By Ramah McKay (University of Pennsylvania)

In my contribution to this series, I want to reflect on the ambivalent position of both teaching and critiquing global health. As an ethnographer, my work has asked how anthropological tools not only reflect but also construct “global health” concepts and practices. Through fieldwork I have conducted in Maputo, Mozambique, since 2006, I have asked what it means to construct health projects as explicitly “global” and about the modes of medicine, caregiving, and health that such definitions exclude.

These questions also animate my teaching. Like many anthropologists of medicine, I often teach courses on themes related to global health, humanitarianism, and development to undergraduates in anthropology and related fields. Yet global health is a highly contingent and polysemic concept. It describes a shifting set of practices and instantiates a diverse array of subject positions and inequalities for health actors and ethnographers alike. As a result, the work of teaching, writing about, and even critiquing global health can be hard to distinguish from the work of constituting it. For instance, ethnographies of health, medicine, and development in many parts of the world are used to illustrate the urgency of “global” health disparities—even as they also demonstrate how global health actors emerge from the same global inequities that produce suffering and ill health to begin with. While student interest in global health provides an opening for anthropological education, much anthropological work is also oriented toward critiquing and deconstructing the very projects, orientations, and modes of intervention that animate it. What pedagogical and analytical questions emerge from the work of anthropologists in both constituting and unpacking global health?

CRITICAL ENTANGLEMENTS “IN THE FIELD”

At many universities, student interest in “global health” has accompanied a flourishing of institutional investments in global health centers, programs, initiatives, and interventions. As historical, social, ethnographic, and anthropological approaches have been incorporated into global health training (e.g., Farmer et al. 2013), undergraduate programs in the humanities and social sciences (anthropology, history, and area studies, among them) have made practical and pedagogical use of this expansion of student interest and institutional resources. Many anthropologists have therefore found a generative institutional niche by engaging with and often advocating for global health, even as they have also reflected critically on the political, economic, and health consequences of contemporary global health models of intervention (Pfeiffer and Chapman 2013).

At the same time, anthropological teaching on global health offers a means of responding to broader student desires and concerns, facilitating both broad-based anthropological engagements with classic anthropological concepts while also offering an object of study that seems more directly tied to professional trajectories. Thus, careers in a range of development-oriented and humanitarian fields (including global health) are sometimes offered in response to student concerns about the practicability of studying anthropology (or related qualitative or humanistic fields). Amid student concerns regarding the privileging of STEM disciplines by employers, government agencies, funders, and even family members, anthropologists can bridge humanistic and medical studies through links to global health. Because “global health” is sometimes more familiar to undergraduates in the United States than terms like “development,” the phrase also seems well-suited for capturing student interest despite student and disciplinary anxieties regarding postgraduation employment. In both my current job and in my previous experience at a research-intensive public university, I have heard concerns with employability voiced students across many majors. Finally, for some students, medical anthropology—and studies of “global health,” in particular— seem to offer a sense of “relevance,” that enables not only an imagined career future but also to help them explain their interest in anthropology to family, friends, and peers.

For anthropologists working in the tradition of critical medical anthropology, however, some of the qualities that make the anthropology of global health so compelling to students are also sources of ambivalence (Locke 2014). While many anthropologists have contributed to global health pedagogy (e.g., Farmer et al. 2013), many have also taken a critical stance toward these interventions (e.g., Wendland, Erikson, and Sullivan 2016). Still others have queried the geographical assumptions and racialized representations that animate both humanitarian logics and accounts of them (Benton 2016). Global health ethnographies, for instance, may aim at disentangling the contradictory logics of humanitarian intervention and global health and at distinguishing situated practices of care from private and transnational resource flows. These accounts show how the work of managing projects takes resources, including staff, away from the implementation of health services, while new regimes of evidence-based medicine, rooted in globally circulating metrics, drive the forms of care and intervention that NGOs make available. As a result, undergraduate interest in global health may create an audience for anthropological courses and texts but also exists in tension with some dominant anthropological orientations towards global health.

