Talks@12: Disparities & Bias in Global Health

[email protected]: Disparities & Bias in Global Health


Good afternoon. I’m Gina Vild. I’m the associate dean and
chief communications officer for Harvard Medical School. And thank you for
joining us today for this very special [email protected]– Disparities and Bias
in Global Health. The [email protected] were
launched eight years ago, as a way to share the
extraordinary knowledge of our faculty with
others on the quad. Today we live stream this
event, and all of our [email protected] And it’s not unusual for them
to be viewed in 36 countries by 40,000 or 50,000 people. So I want to welcome
all of you here today, and the NRB, and also those
watching from around the world on live streaming. I do welcome your topics. I invite them for
future [email protected] so please send me your ideas. We are thrilled to have with us
two HMS experts on health care disparities. Dr. Paul Farmer
and Dr. Joan Reede. Dr. Farmer and Dr.
Reede will discuss how socioeconomic disparities
among the medical community may contribute to inequitable
health care outcomes here in the US and around the globe. And they will share
their thoughts on how health care
providers can improve health access that will lead
to health care justice for all. Dr. Paul Farmer needs
no introduction. His work as a humanitarian
is well-known in far corners of the world. A medical anthropologist
and physician, he has made his
life’s work delivering the most seminal care to
the poorest of the poor, in many different
parts of the world. Beyond this, he also
works tirelessly to improve human rights
and the consequences of social inequity. Dr. Farmer has been a member
of the Harvard Medical School faculty for more
than three decades, and is currently the chair of
our Global Health and Social Medicine department. He is also the co-founder
of Partners in Health– an international
nonprofit organization, that directs health
care services, and initiates research and
advocacy on behalf of those who are ill and living in poverty. A history of this
transformational work of Partners in Health,
the work of Dr. Farmer, as well as Dr. Jim
Kim and Ophelia Dahl, has recently been captured in an
exceptional documentary called Bending the Arc. I have seen it, and
highly recommend that if you have an opportunity
that you try to see it as well. Our moderator this
afternoon is Dr. Joan Reede. She is dean for diversity
inclusion and community partnership. Dr. Reede is a
professor of medicine here at Harvard Medical School. The impact of her
exceptional work is reflected in
the many programs she has created to benefit
minority students, residents, scientists, and physicians. Her work is changing lives. She has launched
more than 20 programs that address pipeline and
leadership issues for minority and women who are interested
in careers spanning medicine, academia, and
biomedical research. She leads Dean
Daley’s task force in diversity and inclusion. Thank you both for leading
today’s discussion. It’ll be a conversation. I know they’ll
welcome your questions at the end of their talk. And I also invite those of
you who are watching from afar to please submit your
questions on Twitter at hashtag @[email protected] That’s hashtag @[email protected] So thank you for
joining us, and thank you Dr. Farmer and Dr. Reede. [APPLAUSE] So Gina has done this
wonderful introduction, and thank you for
that introduction. But I have a slightly
different view when I think about Paul Farmer. I think of him as a
friend, and someone with whom I share common values
about justice and equity. But also someone who
believes that the impossible can be done. So I want to open this with
my introduction of Paul, and he’s not heard this. And I’m taking this from– I’m scared. –taking this from
Muhammad Ali, a man who stood for his principles
also, and a fighter. And Ali said, “Impossible is
just a big word thrown around by small men, who find it easier
to live in the world they’ve been given, than to explore the
power they have to change it. Impossible is not a fact. It’s an opinion. Impossible is not a declaration. It’s a dare. Impossible is potential. Impossible is temporary. Impossible is nothing.” And when I think
about your career, and what you have
done in moving world, I think of someone who
saw impossible and said, let me push this aside. And let’s continue
to move forward. So if you think about
the topic for today around disparities, and
bias, and global health, your work has been around
these inequities, and justice, and injustice. How do you relate that
to disparities and bias? Where’s the link? First of all, that’s
a beautiful Ali quote. I’m often compared to him, so– [LAUGHING] I can see why. –I’m used to that. I just assume, when I
saw this invitation, that these were the same thing. Global health– and this
is just a personal– definition the wrong word. It’s more along the
lines of Ali’s definition of “impossible.” And I’m sorry if I’ve
told this before, but I don’t think
I have in here. But I went to Haiti
before I came to Harvard. I applied to Harvard
Medical School from there. And this was in 1983. I came here for the first
time in December, 1983, for an interview. To do that trajectory,
from Harvard to Haiti, in those years,
or from later at the Brigham to Roxbury, let’s say. Or to– you go
right down the list. We’ve discussed this
many times before. It never occurred to me
that global health could be anything but about the globe. And that Charlottesville
is on the globe, and Boston is on the globe. And on and on, down the list. And then I look at
some of my teachers who are in the room
today, and I understand that in their view as well,
they had this transnational– whatever you want to call it. I mean, it sounds
highfalutin, but this transnational
political economy that has long defined our world. And so to me those were
always related problems. The specifics of bias
and the specifics of health disparities in,
let’s say, an epicenter of medical knowledge
here, might not look the same as health
authorities in another place in that global economy. But one, it was usually
possible to find some trace. I teach this class with, again,
colleagues from Harvard Medical School. We teach at Harvard College– Arthur Kleinman, Anne
Becker, Salmaan Keshavjee. And we’ve been teaching
for a long time. And yesterday was my turn,
