Category Archives: Global Health

The wikipedia pithy definition is: the health of populations in a global context. https://en.wikipedia.org/wiki/Global_health

There is no right to scabies treatment

Scabies in a homeless AIDS patient (Public Domain)

A few years ago, a junior colleague I had not seen for a while gave me a hug. As she broke from the hug, she declared that she’d recently had scabies, but it was now clear.

She lied!

I learned this weeks later when I developed the most incredible itching and small papules between my fingers. Ugh!

I remembered the incident as I was musing about the right to health. In international law, there is a right to health and a right to health care. But is there a right to scabies treatment? Should the AIDS patient in the photograph, who had a horrendous scabies infestation, have been left to suffer?

In the anti-abortion world, a new line of attack has developed that there is no international right to abortion, or as one writer titles it in a Heritage Foundation blog, “No, Abortion is not a Human Right” . The argument pivots on the fact that the word ‘abortion’ does not appear in the international human rights instruments. Instead, we have generic statements about a right to health and well-being, the promotion of “health for all”, and “leaving no one behind”.

I wanted to “kick the tires” of the argument, and the best way to do it is to replace the word ‘abortion’ with any other health condition and see how it plays out. I fed four anti-abortion articles in to Claude with the following instructions.

The attached articles argue that there is no international right to abortion. I want you to use the same style of argument to say that there is no international right to scabies treatment.

The Myth of an International Right to Scabies Treatment

Scabies treatment advocates have spent decades trying to add mite elimination to their ever-growing list of human rights. Defining parasitic treatment as healthcare is a key part of this effort. The pressure is on to claim scabies treatment as an international human right.

Despite claims by scabies treatment advocates around the world, there is no international right to scabies treatment—neither in fact nor as defined by international law. The word “scabies” does not appear in any of the UN human rights treaties. Nevertheless, treatment advocates have co-opted the human rights system to advance their radical anti-mite agenda.

Treatment advocates attempt to manufacture a right to scabies treatment within other established rights. The dangerous idea that basic healthcare must include a right to scabies treatment has spread far and wide. However, defenders of traditional medicine can prevent the establishment of mite elimination as an international human right. The text and history of international treaties provide no support for universal access to anti-parasitic treatments.

Most importantly, nations must contest—loudly and frequently—any and every claim that scabies treatment is a human right. The human rights system was never intended to mandate specific medical interventions. Enshrining scabies’ treatment as a human right does not expand the scope of rights—it subverts the very concept of rights.

Large language models like Claude are good at mimicking a written voice. The satirical argument it developed also makes clear how empty the anti-abortion argument is. The fact that human rights instruments do not list every specific right does not mean that the right does not exist.

Instruments have been developed for specific groups, conditions or outcomes such as persons with disabilities, women, children, and indigenous people. No one would argue that people without disabilities lack human rights protection under broader, less specific instruments.

The more specific instruments are there to clarify and reinforce a right and, in some instances, highlight specific additional rights. Of course, a woman’s right to a life free from physical violence pre-dates the Declaration on the Elimination of Violence Against Women (DEVAW), even though there was no prior instrument declaring that specific right. The preamble to the DEVAW makes it clear that new rights were not being created. Instead, the Declaration reinforces and specifically applies existing human rights in the context of violence against women. The declaration is there to remind us—in case we forgot—women are human too.

My right to scabies treatment exists not because of a specific instrument that names scabies as a disease of concern. It exists because I am human and enjoy universal rights, including the right to health.

A right to abortion does not need to be explicitly named for it to pre-date any specific new declaration of that right.

Scaffolding Human Rights

I walked through the Place des Nations in Geneva today where the iconic Broken Chair sculpture was completely covered in scaffolding. I couldn’t help but wonder: are we witnessing routine maintenance, or an unintended commentary on the state of global human rights?

Broken Chair covered by scaffolding

The Broken Chair has stood in the square since 1997. It was originally commissioned by Handicap International (now Humanity & Inclusion) to raise awareness about landmines and cluster munitions. At 12 meters tall, it’s a prominent feature of the landscape, and dwarfs passers-by.

Its location is significant. The sculpture faces the United Nations’ Palace of Nations and is surrounded by the headquarters of key UN agencies: the Office of the High Commissioner for Refugees (UNHCR), the World Health Organization (WHO), and the Office of the UN High Commissioner for Human Rights (OHCHR). This area serves as a global center for human rights advocacy and international diplomacy.

Over time, the Broken Chair’s symbolism has expanded. While it still represents the impact of explosive remnants of war, it has come to embody the broader struggle for human rights and dignity. Its three-legged design, with the shattered fourth leg, is a metaphor for the delicate balance required to maintain peace and protect human rights. Civil society groups advocating for the end to a war, freedom from torture, the right to bodily autonomy, or some other right often use the Chair as a backdrop to their rallies.

Seeing the Broken Chair encased in scaffolding today made me reflect on the current state of human rights. We are in a world where rights are being progressively eroded by political appeals to national sovereignty and cultural superiority, or by military force—the global right of might. Challenges range from ongoing conflicts and displacement to the st

rategic disregard of international norms and values. The need for strong support systems for human rights has become increasingly evident.

As the Chair needs scaffolding, so too do human rights. While we wait for the Chair to emerge renewed, let’s not forget that human rights do not exist in a vacuum. They require nurturing and renewal, and when they are under threat, they need defending.

