Biosocial Approaches for Global Health Interventions: A Discussion with Dr. Eugene Richardson
INTERVIEW BY MOHAMMAD ZIAD ABDULGHANI
Eugene Richardson, MD, PhD is an Assistant Professor of Global Health and Social Medicine at Harvard Medical School. As a physician-anthropologist, he conducts biosocial research on epidemic disease prevention, containment, and treatment in sub-Saharan Africa. He is also Chair of the Lancet Commission on Reparations and Redistributive Justice.
Mohammad Ziad Abdulghani, who served as Managing Editor at HHPR for the 2018-2019 term, conducted this interview with Dr. Eugene Richardson to inquire about how utilizing biosocial approaches can greatly benefit Global Health interventions.
MA: Can you talk about your experiences serving as the clinical lead for Partner’s In Health Ebola response in Kono District conducting mixed-methods research?
GR: I met Paul Farmer and ended up joining Partners in Health in Sierra Leone because they had set themselves up with a mandate to provide as high a level treatment as they could. I moved to Kono District and there wasn’t a huge epidemic there; most of PIH’s work took place in a district called Port Loko which was the epicenter of the Sierra Leone outbreak in late 2014. But in Kono, we were trialing out this new decentralized approach to containing the outbreak which consisted—instead of a large Ebola treatment unit in the district capital (which take long to build and was eventually was built by another NGO)—of built four smaller twelve bed units throughout the district with the idea that, if we decentralized this response and people don’t have to go far from home and local people could help out, working at the CCC or community care center as well as using these community care centers to sensitize people about what was going on with the outbreak, that might be a better approach to containment. We also staffed each of them with two doctors, so they would have as high level of treatment and care as possible. So, I did that for about six months and as the outbreak started winding down, I switched into more of a research role, because we realized a couple of things:
One: there are a lot more survivors and people affected by Ebola than the 28,000 WHO count would lead people to believe. We also thought that we were seeing a range of illness from possibly asymptomatic infection, all the way to death. So we set up a study to do a rural serosurvey in a previous hotspot and essentially found what he had hypothesized. That there were a lot more survivors that weren’t counted, and it’s important to find them because the sickness of Ebola doesn’t just end when you clear the virus or putatively clear the virus. People can harbor it in their eyes, CSF, brains, testes, and so there is a range of sequelae that people needed care for, so studies like this would help identify them and get them into survivor clinics.
At the same time, not much was known about the spectrum of illness, and so we found that there is a lot more minimally symptomatic infection than people realized and so when you put everything together, we are basically finding that the outbreak was much larger than the published numbers would have us believe. And that’s important because knowing the burden of disease is a helpful corollary to the work we are doing and on exploring the determinants of why there was such a huge outbreak. The biological explanation would basically say, well it circulates in monkeys, it circulates in bats, when people encroach upon the forest, they might accidentally get infected by an animal, or if they’re eating bushmeat, they might get infected, and so it jumps from an animal population to humans. Then, when humans take care of each other and don’t have good infection prevention and control at their clinics, the outbreak can be amplified through health centers. Finally, if it makes it to the city where people live in close proximity, transmission could be further amplified and, to many people, that’s how the Ebola outbreak propagated in West Africa. What we’re trying to do is expand what the word “outbreak” means, that Ebola manifesting in 28,000 people is not just a single unlucky zoonotic jump from a bat or primate in Guinea, that it’s actually a culmination of centuries of social and historical forces that coalesce as pathology in individuals. And so we’ve traced things back to the slave trade or as it’s known in Swahili, the Maafa, Maafa meaning essentially the African holocaust of slavery.
MA: What are some biosocial approaches to epidemic disease outbreak and prevention and containment in sub-Saharan Africa?
GR: Of course, the first thing is treatment for people that are sick. And that sounds more of a bio approach, but you know as clinicians when we talk about the biosocial, we don’t want to forget that the most important thing is that we do have the tools to effectively treat Ebola virus disease—which is reported throughout the news in sort of sensationalistic accounts to have a 70% mortality. Even without the new therapeutics being tested in the Democratic Republic of the Congo, we think with high level supportive care in a good ICU, that it’s actually less than 10%. We have evidence for that as all 9 of 9 repatriated American clinicians survived, several of them because they had access to dialysis and a ventilator, which really didn’t exist in Sierra Leone.
And so, the first part is providing treatment to all those who are sick, aggressive resuscitation, and replenishing electrolytes, along with trailing new therapeutics, those kinds of things. As we march out from there, we can then look at health systems strengthening, which had that been a priority before the outbreak, it certainly would not nearly been as big as it was. You can look to structural adjustment policies for gutting much of the health system strengthening that countries in West Africa were attempting. At the same time, you can also look at the hundreds of millions, even billions, that were marked for Ebola containment. Right when the outbreak ended—even though there was talk of this money shifting into health system strengthening, which would be the necessary thing for preventing future outbreaks of this scale—most of the money was pulled because there was no longer an outbreak. There was no longer, you might think of it, a threat to the high-income countries, and so they could move that money elsewhere along the crisis caravan. What they don’t realize is that the threat will be, if they want to think in those terms, the threat will be recurrent, if there aren’t strong health systems in place to not only contain outbreaks, treat people, but provide health services for all the other manifold illnesses from other infectious disease, to women needing cesarean sections, to non-communicable diseases and trauma, and so health system strengthening is also an important part of the biosocial approach.