and tomorrow is my turn. And the topic was Ebola. But I really wanted to talk
about health disparities, and to have them– these students– again,
most of them very young. It’s more sophisticated
than I was when I was an undergraduate. I understand that where
they’re going tomorrow– where I am actually going
physically tomorrow, but where they are going
intellectually in tomorrow– is through that triangle. West Africa, North
America, and the Caribbean. And that’s just one way
to see– one truthful way, non-fake-news way– of seeing health disparities. And I know it’s a
long answer, and I’m sure you’re shocked by it. I am the Muhammad Ali
of length, however. It’s just the
erasure of history, and the desocialization
of our social worlds, is part of the problem. And that’s part of the problem
among medical professionals. That’s part of the problem among
medical students, residents, faculty, all the
way down the line. It’s our problem. So that’s about as
short as I can go, but I don’t see the value in
doing what I often hear– is, oh, if you think this is
bad you should visit– and that’s just the common
reaction, a common reaction. Disparities hurt no
matter where you are. Disparities hurt,
and we need to be able to identify where they hurt
most, and how they hurt most. And I was reading W.E.B
Du Bois yesterday– well, I’ve been calling it W.E.B
Dubois for about 30 years until my daughter corrected me– on the way back from Haiti. And he was writing
about the same erasure in his time between Western– the same circle. He grew up in Western
Mass, went to Fisk, because he couldn’t get
a scholarship because he was African-American. Then he did go to Harvard,
then eventually became the first African-American to
get his PhD, which was before really the creation
of sociology, history, political economy. But that’s the point
he made again and again in the part of the book that
I read on the way back here, is that the erasure
of history is one of the mechanisms
by which we perpetuate structural violence. Or whatever you care to call it. And keep the
structures in place. How as you talk about something
that is truly global– no matter where you
turn, these issues of disparity, and injustice,
and inequity exist. And lots of this is structural. As a health professional,
as a provider, what is our role
in addressing that? Or do we have a role? Well, you already know that my
belief is the same as yours, that we do have a role. And I think that
role is really roles. For example, if I’m doing an
infectious disease console at the Brigham, and I know that
structurally determined forces like gender,
inequality, and racism have worked themselves
into the body of a patient, that’s not why the surgery team
is consulting me on a patient. And to ignore that– meaning to ignore the
fact that these forces get in the bodies of
patients as they do in the bodies of our
colleagues and our students. To ignore that is
always wrong, I think. But there is a way of– Maybe Remember, this
is a conversation. I’m not assuming that I know
the answer to that question. All I can say is I
struggle with it mightily. A number of our colleagues– my colleagues from
Harvard Medical School. In 1996, we wrote a book
called Women, Poverty and AIDS. I know you’ve read it. Everybody seemed to
buy it like hotcakes. And Mary Jo, [INAUDIBLE],,
contributed, Jo Rhatigan, lot of people you know. Johanna Daily. And there’s no question
that we could at least try to trace how social
inequality, social disparities, structural forces, as
you said, get into– in this case– women’s bodies. But during an infection,
these consult– that’s really not what
you’re being consulted on. It’s like, that’s the
wrong dose of this, you might want to
try that, here’s the combination of antibiotics. That’s their job. The problem is that
then do we back away too much from confronting
structural forces that we weren’t trained to take on? Actually, as an anthropologist
I was trained to do it, but not as a Med student,
or a resident, or a fellow. And I know the answer
to that also has to be, yes, we certainly do
move back too quickly. And that’s one of
the reasons I love being a teacher, whether here,
or in Haiti, or anywhere else. So there’s these
structural forces, and you have to figure out– and the Kenny Rogers– no one
to hold up, no one to fold up, no one to act. Yeah. And what’s your role. But what about
the forces that we bring into the world
at the same time? Well, that’s the
thing about humans. There’s no structural
force that we’re talking about that isn’t
brought into the equation by us. And that means that,
I would assume, that they can be undone by us. And they also affect
us in bias that we’re willing to acknowledge or not. And I think the exercise of
trying to sort through that, as humbling as it
is, is a good one. We don’t do it very well
in a clinical setting, where it sometimes gets
formulaic like a check list. But if you have a
fellowship program, for example, that
goes on over time, that’s not just a
formulaic response. If we have
acknowledgement that we have a serious problem
with all this bounty that we have, that’s
better than saying, ah, we’re doing the best we can. Or these are forces
that are determined– the fates of either faculty,
or patients, or students be patients before we can
get our hands on them. So there is a piece of this,
though, as you even describe– you’re this infectious
disease consult. And you’re sort of saying, my
role in this is to say this is– antibiotic is better than
the other, or how to treat. But if you take it to
that next level of who’s determining what
antibiotics would be available in the formulary. And so it’s not just
for that patient. It’s how you interact
with that system around that decision that may
or may not make that available. So I’d look at some
of the things that are going on in the world today. What’s available in one place
is not available in another. And as a provider,
isn’t there a part of it where we need to
step back and say, we need to speak up about this? It’s not right. It’s not fair. Well, that’s been
the great drama of– I say our work. I’ll say my life, too,
because it’s true. But it’s never — the best way to be able to do
nothing is to think of this is an “I” problem. But I’m looking, and again,
looking around the room, some of my colleagues from Harvard
and PIH, Partners in Health are here– Lee [INAUDIBLE],, and
