Leadership for Health for All: Past Perspectives

The World Health Organization (WHO) appointed a new Director General in May 2017, who has since made Universal Health Coverage (UHC) his ‘top priority’. Dr Tedros has recently stated that one of the key ingredients in achieving universal health coverage will be political leadership.

The need for effective leadership in global health is well acknowledged today, even if there is still heated discussion about what constitutes the ‘right’ kind of leadership. Although we may know leadership when we see it, it is more difficult to analyse and define explicitly. Within leadership studies, it is generally accepted that effective leadership constitutes inspiration, creativity and commitment in action. It is, first and foremost, an attitude and not necessarily restricted a rank or position of authority.

The need for inspirational and effective health leadership is by no means a new concern. It was prominent decades earlier in the drive for Heath for All (HFA) by the year 2000, and as part of the primary health care (PHC) model of health care adopted at the International Conference on Primary Health Care held in Alma Ata, Kazakhstan in 1978 (commonly known as the "Alma Ata Declaration"). Indeed, the Alma-Ata conference called for leadership at various levels including professionals and institutions, governments and civil society organizations, as well as communities and grassroots organizations. The ambitious programme held that HFA could only be achieved through concerted and collaborative action.

What challenges to effective HFA leadership did the WHO anticipate? What kind of leadership did it envisage, and what did it end up with? The WHO Iris portal (an online accesspoint to the WHO’s published material since 1948) contains material which enables us to dig deeper into such questions. Whilst this comes with the obvious caveat that Iris contains mainly official records deriving from WHO workshops, conferences and publications, these often comprise very candid assessments of entrenched problems which can be used to help better understand the leadership concerns in the final decades of the twentieth century.

For instance, we find that the WHO only turned seriously to the question of HFA leadership almost a decade after the Alma-Ata conference. The need to develop leadership capacity appeared ever more frequently in WHO reports and regional meetings, and in response in 1985 the Director General instigated the HFA leadership development initiative. A year later the proposed programme budget of WHO 1986-1987 defined six major objectives which included ‘the building up of a critical mass of health-for-all-leaders’.[1]

One of the chief features of the PHC model was close collaboration between communities and health systems, based on mutual decision-making. Community health workers were envisaged as the go between, and whilst this required effective management, it also depended on effective leadership: PHC needed ‘teamwork’, but also ‘team leaders’.[2] 1986’s ‘Leadership for Primary Health Care’ publication (http://apps.who.int/iris/bitstream/10665/37339/1/WHO_PHP_82.pdf) constituted one of the first attempts by the WHO to research the qualities of leaders and the functions of leadership. Highlighting the important role of community health workers and based on twelve case studies, this publication worked with a broad meaning of leadership and was ultimately intended to be used to help countries achieve improved leadership for their PHC programmes (http://apps.who.int/iris/bitstream/10665/37339/1/WHO_PHP_82.pdf).

Between 28-30th October 1987, the WHO’s Director General, Halfdan Mahler, hosted a Director-General's Round Table on ‘Leadership Development for Health for All’ in, Brioni, Yugoslavia. The aim of this workshop was to discuss fundamental questions including: What is leadership? What drives and motivates leader? What are their values?, and, crucially, what issues or gaps are there in HFA leadership, and the future scenario of HFA Leadership? The resulting document, available on WHO Iris (http://apps.who.int/iris/bitstream/10665/60382/1/WHO_HLD_88.1.pdf) contains the frequently frank thoughts of Mahler and his fellow speakers in terms of the challenges facing HFA.

Hot on the heels of this meeting was another ‘round table’, this time gathered together and published in the WHO journal ‘World Health Forum’. Acknowledging the need for leaders to give the HFA movement momentum, in 1988 the World Health Forum asked eleven leaders to discuss leadership characteristics as well as how they approach and tackle their problems (http://apps.who.int/iris/bitstream/10665/49197/1/WHF_1988_9%282%29_p147-174.pdf). Although the avowed aim of such roundtables and discussion groups was to create practical aides and training tools, in each case there is a powerful sense of diversity of opinion, especially when the questioning moved from ‘what is leadership’ to ‘what is HFA leadership’. Whilst there was general agreement regarding importance and qualities, there was no model of leadership.

On Universal Health Coverage day 2017, questions about effective leadership on HFA are once again under the spotlight. It is worth reflecting not just on how far we have come in developing materials and strategies to bolster leadership for health for all, but also to remember that this role is not confined to those in traditionally recognised positions of power. Health for all requires leaders at all levels.

Alexander Medcalf


[1] http://apps.who.int/iris/bitstream/10665/37339/1/WHO_PHP_82.pdf. 3.
[2] http://apps.who.int/iris/bitstream/10665/37339/1/WHO_PHP_82.pdf. 2.

Towards a History of Manufactured Mental Disorders in Post-Socialist China

On the blog today we have a guest post from Harry Wu, giving us background and insights into his Medical History article ‘The Moral Career of ‘Outmates’: Towards a History of Manufactured Mental Disorders in Post-Socialist China’, which appeared in the special issue: ‘Tales from the Asylum. Patient Narratives and the (De)construction of Psychiatry)’ https://doi.org/10.1017/mdh.2015.70

Harry writes: My article deals with an unusual but popular concept regarding the development of modern psychiatry in China. Bei jingshenbing, a Mandarin neologism in referring to ‘manufactured mentally ill’, was a catch phrase appearing in China in the first decade of the 21st Century. The term was coined to describe conditions of involuntary psychiatry treatment or admission due to unjustifiable, and often non-medical reasons.

Since I began to conduct research into the history of psychiatry, I have been particularly interested in the development of the discipline in the Chinese-speaking world. In the monograph that I am currently working on, I look at how theories and methods of social psychiatry have been jointly framed at the World Health Organization (WHO) by scientists, visionary European thinkers, as well as technocrats from the non-western world. However, the project in the WHO did not include People’s Republic of China, since psychiatry was suspended by the Chinese government during the period of the Cultural Revolution.

After coming back to work in Asia, I took the opportunity to take a closer look at the discipline of psychiatry in China in the neglected years. And I found that the story of psychiatry in China during this period cannot be examined under the existing historiographic frameworks, such as the East-West comparison or localisation of the modern western psychiatry. Chinese psychiatry, in fact, evolved in the complex web weaved together in the emerging strands of medical, economic, political, and legal infrastructures during the period of the building of the modern state. In these fields, psychiatry means different and it functions in very different ways for different stakeholders.

The general readers may think that the term is burdened with a heavy political connotation. The negative comments on Chinese psychiatry proliferated, while Human Rights workers began to report on the likely confinement of Falungung practitioners in the 1990s. But my research has found that the misfortune of unjustifiable psychiatric admissions occurred under circumstances when the aforementioned modernization projects failed to evenly mature.

The publication time of this article coincided the implementation of China’s Mental Health Law, which aspired to remove the stigma of mental patients and decrease the situation of human rights violations regarding psychiatric care. I hope that my article can contribute an alternative analytical framework for historians who writes about modern psychiatry in post-socialist China.

Harry Wu

Illness, Healing and the Dynamics of Reciprocal Exchange on the Upper Guinea Coast

On the blog today we have a guest post from Philip Havik which introduces us to his recent Medical History article ‘Hybridising Medicine: Illness, Healing and the Dynamics of Reciprocal Exchange on the Upper Guinea Coast (West Africa)’ https://doi.org/10.1017/mdh.2016.3. Including travel accounts, missionary reports and documents produced by the Portuguese Inquisition, Philip's article shows how forms of medical knowledge shifted and circulated between littoral areas and their hinterland, as well as between the coast, the Atlantic and beyond.

