DDT but failed
  
  • failure of top-down approach
    
    • negative health/environmental effects of DDT
    • distrust of health teams
    • resistance developed quickly, malaria reintroduced
    • strict protocol: local teams couldn’t adapt intervention to local circumstances
  • Africa totally left out of plan (even with the most cases)
  • emergence of pessimism, suspicion of top-down public health

Question 23

Smallpox 1967

Answer 23

• second attempt at top-down strategy to “save” WHO reputation
• biological factors:
  
  • vax developed to treat, total immunity
  • obvious physical signs
  • no latency period
  • predictable incubation and duration
  • no animal reservoir
• successful— eradication 1977
  
  • return of optimism about international health, about WHO
• critiques:
  
  • forced vaccinations
  • top-down, biomedical approach
  • cherry-picked a “solvable” disease

Question 24

Vertical

Answer 24

health programs focused on specific diseases and interventions

Question 25

Horizontal

Answer 25

health programs focused on distributed health issues and health systems strengthening

Question 26

Comprehensive Primary Health Care:

Answer 26

• Alma Ata Conference, September 6-12th, 1978 → Declaration of Alma Ata
• health as a human right
• “Horizontal” approach
  
  • access to basic care, equitable distribution of resources
  • local participation, achieve level of health that enables productive lives
• championed by Halfdan Mahler, leader of the WHO
• learned from examples from community-led, integrative (of biomed and non-Western medical practices) medical efforts: Indian rural doctors, China barefoot doctors; rural emphasis
• messy, complicated, political- mobilization proved very challenging

Question 27

Selective Primary Health Care:

Answer 27

• pushback against comprehensive PHC from powerful players from US and Europe, in the context of a global debt crisis
• Rockefeller Foundation Conference on Health and Population Development, 1979
• Walsh and Warren New England Journal of Medicine article, 1979
  
  • CPHC not cost-effective, need to select certain diseases and measure benefits
• measurable, fast results; vertical approach, not participatory/engaging for sectors outside health ministries
• facile support from donor community
• Example: UNICEF GOBI-FFF
  
  • growth monitoring, oral rehydration, breastfeeding, immunization, family planning, female literacy, food supplementation

Question 28

Structural adjustment programs

Answer 28

• 1981 Washington Consensus: large loans given to developing countries, put default on loans and higher interest
  
  • gutted healthcare and education systems
• example: Mozambique 1983 deal with IMF and World Bank to receive food aid, allow NGOs to enter
• critiques: UNICEF, World Bank

Question 29

Neoliberalism

Answer 29

• Margaret Thatcher, Ronald Reagan, World Bank, IMF
• reassertion of traditional/free ideas about the market
• markets will regulate themselves and give everyone what they deserve (government distorts markets)
  
  • competition is health and seeking equality is morally corrosive and counterproductive
• viewed health as a commodity, not a right; people can receive services that they can pay for
• greater inequities: decrease in physicians per capita, decrease in use of primary care, increased use of emergency services
• public health and medicine outsourced to the private sector (NGOs, projects)

Question 30

HIV/AIDS: ARVs in Mozambique

Answer 30

• HIV prevalence is high as well as mortality and low life expectancy
• “All I eat is ARVs” → hunger from ARV medicine arguably worse than virus itself
• with hunger, participants are given “food pack” with their ARVs, but food sharing is important for patients
• food and employment given to entire family (avg. $1-2/day, support package value $8-10/day + job)