Going There: Questioning Global Health
From straightjacket
by: Kelly Anderson & Azad Mashari
| a private gaze even though he |
|
Contact: azad.mashari@utoronto.ca. Mailing list: http://www.straightjacketstudio.com/mailman/listinfo/ghethics.
Of the roughly 7000 languages spoken in the middle of the 20th century, half are either already extinct or are no longer being taught to children. By the end of this century only 10% will remain. Every two weeks the last speaker of a language and the last carrier of its culture dies. This loss of diversity not only makes for a less colourful world, it narrows the range of humanity's adaptive possibilities precisely when our most politically and technologically dominant cultural paradigms are proving to be unsustainable. As anthropologist Wade Davis writes, we are "living through a time when virtually half of humanity's intellectual, social and spiritual legacy is being allowed to slip away... It is not change and technology that threatens... it is power... these peoples are not failed attempts at being modern, quaint and colourful, destined to fade away by natural law... these are dynamic living peoples being driven out of existence by identifiable forces..."
As individuals striving to understand and improve the health of the world around us, we have often found ourselves to be the unwitting agent of these forces. In the name of 'help' or 'development,' other ways of life are devalued against our own fully 'developed' civilization. Traditional notions of charity and help are often based on a world view with implicit assumptions that, in retrospect, we hesitate to affirm. These assumptions have shaped our advocacy, our research and our field work. Most importantly they have shaped, in subtle and damaging ways, our interactions with and view of those we were striving to help.
What motivates us to engage in global health? What constitutes “health” for a given people and place? How do we evaluate the impact of our activities on another place? Why do we pick the research questions we do? Who benefits? How do we relate to our hosts? Can we overcome the immense distances created by culture, material wealth and political power? Are we supporting or encouraging the aspirations of other peoples towards our own environmentally destructive and unsustainable life style and institutions? What does it mean to be "culturally sensitive"?
In these workshops we want to create a space for discussion of experiences, questions and arguments on these themes.
Approach: Exploring Ways of Seeing
In an attempt to explore our own ways of seeing while respecting the uncertainties and limitations inherent in our knowledge & experience we focus on raising and refining questions and collecting stories, parables, accounts and arguments that touch on possible answers.
We have a deep respect for the uniqueness of different individual's experiences in different times and places, and a suspicion of simple and overly abstract generalizations that disregard this uniqueness.
Questions & Stories
We believe that by developing progressively more penetrating and unsettling questions and gathering accompanying stories that present multiple and often inconsistent perspectives, we can avoid such generalizations and cultivate a more mindful mode of being that will sharpen our senses and facilitate practical insights in our day to day.
Our final objective is not the achievement of an explicit intellectual position but the cultivation of this mode of being.
We gather and refine such questions and stories by combing our own experience and, more importantly, by soliciting and engaging the stories, experiences & perspectives of others through workshops, conversations and reading.
In practice we have two guiding values for this process: discomfort & elegance.
Discomfort as a harbinger of insight
To expose limits and shortcomings of our ways of seeing, we focus on situations and questions that make us uncomfortable, get under our (or other's) skin. We see this discomfort as a sign that our habitual perspective is not able to properly make sense of these situations or questions. We believe that by embracing and pursuing this kind of discomfort, instead of avoiding it, we can expose false assumptions and break out of these habitual perspectives. We see discomfort as a harbinger of insight.
Elegance for clarity & memory
In so far as the questions and stories are tools to be used "in the field," lenses that help us peer through the mist in times of confusion, they need to capture the core idea without undue complexity or oversimplification, and they need to be memorable.
Neither "ethical paralysis" nor "righteous seizure"
We wish to avoid both of these extremes. The former is well known. The latter is well captured in the following:
“Something must be done; anything must be done, whether it works or not”
- Bob Geldof, NY Times Editorial 6/2005
Hope, Cynicism, Despair, Joy
Facing uncomfortable questions and sharing stories of suffering, destruction and impending dangers does not arise from cynicism. On the contrary it comes from a need for a careful assessment of where we stand so that we can cultivate an active and empowered hope. Otherwise hope merely becomes, in Derrick Jensen's words "a longing for a future condition over which [we] have no agency."
This empowered hope that we seek can (and perhaps must) coexist with despair. Again in Jensen's words:
"...despair is an appropriate response to a desperate situation; the sorrow is just sorrow and the pain is just pain. It’s not so much the sorrow or even the pain that hurts, as it is [our] resistance to it. There’s this idea that if you really recognize how bad things are you have to go around being miserable all the time. But the truth is I’m really happy, and I am full of rage and sorrow and joy and happiness and contentment and discontent. I’m full of all those things. It’s okay to feel more than one thing at the same time.