Although currently knowledge of tropical medicine, vaccinations and medical care for ailments generally associated with the tropics such as malaria, yellow fever, sleeping sickness, Chagas disease, dengue fever, cholera, yaws, etc. has greatly advanced, at the time of European expansion in the fifteenth century little was known about them. Without the benefit of modern medical science, travellers were faced with unknown and unseen threats to their health and lives. As the risks of succumbing to tropical fevers became commonly known, the doubtful reputation these regions gained was associated with high morbidity and mortality rates. West Africa, which formed the earliest region of contact as Europeans advanced southwards, was eventually dubbed ‘the white man’s tomb’ in the early 1800s, on account of its fierce tropical climate and disease environment. However, but for rare exceptions, the question of health in pre-or proto-colonial formations has tended to be overshadowed in academic studies by economic and political issues. This despite the key role it played in conditioning strategies towards imperial expansion and settlement.

My article seeks to bring health related considerations back into the equation by focusing on the early period of Euro-African encounters, and fill a number of lacuna by mapping exchanges of knowledge taking place from the fifteenth and to the eighteenth centuries. Centring on the West African Senegambian/Guinea region, which became an important area for slave and commodity exports from the sixteenth century, it shows that European and local African actors and communities were actively involved in the search for remedies that could cure or prevent certain ailments common in the tropics. It confirms the importance attached to the information circulated by and among traders, settlers and missionaries on the one hand, and local communities on the other, on a variety of medical techniques, compounds and cures. Thus, different elements from Galenic medicine, as well as from Oriental medical practice and local African phyto-therapeutical methods came to be used by an increasingly heterogeneous population in coastal areas.

This shows that the social, cultural and economic encounters occurring in this contact zone would lead to a progressive entanglement between different bodies of medical knowledge against the background of a globalising world. Over time, this intense cross-cultural interaction and borrowing would result in a progressive hybridisation of knowledge and practice assembled in the form of ‘cultural kits’ which could be accessed by incoming and local actors, illustrating the fluidity of boundaries. Based upon data extracted from Portuguese, English and French published and archival sources, my article presents evidence of the dissemination and evolution of biophysical and spiritual healing techniques in some coastal locations. These ‘cultural transfers’ based upon a relational approach to health, would operate in a multi-centred fashion in the Senegambia/Guinea region, producing innovative complementary and competing healing narratives and practices.

Philip J. Havik

‘I’m a psychogeriatrician’

In today's guest post, Claire Hilton argues that historical evidence about psychogeriatrics is crucial to understand the political, medical, social and professional factors which have shaped the specialty, drawing on her 2016 Medical History article ‘Psychogeriatrics in England: Its Route to Recognition by the Government as a Distinct Medical Specialty, c.1970–89’ (Medical History, 2016, 60, 2, 206-228) https://doi.org/10.1017/mdh.2016.4

‘I’m a psychogeriatrician’ uttered at a social event, almost always stops conversation. This was common during the formative years of the specialty of psychogeriatrics (or old age psychiatry) and remains common today. The questioner almost always implies: why would anyone want to work specifically with older people who are mentally unwell?

Psychogeriatricians in the 1970s and 1980s advocated for their patients. They fought to achieve government recognition for their specialty. Recognition enabled dedicated funding and training, and expansion of the specialty nationally and internationally. This helped to ensure that older people received evidence-based treatment for their mental illnesses. Treatment methods, at that time well established for younger people, were used infrequently for older people suffering the same illnesses. Treatment required some modification to take into account challenges associated with ageing, like frailty, risk of falls and co-existing physical illnesses. Importantly, the psychogeriatricians’ medico-psycho-social model of treatment could ameliorate problematic symptoms and behaviours, support carers, and enable older people to live in their own homes for longer, thus reducing bed use in institutions. Psychogeriatricians struggled against stereotypes of the ‘slippery slope’ of old age health expectations, lack of public and political interest in older people’s mental health, and therapeutic nihilism about treatment.

The psychogeriatricians used religious language to describe their work, such as ‘pilgrim’ and ‘crusade’. Those who discovered the rewarding nature of the work described themselves as ‘converts’. Their successors still do.

In 2015, leading psychogeriatrician Dr James Warner wrote about the ‘erosion of old age services’ (James Warner, ‘Old age psychiatry in the modern age’ British Journal of Psychiatry (2015) 207, 375–376). Erosion can be attributed to various factors, including austerity and financial constraints, ongoing under-valuing of older people, and misled political correctness about the anti-discrimination agenda. Anti-discrimination has led to the re-emergence of ‘ageless services’ in many parts of the UK, but this model of one-size-fits-all too frequently marginalises the specific needs of older people, and removes the enthusiastic staff who feel inspired to spend their careers working with them. We once again see older frail people being treated on the same ward as younger physically fit disturbed patients, and the occurrence of fractured bones when frail patients fall if accidentally pushed, an avoidable risk which the early psychogeriatricians aimed to eliminate.

Historical evidence about psychogeriatrics is crucial to understand the political, medical, social and professional factors which have shaped the specialty. This knowledge should help to avoid re-introducing risky treatment and care practices which undermine wellbeing and lead to unnecessary suffering and financial expense.

Claire Hilton

Dynamic Case Notes and Clinical Encounters

In our guest post today, Hazel Morrison provides reflections on her article, ‘Constructing Patient Stories: ‘Dynamic Case Notes and Clinical Encounters at Glasgow’s Gartnavel Mental hospital, 1921-32’ which featured in Medical History 60:1 (2016), 67-86.

My dear Dr. Henderson
              Above everything else congratulations on the second edition of your book! … What psychiatry needs is the courage of the case material and the problems shown therein, and less preoccupation with the traditional and formal principles.

Case notes and case histories, argued the doyenne of North American psychiatry – Dr Adolf Meyer - have the power to alter the course of the psychiatric profession. Meyer’s 1929 correspondence to his former student and colleague, Dr David Henderson, pre-empted the paradigmatic shift that would occur in British psychiatry between the two World Wars; as Henderson, at the height of his eminent career, steered patient case taking practices away from former emphases on description of symptoms, classification and brain pathology, and towards the study of individual personality, set within, and reacting to, his or her environment.

My article begins with Henderson’s articulation of his ‘dynamic’, otherwise known as psychobiological, approach to mental health care during the 1920s. The rest of the paper is an examination of the patient case note records produced during his physician superintendence of Glasgow’s Royal Asylum, Gartnavel, 1921-1932. Examination of the staff meeting record lies at the heart of this investigation. Instigated in Britain by Henderson at Gartnavel in 1921, this clinical practice spanned case presentation, patient examination and discussion of plans for treatment. Bringing together a multidisciplinary team of medical practitioners, the aim of the staff meeting was to study the whole person (body and mind) of a patient, reacting and adapting to the experimental stage of the clinical environment, while the patient’s own language and own understanding of illness formed the basis for therapeutic intervention. Recorded verbatim by clinical stenographers, transcripts allow this paper to ‘sit in’ on such meetings. The near uniqueness of these sources enables a new, rarely accessible kind of history to emerge; a history inclusive of patient-psychiatrist dialogues spoken within, and as an essential part of, the clinical encounter:

                   Dr. Henderson. You have spoken about your spine shifting. Do you believe that your                           spine is –

                   Patient. (breaking in) Yes I do. When the change comes on it about knocked me off my                       mind altogether. I think it was me getting the wind up - it made my nerves worse.”

Rarely can histories look beneath published records to access the clinical conversations, disputes and the situated possibilities for understanding and intervening in patient cases, but here such conversations are laid bare almost verbatim (in ‘real time’). Once the patient was escorted out of the meeting room, debate and discussion of the case continued between Henderson’s staff. Both senior and junior medical staff collaborated within a shared space wherein diverse psychiatric theories – from the most organic to the most psychoanalytic – are brought into dialogue with other branches of medicine, such as presented by staff working in the pathological laboratory or occupation department. Such dialogues almost never make their way into published, official records, as they lay bare the false starts, bold statements and interchanges that speak at cross purposes, before such exchanges were preened and presented at conferences, in papers and medical texts.