on and on it goes. This is a great drama of the
clinical work that we do. That drama is lessened whenever
we have the right staff stuff, space, and systems. So the global disparities,
which I knew you’d bring up and I’m relieved, because I feel
like that’s in my wheel house, that they’re material
manifestations of bias. And I don’t want to go
overboard on the materiality of the social, which is a title
of a paper that I once gave, and I’m sure you’ve read
it, along with my mother. All of us, yeah. All of us, yeah. Cool title, though–
Materiality of the Social. So that was the point. How do you– in this particular
case I was talking about, the distribution of HIV
disease or tuberculosis in a global sense. But that’s only part of
the way that bias gets in. Because what about after
distribution [INAUDIBLE]?? Then there’s the
fact that we know in a global political economy
that there is some tool. And of course you’re going
back and forth from Harvard to Haiti, Harvard to Haiti,
then you really know it– you’re reminded. But I’ll just give an
example because I just saw Louise come in. The only other time
I’ve given a [email protected]– I know you know when it was. It was my first talk after
the earthquake in 2010, and it was very difficult
to do, emotionally. And I was nervous
about doing it. Claire Pierre came. I think Louise
was probably still just working there in Haiti. And I thought, I really
want to get this organized so that I don’t have the
difficulty expressing myself. Love that being the Muhammad
Ali of global health and all. And shortly after that, one
of the great complications and horrors– not a complication
of the earthquake, because this would have
happened with or without the earthquake– was the
introduction of cholera. Now the introduction of
cholera was, obviously, a manifestation of precisely
the structural forces that you’re talking about. Came from– it
happened to be Nepal. Again, if you look
at the history of the great pandemics of
cholera, there’s always these– they’re translocal,
they’re transnational. And there’s enormous
blame and suffering– blame and suffering, both– that happen. And then they run right
along the fault lines of social disparities. But the last time there was a
big epidemic in the Americas, I happened to have been
involved in that one, too. Because it went from Peru,
where I just started working, all the way up Latin America,
across the Caribbean, another disaster. Unknown in Haiti, as
far as we can tell. But the difference
between 1991 and 2010, was that there were new
tools for the diagnosis and prevention of cholera. Old tools for the
care of cholera, but there were some new tools,
too, including an oral cholera vaccine. So that is what I mean about– I know that it doesn’t sound
like a punch line but I’m just saying, therefore, in the view
of those acknowledging that transnational global economy–
which should be all of us, since we’re all part of it– there were tools. And just to say, well, they’re
not cost-effective, available. And that’s exactly
what happened, even though people like Louise
and her Haitian colleagues fought like hell to make
sure that that didn’t happen. But it did. Now who were the people
we were arguing with? No more Haitians who
were running away like superstitious peasants. Again, the accusations of
the colonial authorities across Africa. It was our own peers, again. That is people who had
trained with and like us, who looked like us, who
sounded like us, regardless of what language they
were speaking, by the way. To me, that’s disparities,
and bias in global health. So how did it get into them? How did it get into us? And it is, obviously, through
our professional socialization. If it’s not an
18-year-old, it’s not going to give you a lecture
about whether or not an oral cholera
vaccine is effective, cost-effective, sustainable, or
might possibly distract people from washing their hands. That’s exactly the
kind of discussion that we expected and heard. So that bias, and
that ability to judge what people should and
shouldn’t have access to, or who is deserving and not
deserving is another way to think about it. How do you counter that? In medical education, we train
our students, be they nursing, or dental, or physicians. But how do we also counter
that in the faculty that train the students? Well, I would argue– and again,
I love how this has turned into Joan revealing Paul’s– Why not? –uncertainty. But I’m not trying to sound
like a guru, and you know that. And I don’t know the
answers to these questions. But I do not think the
answer to that question can be only by understanding
health disparities, and their distribution. Now an 18-year-old
probably could guess what the city of Baltimore
might look like in terms of health disparities. And that’s an important
task, to learn about the burden of disease
and health disparities. But if there’s a
materiality of the social, then the response has to
include activism, engagement, to counter the inequalities. And the history. Understanding the history. So part of this is this
history in context. That can fuel us. Right. Then understanding that. But there’s a part
of this for me of, how do you get to this
core of somebody who’s trying to understand
what they themselves are bringing to the table? That it’s not all outside. But these biases, these
stereotypes, these views, I’m carrying into
my deliberations. I’m carrying, and oftentimes,
making the problem worse. How do you build that
capacity for self-reflection? Well, if we had been
successful then we wouldn’t be having arguments
with our own peers, because they’re the very
people you’re talking about. I know some of the
ways that don’t work. Sarcasm, calling
people out by name, which is why I was
a little embarrassed when I did that on that
film you saw last week. Gina probably hasn’t seen it. She’d say, naughty, Paul. So you could be– I mean, Muhammad Ali would
just knock them out, right? But to be effective–
in other words, if we’re just trying to win
the argument, we’ll win. But that’s a very hollow sense
of satisfaction [INAUDIBLE] of winning an argument, when
you’re trying to change. So you just brought up
self-reflection, and awareness, and the cultivation
of discernment. I’ve heard you do it
before, and that’s what you’re talking about. That’s got to be
a big part of it. And it’s hard. It’s hard as– I find it difficult.