This tension, however, is not restricted to anthropologists or to anthropology classrooms. In fact, this dual analytical stance often seems to be common to the actors and institutions that medical and political anthropologists working in this field might study: NGOs, doctors, funders and donors, public health workers, government institutions and actors. Critique not only circulates through anthropological texts but is also widely present in the practice and discourse of global health. In fact, over the course of my research, I have been struck by how well versed health practitioners are in these critiques. From national policymakers to NGO administrators, the value of the public health system and the limitations of nongovernmental assistance often seem so widely shared as to be commonsensical. For instance, a World Bank official with many years of experience in the Mozambican public sector impressed upon me the importance of public institutions, and NGO directors have extolled the virtues of a singular public system. Current World Bank head (and anthropologist and physician) Jim Kim, meanwhile, has sought to mainstream such critical perspectives into World Bank agendas and implementation strategies. Critical views of NGOs thus circulate widely, including at and through nongovernmental offices themselves, as well as in anthropological and public health critiques of them.

In both the field and the classroom, then, concerns with the “global” configurations of health and biomedicine bring practices of engagement and intervention together with practices of anthropological and social science critique. As an ethnographer, I have often found that these entangled political stakes are as much a part of my object of study as the health practices and spaces in which they are embedded. Like NGOs that may both instantiate and critique a humanitarian politics of care, my fieldwork has depended on the very practices and actors that I have studied and frequently sought to unpack. And like NGOs that enact global health as a field through the work of implementing projects, so too do ethnographic and anthropological accounts of something called “global health”—whether located in Maputo, rural Mozambique, Washington, DC, or Seattle—shore up the boundaries of global health as a field through the very work of analyzing and, frequently, teaching it. “Global health” thus serves as a boundary object between ethnography, pedagogy, intervention, and critique.

PEDAGOGY BETWEEN CRITIQUE AND PRACTICE

Learning to teach from, about, and beyond this unstable border has animated much of my recent teaching within an interdisciplinary undergraduate program on Health and Societies at the University of Pennsylvania. A basic precept of the major is that health is fundamentally social—a presupposition shared and articulated by many ethnographers and anthropologists. Students take courses across a wide range of departments and they can submatriculate in a variety of tracks, including “Global Health,” “Gender and Health,” “Medicine and History,” and the most popular, “Health Care Management and Finance.” While varying in disciplinary approaches that range from economics to bioethics to anthropology and sociology, the curriculum broadly seeks to demonstrate the social basis of health and healing across a range of time periods, geographical locations, medical traditions, and technological fields. In many courses, including those beyond anthropology, emphasis is placed on familiar anthropological and social science principles such as attentiveness to local context, the need for critical analysis of health data, the importance of equity and access in considering health interventions, and the historical contributions of primary health care. Thus, ethnographic and global health renderings of illness frequently converge in course topics and themes. (One side effect of this approach is a student complaint that the major can be “depressing” and “sad.”) As students work through literature that both celebrates and critiques practices of health and development, the ambivalences of teaching and critiquing global health make visible broader tensions in the relationship between ethnographic practice and practices of intervention.

Yet critical convergences between anthropological stakes and nongovernmental practice also have conceptual and pedagogical limits. Shared critical perspectives on NGOs, for instance, not only work to critique and refine nongovernmental practice but often also articulate utopian visions of a future without NGOs or without global health—a future in which global health is both achieved and unnecessary. Ethnographic representations that global health inequities visible may also reanimate a racialized suffering slot (Trouillot 2003). And pedagogical approaches that both encourage and critique undergraduate involvement with global health, health disparities, and health interventions may misunderstand the complex, multifaceted, strategic, and sometimes self-interested ways in which students make use of training in “global” perspectives on health and inequality in the service of medical school applications or career aspirations far afield from anthropology or health. The ambivalences of global health ethnography, in other words, produce their own ambivalences in the classroom.

Students in this major have sometimes been described to me as future or aspiring “Paul Farmers.” Yet, in focusing my pedagogy on these aspiring humanitarian actors and future (or current) “do-gooders,” I have come to wonder whether I sometimes misread undergraduate desires for global health and, in the process, overlook some of the complexity of global health practice. Thus, in the remainder of this post, I want to reflect on some alternate pedagogical lives of critical anthropological and pedagogical principles—thinking instead of their trajectories through the careers of those (many) students for whom “Health Care Management and Finance” is a more compelling concentration than “Global Health.”