Drawing parallels with medical humanities scholarship, my paper endeavours to access a historical space in which methods and concepts, drawn from the humanities and biomedical sciences, mesh and are transformed into new medical knowledges. Situated within spaces, such as those of the staff conference, this project questions the extent to which Henderson’s initiation of multi-disciplinary working practices, which intersect with, and underscore the agency of the individual patient, were productive of case materials that transformed medical teaching and clinical practice in Britain.”

Hazel Morrison

To access Hazel’s article and find out more, please do visit Medical History’s website at https://doi.org/10.1017/mdh.2015.69

Focus on CGHH Research - China in the Worldwide Eradication of Smallpox, 1949-1980

In October 2017 Lu Chen joined CGHH as the recipient of a Wellcome Trust Medical Humanities PhD studentship. Lu is researching smallpox eradication in post-war China, focusing on how was smallpox eradication conceived, planned and delivered in China, and what international, regional, national and local political negotiations made success possible.

Lu writes: "In the US-and Western Europe-centric historiographical context on international and global health, China gets only short treatment. Different to many of its neighbouring countries where smallpox was still epidemic in 1950s, the Chinese smallpox eradication work did not rely on US assistance, had nominal links with WHO structures and budgets, and was, instead, built mainly upon a raft of bilateral aid agreements with the Soviet Union, the USSR’s Eastern European allies and, latterly, politically neutral Western European countries like Sweden. These international links provided vaccine, vaccinating kits and the transfer of vaccine production technologies. China’s government worked to its own timetables, independently gauging the value of international political alliances, and agreed to aid flows and involvement of overseas workers through very specific terms. In all this, Chinese representatives engaged the UN, the WHO, and the US and Western European aid agencies in distinctive ways, and only as and when they regarded it useful to do so (and, when internal politics allowed it). My research will investigate all these programmatic complexities independently and critically."

We look forward to hearing how the project progresses and would like to take this opportunity to welcome Lu to CGHH!

Smashed by the National Health

In our guest post today. Philip Conford gives us some insights into the reasons behind the Pioneer Health Centre, Peckham's demise. You can read his article “‘Smashed by the National Health’? A Closer Look at the Demise of the Pioneer Health Centre”, which appeared in Medical History 20:2 (2016), at https://doi.org/10.1017/mdh.2016.6

Philip writes: "In 2014, the medical journalist Ben Goldacre published a book called I Think You’ll Find It’s a Bit More Complicated Than That. This title struck me as an appropriate response to some comments made by former members of South London’s Pioneer Health Centre (PHC), about the reasons for the Centre’s closure in 1950. “The National Health smashed it,” said one of them, bitterly. But was the explanation for the Centre’s demise really that straightforward?

Material at the Wellcome Trust, the National Archives and the London Metropolitan Archives suggested not. For a start, the PHC had always struggled financially. A decade before the NHS was established, it was having to be bailed out by loans and donations because it was attracting insufficient numbers – payment of a subscription was necessary – to make it viable.

The reasons for this reluctance to be involved lay in the minds of all those families who chose not to belong to the Centre, and have therefore never been open to analysis, though Paul Rotha’s documentary film The Centre (1947) provides at least some idea of why people might have resisted what the PHC was offering.

Unable to raise sufficient money through membership, the PHC sought help from the government and the Medical Research Council (MRC). But the tone of George Scott Williamson, one of the Centre’s founders, in his correspondence with officialdom, and the fact that he was deeply antagonistic to the proposed National Health Service, would not have helped his cause.

Whereas the MRC had been sympathetic before the war, it was markedly less so after it. Techniques of medical statistics were rapidly advancing, and the PHC’s standards of record-keeping evidently did not meet the standards that the leading figures in this new field (for example Austin Bradford Hill) required. Again, Scott Williamson did not help his cause by emphasising that the PHC’s work was not an exercise in orthodox science. Harold Himsworth of the MRC was distinctly cool towards the Centre, which he seemed to regard as an irritant.

Nor was the cultural climate favourable to the PHC’s approach. A mood of what I have termed “chemical triumphalism” was abroad: the invention of sulphonamide drugs encouraged an aggressive faith in the power of industrial chemistry to defeat sickness and disease. The unorthodox and exploratory approach of the PHC would have seemed very uncertain in comparison with the dramatic, specific, results achieved by the pharmaceutical industry’s “silver bullets”.

The NHS was not directly responsible for the Pioneer Health Centre’s demise, although its medical approach to curing sickness rather than promoting health took health policy (or sickness policy, as its critics maintained) in a different direction from that explored at the Centre. Blaming the NHS fits in well with the current ideology of the “small state”, and one of my aims in writing this article was to suggest that the truth about the Pioneer Health Centre’s closure was indeed “a bit more complicated than that”."

Mental Health: Pasts, Current Trends and Futures

This is a guest post from Dr Philip Kerrigan, co-editor of Mental Health: Pasts, Current Trends and Futures

The Centre for Global Health Histories has co-produced a new book with the University of York’s Centre for Chronic Diseases and Disorders (now the Centre for Future Health) entitled Mental Health: Pasts, Current Trends and Futures (published by Orient BlackSwan). The book is available free to download from the University of York’s Digital Library [https://dlib.york.ac.uk/yodl/app/home/detail?id=york%3a932416&ref=browse].

Securing better mental health for everyone around the world is one of the greatest current challenges in global public health. Historically and to this day mental disability and illness has been closely linked to social and political stigmatisation, which has led this specialism to remain under-provisioned and under-represented in health structures.

Advancing the mental health of the world’s population is hence a challenge that requires multi-faceted solutions, cooperation between many stakeholders, and a fulsome understanding of the political, social, economic and cultural determinants of health. Mental illness is also in many cases not a condition existing on its own but rather one which connects to a wider range of afflictions (for example, post-epidemic disease community support, as has been seen in relation to Ebola in western Africa).

This new work offers a number of carefully researched but accessible case studies from different areas of the world and across periods in time which shed light on some of the many motivations and innovations in the field of mental health, and analyse the range of barriers and opportunities that continue to impact on this complex area of work. Each one is complemented by specially chosen photographs, prints and other visual records, drawn from a variety of libraries and repositories, including Wellcome Images and the WHO Picture Library, and which help to enrich and expand the arguments and themes presented in the text.

As well as highlighting historical failures and enduring problems, the chapters give hopeful evidence of successful initiatives that could be adopted and built on across the globe and of a burgeoning commitment by individuals and national and international organisations to bring forward changes for the better.

The book is trilingual with English, Portuguese and Hindi translations side by side so as to reach the widest possible audience within international agencies, national and local governments, and civil society groupings.

The origins of the work, which is the latest volume in a series examining a range of issues in global public health and health policy, lie in the University of York's commitment to health equity and promotion internationally, which it seeks to advance through independent and evidence-based research. The opportunities to prepare this book in close partnership with colleagues at the World Health Organization were made available through the Centre for Global Health Histories’ designation as the WHO Collaborating Centre for Global Health Histories through which it works closely with UN agencies and national governments on policy advocacy and public engagement. The editors have worked closely also with the Brazilian Federal Government (via Fiocruz, Rio de Janeiro), and the World Bank. The research and editing work was funded by the Wellcome Trust, a global charitable foundation based in the UK, via Centre for Chronic Diseases and Disorders, and the Centre for Global Health Histories at the University of York, UK.

A poster exhibition has been created from twenty of the most striking images from the book.  The exhibition will go on display in the University of York’s Ron Cooke Hub as part of a day of events to mark World Mental Health Day on 10 October 2017. The book will also be officially launched at a public lecture in the evening and free copies will be available to the public to take away.

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The book was co-edited by Philip Kerrigan, Sanjoy Bhattacharya, Samantha Peel, Magali Romero Sa, Raghav Kishore and Alex Wade.