And I noticed that when we bring this up
among first-year students in our social medicine class,
one of the first things we hear is, oh, we already
know about bias. We already know about
racial disparities. I know the definition. And we would never do that. And yet, somehow we do. And so and then it’s
probably too cheap to say, well, structured German. There’s nothing we
can do about it. So I want to challenge
you on one part, because you mentioned
what doesn’t work. But what happens when you don’t
name the elephant in the room? I shouldn’t have said it doesn’t
work, because we can all find examples in which it does work. And one of the ones
that has struck me most is AIDS activists, taking
precisely those tactics. But they also
complemented their efforts with the pragmatic
solidarity of thinking about the provision of care. And again, this at a time
when some people were just willing to write off
the provision of care. And not just in Africa. This happened in
Mississippi, Louisiana. There were state lotteries
for these new medications. I could go right
through the list. So it’s not just
about over there. So that’s, to me, a
very important model. And being strategic
in naming it. So I think about when I
turn on the television or look at my
smartphone, and see the divisiveness, and the
anger, and the disrespect, and the devaluing
of individuals. And in that space, what
happens if you don’t name it? If you don’t call it out. And what are the
risks that are there? So I understand being sort
of strategic and tactful. But are there moments
when you have to just say, this is wrong, or you’re wrong? Yeah. I think it probably
happens on a daily basis. Now avoiding sanctimony,
or smacking of it, is another challenge. But at some point
after the Civil War, reconstruction fell apart. At some point after
the Civil War, Jim Crow came and placed– those
Confederate statues weren’t put up by grieving widows in 1866. Those were the
work of legislators and white supremacists, who
not only had local backing, but translocal backing. In other words, if President
Grant said, no, we’re not going to let this
happen– which, evidently, he did– somebody later said,
it takes a long time. And so I think naming problems–
we’re talking about that one– is an important part
of this undoing. And that’s a very
commonplace thing to hear. Do some reconciliation in
South Africa, gacaca in Rwanda. But I’ve seen some
pretty remarkable things happen in Rwanda in a
fairly short amount of time. And I guess that’s why some of
what I’ve been seeing with this divisive– or feeling, rather– what we’ve been
seeing as Americans, has been, in addition to
maddening, it’s been saddening. It’s very sad. It’s very tragic. And then you
realize, look, if we don’t go through more
personal discernment, or if the medical
profession says, well, that’s not really us. It’s not really our job. That obviously, we’re not going
to move forward quickly enough. I think that, and
understanding– We’ll step backwards. –a couple of things. One, the importance
of coalitions. And sometimes those
movements of medicine come outside of medicine. So as we look
back, and you trace this sort of history
of civil rights, and justice, and medicine,
it wasn’t medicine that integrated the hospitals. It wasn’t medicine
that said, we’ll give blacks privileges
in our hospitals. It was a legal
system that came in. And so sometimes
medicine, as much as we may talk about
equity, and justice, and those types
of things, we need pushes from outside to act. Absolutely. And if you look at the
assault on affirmative action, which is an ideological
and legal assault, the fact that there exists any– Thurgood Marshall’s
dissenting opinion after one of those reverse
discrimination judgments from the Supreme Court, was– I’m sure all mangled up,
but the basic idea was it’s just bizarre to assert that
there is no legal remedy needed to undo something that has
been going on, which is– he was talking about the
institutional racism that’s been going on for
hundreds of years. And it’s absurd, likewise,
to assume that we don’t need, as you said, broad coalitions. And to think about all the
remedies at our disposal. A lot of our work has
been broad coalitions that include community
health workers, women’s groups, peasant cooperatives,
et cetera et cetera. It’s also– if we work in a
prison in Rwanda– we were talking about prison health this
morning, your early engagement. There’s only two ways to
get into a Siberian prison. Let me put it that way. For a doctor. And I prefer only
one of those two. And that involves
make a coalition not just with the
legal authorities, but with the
Ministry of Justice. That’s what they call their
national legal system. And anybody who’s been
successful in global health– and I’ve already said, I don’t
think we’re very successful. I don’t think we’re
very successful. But anyone who’s been
successful on a modest level, knows there’s no other way
to do it than coalitions. And coalitions are hard. And they’re frustrating. They’re also the only
way for it, though. I can’t imagine any
ranking problem, even in a resource-rich
city like this one– any ranking problem in
disparities and bias that isn’t going
to require that. And I think with that, as you
talk about community work, is this understanding
of you have these different methodologies,
different kinds of expertise you bring to bear,
but people with very different perspectives. So how does the community,
how do our patients, how do they bring their
understanding of the issues as we come up with our grand
solutions, that may or may not be on target with what
our community needs? Well, you and I, again,
agree entirely on this. I wanted to just give an example
that you already know about, but many will not. I just came from a meeting with
Michelle Morris, faculty member at HMS, at Brigham. And she, and some others started
this group called Equal Health. And it’s related to a
number of other endeavors in social medicine,
which is obviously a term that I care about. And that my
colleagues, and I hope the students here care about,
because they have to take it. This is one of the few medical
schools in the United States where those are required
in the curriculum. Looking at health
disparities and thinking through the social
determinants of ill health, or good health, but also,
the social determinants of distribution of access
to diagnosis and care. And again, it’s the
fruits of basic science. And this group, Equal
Health, proceeded along precisely those lines. That yeah, they were
mostly physicians and medical students,
but they weren’t mostly from the United States. When I saw a huge gathering
of this last social medicine meeting– well, not the last one. One of the earlier ones– there must have been 700 people
there, including people I knew quite well from Rwanda,
and Haiti, and all over. Mostly the United
States, but all over. But that’s not the diversity
that you were talking about. That’s not a
professional diversity. Those are physicians, and
physicians in training, and some other
health professionals. But that required
sitting and listening to people in where they
live or where they work, which we often describe
as “the community.” Most social scientists
don’t say “the community” because Harvard Medical
