23 Sep Dissertating Haiti
We have not reached the consensus that to eat is a basic human right. This is an ethical crisis. This is a crisis of faith.
Global capitalism becomes a machine devouring our planet. The little finger, the men and women of the poorest 20%, are reduced to cogs in this machine, the bottom rung in global production, valued only as cheap labor, otherwise altogether disposable. The machine also does not measure the suffering of our planet. Every second, an area the size of a soccer field is deforested. This fact alone should be mobilizing men and women to protect their most basic interest – oxygen. But the machine overwhelms u. The distance between the thumb and the little finger stretches to the breaking point.
~ Jean-Bertrand Aristide
I’ve been trying to understand just what it is that i’m supposed to be writing about in my dissertation. What it is that i’m supposed to go to Haiti to actually ask about. I am, by trade, a health geographer, with an emphasis in political, economic, feminist, and development geographies. We all wear a million hats, we geographers.
The 1957 WHO Annual Report noted that verticalized health care delivery would be an exceptionally poor choice for developing countries, yet, 50 years later, global (south) health is decidedly verticalized. Although global health initiatives (GHIs) with foci on major health issues have undoubtedly benefited millions, there is an un-problematization of this verticalization of health service delivery. I am interested in exploring the long-term deleterious effects of GHIs on national health systems of low and middle income countries.[1] To do this, I would like to explore five main themes:
- A recent World Bank report indicates that financial commitments for development assistance in health (DAH) has grown from $2.5 billion to $14 billion from 1990 to 2005 years.[2] A Lancet report states that global health funding has grown from $5.1 billion to $21.8 billion in 2007.[3] Yet another study places actual disbursements in 2005 at $8.11 billion.[4] This disparity in estimates illustrates the lack of systematic tracking mechanism by which health resource flows are monitored.[5]
- At the same time, global health has become a competitive industry, and as such, raises questions about whom, exactly, is benefiting from this fragmented and inadequately monitored system. The shift to a competitive market for DAH could undermine the role of the World Health Organization and UNICEF as neutral brokers within the scientific community and between developing countries.[6] Also, how is this money being spent? Much of the aid disbursements are going back into donor countries through NGOs (including high rates of reimbursement for executives and support staff) and through unilateral and multilateral donations tied to conditionalities, to name a few. Also, private foundations and corporations are being publicly supported through tax exemptions.4
- The disparity in estimates, however, hides more pressing issues regarding who is receiving funding. For instance, three countries among the top 30 in terms of disease burden, Burkino Faso, Niger, and Mali, are well out of the top 30 in terms of funds received. Although Bangladesh is ranked 7th in the world in disease burden, the country only received $1billion between 2003 and 2007. These disparities are not considered controversial.[7] There is some thought that this funding is tied to security issues.[8]
- Global health as an issue of security begs close consideration of how this will change / has changed the face of the “meaning and practice of global health” through the shift from considerations of health as a human right to health as a security issue; health as a medium for surveillance; and health as a new frame for state interventions. [9] Re-figuring health within this context may drive the work of global health toward a new function of neoliberal technologies and ideologies that may further undermine sovereignty of countries of the global south.
At the root of these questions is one thread: who is actually receiving health care and how is this affecting their lives and the lives of those who are not receiving care?
I originally intended to use Demographic Health Survey (DHS) data to look at health access and health disparity in the Central Plateau. I wanted to see what the data said and then ask the people what they thought. Why do you go to a USAID-funded health station, or NGO-run clinic, or non-profit local clinic, or Haitian public health hospital for care? What is the care like? What kind of services would you like to see? Are you getting them? How is bedside manner? Do you get what you really, truly need? I was (and still am) interested in the stories that are told about particular kinds of health provider places. How are decisions made by people? What is it that they want out of health care? Can the WHO Toolkit on Monitoring Health Systems Strengthening (TMHSS) be an effective measure of health care delivery? Is it possible to only view the quantitative outcomes as the be-all, end-all measure of a health system?
Obviously, i don’t think so. I was breaking rule one – don’t know your answer before you start. But i want to be able to answer the Why…
The project made sense before the earthquake. The WHO TMHSS uses DHS data. The sites are located, the people counted, the materials cataloged, providers rated according to forms, etc. But how can you quantify quality of care? And who does that serve?
This has been a major issue for Haiti. Even before the earthquake, this tiny island nation had the largest per-capita ratio of NGOs in the world. There was in-fighting, scrabbling, vying, jockeying going on. But who had asked the Haitians what they wanted? What they perceived their own needs to be? Who was stopping to listen to their voices? Oh, yes – once – the democratic election of Jean-Bertrand Aristide. That didn’t last long. Then it did. Then it didn’t. Then it did. Then it wasn’t. America, the brandisher of Freedom and Democracy has been multiply-implicated in the coups d’etat. In the meantime, the U.S. cherry-picked embargoes in the favor of American businesses.