Contents

Introduction

1) Andrew Scull – Asylums and care in the community: The dilemmas of mental health policy

2) Samantha Peel – A short visual history of the use of electricity in mental health

3) Jerome Wright – Building capacity and increasing access to community mental health care

4) Carlos Estellita-Lins – Mental health, indigenous suicide and shaminism in Brazil

5) Stephanie Charles & Poppy Nash – The role of schools in promoting the mental wellbeing of young people in the UK

6) Soumitra Pathare, Jasmine Kalha, Titus Joseph, Michelle Funk, Natalie Drew-Bold and Akwatu Khenti – QualityRights Gujarat

7) Patricio V. Marquez and Timothy G. Evans – Global burden of mental disorders: Is there a way forward?

8) Shekhar Saxena, Global mental health and the World Health Organization

History, International Relations and Medical Humanities as tools for strengthening and widening health management

We at CGHH believe that history and the medical humanities have important roles to play in helping the global public health community to respond to the challenges of today. That is the ethos behind the Global Health Histories initiative, which has been running since 2004. Whilst seminars are an important part of delivering this message, we also recognise that a hands on, collaborative and inclusive approach with partners is a crucial component in using history to help shape a healthier future for everyone.

On 7 September, Professor Sanjoy Bhattacharya delivered an afternoon training seminar titled, ‘Strengthening and Widening Health Management: History, International Relations and Medical Humanities as tools for increasing information and relevance of government policy’ to staff from the College of Medical administrators of Sri Lanka. The training was built around sessions explaining how the study of recent history can be used critically to collect information about the political and social complexities of health campaigns, as well as the multi-faceted social and cultural responses to these interventions. Drawing upon Prof. Bhattacharya's work on the formation and expansion of the World Health Organization, the worldwide eradication of smallpox, and the connections between the international and national explications about how primary healthcare could promote the provision of universal health coverage, the training session involved a mixture of presentations and practical breakout sessions. The latter involved attendees being divided by specialty and then being shown how to problematise the recent history of the work of their Departments through peer interviews. Attention was paid to issues of institutional and individual bias, the dangers of retrospective diagnoses, the challenges of US- and Euro-centricism, and the importance of using correct ethical frameworks and protections, as well as multiple languages relevant to the geographical areas being studied.

The event was organised by the University of York in collaboration with the College of Medical Administrators of Sri Lanka, held at the Kingsbury Hotel, Colombo, Sri Lanka. Participants included officials from all ranks of Sri Lankan Government, including medical and public health administrators from across the country, and sixty medical administrators from around Sri Lanka, who are in the process of moving into senior administrative roles after completing their MD training in specialist subjects. The training followed Global Health Histories (GHH) Seminar 102 ‘Strengthening Universal Health Coverage for the fight against Anti-Microbial Resistance’, held earlier in the day.

We would like to extend our heartfelt thanks to all involved in the planning and running of this event, including College of Medical Administrators of Sri Lanka, the WHO Regional Office for Europe and the Wellcome Trust.

                             

Governing the world 'as if' it counts

Today we feature a guest post from Professor Morten Jerven (Professor of Development Studies, International Environment and Development Studies (Noragric) Norwegian University of Life Sciences), based on his presentation at Global Health Histories Seminar 101. You can access a recording of the entire event at www.youtube.com/CGHHYork

The most challenging notion to take on board in the governance of today’s world is that not all that counts can be counted. We increasingly rely on numbers as shortcuts to information about the world that we do not have time to digest.

The name of the game is governance “as if” the world counts. It might be a smart shortcut sometimes, but we are in deep trouble if we forget that we are doing it “as if” the world counts. Leadership should take making good decisions seriously. If the method by which we get knowledge and the method by which we make decisions is limited to what can be numbered, we are setting up a system of governance that’s systematically getting stuff that actually counts wrong.

Unfortunately, we are being led down the wrong path by the United Nations and its experts. In 2014, the U.N. High-Level Panel delivered its report with recommendations for the Sustainable Development Goals, subsequently to be adopted by the U.N. General Assembly in 2015. One small aspect of the report very soon caught everyone’s attention. Buried on page 8 was a call for a “data revolution” in development. It generated a frenzy of enthusiasm among the international development community.

Later the same year the secretary-general’s Independent Expert Advisory Group on a Data Revolution for Sustainable Development put forward its recommendation, titled “A world that counts.” The report laid out a grand ambition: It recognized that currently “whole groups of people are not being counted and important aspects of people’s lives and environmental conditions are still not measured.”

From that acknowledgement it took a surprising next step. From now onwards, the report declared, “Never again should it be possible to say, ‘We didn’t know.’ No one should be invisible. This is the world we want — a world that counts.”

It is not the world I want. The most important things in this world are the things that we cannot count. The most marginalized issues are those issues that, willfully or not, remain and will remain uncounted. That should be the first principle when it comes to making plans for global governance. Yet, on expert advice, the U.N. did exactly the opposite. In the year 2000 the world adopted the eight Millennium Development Goals, 18 targets and 60 indicators, and this year, intoxicated on what the establishment perceived as a ringing success, laid down the path for the next 15 years with 17 goals, 169 targets and so far over 1,000 suggested indicators.

I bet the majority actually believed the U.N. when we were told that world poverty was halved by the MDGs. It was an elaborate hoax on many levels: To begin with it was a basic lesson in “how to lie with statistics.” World poverty has been on the increase until very recently. Last time we had some data, the total number of poor was still on the increase in sub-Saharan Africa. It would have been most accurate to say, “We don’t know.” Failing that, one could have said that probably there have never been more poor people on the planet than right now. But the story they were selling was that the ratio of extremely poor people to not so poor people in poor countries was halved.

Except, we don’t know that. We actually do not have a good grasp of the total number of poor people today or in 1990. The freshly minted Nobel Prize laureate Sir Angus Deaton, memorably called measuring poverty and agreeing upon who is below and above the magic one dollar and something cents day line “a statistical problem from hell.”

According to a study using World Bank data, for the 150 countries it monitored poverty in between 1990 and 1999 only in 41 countries, not even a third, was there “satisfactory” poverty data. That meant two or more points of observation. First, famously you need two points to draw a line; the majority of countries had less. Second, for 50 of the 150 countries there was no poverty data. At all.

U.N. Secretary-General Ban Ki-moon should not step up to the podium to declare anything about halving poverty. Not yet anyhow. The 2015 data will not be ready until sometime in 2018. So any pronouncements about what has happened or hasn’t happened by 2015 is not telling us anything about poverty in the world, but is rather giving us some strong indications about the relative importance of public relations versus real knowledge when it comes to counting poverty.

Even when this 2015 number is ready, it is still largely guesswork how it relates to actual poverty in the majority of the countries. According to the World Bank study, for the last decade for which we actually have some data (2002-2011) there was satisfactory data for 63 out of 155 countries, whereas 29 countries are just borrowing poverty data from other countries because they have none themselves.

The number which we spend so much time and energy on trying to understand and to collect data for is largely irrelevant for actually doing something about poverty. It is a classic case of aggregating something upwards to provide an indicator, but not being able to disaggregate down again to find a poor person. Because it is an indicator. It is like the weather. If someone tells you it is 17 degrees Celsius it won’t give you a grip on whether it is warmer or colder than it should be. Most fundamentally, it contains no information as to what causes temperatures to go up or down. So it may be counting, but it fails the basic test of accounting. That is, being able to tell you what caused stuff to go up or down.

More fundamentally, it is also fails the accountability test with flying colors. Let us recount our steps. The step from just counting stuff, to actually accounting for stuff is to say “Hey, I know why the numbers stack up like this,” instead of just grunting, “It’s 324.87.”

Accountability is the crucial step. It is about who is responsible for what, and who owes what to whom. That’s why adding up assets and liabilities matters. Someone’s ass is on the line.

