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Global Health and the Voices of the Poor: Inverting the Problematic Top-Down Approach

On September 16th, 2019, I had a great opportunity to attend a one-day conference at Boston College on the “Ethical Challenge in Global Public Health: Climate Change, Pollution and the Health of the Poor.” As a result of this day, I share some of my impressions of this event that brought together an interdisciplinary group of scholars from different parts of the world.

First of all, I was happy to see that BC brought ethical questions to the center of the global health debate aiming to have discussions grounded on values and principles able to promote the human dignity and population health. Although everyone recognizes that ethics is essential for the global health initiative and actions, it is not a topic commonly addressed in the global health field. On the side of ethics as a discipline, especially among bioethicists, global health is not their favorite theme. The field of bioethics, especially the one developed in the USA and its influence around the world, has neglected global health and its ethical concerns. This conference created a bridge between these two areas, that need one another, but have difficulty to dialogue.

One of the speakers, Nils Henning, who has a broad international experience serving in humanitarian missions after natural and human-made disasters, ended his talk presenting some ethical principles needed to be embodied in the practice of health professionals in global health. An attendee asked him if these ethical principles have been discussed during the training of health professionals. His answer was “not really, they are not part of the curriculum.” But Henning affirmed that global health organizations should favor this discussion with professionals who come to work with them.

I have a feeling that ethics in health care is a standard that everyone assumes the professionals, especially after graduating from medical schools, are embodying in their practices. But things are not that simple, especially in a field of actions that have international dimensions.  Global health requires that professionals engage in different parts of the globe, meeting people from different cultures and worldviews. This in itself is enough to create ethical challenges that need to be reflected upon. Otherwise, global health initiatives can be another form of colonization, because it will be a top-down approach led by rich nations imposing their worldview and values into poor countries and communities.

The top-down approach in global health is part of the mainstream. Many organizations, universities, and governmental sponsored projects in this field use this approach. I don’t question their good intentions, but I question their efficacy and their ethical respect for particularities and the self-determination of those people they aim to serve. In this conference, it seems that most people came to the agreement that global health actions must begin with local communities, valuing their knowledge, culture, and experiences. Thus, global health initiatives promote actions with local partners in order to create independence.

However, an approach that begins from the bottom, empowering local communities, is not the one that some global health leading organizations embrace, such as the World Health Organization. Thana Cristina de Campos showed that centralization is the mainstream perspective in global health governance, with actions, projects, and systems being controlled by a central power in which the WHO would have, or even higher levels, such as the United Nations. According to Campos, lack of clear common ends, lack of inclusion of local communities, and lack of coordination are the main problems in global health governance, recognized by those who defend centralization, but this perspective cannot properly address these problems. Campos argued for a global health governance grounded on the principle of subsidiarity. This principle – that is in the Catholic social teaching and was included in the Treaty on European Union, Article 5 – creates a path for a global health governance that includes local experiences and communities, empowering and respecting their own particularities. This would occur because the principle of subsidiarity is based on three pillars: non-abandonment, non-absorption, and coordination. These three aspects are more appropriated to address the three main challenges for global health governance in a way that communities are agents of global health from their own reality, including their worldview.

Campos’ suggestion of using the principle of subsidiarity for global health governance moves in the same direction of the perspective of global health promotion grounded on the preferential option for the poor developed by Alexandre A. Martins from his experience among the poor and emphasized by Michael Rozier and Lisa S. Cahill. This option directs global health initiatives to engage in local communities, considering the knowledge of locals and their experience in the midst of poverty. Therefore, the poor become active partners of global health and not only recipients of charitable actions from affluent nations.

As the question of justice is a central ethical challenge in global health, the preferential option for the poor offers a perspective that inverts the most common approach to health care, placing the poor and their voices as core partners in the effort of promoting global health. This works to break the vicious cycle created by impoverishment (poverty – vulnerability – illness – lack of health care – premature death). It is a perspective from below that respects particularities of local communities because the voices of the poor matter. Hence, it can address a common criticism that global health organizations promote a new form of colonialism because they create dependency and do not work for the empowerment of impoverished communities and their development from their own worldview and strengths.

Paul Farmer ended the conference stressing a preferential option for the poor in health care. Instead of developing a theoretical argument to show why this perspective is necessary for global health, he presented his practice and the work of Partners in Health grounded in the option for the poor in health care. He affirmed that his perspective is not in the mainstream of global health, but it should be.

Although my impression is that most people at the conference support a global health perspective that begins from initiatives from and with local communities, empowering their experiences and supporting their agency, some people are not in favor of this way of action in global public health. These people still believe that they are the authority to promote global health action from a view of going to an impoverished region and simply acting for (and not with) the poor. No doubt this is a theme for more discussion and studies. The inclusion of ethics in the global health agenda and the global health in bioethical discussion will contribute to the development of the field, especially in its practical aspect of health care delivery in impoverished, diverse communities around the world.