No one smells entirely of roses. I don’t know enough to be able to unabashedly state that Aristide was or was not a good president. What i do know is that he scared people with his foregrounding of the needs of the poor. And that he was a far-sight better than the Duvalier dictatorships or the military dictatorship that followed the Duvalier reign. I do know that he brought to court numerous Tontons Macoute and began investigations into numerous human rights violations – and that was in his first round of presidency. I also know that the U.S. government helped Raoul Cedras into exile in Panama. Emmanuelle Constant was invited to live in the U.S. and never stood trial for his atrocities (though the eventually stood trial for a whole new slew of mortgage fraud as well as was successfully sued by 3 rape victims). He disappeared off of everyone’s radar after his 2008 convictions.
So how does this all tie back into dissertating? Since the earthquake, there have been several (mostly ignored, it seems) calls to engage the Haitian people in their own rebuilding process. But there is little to indicate that this is happening. The few news reports trickling through the media today are generally heart-wrenching in nature – stories of lack of adequate health care (if you lost a limb before the earthquake, don’t you still deserve a prosthetic?), lack of affordable potable water in refugee camps, lack of food, lack of hope. How do i ask questions about general health systems when there doesn’t seem to be much systeming going on?
Not to mention…i can’t bring myself to go marching over there, all government funded, to ask questions. What kind of monster does that? Yes, the questions need to be asked, but then action has to happen. Action much bigger than my personal advancement, my dissertation, my PhD and future job. It makes me sick to think that i could be given money to do this – to ride in on my high horse…what a twisted world we live in. My thoughts and words are worth more than their lives?!
My heart has been breaking since January 12th. It has been breaking and been re-sealed with a callousness of my own needs and desires. Back and forth – breaking and mending, breaking and mending. It’s turned to a rotten lump thumping labourously in my chest. And i hate myself for it all.
Which brings me back to Jean-Bertrand Aristide’s quote above. We have lost sight. I don’t want the Haitian people to become the cogs in my machine. I am daunted by The Machine, feeling lost in my petty questions and concerns about the verticalization of health care in the face of the magnitude of pain and suffering that is held by this one tiny nation. What of the rest of the world? What of it all?
[1] Kaiser Global Health Daily Policy Report (2009). “Lancet Studies Examine Aspects of Global Health Funding.” The Henry J. Kaiser Family Foundation, U.S. Global Health Policy. 19 June 2009. http://globalhealth.kff.org/Daily-Reports/2009/June/19/GH-061909-Lancet-Studies.aspx
[2] World Bank (2007). “Healthy Development: The World Bank Strategy for health, Nutrition, and Population Results.” Washington, DC: World Bank. 22 February 2007
[3] Goldstein, J. (2009). “Funding for Global Health Quadruples to $22 Billion.” The Wall Street Journal. 18 June 2009 Health Blog, Online Edition. http://blogs.wsj.com/health/2009/06/18/funding-for-global-health-quadruples-to-more-than-20-billion/
[4] McCoy, D., Chand, S., and Sridhar, D. (2009). “Global Health Funding: How Much, Where it Comes From and Where it Goes.” Health Policy and Planning Advance Access. Health Policy and Planning, 2009;1-11
[5] Devi S., Rajaie B. (2008). “Misfinancing Global Health: A Case for Transparency in Disbursements and Decision Making.” The Lancet, 372(9644); 27 September 2008-3 October 2008, pp 1185-1191
[6] Ravishankar, D, Gubbins, P, Cooley, RJ, Leach-Kemon, K, Michaud, CM, Jamison, DT, Murray, CJL (2009). “Financing of global health: tracking development assistance for health from 1990 to 2007.” The Lancet, 37(9681); June 2009, pp. 2113-2124.
[7] Ruiz, R. (2009). “The World’s Under-Funded Health Crises.” Forbes.com, 18 June 2009, Public Health Section. http://www.forbes.com/2009/06/18/public-health-disease-business-healthcare-health-aid.html
[8] Hood, M. (2009). “Soaring Global Health Funds Not All Wisely Spent: Studies.” Google, American Free Press, 18 June 2009. http://www.google.com/hostednews/afp/article/ALeqM5j2VmiLY6S8Y08gqKOtZmzODjggOw
[9] Ingram, A (2005). “The New Geopolitics of Disease: Between Global Health and Global Security.” Geopolitics, 10:3, pp 522-545.
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