Then we can take it one step further, and look at some of the more upstream determinants of why there are outbreaks like this that go beyond the issue of health system strengthening—to look at why there weren’t strong health systems in the first place, and recently as I mentioned, you can link some of that to structural adjustment policies which are handed down from the international monetary institutions. You can look at illicit financial flows, and interestingly, there is report called Honest Accounts that says something like 160 billion dollars, more or less, was invested into the continent of Africa in 2017, in the form of development, loans, personal remittances, and aid, and then about $200 billion came out in illicit financial flows, essentially trade misinvoicing and tax evasion. Finally, we arrive at legacies of colonialism and the Maafa.
MA: How does the etymology of diseases shape our understanding of them and how can some cultural changes help combat disease epidemics?
GR: That’s a great question. I think a striking example would be to consider the Institute of Health Metrics and Evaluation (IHME) and. I believe they have been funded at least $387 million just by Gates alone. If you look at some of their recent publications, they’ve been charged with explaining the global burden of disease, essentially why people are sick around the globe. You could look at IHME as similar to the social entrepreneurship that’s described in the book, Winners Take All by Anand Giridharadas, and you could go so far as to say that the modest improvements in wellbeing that are offered by global public health science with one hand are actually disguising what global elites and their looting machines take with the other. And that’s another book I recommend to you, The Looting Machines, by Tom Burgis. So, I mentioned that the Gates supports the IHME, and the IHME is considered the world’s premier center for health metrics, and health metrics are the science of measuring and analyzing global health problems.
But, a lot of critical social science will tell you that epidemiology in its most popular form is ill-suited for considering social quantities as risk factors. It is different with the sub-discipline of social epidemiology, but they are not nearly as mainstream, they are not getting $384 million to tell the world why we are sick. The IHME mission statement is to improve the health of the world’s population by providing the best information on population health, and one might go so far as to say that might be like suggesting, we could improve the health of Jews during World War II by counting the millions that died and determining the relative contributions of gas chambers, bullets, torture, and starvation, and that’s where our analysis ends. In short, there is no analysis of power, and if there is no analysis/critique of power, then their reasons for why people become sick become the common-sense explanations. That is, structural determinants are effaced and thus radical, structural interventions.
For example, one of their highly cited papers says that the three main reasons for global burden of illness are high blood pressure, tobacco, and alcohol. These are very downstream factors, they stop far short of analyzing whether a world system that allows the eight richest people in the world, Gates included, to hold the equivalent wealth of the bottom 3.5 billion is just. These ‘scientists’, charged with explaining the global burden of disease, reify these risk factors, and for this reason have been called “prisoners of the proximate.” Through publication in the top medical journals, the essentially achieve a type cultural hegemony in people’s understandings of why they get sick. As such, they cut off analysis to more upstream factors, and therefore, handcuff structural interventions, usually because they are not well defined our difficult to quantify. And so, you could sum it up by saying they actually help perpetuate the status quo of global apartheid by decoupling analyses of power from disease dynamics. Indeed, I find IHME to be a conservative entity, not unlike the Hoover Institution at Stanford for example.
How do you see that the World Bank and Neoliberalism Policies Influence Global Health Interventions Worldwide?
Another great question. You could approach this in two parts, the first part of the influence is through actual practice, through actual institutions that are on the ground doing work. Salmaan Keshavjee wrote an excellent book called Blind Spot, which I recommend to everybody, and he traces how USAID instituted a revolving drug program in Tajikistan. Under the guise of trying to improve TB treatment and provide drugs in a place that was post-communist and where lot of the safety nets that fallen through, they were actually trying to introduce them into a more consumerist world, a world where they would participate rationally in purchasing things instead of relying on safety nets. But he goes into a much deeper explanation of it and, again, I recommend it. So, that’s more of the practical working way of how neoliberal tenets infiltrate into global health, but there’s also epistemological ways and I think those are best summed up by what I was talking about earlier with, for example, the health metrics institute.
The reifying of downstream or proximal risk factors go hand in hand with neoliberal philosophy that says that humans are rational actors, that they can choose their paths, they can mitigate risk factors, they can choose not to drink, not to smoke, they can choose to get treatment for their afib, those kind of things. So, it enshrines this type of actor that really doesn’t exist in situations of deep poverty, where there is hardly any agency to make some of the rational decisions that economics enshrines as a paradigm for human action. So, you can therefore look at disciplines like economics more as normative theory than as actual social sciences because they really presuppose a way of being, i.e. the rational actor, and then prescribe ways that that actor can maximize their benefits. Same thing with burden of disease, if it’s just about the risk factors that are most proximal to you, and you can modify these, then it is a normative theory of what a human can do and what they should be doing.
It really has no capacity for examining more upstream, distal determinants, that is how socio-historical forces become embodied as pathology, and therefore it does not provide a means for critiquing them, or acting on them, or developing structural interventions, and often those structural interventions would challenge a system where these global elites continue their reign. And so, under the guise of global health science or economics, these normative theories, these ways of seeing the world are really not sciences, they’re ways of maintaining the status quo of global apartheid disguised as scientific inquiry.