[TLDR (too long didn’t read): If you are reading this, chances are you care about HR. This Reader is about a new health paradigm coming to us from the Global South and what it will take to transition into it. For a quick overview, just read the bolded text]. Traducir/traduire los/les Readers; usar/utiliser deepl.com
[Because of its importance, I here excerpt and summarize the piece from Oscar Feo et al, ‘Rethinking and Decolonizing Theories, Policies, and Practice of Health from the Global South’].
1. Epidemiology and the implementation of health systems tend to reproduce the colonial aspects of power and of Northern established health knowledge. In it, health systems are viewed as an accumulation of reforms based on theories and policies of the Global North imposed on countries rendered poor. These systems have been built as bureaucratic, biomedicalized, treatment-oriented, and commercialized health systems that must be perceived as external to societies in the South —and thus far flung from the right to health; they also reproduce mistreatment, violence, and racism.
2. The foundation of current health systems and epidemiology has been conditioned, and even adversely impacted, by ‘modern’ scientific thought that reinforces deep asymmetries of dependence and hierarchies anchored in geopolitical power, biostatistics and technical expertise.
3. The biomedical model of health, focused on individual diagnosis and treatment, is regrettably embedded in the world of academia, health ministries, schools of public health, and in the theory, policies, and organization of health systems worldwide.
4. ‘Population pathology’ reigns as if the population were only a sum of individuals. Herein, the State directs unilateral action toward the object ‘society’ and thus mobilizes health-workers-and-technicians-acting-as-the-state’s-agents to carry out a bureaucratic function in which medical care institutions and the population are objects to be controlled and surveilled. The prevailing norms and functions act as barriers for rethinking a critical theory of health from the South that is congruent with the right to health. In this framework, social problems, including health problems, are merely seen as functional imbalances, i.e., mismatches that can be corrected in a series of vertical subsystems. It is, therefore, presumed that inequalities are merely imbalances that require correction, rather than the result of an underlying determinative process. This dependence generates a homogenization of possible pathways with a limited understanding of the specifics of the South. This enables the mercantilization of life through a medical-industrial-financial-insurer complex.
Against this backdrop of obstacles, how do we free ourselves from these legacies and create space for a holistic vision of health policies and health sovereignty?
—How to exit this dynamic of reproduction of coloniality and concomitant dependence on its theory, praxis, and policies in the health sector?
5. This all makes the need self-evident to push for self-determination, for the right to health and for health sovereignty in policies and health systems of the South —away from spaces that anchor the regulation of financial coverage markets through systems of insurance. No cumulative reforms will resolve the question of social and health inequalities that are intertwined and overlaid with social class, race/ethnicity and gender, especially if they do not respond to collective health determinants in each region.
6. The solution implies a whole other system of knowledge for liberation; a veritable categorical reframing; not only a change of language, terminology or changes in the type of reforms within; no canned solutions or care-healing packages; no vertical programs with ‘doctored’ community participation that is a telltale sign of health colonialism.
7. The organization of universal systems is more than an end; it is a strategy to confront structural inequalities by social class, race/ethnicity, and gender. Any reorganization will have to include alternative frameworks that sustain the reinvention of health and political education, as well as human rights learning. Through critical epidemiology*, health and disease will have to be considered and understood in light of the concrete conditions in which groups of human beings are born, live, and work, as that changes over the life cycle.
*: In contrast to the traditional focus of public health, which analyzes populations as an additive aggregate of individuals or artificial groups according to their morbidities, critical epidemiology recognizes the limitations of biostatistics in its attempt to scientifically quantify and instrumentalize what is actually qualitative. Critical epidemiology suggests the characteristics on human groups are heterogeneous and changing –and must be put at the center. Social organizations have their individual identities, conditions, contexts, cultures, territorialities, life histories and specific situations. This implies, in large measure, an exit from the modern scientific method that reduces the whole to component parts and afterwards sums the parts in order to explain the whole. (The use of maps can be deceptive by presenting an attractive format which glosses over concerns with data quality creating confusion regarding units of measurement and data collection). An important foundation of modern epidemiological thought is: quantify first, reflect later. Perhaps it ought to be necessary to first reflect and later investigate what to measure and how to do it, no?