My interest in doing so is shaped by two observations. First, students who begin with a commitment to global health nevertheless arrive in my office halfway through their junior year to let me know that they have decided to seek an internship. The first few times I heard this, I recalled my own college internships, stuffing envelopes for tiny NGOs in cramped offices and church basements. I soon realized they meant internships with “Goldman,” Bain Capital, Boston Consulting, and a host of consulting firms with acronyms for names. For many students, this is facilitated by a university-sponsored process of on-campus recruiting, or OCR. These internships are the first step toward securing competitive and lucrative postgraduation jobs, for example, as health-care consultants or management consultants. What does critical global health pedagogy have to say to these students?

My second observation has to do with the practice of global health itself. In Mozambique, as in many places, much of the work of global health and development is performed not only by humanitarian actors and public health employees. Rather, global health and development are, and have long been, profit-making landscapes constituted by public-private partnerships, consulting firms, and market actors. Just as medical anthropologists have queried how accounts of transnational governmentality, structural violence, and neoliberal economies travel out of our departments and classes into institutionalized practices and efforts at reform, so too might we try to account for how anthropological education does or does not take root in diverse worlds of practice, including the private sector and financial practice.

Such questions may be more pressing as transnational funding for global health plateaus and even falls. In an imagined future world after global health, often figured as one in which health interventions are ever more securitized, financial models increasingly constitute African health systems as among the few remaining lucrative health markets. Moreover, in many places, private sector and consulting practices are already (and have long been) key sites in which ethnographic knowledge is generated, circulated, and enacted. How to speak, anthropologically, critically, and pedagogically to the students who will populate these fields of market creation and profit generation?

WHAT COULD I SAY?

The necessity of such questions is evidenced by the many students who describe to me their discomfort with the experience of consulting even as they also struggle to identify or follow alternative paths. One student, for instance, described to me his experience at a “super day”—the highly competitive final interview—hosted by a well-known consulting firm. The interview entailed solving “cases,” he mentioned, some easy and others more difficult. The first one I got, he added, was pharmaceuticals: “It was like, you buy a company that has a drug with three years left on the patent. You think the drug is underpriced but if you raise the price, sales will fall. What do you do?” What did you say? I asked. “Well, what could I say? If you raise the price by this much, sales will fall, but you’ll still make an additional $80 million dollars over the three years of the patent.” After a pause, he added: “I know! It’s not what we learn in HSOC [Health and Societies]!”

What could he say? And what could I say to him? It is true that students in my courses do not learn to set drug prices or calculate drug futures. They do, however, learn what happens when markets determine access to medicine. They learn how the financialization of care excludes increasing numbers of patients and how it may lead to drug shortages or drug resistances that put public health and well-being at risk. Sometimes, they learn that the solution to all of this is structural change, the overthrow of global capitalism, or a return to primary health care. In the face of declining aid funding, an expanding private sector, and the constitution of health systems around the world as markets, where services are driven more by the demands of private equity than by any concern for health delivery (even along marketized lines), such critical solutions are often a hard sell. Yet many students remain ill-equipped to transform or intervene in the production of inequality in the more complex array of sites in which many aspire to work. The “future Paul Farmer” is one potential future for students in my courses, but it is only one among many. As I recall our conversation, I no longer hear this student’s remark as a comment on the inexorable financialization of medicine, but rather as a challenge. “What could I say?” asks me to rethink not only who my students are and what futures they find desirable but also to embrace an expanded notion of the sites in which global health, development, and inequality are fashioned. Not restricted to the clinic, the family-planning program, the food basket, or the conservation effort, our teaching of “global health” might require or benefit from a more explicit engagement with studies of finance, employment, politics, and ideologies in the sites where policies are made and those in which they are enacted.