-The Complexities of Hope, Interview with Derrick Jensen
Questions & Stories
Helping
How do we conceptualize help in the most concrete sense?
- You need help. You ask for help. I help you.
- I see you struggling. I ask if you need help. You accept. I help you.
- I suspect you may need help. I ask you. You cannot responsd (maybe you are unconscious). I do what I decide you need.
Which of these senses of helps comes closest to the one invoked in your global health experiences?
If you insist on working with the poor, if this is your vocation, then at least work among the poor who can tell you to go to hell. It is incredibly unfair for you to impose yourselves on a village where you are so linguistically deaf and dumb that you don't even understand what you are doing, or what people think of you. And it is profoundly damaging to yourselves when you define something that you want to do as "good," a "sacrifice" and "help."
-Ivan Illich, To Hell with Good Intentions
If you have come to help me you are wasting my time. But if you come because your liberation is bound up with mine, then let us struggle together
-Lilla Watson
Three accounts
I
[Jesus] answered: “... Love your neighbor as yourself.'”
...“And who is my neighbor?”
In reply Jesus said: “A man was going down from Jerusalem to Jericho, when he fell into the hands of robbers. They stripped him of his clothes, beat him and went away, leaving him half dead. A priest happened to be going down the same road, and when he saw the man, he passed by on the other side. So too, a Levite, when he came to the place and saw him, passed by on the other side...
But a Samaritan, as he traveled, came where the man was; and when he saw him, he took pity on him. He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him. The next day he took out two silver coins and gave them to the innkeeper. 'Look after him,' he said, 'and when I return, I will reimburse you for any extra expense you may have.'
“Which of these three do you think was a neighbor to the man who fell into the hands of robbers?”
-Luke 10:27-35 (NIV)
II
It wasn't long before sunrise when we headed towards our own nests, not quite disgracefully and not quite with grace. Long and joyous night. We wondered whether any of us would remember much of it. In our state of insobriety we passed a man, more coherent than ourselves, asking for spare change. He was handed a few coins by one of us. The culprit was duly chastised by the rest.
What if he spends it on drink? we kindly asked our friend. Do you not see that what he needs is real help not the help he was asking for?
III
[The] message that we were less than human was repeated over and over. I recall that from time to time [the refugee camp] was shelled and all foreigners working there were taken out to safety. We were left inside. We would often say that the foreigners were like the angels who could fly from danger; greater than ordinary human beings. We on the other hand were less than human, more like the spirits in hell.
- Meas Nee, Towards Restoring Life in Cambodian Villages
Two experiments
I. The Good Samaritan experiment, Princeton Theological Seminary 1973
- C.D Batson and J. Darley, “From Jerusalem to Jericho: A study of Situational and Dispositional Variables in Helping Behaviour,” Social Psychology 27 (1973): 100.
A group of divinity students were told that they were going to be giving a practice Sermon. Half were given the story of the good Samaritan as their topic. The other half got other random topics. They had some time to prepare and then, one at a time, they were told to go to a room in another building and give the sermon. On their way they would each encounter a man bent over and moaning, clearly in need in of help. The question was: would the people who had just been thinking about the Good Samaritan story be more likely to stop and help than the others? The answer: No.
II. The charity letter & the highway
Consider the following two situations.
- Situation ONE: I am driving along and I see someone severely wounded and bleeding on the side of the road and I am quite certain that if she doesn't reach a hospital soon she will die. I am about to stop, but then I think of the time and the mess. I press on the gas and speed past.
- Situation TWO: I get a letter from a reputable charity that I trust, asking for $50 or $100 to provide emergency care to victims of a massive global food shortage. I look at it then ignore it.
How do you feel about the my actions in these two situations. Why is it that in the first case I seem like a monster, but in the second situation, when I could have probably saved more lives with less resources, my actions seem less bad, even permissible?
One more perspective
"There is no odor so bad as that which arises from goodness tainted. It is human, it is divine, carrion. If I knew for a certainty that a man was coming to my house with the conscious design of doing me good, I should run for my life, as from that dry and parching wind of the African deserts called the simoom, which fills the mouth and nose and ears and eyes with dust till you are suffocated, for fear that I should get some of his good done to me, some of its virus mingled with my blood.