School is a community as well. Quad, for example. Anyway, it’s just that
that work, where you say, well, we’re lucky
that we get to go to medical school, or nursing
school, or graduate school, whatever. And we know that we
are in institutions that are reflecting these global
biases, and national biases– national being part of global– but we’re going to take
active steps to counter them. There was that
personal reflection that you’re talking
about, and often do. That collective reflection
as professionals, but then also shutting up
and listening to people. And that kind of
reverent attention is easy to talk about in
medicine, and hard to do. But that’s supposed
to be what we do. Same with
anthropologists, right? It’s either you talk about,
I’m going to be quiet and– And just listen. And just listen. But it’s very important. What are the ways we can help
our institutions understand the values of things
we’re talking about, and move them in this direction? So there’s a part of this
understanding this diversity, and there’s all
types of diversity. But often, that’s
not reflected in who we see within our institutions
as we look at our leadership, as we look at our faculty. Our student body at
Harvard Medical School is wonderfully diverse, but it’s
not reflected across the board. How do we move in a direction
so that that diversity and that inclusion
is truly valued, and we get the full benefits? Well, one thing I
just want to say. I think it’s only fitting for
me to start answering that. I mean, you already 89% of what
I’m going to say, if not 94. But for the benefit
of the exercise, I always try to start by
saying, Harvard Medical School has given me everything. If I had not been a
scholarship student at HMS, I would certainly not have
been able to do an MD-PhD here, and then go to the
Brigham, and then serve right on the faculty. So that’s my first
thing I want to say, and I would recommend
it to others. And I’m talking about
others who define themselves not as some nice,
little, white guy. That starting with gratitude
for your own good fortune is a big part of that reflection
that you always recommend to us, to your Fellows. That’s the main thing,
is we’re already– It’s privilege. We’re already these
incredibly privileged people no matter what our background. And I also think
that gratitude only makes it easier to be a voice
within a privileged institution for change within it. But I just want
to start that way. And not because we’re in the
Joseph Martin conference room, and Joseph Martin’s here. Really. I swear. I said this before he was dean. It’s just I feel like
I owe everything. Now that said, there’s
no buts, but next. Clearly, if we can celebrate the
diversity of the student body– and it’s varied kinds
of diversity, as no one knows better than the
dean who is tasked with thinking it through. Sometimes there is a
lack of class diversity. And that’s only going to
be addressed by active case finding, as the School of
Public Health people might say. And I know there are
some of you here. It’s interesting. Because even as you talk about
that, many of our students are very– they’re different generation. And they feel like
they are the only ones. And as we’ve talked about it
more, there are many of us. As you talk about your journey
here, and lack of privilege but privilege in being able
to come here and move forward. As I think about my journey,
and my family’s journey. As I talk to more
and more faculty, their stories aren’t told,
and there’s this myth of who’s here sometimes. And I’m wondering if there are
ways for us to be more open and sharing about who we
are, and how we got here. And that might help
our students to be more open to exploring
their own sort of journeys, and this concept
of self-reflection. We try to put on a
Harvard professor facade, and then behind
it is who you were when you grew up, and your
family, and the rest of it. And so really trying
to find a space to have those kind
of conversations. I think it’s about time to
open it up to some questions or comments from everyone. There’s microphones here. While you shy people
are coming forth, I think there are
reasons for someone like me to also mistrust. Again, I’ve just been
preaching– preach, for Reverend. Listening. But you’re right. Maybe it is helpful. I know that I’ve learned
a lot from listening to medical students,
from listening to people at the Brigham. I’m talking about my colleagues. Again, starting with your own
privilege, if at all possible. And for us, it
should be possible. Because I keep saying– I keep thinking. I often don’t say it, but
I’m going to say it here. Sometimes the discussions that
I’ve heard within universities, research universities–
not just this one– the discussions are happening
as if they’re cut off from the rest of the world. And I think that’s part of
the pathogenic force, not part of the solution. And if you define
your institution as the quad, or a hospital, the
faculty of Arts and Science– I’m not talking about this
one only, but any place. I went to Duke, and I
still involved Duke, again, with the same kind of gratitude. And I’ve just heard some of
these internal discussions, and I keep thinking–
what on earth would someone living in a
squatter settlement in Haiti think of this discussion? So divorced from the
rest of the world. And you don’t always
get lot of applause when you say that in the middle
of a meeting about student faculty diversity,
or Med school. And again, that that
could just reflect a lack of Ali-esque courage,
for saying it anyway. That, and understanding
that the faculty, the students, our
trainees residents, are not the only ones
in the institutions who could help us understand. So if we look at our staff,
if we look at everyone from the custodial, to the
park, and the others who help make our institutions work, and
having conversations with them about their real lives. So if I think about
some of our programs where individuals
on our staff are able to bring their
children into programs, and to see their children
having the potential to be a future doctor, or
a future whatever. So how do we break down
some of the bridges in our own institution? You have somebody
on the microphone? Thanks, Dr. Reede
and Dr. Farmer. Early in the Ebola response,
one of our colleagues, when asked in an interview to
describe the Ebola response up until that point– I’m talking maybe July
or August of 2014– she described it very
appropriately as racist. Period. And I think caught a
lot of grief from that. Certainly not from our
groups, but otherwise. Can you talk about– and I think she was
saying that in a way to address this idea of
disparity within global health, and Ebola specifically. Can you talk about the moment
within the Ebola response that the global community
started to take interest, and started to decide it was a
problem worth their addressing? Thanks. Is that like a set-up, John? So I get to give a disposition? Yes, please. Because I will Happily do it. Yes, please. And my students here know. And my colleague. It’s a great question
and I’m going to try to be brief,
but not too, too brief. Because this is the
kind of complexity that we just don’t
have the time– I mean, we’re not given the time
to address in global health, as many of you will