8. Moreover, it cannot be forgotten that all health issues have an unescapable socioenvironmental dimension. This makes each person into an active subject living in a moment in history and a place where life, health, and disease are produced.
Bottom Line:
—After Alma Ata, primary health care became a symbol that seduced us as an all-encompassing strategy that was to achieve its ends only if it was correctly implemented.
9. Questioning the ways in which researchers, managers, technicians, and professionals engage in epidemiology and health and go about their work is also a call to decolonize the academies and the technical health practices in the Global North. This is an exercise and effort that does not concern the South. Rather, for ourselves in the countries rendered poor, we will advocate for: formulating and contextualizing our problems**; reinventing and radicalizing the questions of research; creating a methodological focus and interpreting new findings from our perspective; reviewing, understanding, and elevating alternative systems of knowledge, producing theory and policy from innovation and audacity. This calls for a self-criticism that engages our academic practice in the South. (Oscar Feo et al)
**: Recapitulating: The reductionist paradigm explained above understands health as a fragmented whole decontextualized from empirically perceived problems and measured as variables separate from social relations, as well as from the determination of power (economic-political, cultural and gender). In capitalist societies, economic-colonial-patriarchal power has historically invested vast efforts to position the science that leads us to understand bioethics as an essentially individual and medical challenge at the center. So, as part of the right to health, we must understand what laws and rules makes this right justiciable, as well as the depth with which existing legal tools are in the way or contribute to repair the destructive processes that impact health. We must look at health rights beyond patients’ biological and psychological individuality, radically reframing the world of health to investigate its upstream determinant substrate. (Jaime Breilh)
Claudio Schuftan, Ho Chi Minh City
Your comments are welcome at schuftan@gmail.com
Postscript/Marginalia
–As of 2017, 52% of the world’s written constitutions had recognized an explicit right to health, including those of 19 Latin American countries. There remains a need for this right to be enshrined in the constitutional text of other countries. Certain elements are key:
Any new Constitution ought to define health as a state of physical, mental and social well-being plus:
- it ought to embrace the social and environmental determinants of health (recognizing the intersections of these rights must create the legal environment necessary to develop policies that address the structural factors that determine health inequalities and contribute to the social and economic progress of communities);
- it ought to recognize all dimensions of the right to health and the duty not to discriminate in relation to this right (it must also encompass other freedoms and entitlements, such as the right to informed consent, to control one’s own body and health and to preventive measures that create the conditions for enjoying the highest attainable standard of well-being);
- it ought to enable a legal environment conducive to the equitable implementation and enforcement of comprehensive primary health laws and policies;
- it ought to create the legal capacity of the State to regulate, supervise and oversee the activity of those involved in the health system (measures must be taken to prevent third parties from interfering with this right);
- it ought to include measures to ensure that public and private actors that provide medical care or finance the health system do not arbitrarily interfere with the availability, accessibility, acceptability and quality of health goods and services;
- it ought to lay the foundations for primary health care and its universal access as one of the key components of the SDGs; and
- it must explicitly enable its enforceability before the courts, especially if the current constitutional framework does not allow for the justiciability of all dimensions of this right, which has become a major obstacle to seeking adequate and effective redress for violations of the right to health.
Constitutional law is the most important tool to ensure this type of legal and regulatory capacity to enable courts to adjudicate health-related claims that will ensure that all people have access to an effective remedy for violations or threats to this right, and allow the judiciary to play a greater role in protecting health by creating the constitutional framework and tools necessary to increase the coverage of available, accessible, acceptable and quality goods and services. (Lawrence Gostin)