Who precisely is the “common good” that the public health sector purports to serve?
It has been barely a year since the Ebola outbreak in West Africa released its grip on the frightened imaginations of the Global North, and already global health officials are in the midst of another viral panic. After spreading across the Pacific to Brazil and Puerto Rico, the mosquito-born Zika virus this summer is expected to continue its march to the mainland United States, where it will make landfall on the Gulf Coast. The message from global and American health authorities is the same as it was in 2003 with the appearance of SARS, in 2006 with H5N1 avian flu, and in 2014 with Ebola: Be very afraid.
“This could be a catastrophe to rival Hurricane Katrina or other recent miseries that disproportionately affect the poor,” writes Peter J. Hotez, Dean of the National School of Tropical Medicine at Baylor College of Medicine in a recent New York Times Op-Ed. “If I were a pregnant woman … in an impoverished neighborhood in a city like Houston, New Orleans, Miami, Biloxi, Miss., or Mobile, Ala., I would be nervous right now.” Of course, Hotez is none of the above. So are those women nervous? Will controlling Zika end up helping them? And would Hotez listen if the affected women thought it wouldn’t? As we enter another round of emergency epidemic control, these questions are critical to ask.
Public health professionals felt it was their duty to manage this threat carefully in order to serve the “common good.” But who made up the “common”?
What I have found from my own research is that even when a global disease response appears to be effective, unintended consequences can emerge that threaten to undermine, rather than support, the long-term health and well-being of vulnerable communities most affected by the disease in question. In the urban Chinese settings I studied during and after the SARS outbreak, China’s enormous population of rural-to-urban migrant workers was seen as a public health menace capable of spreading the same dangerous diseases that threatened it. In the wake of the 2003 outbreak, Chinese public health professionals felt it was their duty to manage this menace carefully in order to serve the “common good.” But who made up the “common”?
When they talked about serving the common good, my interlocutors sometimes meant serving middle class, educated Chinese like themselves. Sometimes they meant the public health profession. Sometimes they meant the health of the globe, in all the abstraction that that implies. Rarely though did they mean the same migrant population that they were charged with governing. The population to be governed was not the same as the “common” to be served.
Although the details of this problem might be peculiar to China, the overall challenges for developing an ethical and equitable global health response are not. Global health professionals are tasked with improving the overall health of the world’s billions. When dealing with the enormous diversity that this entails, the boundaries of the global health ‘patient’ can become fuzzy. They can shift. They can include some and leave out others. And very often this happens in a way that distributes the burdens and benefits of global health actions unequally.
The reasons this happens are many. For example, we cannot assume that everyone who is working to stop Zika is primarily concerned with acting in the best interests of poor pregnant women. Some scientists may be seeking an intellectual challenge or professional opportunities; some, particularly those working for pharmaceutical companies, may hope to make a profit; some might do it to protect the biosecurity of the United States or other powerful countries. A coalition of interests is essential to building any global intervention, and is not inherently unethical or objectionable. Still, it is essential that we keep in mind that for many involved in a global health response, improving the health of the world’s most vulnerable is not their first priority.
It is essential that we keep in mind that for many involved in a global health response, improving the health of the world’s most vulnerable is not their first priority.
And yet for many it actually is. So what else might go wrong? One problem can be traced to the use of language. Read any description of the places where Zika flourishes and you will see echoes of similar descriptions of the places harboring SARS, Ebola, and dengue fever. These are invariably poor communities in which residents do seemingly backward things unfamiliar to middle class residents of the Global North, such as eating strange animals (SARS and Ebola), raising chickens in backyard farms (avian flu), and keeping recyclables in their homes or yards (dengue, Zika). Anthropologists have shown that these practices are often overblown as causes of disease. They also are usually born of economic necessity and as such can be nearly impossible to eliminate. Asking the poorest of the poor who depend upon these practices for their livelihoods to dispense with them for the purposes of achieving some abstract global common good can be both ineffective and unfair.
Some have suggested that the answer to this conundrum is “community engagement.” A recent New England Journal of Medicine article notes, “Engaged communities can be highly effective in detecting outbreaks and, as was demonstrated with Ebola, are a prerequisite for effective response”. One hurdle to this approach has to do with how one defines “community” in the first place. Often the lines around a given “community” are drawn arbitrarily, based on census categories like ‘African American’, ‘female,’ or ‘low-income’. Global health professionals seeking buy-in from a given community will then assign to this community a set of homogenous values.
In the case of Zika-induced birth defects, poor Latin American women are assumed to either value large families and resist birth control and abortion, or to desire access to birth control and abortion but be hampered by conservative religious restrictions. These are both broad characterizations that do not allow for the enormous diversity of values and viewpoints within Latin America. This problem becomes clear if we apply it to the American context. What would ‘American values’ or ‘North American values’ look like with regards to abortion and birth control?
Also missing in these discussions is an inquiry into whether and how community members themselves feel they should be addressing global outbreaks. In the case of SARS, local communities where I worked in China did not at first prioritize the control of SARS—not because they did not understand what it was or that it was dangerous, but because this danger for them paled in comparison to other dangers with which they were already dealing.
Missing in these discussions is an inquiry into whether and how community members themselves feel they should be addressing global outbreaks.
I suspect that in many of the communities where Zika is spreading, the control of this virus similarly would not count among the community’s top public health priorities. Again, this is not because poor women don’t fear having babies with microcephaly, but rather because this risk must compete with many other more present dangers, like hunger, diabetes, and violence—dangers that the international community has shown little willingness to invest large amounts of resources in addressing.
In these cases true community engagement may be impossible to achieve because it would require global health officials to be open to altering their own priorities. What if impoverished mothers in Biloxi said they wanted help with basic health infrastructure rather than mosquito control? What if they said they would worry about the risk of microcephaly after they no longer had to worry about sky-high infant mortality rates that among black women exceed rates in post-Soviet Eastern Europe and several Southeast Asian developing countries? Would the CDC respect that choice and change its priorities accordingly? If not, then “community engagement” really means “community cooperation with national or global priorities.” While still perhaps a worthy goal, this may leave local communities with the impression that they are important to global health authorities less for their unmet needs than for the public health threat they represent.
Global health practitioners might protest that a community’s other health priorities would be addressed through effective epidemic response anyway, since fighting Zika would translate into improved local health systems. A key finding of my research, however, is that pumping money into fighting a specific disease usually does not translate to broader systemic change. In China, post-SARS surveillance systems were good at detecting cases of new diseases during the drama of an acute outbreak but proved poor at detecting other diseases when motivation, time, and resources dwindled. Personnel recruited to support epidemic control lacked the local connections crucial for implementing more sustainable public health improvements. In short, building a system in Brazil or Biloxi to address Zika will not necessarily result in a system that addresses these places’ other health problems.
With each new infectious threat the global health community seems newly horrified at how unprepared we are and how little we seem to have learned from previous threats. This horror leads to more plans to find new ways to make sure everyone around the globe is “prepared”. But all of these approaches to infectious threats in poor places invariably run up against the problem that where people are poor, unhealthy, and wanting for basic necessities, the threat of a virus du jour will rarely invoke the kind of urgency that global health officials wish it did. Even if it did, those most affected might later wish that it hadn’t. A more genuine form of community engagement—one that allows for the possibility that local communities may have much to teach us about global health priorities—might be a good first step in constructing an effective, ethical global response to emerging infectious diseases.