be thinking of it. But in that particular instance
of the current West African epidemic– the 2013, 2016– this is,
to me, an overlooked point. What did we hear that summer? By the way, I only knew
four Sierra Leoneans in June of 2014. One of them in Harvard
Medical School. The other three, also doctors. Four doctors. By November, two
were dead of Ebola. And no white American stricken
with Ebola died of Ebola. And that’s because
they were airlifted out of that clinical desert here. But what you asked, John,
is when did it start. Well, first of all, the claim
that it was new to West Africa. How about you,
like an HMS student who you know, Cameron
[INAUDIBLE],, how about just go on to Google
Scholar and find out that there are
several papers showing that it was already present
in Liberia and Sierra Leone? I understand why– I’m just guessing the
colleague you’re referring to. Why is it permissible to not
even get that part right? That it was not new, or that
the retrospective stories that were held up to be the origin
stories, that there really were not ever confirmed. Because there’s no way
of confirming things in a public health
and clinical desert. So all the way through was– or it’s looking at the previous
ones, the previous epidemics of Ebola– it’s a good way, again,
to reflect on disparities. And they’re very subtle. What you’re looking for me
to say, and then I will stop, is that when it becomes a threat
to us that the world reacts. And the other part
is how do we react? We react with a disease
control paradigm. Not with the care paradigm. It’s a disease of caregivers. That’s why it’s spread. Because people care
about each other. Nursing and last rites. That’s the last step
of caregiving, right? Burying the dead. You don’t have to be
a Catholic to know that that’s one of the seven
corporal works of mercy. Anyway, so I
personally would argue that a disease control over
care response is racist. Now how do you say that
effectively and not alienate the very colleagues of
yours– mine, anyway– who are totally
accustomed to doing things like that in Africa,
and have been since the end of
the 19th century? That wouldn’t fly here. You’d say Tuskegee. It did fly here. That’s a control
over care example. When I say, it wouldn’t fly, it
flies, but then you get busted. Hopefully. Hopefully. And I’m not even sure
that we got busted yet, as far as West
Africa and Ebola go. Not that I feel strongly on it. It’s interesting that racism
is such a charged word and we’re so afraid to
say it, or to acknowledge its existence. And so we push it
aside, which gives it even more power because
it’s still present, but we’re not doing anything
about it or acknowledging it. We were talking
before, and we were talking about this concept
of something that’s sort of caged, being better
than something that’s let loose. And when I thought about
that was the problem– when you think
something is caged, and you think it’s solved,
and then you it’s put away, is that you can start to
forget that it’s dangerous and it hurts. And so when I think about
some of the issues of racism and these other issues,
particularly in the United States, and what we’re
seeing today, where there’s this surprise that it’s there. It was always there,
and it’s let loose. But that allows us
to be able to name it and to do something about it. Maybe we need more spaces
where we can talk about racism, and not feel the sense
that we’re being– somebody is talking about us,
rather than about something that just exists. Hi. Thank you for allowing us all
to witness this conversation. I feel very privileged to
be in this space right now. I just have a question
maybe going back to the idea of just
global health at its core. Because when I hear
global health outreach, American global health outreach,
I think US imperialism. You think what? US imperialism. So I guess my question is, if
we’re thinking about things in a framework of
community organizing, and this idea of
working with, and not on behalf of
communities, how do you ensure that you, as a white
man, you as someone working from an American organization,
are working with, and not on behalf of? And how do you navigate that
in a space that isn’t actually your own? Yup. Well, I’m going to
take that as a– I know that is a
sincere question, and so I don’t want to
sound overly technical, especially after Joan’s
soul-ripping suggestion just now, which I
hope you all heard. That is the beast wasn’t
caged, it never was. And maybe it’d be better if
we just didn’t fool ourselves. The technical response–
first of all, this is a question that I hear
very often, almost always in an American University. It’s not something I bump
into in Haiti or Sierra Leone. That doesn’t mean it isn’t
being said, although I would be shocked to believe
that the people I’ve lived with for that long
in Haiti, who are unable to hold their tongues
on many other subjects, would. But I don’t know about Rwanda,
even though I lived there for 10 years. So it is also interesting to me
given Joan’s comment just now about why we don’t talk
about this more openly here, that that question
about identity politics, I routinely hear in
American universities. And pretty much only. And I’m not just saying
that as as my reporting, where I hear certain
questions and where I don’t. Is that fair enough? But what you said about it’s
an American organization is actually not the case. Partners in Health
was set up as a– if you go back and look at– and I assume you’re talking
about Partners in Health and not the other
organizations I belong to, like Harvard Medical
School, the Brigham Women’s hospital. They’re actually set up as
sister organizations, not as daughter organizations. When we were starting
this organization, the Haitians we work with
had already started it. And the Haitian sister
organization is called [NON-ENGLISH],, which
means “partners in health” in Haitian Creole. And in Rwanda it’s
[NON-ENGLISH],, which means “partners
in health” in Rwanda, which I’m sure you
all speak fluently. So my point is that is baked
in, at least an an idea. Now how do you do
that without erasing history and political economy? That’s my ponderous and
clumsy way of putting it. But to talk about community,
organizing communities already stripped of resources
is erasing history. If you talk to Alabama
sharecroppers who were involved in a non-treatment experiment– neuros syphilis or complications
of syphilis, and saying, all right, we need to organize
within our communities. But their community includes
the medical institutions that designed this
program, and would continue to do so until the Atlantic
Constitution exposed it, I think, Alan Branislav in 1972. So the word “community,” as
I said, is a tricky word. But shutting up and
listening is not that tricky. I’m not saying I’m
good at it, as you can guess by my
long-winded answers, but there’s two
different things. So a social justice
approach to global health, as opposed to an
empire-focused approach. You just said US imperialism. And I just described what I– disease control over care,
control over care paradigms was born in the
late 19th century. Born how? Out of colonialism. I’m not denying that that’s
the roots of many health interventions. I just don’t think that’s where
