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Zika continues its romp around the world. In its wake, controversy erupted over the Olympic Games in Brazil, with some calling to move or postpone the Games – but is that really justified? Zika has already moved outside of Brazil in a big way. To be clear, the Zika epidemic is dramatic and awful. Mosquito-borne transmission of this previously obscure and seemingly wimpy virus is ongoing in 60 countries
After the West African Ebola epidemic of 2014, hardly anyone contests that the World Health Organization (WHO) made fatal mistakes during the crisis. It reacted too late and did too little to contain the outbreak before it got out of control. And it once again exposed its deeply entrenched dysfunctions that make it so difficult for the organization to live up to its role as the central standard setter, coordinator and crisis manager in global health
It is every human being’s right to enjoy a state of complete mental, physical, and social well being on this planet. However, health is also a right that is unequally distributed throughout the world due to lack of access to proper healthcare facilities and professionals, lack of sanitation, feeble vaccination delivery systems, and treatment-oriented healthcare systems rather than preventative systems.
Is religion a plus or minus when it comes to global health and the “right to health” in the twenty-first century? A little of both, I’d say, but what does that look like? For me the connection is seen most clearly in the “social determinants of health”; that is, “the everyday circumstances in which people are born, grow, live, work, and age.” This post considers a selection of photos that shape how I see social determinants intersecting with religion.
Child at the Kumbh Mela
Photo by S. R. Holman.
This child met my gaze at the 2013 Kumbh Mela, a Hindu bathing festival in rural India, where her family was working. She stands just a few yards from a new-built latrine and the faucet providing piped clean water to this workers’ camp. Simply because she is a poor girl, her chance of education is dismal and, according to recent research on maternal literacy, her literacy level will someday directly affect her children’s health. Yet unlike Americans, she lives in a nation that ratified (official accepted under law) the International Covenant on Social, Economic and Cultural Rights (ICESCR), meaning that families like hers ought to be able to enjoy equal rights to food, housing, and education. I see here a little girl hugging a beloved blanket. What do you see?
Leuven sanctuary
Photo by S. R. Holman.
This side aisle in the church of the Great Beguinage of Leuven, Belgium, reminds me that faith communities are sources for “religious health assets” (RHAs), that is, faith-based resources that contribute to individual health and the greater social good. A 2006 report of the African Religious Health Assets Programme (ARHAP) spells out a broad range of RHAs, including those that are tangible — e.g. rituals, medical facilities, education, funding, and opportunity for training in leadership — and those more intangible, e.g. prayer, advocacy, resistance, and belongingness.
Microscope and rosary
Photo by S. R. Holman
American health policy today has roots in 18th- and 19th-century ideas that continue to shape decision making. My research on Dr. Henry Trevitt (whose ca. 1850 microscope is seen here) has shown me more clearly how complex connections are between medicine — individual disease treatment — and public health — which relates to groups, economics, and public policy. A Protestant Yankee, Trevitt got embroiled in a tangle of health controversies over prisoners, paupers, insanity, revolution, the medical marvel Phineas Gage, maternal mortality, and murder. The rosary here belonged to his wife who herself would die impoverished, a ward of the state.
Dives and Lazarus
Woodcut illustration by Jacob Locher, used by Silvan Otmar of Augsburg (d. 1540). From the “Provenance Online Project” (at Penn Libraries). CC BY 2.0 via Flickr.
Global health crosses time, as our own heritage of religious tradition, class, and economics shapes present realities. The Protestant reformers who influenced so much North American policy leave us images such as this 1540 woodcut of the biblical story of Lazarus and the rich man (Luke 16:19-31). I’m struck by the spare simplicity of the rich man’s table, a contrast to our culture’s focus on “all you can eat.” But why is Lazarus wearing a necklace?
Informal settlement
Photo by S. R. Holman.
Human rights abuses often start with the rich. The Christian social worker who accompanied me through this informal settlement in urban Delhi, where residents of manifest dignity were creating beauty against impossible odds, told me how a rich NGO had taken photos of their poverty in order to profit from false charitable appeals. Katherine Boo’s recent book, Beyond the Beautiful Forevers, based on life in such an impoverished community, is a good companion for thinking about how we might engage with more responsible ethics.
Scarborough gravestone
Photo by S. R. Holman.
This 1758 gravestone overlooking the North Sea mourns two children who died “in their minority.” Like them, more than half of the 6.3 million children under five who died around the world in 2013 also succumbed to conditions that could have been prevented or treated with better health care access. Such markers witness the fragility of children’s lives, and the role religion plays in the social fabric of such risks.