No. In this case I would rather suffer evil the natural way. A man is not a good man to me because he will feed me if I should be starving, or warm me if I should be freezing, or pull me out of a ditch if I should ever fall into one. I can find you a Newfoundland dog that will do as much.
Philanthropy is not love for one's fellow-man in the broadest sense."
- Henry David Thoreau, Walden
Four questions
What is our relationship to the individuals & populations we are trying to help?
What separates us from them? Why are we in a position to give and they to receive?
How do they see us?
How does our helping effect that relationship? Does it close the distances (culture, gender, age, material wealth & political power) or reinforce them?
Health, Healing & Healthcare
Are our models of health & health care systems more effective & powerful in the long-run than other cultures notions of health & healing? What can we learn from other conceptualizations and models and health?
What does cultural sensitivity mean in this context? "Polite respect for the amusing but dispensable quaintness of other cultures"?
"... even those of us sympathetic to the plight of indigenous people view them as quaint and colourful but somehow reduced to the margins of history as the 'real world,' meaning our world, moves on. Well the truth is, the 20th century, 300 years from now, is not going to be remembered for its wars or technical innovations, but rather as the era in which we stood by and either actively endorsed or passively accepted the massive destruction of biological and cultural diversity on the planet. The problem isn't change. All cultures, through all time, have constantly been engaged in a dance with new possibilities of life. And the problem is not technology itself. The Sioux Indians did not stop being Sioux when they gave up the bow and arrow any more than an American stopped being an American when he gave up the horse and buggy. Genocide, the physical extinction of a people is universally condemned but ethnocide, the destruction of a people's way of life is not only not condemned it is universally, in many quarters, celebrated as part of the development strategy.
"... These are not dying peoples, on the contrary if you have the heart to feel and the eyes to see you discover that the world is not flat, the world remains a rich tapestry, it remains a rich topography of the spirit. These myriad voices of humanity are not failed attempts at being you, failed attempts at being modern, they are unique facets of the human imagination, they are unique answers to a fundamental question: what does it mean to be human and alive? and when asked that questions they respond with 6000 different voices and collectively those voices become our human repertoire for dealing with the challenges that will confront us in the ensuing millennia. Our industrial society is scarcely 300 years old. That shallow history should not suggest to anyone that we have all the answers to all the questions that will confront us in the ensuing millennia."
"The myriad voices of humanity are not failed attempts at being us they are unique answers to that fundamental question, what does it mean to be human and alive? and there is indeed a fire burning over the earth, taking with it not only plants and animals but the legacy of humanity's brilliance. Right now ... of the 6000 languages that were spoken the day you were born fully half are not being taught to children, so you are living through a time when virtually half of humanity's intellectual, social and spiritual legacy is being allowed to slip away. This does not have to happen, these peoples are not failed attempts at being modern, quaint and colourful, destined to fade away by natural law. In every case these are dynamic living peoples being driven our of existence by identifiable forces. That is actually an optimistic observation because it suggests that if human beings are the agents of cultural destruction we can also be and must be the facilitators of cultural survival."
- Wade Davis (2008) The Worldwide Web of Belief and Ritual
Sustainability
You find a stranger who is cold, shivering. You can give him a match and he might be warmed for a few seconds; set him on fire and he will be warm for the rest of his life.
- Anonymous
Are we supporting the aspirations of other peoples towards our own environmentally destructive & unsustainable life styles & institutions?
"Next to money and guns, the third largest North American export is the U.S. idealist, who turns up in every theater of the world: the teacher, the volunteer, the missionary, the community organizer, the economic developer, and the vacationing do-gooders. Ideally, these people define their role as service. Actually, they frequently wind up alleviating the damage done by money and weapons, or "seducing" the "underdeveloped" to the benefits of the world of affluence and achievement. Perhaps this is the moment to instead bring home to the people of the U.S. the knowledge that the way of life they have chosen simply is not alive enough to be shared."
- Ivan Illich, To Hell With Good Intentions
Is our medical model environmentally sustainable?
What would it look like without non-renewable resources?
Where should we be looking for alternatives?
Motivation & Intent
What motivates us to get involved in global health?
Is altruism an appropriate foundation for our endeavors to increase health equity and social justice? What alternatives are there? Solidarity? Others?
Are guilt or anger or ego or "moral indignation" appropriate sources of motivation?
Aside from the significance of the issues and principles themselves, is there something about our personalities and the ways we deal with our own personal challenges that makes us want to pursue such causes?