global health equity comes from. I think that’s a rupture
with those paradigms. And again, I would credit
activism, and particularly AIDS activists, with
helping to break that. If I may, when I
came here, again, feeling like the luckiest person
in the world, which I was, I made a really
adventurous trip. Not from Harvard to Haiti or
back, but all the way across the courtyard to the
Harvard School of Public Health for a class,
which actually, most medical students didn’t do. I took a class
there, thinking well, this is where you’re going
to learn about what was then called International Health. We actually had clubs called
the International Health club. It’s not a very critical
way to think about it. What nation? What empire? Where’s the role of equity? Organizing? Activism? These are some of the
things you’re asking. And that was where I learned,
at least for me personally, about the peril of erasing
history in political economy. Because the recommendations
that something wasn’t cost-effective,
sustainable, or you could even do this
community interviews, and surveys. You could listen to
what people said, and then ignore it as policy. That was very much
the case in the 80s. So for me, global health
is global health equity. Not global international
health as constituted in the area of structural
adjustment et cetera. I don’t want to
sound like a windbag. I am, but I don’t want
to sound like one. This is the rupture
fighting back with redistribution
of resources, acknowledgment of
historical past, acknowledgement of
historical injustices, acknowledgement of things
like institutionalized racism. That’s what global
health should be about. And that’s why I think we should
just call it global health equity, and not global health. Love, Paul. I have a Twitter question. Twitter question. And it says, how do we
allocate efforts to the quote, “right people,”
places, et cetera, and control for systemic biases? Well, I’m focusing today
on our own systemic biases. So I’ve just described again,
and again, these fatal errors are not made by poor people
facing huge burdens of disease. I’m looking at it
wherever Twitter is. I haven’t quite
figured that out, although we have rude and
regular reminders these days. Since I’ve already said– I’m talking about us, right? This is about as often
and openly as I can. I think that, again, there are
sort of quasi technical answers to that. And one of them is to understand
the burden of disease. Like where does this burden
of disease sit most heavily? 19th century social medicine
folks figured that out. Berkow, et cetera. And the second, though, is in
this era of real possibility, given that now, thanks to
actually biomedical research– basic science research– if
you think of these three– I’m looking at you. This is what you’ve been
fighting for your whole life. Not to say we don’t care
about basic science research, but to say, we want it
to be justly distributed. We want our people, however– not however we mean our people. We want our people,
really, to participate in the production of
scientific knowledge and care. By the way, that’s another big
part of it, to your question. One of the other
ways to do that, is actually to listen to
people that say, hey, I want to be a doctor, or
a nurse, or a researcher. That happens every day in the
places we work in Africa, just like it does here. But to get back to this
formulaic response, and then I’ll hush up
again, understanding the burden of disease
is not enough. Understanding to understand
disparities and bias, you have to look at gaps. And you have to
go look for them. Because you could say, well– and again, this is
right here in Harvard. Just look at the
historical record to say that the three
leading infectious killers of young adults in the
world in the year 2000, they were HIV, TB, and malaria. That’s not the burden of
disease in Boston anymore, or in the Mississippi Valley. It is on that continent, and
in particular parts of it. So there you got number
one, two, and three. For none of them is there
a effective vaccine? Where is that
going to come from? Basic science research. For none of them was there
readily-available rapid diagnostics that
would require more? They exist. The platforms exist, but this
distribution is critical. And then third, we
had our peers saying, it’s not cost effective, not
sustainable, not realistic, not– again, I never heard anyone
in Africa who had HIV disease, AIDS say that. But it was coming from us. So again, just like
where you haven’t yet been busted on Ebola– back to John’s question– I think we should reckon
with that it can only be– if you just say “racist” at
the end of the conversation, it’s the beginning
of the conversation. It does reflect,
and must reflect in the global political
economy the belief that some people’s lives
are worth less than others. What else could it be? Of course, then you get
told, lectured, well, no it’s just that we’re living in a
world of limited resources. But they’re more
limited for some people, and unlimited for other. It’s the same world. And some of what might
impact that is having some of those individuals
represented in the discussions, and the decision-making, and the
allocation of those resources. And that’s exactly
what AIDS activists helped us to recognize. Survivorship, whether you’re
talking about breast cancer, or– we have to embrace that openly. And then you look at
survivorship in cancer, for example, and you
see there’s again, a preponderance of these
same social disparities among survivors for
various reasons. But also among those who
are engaged in survivorship. It’s not like there’s any way
of getting away from that basic “the beast was never
caged” question. You were waiting longer. Thank you so much. Thank you for this
great conversation. I was really excited when I
saw the title of this talk, because having lived in Rwanda,
providing care there with HRH, I felt like every week we had
a new kind of organization coming in providing aid in
one way or another, visiting. And there’s so
much kind of racism embedded in the way
they come in and help, in a very different model
than PIH is providing. My question is around– global health has become
so popular now in medicine. I think largely as a
result of your advocacy, and leadership on the subject. And we have all of these
trainees, students, residents, Fellows, wanting to go abroad
and do global health rotations. How do we make sure that
the rotations that we’re sending them abroad for
are done in a way that’s really sensitive to that
bias and racism that’s present in a lot of that global
health work that’s happening? We’re sending them out there
not necessarily with US faculty to observe. Not even necessarily with
trusted local faculty to observe. And they’re often
going in kind of– and they’re excited because
they get to see new diseases, and try procedures they would
never get to try at home. I feel really strongly
while I was abroad never to do anything outside
of my scope of practice. I felt like, ethically, I
wasn’t there to kind of try new sexy things. But I’ve talked to
leaders in global health even here in Boston, who
are very senior, saying, I opened the book and the
child had no better option, and so I did the
surgery on the child. I think that that wouldn’t