Works of mercy
Stained glass window by Lavers, Barraud and Westlake, 1884. All Saints’ Church, Mountfield, East Sussex, UK. Photo by jpguffogg. CC BY 2.0 via Flickr
In Matthew 25:31-46, illustrated here, Jesus describes faith-based “righteousness” as providing food, drink, housing, clothing, shelter, medical care, and relief to the needy. These are the same resource mandates affirmed in Article 25 of the Universal Declaration of Human Rights and human rights law under the ICESCR. They also define almsgiving in Islam (depicted vividly in Ismael Ferroukhi film on the hajj, “Le Grand Voyage”), Judaism, and even Hinduism, where “daan” is a secret donation that even the giver should forget.
Jerusalem street
Photo by S. R. Holman.
Sometimes the most enduring image of how religion affects health is not what you see, but what you don’t. Old Jerusalem’s alleys are narrow and usually crowded with vibrant markets, and religious pilgrims. This empty street, seen between Muslim and Christian neighborhoods a few years ago, is a haunting reminder of tensions in the body — individual and collective — that can follow when faith identities and health-related resources and practices go missing, or fail to connect equitable human rights with hope and health for all.
Although the number of Ebola cases and deaths has jumped dramatically in the short time since we wrote our December Briefing on the epidemic, there are signs of hope. Ebola is slowing down in areas where there was previously high transmission, in Liberia and in Eastern Sierra Leone for example. The lesson from past Ebola epidemics is that learning and local adaptation has played a central role in controlling previous outbreaks; now in West Africa the curve of the epidemic seems to be turning as people alter their behaviour. The apparent avoidance of continued exponential growth is a relief but it is no cause for complacency.
Freetown and the North of Sierra Leone are still suffering heavily. There is likely to be ongoing transmission for some time with sporadic clusters of cases as the epidemic moves into its next phase. The message, that local people should be involved and that their perspectives and knowledge are both valid and valuable, is still essential. Now is the time to find a balance between medical interventions, emergency thinking, and more humane and localised approaches based on collaboration.
As and when the epidemic ends, there should also be no complacency about the structural violence which produced this crisis. Structural violence refers to the way institutions and practices inflict avoidable harm by impairing basic human needs. The long term view — which locates this epidemic in the context of economic, social, technical, discursive and political exclusions and injustices — needs to be at the forefront of recovery and ‘development’ post-Ebola. The stark evidence of violence, in the form of distrust, the collapse of already dysfunctional health services, the catastrophic costs of Ebola on families and countries, the unpaid salaries of nurses and burial teams, the lack of protection – whether in the form of plastic gloves or welfare nets in times of crisis – must not fade with a return to business as usual. The Ebola crisis should be a game-changer for development.
In pointing to structural violence, we aren’t talking of a single social institution, but of overlapping institutions and practices that have produced interlocking inequalities, unsustainabilities, and insecurities. Aid and development have failed to address these conditions. Sierra Leone and Liberia attract considerable foreign direct investment and record some of the world’s highest growth figures yet most of their populations live in continued or worsening poverty. The emerging field of global health emphasizes networks and shared vulnerabilities, but in practice — through disjointed programmes and a tendency towards ‘quick wins’ — has neglected dire inequalities, which mean a virus like Ebola can tear a country up due to an absence of the most fundamental public health and state capacities. These structural and related socio-cultural conditions are not quickly or easily addressed, but Ebola has highlighted how vast disparities, internationally and within countries, are not sustainable. A greater focus on inclusive institutions and economies, and on conceiving of health as a global public good, is needed in order to build trust and resilience. Achieving that will involve asking difficult questions about aid and development as practiced in this region.
Both the crisis response and efforts to address its structural underpinnings are strengthened by recognition of the complex and historically-embedded logics and relationships which shape people’s lives. The Ebola Response Anthropology Platform has been set up to network anthropologists and other social scientists across the world with fieldworkers and communities, and to provide an interface with those planning and implementing the Ebola response so that such perspectives can be integrated into the response. Complementary initiatives, like one supported by the American Anthropological Association, mean that there is now a groundswell of debate and commentary on these critical dimensions. Much of this is building on research conducted over decades of post-colonial development and post-conflict reconstruction that, with the benefit of hindsight, is revealing of the fault-lines of the Ebola epidemic. As ‘the response’ transitions into another phase of reconstruction it is critical that these lessons, and the complexities they reveal, are fully appreciated to prevent further disasters for this region.