In my ongoing work, I am beginning to explore the transnational investment practices through which medical markets are being constituted in Africa. Thus, at a panel on “African health” at the Wharton School of Business, I listened to “angel investors” diagnose the role of NGOs in disrupting primary health-care systems in ways that were almost indistinguishable from anthropological critique. Vice presidents of private equity firms spoke to the irreducibly public and systemic dimensions of health and addressed the social, legal, and political specificities of diverse African locations. Unlike in my classroom, however, here in a conference room on the twenty-first floor of a luxury hotel, the critique of NGOs and the diagnosis of infrastructural failure were recuperated not through a return to primary health care but through new circulations of venture capital. Arriving late to the final session, I took one of the few empty spots only to find myself sitting next to my student. As pedagogies of “critique” and of engagement converge, then, they travel not only through humanitarian efforts but also into a diversity of professional, medical, political, and financial spaces whose aims may be different from or adjacent to my own. They open new audiences, and new objects of analysis and intervention, and in so doing expand the field of critical global health both geographically and conceptually.

CONCLUSION

Commentators have described global health as an unruly and obscure object. Encompassing a wide variety of technological, medical, epistemological, and political projects, the term elides important distinctions between the variety of political and medical configurations that are enacted under the sign of global health. Overlooking such ambiguity can be dangerous, scholars warn, since “the mere fact of taking global health as an object worthy of academic interest and scientific publications can be seen as concordant with technocratic common sense of even neoliberal ideology” (Fassin 2012, 104). These cautionary notes are salient not only for ethnographic practice but for global health pedagogy as well. As “global health” coheres, in ethnography and pedagogy alike, anthropologists not only risk fashioning a single medical-anthropological story (Mkhwanazi 2016) but also imagining a singular anthropological-pedagogical subject: the future do-gooder whose moral horizons are assumed in advance. Yet, as World Bank directors and private-equity analysts espouse critical stances familiar to and even informed by anthropology, the question of the usefulness of global health pedagogy—the simple question posed by my student—“What could I say?”—seems urgent.

Rather than emphasizing humanitarian and nongovernmental framings alone, pedagogical investments in “global” perspectives and “global health” might instead attend to the equally unruly but surprisingly convergent market-health spaces through which medicine is delivered. Students, like the ones I’ve described here, engaged in and by worlds that encompass but also exceed the anthropological/global health “slot” (Trouillot 2003) make clear that the careers of anthropological critique can be unpredictable, leading to formations of health and capital that I might not anticipate. As a teacher, I hope that some of the insights of global health ethnography—including intellectual humility, accountability to multiple actors (including those with the least capacity to enforce it), and attention to entangled human and more-than-human futures—remain salient no matter what. But these students also remind me not to assume a single way of imagining, constructing, intervening in, or critiquing a moral world of anthropological and global health insight.

 

REFERENCES CITED

Benton, Adia. 2016. “Risky Business: Race, Nonequivalence, and the Humanitarian Politics of Life.” Visual Anthropology 29 (2): 187–203.

Farmer, Paul, Jim Kim, Arthur Kleinman, and Matthew Basilico. 2013. Reimagining Global Health: An Introduction. Berkeley: University of California Press.

Fassin, Didier. 2012. Humanitarian Reason: A Moral History of the Present. Berkeley: University of California Press.

Locke, Peter. 2014. “Anthropology and Medical Humanitarianism in the Age of Global Health Education.” In Medical Humanitarianism in States of Emergency, edited by Sharon Abramowitz and Catherine Panter-Brick. Philadelphia: University of Pennsylvania Press.

Mkhwanazi, Nolwazi. 2016. “Medical Anthropology in Africa: The Trouble with a Single Story.” Medical Anthropology 35 (2): 193–202.

Pfeiffer, James, and Rachel Chapman. 2010. “Anthropological Perspectives on Structural Adjustment and Public Health.” Annual Review of Anthropology 39:149–65.

Trouillot, Michel-Rolph. 2003. Global Transformations: Anthropology and the Modern World. New York: Palgrave Macmillan.

Wendland, C., Erikson, S. L., & Sullivan, N. 2016. “Beneath the Spin: Moral Complexity & Rhetorical Simplicity in ‘Global Health’ Volunteering.” In Volunteer Economies: The Politics and Ethics of Voluntary Labour in Africa, edited by Ruth Prince and Hannah Brown. Suffolk, UK: James Currey Publishers.