If every Malawian under the dollar per day line had a dollar each time some U.N. or nongovernmental organization person having some claim to work under the MDGs umbrella implied that they had something do with “halving world poverty” between 1990 and 2015, we would have gone some way to relieving poverty in Malawi. Frequently heard is the phrase that the MDGs “contributed to” halving poverty. It does not pass the accountability test. The U.N. MDGs taking credit for halving poverty is as credible as it would be to blame the U.N. for all the people who died in civil war during the same period, because civil war deaths were not counted as part of the MDG exercise.

Our knowledge problem in development statistics is double biased. We know less about poor countries, and less about the poor people in those poorer countries. This knowledge problem is replicated in big data and may be worse. A traditional survey misses, by design, criminals, the homeless, refugees, nomads and the sick — if you do a survey on mobile phones, or capture passively exhausted data from smartphones, you miss most of the population, and you lose the poorest part (most of these people live in rural areas).

If high-quality data are scarce in supply, we must be very conscious about our demands on data. The deeper point for data users in the development community here is that numbers need to be interrogated meticulously. Confronted with secondary data in international databases, users need to conduct basic source criticism and ask “Who made this observation?” “Under what conditions was this observation made?” and “Is there any reason to think that the observation is biased?” Failure to do so increases the distance between the observer and the observed and may lead to a disconnect between reality and the numbers.

Even if there was a world where “superbureaucrats” counted everything correctly, we must not forget that all the time we have pretended to approach poverty “as if” it can be counted. Decades of research has told us that poverty is multidimensional, contextual and cannot be reduced to dollars and cents. Let us keep that in mind for a while before we move ahead and continue governing the world “as if” it counts.

Morten Jerven

Focus on CGHH Research - Nutrition Projects in Colonial Fiji, 1945-60

Sarah Hartley is a third year PhD student at CGHH, researching the racial politics of maternal and child health in post-war Fiji. Part of this research has recently appeared in Medical History, titled 'Interweaving Ideas and Patchwork programmes: Nutrition Projects in Colonial Fiji, 1945-60’. The article is fully open access and available to read via Medical History's website.

Sarah’s article brings to light the influence of a range of actors in nutrition projects in the South Pacific during the period after the Second World War. These included international trends in nutritional science, changing ideas within the British establishment about state responsibility for the welfare of its citizens and the responsibility of the British Empire for its subjects. It also explores the mixture of outside scrutiny and support for projects from post-war international and multi-governmental organisations, such as the South Pacific Commission. Nutrition research and projects conducted in Fiji for the colonial South Pacific Health Service and the colonial government also sought to address territory-specific socio-political issues, especially Fiji’s complex ethnic politics. Sarah’s study examines the subtle ways in which nutrition studies and policies reflected and reinforced these wider socio-political trends. She suggests that historians should approach health research and policy as a patchwork of territorial, international, and regional ideas and priorities, rather than looking for a single causality.

Sarah's work was funded by the Wellcome Trust, a global charitable foundation, which supports scientists and researchers to take on big problems, fuel imaginations, and spark debate.

You can find out more about Sarah’s research and other research projects at CGHH via the Centre’s website.

What did we learn at the Inspiring Communities workshop?

This post originally appeared on reachoutconsortium.org.

We're featuring a guest post today, from Kate Hawkins on 'Inspiring communities in global health: Community Health Workers and Universal Health Coverage', an interdisciplinary workshop held at the Wellcome Collection on 12th June 2017.

By Kate Hawkins

On the 12 June 2017 the University of York’s Department of Politics and Centre for Global Health Histories held a fascinating meeting which explored the impetus towards the mobilization of communities in the definition of health policies and the delivery of care; and the role played by community health workers (CHWs) in this process. It was a chance to look backwards and get a historical view of the formation and adaptation of CHW programmes in different settings as well as looking at some of the more contemporary challenges and how these two things might relate. Three elements of the discussion stood out for me: religion, gender, and community and participation.

Religion

Recently I have been working with colleagues on a literature review on gender and CHW programming which is part of a larger paper. One of the things that struck me is the only papers that we found that made an explicit link between gender and religion were those from Muslim-majority countries. One can only speculate at the reasons for this. These papers tended to focus on how becoming a CHW increased women’s mobility in settings where they have traditionally stayed in the home and how this can be an empowering experience. They also point to the potential dangers of women breaking social norms and their vulnerability to attack and sexual assault by men when out and about in the course of their work. It may be due to our search terms, or the journals we are limited to, but I was surprised at the lack of papers where Christianity was at the forefront of analysis. As an atheist, I have had time to contemplate faith while at meetings on CHW programming that begin (and often end) with a prayer. The workshop was refreshing in that we heard new perspectives on how Christianity has influenced the conception and function of CHW programmes in different settings.

What became clear from our discussions is that Catholic and Protestant organisations have different models of mobilising communities, and attitudes towards them, which plays out in the design and functioning of CHW programmes. Ben Walker presented on Medical missionaries, Community Health Workers and NGOs competing and creating universal health care in Ghana between 1967-1983. Ben challenged the perception that the implementation of Community Health Workers was an entirely secular venture by describing the way in which missionaries and Churches in Ghana were involved in their formation. He tracked the changing attitudes amongst the Presbyterian and Catholic churches in Ghana across the 1950s to the 1970s in order to show how, whilst initially mission doctors and Ghanaian Christian health work prioritised a hierarchical relationship with local communities, reformations in mission theology in the 1960s shifted their practices. Particularly he emphasised how Vatican II, medical missionaries connection to local anthropologists and Christians studying at U.S. public health schools all encouraged community-oriented perspectives on how to incorporate Ghanaians into medical work.

We heard how Liberation Theology (of the type found mostly in Latin American countries) purposefully centred on the agency of communities and their active participation in overcoming socio-economic inequity. This essay by Paul Farmer describes how this approach underpins community health interventions in Partners in Health. We heard how in the Brazilian health system Catholic and African religions are integrated and this was central to the development of their model of health care. Community conceptions of what constitutes good health and wellness were what shaped the interventions provided, which is why homeopaths/herbalists are licenced providers of care. Polly Walker described how World Vision’s faith-based approach to development has evolved over the past 60 years, moving away from a provider-beneficiary relationship towards a model of transformational development and partnership (which reflects local ownership and definition).

Gender

REACHOUT was represented by Rosie Steege who reflected on some of the gender issues that have been raised as part of the work of the consortium and in her PhD research. She concluded that gender impacts upon CHWs in a multitude of ways and current CHW policies do not acknowledge the complexity gender plays ‘supply side’. This is a missed opportunity to promote gender transformative approaches at all levels of the health system. Her overall argument was that approaches on the ground are often governed by gender but not gender transformatory policies as a result they are sub-optimal.

Gender was also a focus in the presentation by João Nunes (Department of Politics, University of York) on CHWs in Brazil. He described CHWs as simultaneously vulnerable and empowered and in part this is because a big percentage of them are women (98% in some states). CHWs are often precariously employed with short term contracts, underpaid, and seen as disposable members of the health teams. They experience occupational health problems, such as trauma, stress, and physical injuries. João described how the community health programme is deeply heteronormative. Women are chosen as CHWs as men are not allowed to go into people’s homes unaccompanied, reflecting dominant conceptions of what is ‘appropriate’ for men and women. He relayed an anecdote where a member of staff recounted, ‘we have one male CHW but he is a homosexual so that is alright’. Heteronormative structures are very much present in many of the CHW programmes that I have seen – in anything from the way that households are defined, to assumptions about women’s caring responsibilities and natures, to CHW attitudes towards clients who break norms related to sexuality such as having children as teenagers - but they are rarely remarked upon. It would be great to see further analysis of this area.

Group discussion focused on whose ends are served by pushing women into positions where they are vulnerable to community violence and other forms of harm. I have long wondered why there is not more discussion about workplace health and safety in relation to CHW programmes. Employers have a responsibility to those who labour for them whether their workplace is an operating theatre or a doorstep.