Headline image credit: Conakry, Guinea, 2011. Photo by CDC Global. CC BY 2.0 via Flickr.
How did the international community get the response to the Ebola outbreak so wrong? We closed borders. We created panic. We left the moribund without access to health care. When governments in Liberia, Sierra Leone, Senegal, Guinea, Mali, and Nigeria called out to the world for help, the global response went to mostly protect the citizens of wealthy nations before strengthening health systems on the ground. In general, resources have gone to guarding borders rather than protecting patients in the hot zone from the virus. Yet, Cuba broke this trend by sending in hundreds of its own health workers into the source of the epidemic. Considering the broader global response to Ebola, why did Cuba get it so right?
Ebola impacted countries, and the World Health Organization (WHO), called out for greater human resources for health. While material supplies arrived, many countries tightened travel restrictions, closed their doors and kept their medical personnel at home. At a time when there has never been greater knowledge, more money, and ample resources for global health, the world responded to an infectious pathogen with some material supplies, but also with securitization, experimental vaccines, and forced quarantines – all of which oppose accepted public health ethics. The result is that without human resources for health on the ground, the supplies stay idle, the vaccines remain questionable, and the securitization instills fear.
The Global North evacuated their infected citizens. These evacuations spawned donations to the WHO and then led to travel bans. The United Kingdom provided £230 million in material aid to West Africa. The United States committed $175 million to combat the virus by transporting supplies and personnel, with an estimated 3,000 soldiers to be involved in the response. Canada’s government provided some $35 million to Ebola, including a mobile testing lab, sanitary equipment and 1,000 vials of experimental vaccines that have yet to arrive in West Africa or even be tested on humans. Canada then followed the example of Australia, North Korea, and other nervous nations, in imposing a visa ban on persons traveling from Ebola affected countries. Even Rwanda imposed screening on Americans because of confirmed cases in the United States.
Despite this global trend, Cuba — a small and economically hobbled nation — chose to make a world of difference for those suffering from Ebola by sending in 465 health workers, expanding hospital beds, and training local health workers on how to treat and prevent the virus. Cuba is the only nation to respond to the call to stop the Ebola epidemic by actually scaling up health care capacity in the very places where it is needed the most. Even with a Gross Domestic Product per capita to that of Montenegro, Cuba has proven itself as a global health power during the 2014 Ebola outbreak. Many scholars and pundits have been left wondering not only how a low-income country, with its own social and economic challenges, could send impressive medical resources to West Africa, but also why they would dive into the hot zone in the first place — especially when nobody else dares to do so.
Cuba is globally recognized as an outstanding health-care power in providing affordable and accessible health services to its own citizens and to the citizens of 76 countries around the world, including those impacted by Ebola. Cuba’s health outreach is grounded in the epistemology of solidarity — a normative approach to global health that offers a unique ability of strengthening the core of health systems through long-term commitments to health promotion, disease prevention and primary care. Solidarity is a cooperative relationship between two parties that is mutually transformative by maximizing health-care provision, eroding power structures that promote inequity, and by seeking out mutual social and economic benefit. The reason for the general amazement and wonder over Cuba’s Ebola-response stems from a lack of depth in understanding the normative values of solidarity, as it is not a driving force in the global health outreach by most wealthy nations. The ethic of solidarity can even be seen on the ground in West Africa with Cuban doctors like Ronald Hernandéz Torres posting photos of his Ebola team wearing the protective gear, while giving the thumbs and peace sign — an incredible snapshot of humanity that contrasts the typically frightening images of Ebola health workers.
Solidarity is not charity. Charity is governed by the will of the donor and cannot be broad enough to overcome health calamities at a systems level. Solidarity is also not pure altruism. Selfless giving is based on exceptional, and often short-term, acts for no expectation of reward or reciprocity. For Cuba, solidarity in global health comes with the expectation of cooperation, meaning that the recipient nation should offer some level of support to Cuba, be it financial or political. Solidarity also means that there is a long-term relationship to improve the strength of a health system. Cuba’s current commitment to Ebola could last months, if not years.
Cuba’s global health outreach can be approached through the lens of solidarity. This example implies engaging global health calamities with cooperation over charity, with human resources in addition to material resources, and ultimately with compassion over fear. This approach could well be at the heart of wiping out Ebola — along with every other global health calamity that continues to get the best of us because we have not yet figured out how to truly take care of each other.