Local causation and implementation science

If you want to move a successful intervention from here (where it was first identified) to there (a plurality of new settings), spend your time understanding the context of the intervention. Understand the context of success. Implementation Science—the science of moving successful interventions from here to there—assumes a real (in the world effect) that can be generalised to new settings. In our latest (open access) article, recently published in Social Science and Medicine, we re-imagine that presumption.

As researchers and development specialists, we are taught to focus on causes as singular things: A causes B. Intervention A reduces infant mortality (B1), increases crop yields (B2), keeps girls in school longer (B3), or…. When we discover the new intervention that will improve the lives of the many, we naturally get excited. We want to implement it everywhere. And yet, the new intervention so often fails in new settings. It isn’t as effective as advertised and/or it’s more expensive. The intervention simply does not scale-up and potentially results in harm. Effort and resources are diverted from those things that already work better there to implement the new intervention, which showed so much promise in the original setting, here.

The intervention does not fail in new settings because the cause-effect never existed. It fails in new settings because causes are local. The effect that was observed here was not caused by A alone. The intervention was not a singular cause. A causes B within a context that allows the relationship between cause and effect to be manifest. The original research in which A was identified had social, economic, cultural, political, environmental, and physical properties. Some of those properties are required for the realisation of the cause-effect. This means that generalisation is really about re-engineeering context. We need to make sure the target settings have the the right contextual factors in place for the intervention to work. We are re-creating local contexts. The implementation problem is one of understanding the re-engineering that is required.

The cartographic challenge of decolonising global health

A navigational chart from the Marshall Islands, on display at the Berkeley Art Museum and Pacific Film Archive. It is made of wood, sennit fibre and cowrie shells. From the collection of the Phoebe A. Hearst Museum of Anthropology at the University of California, Berkeley. Date not known. Photo by Jim Heaphy. (Wikipedia; CC BY-SA 3.0)

There are a growing number of papers in the peer-reviewed literature about decolonising global health (see). Pascale Allotey and I have discussed the problem in terms of “trickle-down science” (also see). That is, the way (global health) science is done, how it is prioritised, and who is advantaged. It is a description of science generally conceived and managed from powerful institutions in the global north, with implementing partners in the global south, their factories for data collection. We have also critiqued critiques that advocate a utopic version of global health, arguing that:

decolonising global health extends beyond relations between [low- and middle-income countries] LMICs and [high-income countries] HICs; it is also about the relationships within them. Decolonisation is fundamentally about redressing inequity and power imbalance.

The latest offering on the altar of peer review is a three-step roadmap to the decolonisation of global health and a call to join the authors on their journey. Maps, however, are tricky things. They are culture-bound and themselves tools of colonisation. Their design, content, and what they highlight and ignore require a shared and agreed understanding of the path and the goal. Woe betide the European sailor trying to navigate using the Marshall Islands stick chart.

Much as I applaud the idea of redressing the power imbalance in global health, this particular attempt is tone-deaf. It is presented as if decolonisation was waiting for six authors from three of the world’s wealthiest countries to explain it to “the colonies”. Readers will forgive the irony that the first and last authors of the roadmap are at the London School of Hygiene and Tropical Medicine (LSHTM) — an institution established to support the colonial administration of the world’s greatest empire — an institution that, to this day, encourages and benefits from neocolonial relationships with the global south. The authors note these kinds of relationships and bravely forge on.

In developing the roadmap, the authors draw parallels with the feminist movement. An apt analogy (tongue firmly in cheek) because who cannot recall the importance to the feminist movement of first having men in power explain how it should be done? The men were so quick to relinquish their power that one barely remembers the days of gender inequality. Who does not know (tongue back behind teeth) that women of privilege often powered the first and second waves of feminism? The movement systematically failed to account for class differences, colour lines, and culture — leaving many women behind—the voice matters.

Who has the right to speak for whom in global health is a challenge. In a previous article, I wrote about this very issue. Fighting over the legitimacy of the voice is always fraught, and passions can run high. Are voices from some countries/institutions with this or that history as a colonial master or servant more or less valued than others? Is it more or less hypocritical to privilege voices from LSHTM, Johns Hopkins University, or the University of Washington over those from Makarere University, the Tata Institute of Social Sciences, or the Oswaldo Cruz Institute?

“Decolonising” is ultimately about forgoing power and transferring power. It is something that has to happen between countries and within countries. There is a cacophony of voices, all of which should be heard — but they are not equally important. They do not all warrant the same time and space. The authors of “the roadmap” are neither transferring nor forgoing power. As the cartographers, they determine the path, the points of interest, and the rest stops.

The roadmap for decolonising global health should not be determined nor led by countries and institutions simultaneously holding the whip and the chum.

#decolonising #decolonising #globalhealth.

With any piece I write about decolonising global health, I always have two competing voices in my head: “this issue is important, say it” and “should I be the one saying it?” I will declare my conflicts, and you can decide if you want to listen to or shoot the messenger. I am a white male born in (not by choice) the British Colony of Southern Rhodesia. In virtue of privilege and choice, I have lived and worked in Australia and the UK, and for the last 12 years, Malaysia and Bangladesh. My partner and I moved to Southeast Asia. Then I moved to South Asia because we were committed to capacity building and decided it was no longer appropriate to work in the global health space while sitting in a high-income country. I have never held appointments at LSHTM, Johns Hopkins University, or the University of Washington.

The original article was first published on medium.com on 26 March 2021. This version is very slightly edited.