Community and participation

In the CHW world there can be a tendency to posit communities as benign and all community participation as positive. Yet conversations at the workshop pointed to some of the limits of CHW programmes and how good intentions within drives for community health could have negative unanticipated consequences.

An excellent presentation by Karina Kielmann (Institute of Global Health & Development, Queen Margaret University) described how relationships and provider/client interactions are key to the delivery of HIV interventions through CHW programmes. She talked of how pre-existing social bonds can be instrumentalised by community health programmes and these can have negative consequences. For example, the creation of ‘expert patients’ to support adherence to ARV treatment in Malawi weakened horizontal links between peers and therapeutic solidarity as their positions were professionalised. In Zambia, the professionalisation of home based care practices meant that CHWs were less involved in physical care and did not support households through the provision of food. As their traditional role transformed people felt surveilled and policed by CHWs who were thought to adopt a berating attitude and meddle in household affairs through their treatment adherence practices.

Emma-Louise Anderson (University of Leeds) presented a paper on dependent agency and the limits of community mobilisation for democratisation and equity. Based on work in Malawi and Zambia (both countries which are extremely aid dependent in terms of their HIV programmes) she described how networks of people living with HIV and the support groups that followed from them are considered potential mechanisms to foster equity. However, in these settings aid recipients are ‘dependent agents’ who are constrained by exclusionary informal networks, donor recipient relationships and patronage politics. This is not to say that they were powerless and there were many ways in which structures were subverted, for example, through 1) the outward performance of compliance, such as using human rights language without a commitment to their realisation for all; 2) extraversion, or making dependency obvious so that it is advantageous in terms of additional resources; and 3) resistance below the line such as using euphemisms, stretching rules, and dragging feet. Nevertheless, community health in this environment has undermined the solidarity, accountability, transparency and the trust needed for democracy. It has led to the exclusion of certain groups and the pitching of different communities against each other. CHW interventions need to better understand the behind the scenes ways local people are enmeshed in unequal power hierarchies and social obligations if their programmes are to be successful.

In other conversations, we discussed how regimes of expertise and practice take up and then discard community members as the popularity of CHW programmes ebb and wane. One participant described CHWs as the ‘handmaidens’ for opening up markets for Western drugs as part of a global trend that is moving away from community care towards biomedical interventions.

The workshop was an excellent opportunity for academics from different backgrounds and disciplines to come together and share. I am hopeful that it will lead to fruitful collaborations in the future.

The organizers gratefully acknowledge the support of the Department of History and the Department of Politics at the University of York, and the support of the Wellcome Trust.

Global Health Histories: Engaging policy to promote transparency and equity

By Sanjoy Bhattacharya, Professor in the History of Medicine at the University of York Department of History, Director of the Centre for Global Health Histories, and Head of the WHO Collaborating Centre for Global Health Histories.
The historiography of international health after the Second World War is now rich and extremely well populated. And yet, significant sections of this body of work remain stubbornly and peculiarly focussed upon the views and actions of relatively small numbers of people within North America and Western Europe, even when the events and activities being described relate to regions and countries far afield. The biggest problem is that this body of work is rooted in unmoving assumptions about the importance of a small set of nations in the post-war era and insufficiently tested presumptions about their dominance over the negotiations that led to the creation of new post-war institutions (such as the United Nations). Post-war agencies are, in turn, described simplistically, where their Europe- and USA-based headquarters are presented as all powerful and capable of dictating the actions of representatives all over the world. Furthermore, this is done with suspiciously limited research, with almost no attention being paid to the birth of regional and national branches of UN organisations and their intricate negotiations with governments of newly independent, assertive countries who were willing to invest heavily, both financially and through new international alliances, in the modernisation of health, science and technology.

These academic attitudes seem to me to be deeply entrenched in present-day notions of the hierarchies of specific nations, races, languages and educational backgrounds, and their supposed worth in the creation of the so-called post-war policies of internationalism and consensus. Such predetermined notions of pre-eminence are then fed back to inform assessments of past experience, which has helped to entrench deeply problematic assumptions. These trends are often promoted and sustained by cosy relationships between historians, other medical humanities experts, social scientists, and the officials of government and international agencies that they are writing about. The resultant lack of analytical independence, which has limited scholarly criticality and reduced the commitment to study situations and contexts in all their complexity, has stymied more democratic and realistic assessments of the intricacy of health programmes on the ground.

Indeed, very few academics have dared challenge these historiographical trends by publicly discussing the factors underpinning them, perhaps for fear of isolation from the established, high profile and powerful academic networks that have considerable say in publication, grant making and prize selection processes. Sadly, and to compound problems for those seeking to promote the adoption of a wider and more equitable analytical frame, many elements of such academic formations have, for some time, become far too comfortable about quoting work authored by friends in their network. Exacerbating the problem, these scholars do not read widely enough, refuse to study non-European and non-contexts in their own terms, and rarely carry out research in non-European languages or, perhaps more importantly, working with academics with the necessary skills, creating exclusionary and harmful hierarchies of academic worth. All of this goes a long way in helping to explain why several academics choose to focus on a small number of historical actors’ ideas and reports on how others responded to them, rather than the numerous, complex processes wherein a set of recommendations, from new specialist agencies associated to the United Nations would be discussed, negotiated, reworked, implanted and reshaped both regionally and nationally in wide-ranging ways.

Therefore, we have a situation where histories purporting to describe the impact of the ‘Cold War’ on international and global health projects consider it sufficient to describe debates and discussions between representatives of the USA and the Soviet Union on the basis of extremely narrow research (generally, for example, by focussing on US government reports on the USSR’s representatives’ arguments and positions, with no effort being made to study Soviet papers, in Russian, on these negotiations). Similarly, histories of the worldwide eradication of smallpox – widely regarded as the 20th century’s greatest achievement in international public health, interpretations of which continue to be considered in policy and academic circles, and presented as proof of the WHO’s ability to offer ‘global’ leadership – choose to focus on the roles played by small groups of people. In doing this, these bodies of work ignore or downplay ideas, activities and work carried out independently in important contexts such as India and the People’s Republic of China. This trend is particularly inexplicable, considering that these regions had significant populations, large and well-established administrative frameworks, were marked by great cultural and social diversity, wielded great regional political importance, and were regarded as important politically both by the USSR and USA, and the international alliances they spawned, at different historical junctures. That these attributes and determinants in South and South East Asia have been considered largely unimportant by generations of academics is a powerful indicator of the damaging nature of US- and Euro-centric scholarship about the birth and expansion of international health after 1945.

The WHO is not, and has never been a monolithic organisation, and many of its workers in offices around the world have shaped international engagements in health in significant ways. From this perspective, the support that the WHO Global Health Histories initiative has received from within many quarters of a complex organisation is unsurprising; many of its officials have recognised and supported the initiative’s ability to promote inclusivity, and collect information transparently and collaboratively. As these open-minded and democratically-inclined WHO officials work with talented academics from all over the world, who are united in seeking to study the widest range of voices and actions to develop intricate and realistic historical mosaics of internationalism in health, they create new forms of discussion and debate that mobilise and support new coalitions for equity in health. This inter-sectoral cooperation does not, of course, go unopposed within the complex maze of the structures of international and global health programmes. There are, for instance, those who seek to ensure the dominance of the English language in health research and its communication. However, as major health problems persist, leading many thoughtful and independent analysts to increasingly query the overshooting of targets and budgets in major programmes such as Global Polio Eradication Initiative, and the barriers created by the unwillingness of UN- and US-led initiatives to use multi-lingual research to properly understand and engage local populations threatened by new pandemic emergencies (Ebola being a good case in point), the imperium of those seeking to promote work in the English language and then label this as being the most important for all future responses everywhere is being challenged. The unmistakable shifts in the world’s political and economic orders are an important contributory factor and new international alliances, such as the BRICS nations, are becoming assertive in unprecedented ways.