Case Studies
Presentation notes, slides & archives
- Healing Parternships
- Healing Partnerships. Canadian Conference on Global Health 2010, Ottawa - PDF
- International Conference on Woman and Child Health 2009 - PDF
- UWO School of Medicine 4th Year Global Health Course 2009 - PDF
- UWO predeparture workshop 2009 - PDF
- SUNSIH 2008 - PDF
- Healing, Distance & Harm Presentation for UWO Hungry for Change Gala 2007
References
- Jorg Steiner, The Bear Who Wanted to Be a Bear, 1st ed. (Heryin Books, Inc., 2007).
- Nikko Snyder, The complexities of hope, Ascent, 2007, http://www.ascentmagazine.com/articles.aspx?articleID=282&page=read&subpage=past&issueID=38.
- Meas Nee, Towards Restoring Life in Cambodian Villages (Phnom Penh: JSRC, 1999).
- Ivan Illich, To Hell with Good Intentions (presented at the Conference on InterAmerican Student Projects, Cuernavaca, Mexico, April 20, 1968), http://www.swaraj.org/illich_hell.htm.
- William Easterly, White Man's Burden, 1st ed. (Penguin Paperbacks, 2007).
Additional References
1. Hans A. Baer, Merrill Singer, and Ida Susser, Medical Anthropology and the World System: Second Edition, 2nd ed. (Praeger Paperback, 2004).
2. Nicholas Banatvala and Len Doyal, “Knowing when to say “no” on the student elective: Students going on electives abroad need clinical guidelines,” BMJ : British Medical Journal 316, no. 7142 (May 9, 1998): 1404–1405, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1113113.
3. Walden Bello, Deglobalization: Ideas for a New World Economy, Revised. (Zed Books, 2005).
4. Walden Bello and Tom Engelhardt, Dilemmas of Domination: The Unmaking of the American Empire (Metropolitan Books, 2005).
5. S. Bezruchka, “Medical tourism as medical harm to the Third World: Why? For whom?,” Wilderness Environ Med 11, no. 2 (2000): 77-8.
6. R. Bishop and J. A. Litch, “Medical tourism can do harm.,” BMJ 320, no. 7240 (2000): 1017.
7. John Cavanagh et al., Alternatives to Economic Globalization, 1st ed. (Berrett-Koehler Publishers, 2002).
8. Ha-Joon Chang, Kicking Away the Ladder: Development Strategy in Historical Perspective, 1st ed. (Anthem Press, 2002).
9. Ha-Joon Chang, Bad Samaritans: The Myth of Free Trade and the Secret History of Capitalism (Bloomsbury Press, 2007).
10. Wade Davis, “Cultures at the far edge of the world” (presented at the TED Conference, Monterey, California , February 2003), http://www.ted.com/index.php/talks/wade_davis_on_endangered_cultures.html.
11. Wade Davis, “The worldwide web of belief and ritual” (presented at the TED Conference, Monterey, California , February 2008), http://www.ted.com/index.php/talks/wade_davis_on_the_worldwide_web_of_belief_and_ritual.html.
12. Gustavo Esteva, “Development,” in W. Sachs (Ed.) The Development Dictionary: A Guide to Knowledge as Power (Zed Books Ltd, 1992), 272.
13. Daniel Goleman , “Why aren’t we all Good Samaritans? ” (Monterey, California , March 2007), http://www.ted.com/index.php/talks/daniel_goleman_on_compassion.html.
14. T. Grennan, “A Wolf in Sheep’s Clothing? A Closer Look at Medical Tourism’,” Medical Ethics 1, no. 1 (2003): 50-54.
15. Timothy C Hardcastle, “Ethics of surgical training in developing countries,” World Journal of Surgery 32, no. 7 (July 2008): 1562, doi:10.1007/s00268-007-9449-9, http://www.ncbi.nlm.nih.gov/pubmed/18228090.
16. Koss-Chioino, Medical Pluralism in the Andes, 1st ed. (Routledge, 2002).
17. Meas Nee, Towards Restoring Life in Cambodian Villages (Phnom Penh: JSRC, 1999).
18. Andrew D. Pinto and Ross E. G. Upshur, “Global Health Ethics for Students,” Developing World Bioethics (2007).
19. Kevin M Ramsey, “International surgical electives: reflections in ethics,” Archives of Surgery (Chicago, Ill.: 1960) 143, no. 1 (January 2008): 10-1, doi:143/1/10, http://www.ncbi.nlm.nih.gov/pubmed/18209147.