As their representatives within the UN work ever harder to ensure that their voices are heard and the contributions of a wider range of countries is recognised as major, new health initiatives are rolled out, it may well be that conditions will be created for a more equitable, non-US and non-Eurocentric historiography, based on careful research in multiple languages. The election of the first ever WHO Director General from Africa, on the basis of a vote that involved all national member states, represents an important and, hopefully, lasting shift that will promote complex, open-minded engagements between policy managers, academic allies and target populations. However, to thrive and make an impact, any reforming agenda needs to avoid the pitfalls of what it displaces: the imposition of select nationalisms on deeply international bodies; racially informed superiority complexes and attendant hierarchies of worth; and the denial of sufficient space to describe and assess a multiplicity of voices from the regions and countries. If such reforms are to empower future generations of scholars, allowing them to come up with innovative new research in unfettered ways, then resultant socially-, culturally- and politically-sensitive historical work is much more likely to be able to engage those involved in delivering health and development policy around the world on a day to day basis.

Made to measure: Data in the movement for primary health care

In the run up to the 101st Global Health Histories seminar ‘A world that counts?' Contexts of health: Information for Health, we're considering the data issues present in our work on the 'Local Bases of Global Health’ project. What was the role of data in the global movement for Primary Health Care (PHC); who was responsible for data collection; and how was data used? Dr Alexander Medcalf considers such issues below.

Global Health Histories Seminar 101: 'A world that counts?' Contexts of health: Information for Health’ will be streamed live online on Thursday, the 22nd of June starting at 12.30pm CEST (11.30am GMT).

Data and information collection was viewed as a vital component in improving health after the Second World War. It became an important issue for the nascent WHO; the first Director General Brock Chisholm recognised the ‘growing need for quantitative data, not only to provide comparable information on the health of populations, but also for the adequate planning of health programs and for the sound evaluation of results’. The Organization’s early annual reports displayed the extensive systems adopted for collecting and disseminating information and health statistics. In 1951 for instance, a conference on morbidity statistics was held in Geneva in connexion with a meeting of the Expert Committee on Health Statistics, and a training course for statistical coders was held at the WHO’s headquarters. Regional courses in vital and health statistics were held in the South-East Asia and the Eastern Mediterranean Regions, and surveys of the existing methods of collecting and compiling statistics were made in various countries.[1]

Whilst the WHO’s work priorities shifted in the 1970s to promote Primary Health Care (PHC), the interest in data remained constant. The 1978 Declaration of Alma-Ata at the International Conference on Primary Health Care outlined PHC as comprising ‘essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford’.[2] Information was seen as vital to success, and the gathering and analysis of data was envisaged as an integral part of PHC programs to help monitor and evaluate health programs, identify pressing health problems, and build up a comprehensible picture of the health needs within communities. A joint report by the WHO and UNICEF specified that the planning and management of PHC programs depended on the ‘right kind of information’: data collection should be kept to a minimum by identifying only relevant information. ‘Timely’ and ‘useful’ were the main watchwords.

Although this was the aspiration, the collection and usage of data played out differently in countries and communities around the world. We get a glimpse of some of the experiences and responses in a series of articles which appeared in the World Health Forum in the mid-1980s,[3] a half-decade after the start of many PHC programs. In ‘Information for Health Development’, Paul Freund and Katele Kalumba argued that in many cases health systems data was unavailable, and that which existed was of ‘doubtful value’. One problem was that health information systems ‘imported from developed countries overemphasises the role of curative care in combating disease, reflecting little of prevention or other health maintenance inputs’. In some cases data collection was not so timely, with a lapse, as long as 4-5 years in some cases, between collection and the compilation and publication of results. In ‘Look, listen and learn : preparing the ground for primary health care’, Shirley Buzzard warned that where there were no clear objectives for data collection a ‘shotgun’ approach was used – asking a little about everything but not much about anything. Data collection had indeed become a part of PHC programs, to identify common health problems, but questionnaire replies frequently confirmed what was known already; that poor housing, low income, ineffective water supplies and sewage systems led to poor health. More damagingly, survey taking could give the impression that people were being listened to and steps taken to address their complaints, expectations which might later be dashed if the surveys were not followed by action. Logistical problems, such as the lack of stationery and questionnaires and inefficient mailing systems, also stifled efforts

More damagingly, whilst some program planners tended to overlook existing sources of data which might have helped avoid duplication of efforts, others overlooked the input of the communities they intended to help. Worryingly in the context of the wider aspirations of the Alma-Ata declaration, some surveys involved little or no participation from community members.

The articles also reflected on some of the responses developed to deliver better data for improved health, and agreed unanimously on the necessity of community involvement in planning and collecting data. In ’Gathering information for health’ Evangeline Suva reported that the ‘few and simple tools’ used in lay reporting in Manila provided a clear picture of the health scene and helped people to be self-reliant in health matters. The articles by Freund and Kalumba and Buzzard suggested that children should not be overlooked as potential data collectors as they were keen and dedicated observers. In addition to questionnaires, Buzzard advocated using anthropological approaches including participant observation, life histories and interviews, because they provided data as well as identifying community belief systems that affect behaviour. Life histories could reveal critical information for maternal, child health and family planning programs. She suggested that ‘listening may be one of the most important skills a health promoter can develop’.

Involving community did not just result in more relevant and useful data but also helped inspire a deep-seated concern for health issues. Freund and Kalumba detailed how, in Zambia although intended for monitoring and evaluation, community participation in data collection created linkages between CWS, schools and health centres united in a common purpose. Involving children in data collection was practical and logical, but also helped spark an interest in the health of the community from an early age. The overarching conclusion was that listening to local concerns and involving communities in the planning, collection and analysis of data provided a better way forward regardless of the country or region.

This is just a brief snapshot of the conclusions drawn from a small sample of programs, but sets out some interesting considerations when looking at the aims of data analysis, the problems of collection, and how these were overcome or worked to the advantage of communities in the 1970s and 1980s. Towards the end of 2016, to mark Universal Health Coverage Day the WHO launched a new data portal aimed at tracking progress towards universal health coverage (UHC) around the world. The portal shows where countries need to improve access to services and where they need to improve information. At the launch the then WHO Director General Dr Margaret Chan said that ‘Any country seeking to achieve UHC must be able to measure it…Data on its own won’t prevent disease or save lives, but it shows where governments need to act to strengthen their health systems and protect people from the potentially devastating effects of health care costs’. (www.who.int/mediacentre/news/releases/2016/portal-universal-health/en/). This marked a very twentieth century response to a decades-old preoccupation.


References:

[1] Work of WHO 1951, 4.

[2] The Declaration of Alma-Ata, 1978.

[3] Shirley Buzzard, ‘Look, listen and learn : preparing the ground for primary health care’, World Health Forum 6:4 (1985); Paul J. Freund & Katele Kalumba, ‘Information for health development’, World Health Forum 7:2 (1986); Evangeline Suva, ’Gathering information for health’, World Health Forum 7:4 (1986)

'A world that counts?' Contexts of health: Information for Health, Global Health Histories Seminar 101

Do join us live online for Global Health Histories Seminar 101: 'A world that counts?' Contexts for Health, Information for Health' on Thursday, 22nd of June 2017 (12:30 pm CEST). Broadcast live over the internet, via webinar: http://www.euro.who.int/ghh

In today’s world, an enormous amount of information about our life (and death) is being recorded as data. Health is no exception. We are surrounded by numbers, from statistics on well-being and quality of life to epidemiological data that can help fight disease and even predict epidemics. In fact, a recent UN report about mobilizing the data revolution to support sustainable development describes our world as “a world that counts”.
However, there are many important social, political, and cultural factors that influence the process of collecting, producing, analysing, and managing quantitative data. This panel discussion will explore the cultural contexts of data and the powerful potential for (and possible pitfalls of) ruling the world by numbers.

More details available via https://www.york.ac.uk/history/global-health-histories/events/ghh-seminar-101/

Vital Statistics: The problem of exploring the burden of Non-communicable Disease (NCDs) in Sri Lanka, 1950-2000

In the run up to Global Health Histories Seminar 101: 'A world that counts?' Contexts of health: Information for Health’ (https://www.york.ac.uk/history/global-health-histories/events/ghh-seminar-101/) we are taking a look at the health data issues present in the work of our colleagues on the ‘Local Bases of Global Health’ project. We asked Dr Margaret Jones, a research fellow at CGHH, to reflect on her work on Sri Lanka.

My research on primary health care policies in Sri Lanka in the period 1950-2000 (https://www.york.ac.uk/history/staff/profiles/jones/) has entailed an exploration of the burden that NCDs have imposed on the health services of the island and its population. The demographic and epidemiological transition that Sri Lanka underwent in this period arising from declining death rates, increasing life expectancy, a decline in infectious disease and an ageing population, brought NCDs to the forefront of the island’s disease burden.

NCDs therefore form a significant part of the primary health care story. But a major obstacle, for both contemporaries and historians, to assessing the significant problem that NCDs presented is the lack of reliable and extensive statistics on the morbidity and mortality from the most common ones – heart disease, cancer and diabetes. Throughout this period the reliability of mortality and morbidity statistics generally cannot be taken for granted but finding information on the prevalence of NCDs presents a particular challenge. The health authorities made little attempt to collect data on NCDs, quite reasonably focusing their constrained resources on the far more pressing problem of infectious diseases. The mortality and especially the morbidity NCDs caused remained almost entirely undocumented. Extensive statistics on the special campaigns against the infectious diseases – malaria, tuberculosis, leprosy, filiariasis and VD - for example, appear assiduously in annual medical reports, health bulletins and the weekly epidemiological reports issued by the Health Department. But data on NCD morbidity could only be obtained from hospital admission records. Sri Lanka, alongside other developing countries, did not have the resources to collect population-based morbidity statistics.

As awareness of NCDs developed from the 1980s onwards the annual health bulletins pointedly and repeatedly highlighted this knowledge gap, noting that hospital records were the only source of data on morbidity, and that they could therefore present only a partial picture of the burden. There was no data, as for example the 1992 Annual Health Bulletin explained, on those who “were admitted to Ayurveda and private hospitals, and the large numbers who were attending the outpatient departments of Government medical institutions, dispensaries of private practitioners and offices of Consultants”. Furthermore, “the private sector comprising of western and traditional medicine, accounts for 55 per cent of the patient load which is mainly outpatient management”. Added to this there was the factor of self-medication, facilitated at this time as highlighted in this Bulletin by the “laxity of the Cosmetic Devices and Drugs Act which permits the purchase of a wide range of drugs without professional prescription”. The Bulletin concluded therefore that, “the morbidity load, as indicated by statistics obtained from Government hospitals is only the tip of the iceberg”. (Annual Health Bulletin Sri Lanka, Colombo: Ministry of Health, 1992).

The result is that the burden of NCDs was largely invisible for much of the period of my study and it was only as the demographic and epidemiological transition in Sri Lanka took hold that attempts were made to make them visible. But, still determined by the lack of resources, this could only be done through population surveys varying in size, population profile and geographical coverage. These surveys have, however, led one contemporary to talk of an “explosive epidemic of NCDs”(Premaratne, Amarasinghe and Wickremasinghe, “Hospitalisation Trends due to selected non-communicable diseases in Sri Lanka, 2005-2010, Ceylon Medical Journal, 50:2, June 2005). In terms of epidemiology NCDs are now being given due prominence in the health policy landscape and increasing attention is being given to assessing their true prevalence in order to facilitate the implementation of effective policies to reduce the threat they pose.

Five Lessons from the Archives of the History of Medicine in Ghana

CGHH PhD student Ben Walker recounts his archival fieldwork in Ghana, with tips for researchers

'Making Friends and Acknowledging People: Five Lessons from the Archives of the History of Medicine in Ghana' by B. B. Walker

Searching through the archives for material to put together a history of medicine in Ghana can be a challenge. Getting the right letter from the right person or physically locating the archive for example, can often involve a far greater effort than actually reading the documents themselves.

Unlike for histories of Europe and North America, Ghana’s historical record is not to be found in vast libraries of catalogued papers (though it must be noted, the Balme Library at the University of Ghana has an excellent stock of a wide range of government, media and academic publications). Its past is in people’s homes, in their funeral brochures, in church storerooms and in obscure corners of hospitals. This is not because Ghana is more ‘primitive’ but because it has not had the stable institutional capacity to maintain a full national archive since the years of its independence from British rule in 1957. Coups, economic collapses and revolutions have led to the loss of large swathes of written material.

The research may be more physically grueling but it is no less rewarding. Ghana’s records are a patchwork, but no less worthwhile or valid than any of the red ribbon-tied bundles one might find at the British National Archives in Kew. For those who wish to try it for themselves, here are five key tips:

1)     Get Signatures: To get into PRAAD (Public Relations and Archives Administration Department of Ghana) you will need a signature on an official archive document in order to be allowed in. This signature can best be obtained from a friendly academic colleague at the University of Ghana. It cannot be obtained from the British High Commission (yes, I tried). You may have the option to try to get the form in advance and have a Head of Department from your own institution sign it, although I cannot vouch for this route.

2)     Make Friends: Your best pathway to understanding anything about the country of which you are researching is to get to know the people and fellow researchers. Ghana is no different. My research would have been much more problematic had I not received help at every turn by incredibly kind Ghanaian academics, students, librarians, businessmen, solicitors, fashion designers, doctors and hoteliers. Not only will this likely facilitate your only access beyond the national archive storehouses, it will make the whole thing make far more sense and be far more fun.

3)     Interview, interview, interview: I conducted many interviews with many elderly Ghanaian doctors and clerics, each of them with their own surprising and important insights. Obviously the aim is not to take on their opinions as your own. Sometimes these interviews tell one far more about present concerns than about past ones. Nevertheless, actually talking to people involved is vital if one is to get a sense of what is beyond the written record, what has been hidden and what was never recorded on paper. By listening to the voices of individuals historians can counter the claims of the powerful to control the national past.

4)     Go West: Many of Ghana’s best-written historical material can be found in the UK and the US, even material after the end of colonialism. Copies were made and stored more effectively and systematically. As Jean Allman recently emphasised in her article on Ghana’s archives on the Nazi Pilot named Hanna, a history of Ghana requires travelling all across the world.[1]

5)     Tip and Acknowledge: Making friends with local librarians and taxi drivers, both of whom are vital to any good historical work often requires good tipping and payment. Buy gifts for those who help you out. Pay when you are given photocopies. Many of these people have little money. Don’t forget about their real lives beyond the archive. Secondly, there are terrible historical relations between European researchers and African communities because of broken promises in the pursuit of information. If you promise something, deliver it. If you publish something, send it to the people that helped you and of course, acknowledge them. Finally, don’t forget that you are a guest.

Overall, the value of the archives (whether in the sense that one might expect or not) to be found in Ghana far outweighs the difficulty of accessing them and connecting to their keepers. They can shed light on histories that have for too long remained disclosed, submerged in imperial and post-imperial narratives constructed from the records of the powerful. Whether or not you ever choose to study Ghana, the principle can be generalised. Attempting to uncover hidden histories matters if scholars are to continue confronting the assumptions of their audiences and to extend their own understanding beyond previous expectations. If we do not, we will continue to misunderstand, misinterpret and demean cultures and pasts which look unlike our own.

[1] Jean Allman, “Modeling Modernity:  The Brief Story of Kwame Nkrumah, a Nazi Pilot Named Hanna, and the Wonders of Motorless Flight.” In Peter Bloom, Takyiwaa Manuh, and Stephan Miescher, eds. Modernization as Spectacle.  Bloomington, IN: Indiana University Press, 2014, 229-43.