20. Kevin M Ramsey and Charles Weijer, “Ethics of surgical training in developing countries,” World Journal of Surgery 31, no. 11 (November 2007): 2067-9; discussion 2070-1, doi:10.1007/s00268-007-9243-8, http://www.ncbi.nlm.nih.gov/pubmed/17896129.
21. David W Robertson et al., “What kind of evidence do we need to justify humanitarian medical aid?,” Lancet 360, no. 9329 (July 27, 2002): 330-3, doi:12147390, http://www.ncbi.nlm.nih.gov/pubmed/12147390.
22. Wolfgang Sachs, The Development Dictionary: A Guide to Knowledge as Power (Zed Books Ltd, 1992).
23. Vandana Shiva, Staying Alive: Women, Ecology and Development (Zed Books, 1989).
24. Vandana Shiva, Monocultures of the Mind: Perspectives on Biodiversity and Biotechnology (Zed Books, 1993).
25. Vandana Shiva, Earth Democracy: Justice, Sustainability, and Peace (South End Press, 2005).
26. Henry David Thoreau, Walden; Or, Life in the Woods, 1st ed. (Dover Publications, 1995).
27. Jim Yong and Joyce V Millen, Dying For Growth: Global Inequality and the Health of the Poor, 1st ed. (Common Courage Press, 2002).
28. Jill Eisen, “Sick People or Sick Societies,” Ideas - The Best of Ideas (Toronto: Canadian Broadcasting Corporation, March 2008).Part 1 | Part 2.
29. American Medical Association. Virtual Mentor. 2006; 8 (12):795-884.
30. Garten, Ariel. Neuroscience of Morality. Great Ideas, TVOntario. 2007
31. Mashari, A. Healing and Distance. 2007. http://www.straightjacketstudio.com/node/17
32. Anderson, K. and Hamadani, F. What is Our Responsibility? Global Health Ethics in Practice. Presentation at Canadian Federation of Medical Students Conference 2007.
33. Duncan Pedersen, “At the crossroads between global health and local cultures: a critical perspective,” in Lolas F., Martin D.K., Quezada A. (Eds.) Prioridades en Salud y Salud Intercultural, 1 (Santiago de Chile: CIEB and Universidad de Chile, 2007), 141-162.
34. James A. Trostle, Epidemiology and Culture, 1st ed. (Cambridge University Press, 2005).
35. Nuyens, Y. (2005). No Development Without Research: A challenge for research capacity strengthening. Global Forum for Health Research: Geneva.
36. Dubois-Flynn, G. (2007). Ethics in Research in Low and Middle Income Countries (LMIC). CIHR PopNews, 13: 6
37. Nuffield Council on Bioethics. (2002). The ethics of research related to healthcare in developing countries. Nuffield Council on Bioethics: London.
38. Nuffield Council on Bioethics. (2005). The ethics of research related to healthcare in developing countries: a follow-up Discussion Paper. Nuffield Council on Bioethics: London.
39. Aboud, F. (1998). Health Psychology in Global Perspective. SAGE Publications: Thousand Oaks
40. Rachel Mandleson, “Helping the world. And me,” Macleans on Campus, September 19, 2008, http://oncampus.macleans.ca/education/2008/09/19/helping-the-world-and-me .
41. John A. Crump and Jeremy Sugarman, “Ethical Considerations for Short-term Experiences by Trainees in Global Health,” JAMA 300, no. 12 (September 24, 2008): 1456-1458, doi:10.1001/jama.300.12.1456, http://jama.ama-assn.org.myaccess.library.utoronto.ca.
42. Paul Collier, The Bottom Billion: Why the Poorest Countries are Failing and What Can Be Done About It (Oxford University Press, 2008).
43. Dambisa Moyo, Dead Aid: Why Aid Is Not Working and How There Is a Better Way for Africa (Douglas & McIntyre, 2009). Interview: http://www.guardian.co.uk/society/2009/feb/19/dambisa-moyo-dead-aid-africa
44. T. Pogge, “World poverty and human rights,” Ethics 19, no. 1 (2005).
45. M. Ravallion, “How Not to Count the Poor: A Reply to Reddy and Pogge,” World Bank. www. worldbank. org/research/workpapers (2002).
46. S. G. Reddy, T. W. Pogge, and World Bank, How not to count the poor (Columbia University, 2005).