happen if that child was white. I think that we’re
kind of experimenting on black and brown kids. And how do we
address that racism, as we’re sending
more and more people out to these global
health opportunities, and training them for a
career in global health? Thanks. Well, let me make three points. Don’t worry. First of all, again,
we’re saying that– I believe we’re both saying that
we don’t think of global health as something over there. So that needs– again,
one of the minor problems of international health as
constituted in the 70s and 80s. In other words, there are
lots of major problems. But we don’t even
share, yet, an analysis of what global health means. Which is why we ought to keep
thinking of it as global, and adding the “E” word,
equity, every time. Because then we’ll
be making it clear– back to the wonderful question
that was asked about how do you do this to avoid it. Getting back to
[INAUDIBLE],, I would say that it is really
a good exercise for us to recognize those
same sins in ourselves. I certainly know the unseemly
excitement of seeing something new, the unseemly desire to
do something that I wouldn’t– where I get to feel like
I did something heroic. So that’s an important
part of the process if I’m reading you right. Is that the self-reflection,
we’ll see that in ourselves. At least I see it in myself. And I’m ashamed of it, but
I’m very familiar with it. The third part is,
again, you can’t do what you’re calling us
to do without acknowledging that history has
already happened. History which is what– we’re living in the aftermath. Whether you have
Charlottesville, or the Human Resource for
Health project in Rwanda. And again, what
would be good, and I try to do it in my
limited interaction with– too limited interaction
with faculty, said, this is going to happen,
and on their first beginning, as part of their orientation. I said, this is going to happen
and it’s not going to be good. But one of the things
about listening, is in addition to listening
to people afflicted by poverty and disease, the so-called
community, which again– we’re part of the
medical community and our colleagues,
various colleagues, had a lot to say about this,
our colleagues in [INAUDIBLE].. I think listening
to them is good, and it’s not like they’re
speaking with one voice. But those are three
things that I would add– is global health is global. I recognize anything that you
could say, no matter how bad. I’ll recognize it in
myself as an exercise because it’s an important one. And third, health disparities
are already profound. So a child with a acute abdomen,
having one of us– not you. But one of us said,
well, I would never do this in that part of
the political economy, but I’m doing it here. We should acknowledge,
then, that there will be a very
good chance that we get to feel good about
something that’s still going to result in a death. And that’s a very hard
process, especially when you’re trying to bridge– this is a Harvard Medical
School backed program, that I think has bridged the
most stunning divide, much more than Harvard in Haiti, actually. And that was Harvard
Rwanda in recent years. Now that divide has
been lessened by people like you going to serve there. And the right way to
do it, in my view, is not as like me, a
23-year-old in-between college and medical school,
but faculty as well. The people who are
experienced, and at the height of their powers clinically,
working collegially with Rwandan professionals. And raising the
Rwandan, and increasing the capacity for
Rwandan professionals to act on their own behalf. Exactly. And be a part of it In a way, I’m just
saying I think you’re choosing one of the least
racist global health programs. [INAUDIBLE] No, I know. I know you weren’t. I’m just saying that
is something Harvard Medical should be proud of. I just was saying to one
of Gina Vild’s colleagues that this is like the
dean’s report ought to have a whole– it’s an
amazing kind of engagement. I have gotten the wrap-up. But wait, I’m just
getting started. I came all the way– And I know you’re
just getting started. But I have also
gotten the wrap-up. And want to– Hey, you’re a dean, too. You can just fight right back. I’m a dean and an
African-American woman. Now I’ve been told
I can take orders from all different places. This side of the
room I’m wrapping up, and this side of the room I
can take one more question. So one more question. OK. Thank you. Thank you. So to that point is
a question about kind of channeling power for good. Common scenario. A person of means,
a celebrity, shines a light on a global issue,
and the funds come in, and the resources go at it. Can you speak to how
to channel that power while being mindful of bias? And I guess there’s a
danger in sort of following the celebrity to the cause. How can we spread
that mindfulness out and be more equitable about it? Spread the mindfulness out. God, You guys are tough. Meaning, I don’t know. I wish I did. I’m doing my best up here, OK. I get uncomfortable with that. So it’s kind of– to the question about HRH,
human resources for help, that was a great question
that she just asked. I’m talking to you over there. Where did you go? Sam? I’m saying I’m praising you. This discomfort
that I may feel when there’s a celebrity-directed
Angelie-style approach to something– it’s really not about me. It’s really not about us. I do still feel
uncomfortable, just like I feel uncomfortable
about the unseemly enthusiasm that I saw in myself, and
see in my American colleagues when they suddenly show
up in the clinical desert like, where’d you been, surgeon? But I’m glad they’re there. And I’m glad we’re there. And I’m glad that
there is someone there. Now the next question is, OK. This makes me uncomfortable,
makes you uncomfortable, makes you uncomfortable. Why? And again, that’s restoring
history to understand that. I don’t understand
celebrity culture. Even though I tried
for many years to read the Journal
of Popular Studies– people– I don’t
understand how that works. There are sociologists,
anthropologists, and psychologists
who do study that. But I am very reluctant
to be entirely dismissive, and sanctimonious,
and to above that, and I don’t want
to be close to it. But it’s not about how I feel. Because it’s about a
materiality of the social. Again, it’s about a
fact of disparity. So if a celebrity
fights to ban landmines, or to eradicate
polio, or to take on breast cancer in Uganda,
I would be very, very careful to understand that I don’t
have breast cancer in Rwanda, and I don’t have polio,
and I do have clean water. Thank you, Matt Damon. You know what I’m saying? I worry about, again, our
university-based ethics, that kind of race history and– not yours, but I’m
saying it is something I’ve seen a lot in
privileged institutions. Let’s go to the corporate world. To have a workshop on diversity,
of course they all have– they can all afford those
kind of workshops ad nauseam, if that’s not mean to say. But that doesn’t mean that
a corporation is actually– it may have a diversity inside. And which they
don’t, by the way. But it doesn’t
mean that changing the makeup of, let’s say,
the board of directors, is going to alter
a fundamentally extracted process. And I think that requires
hard-nosed analysis. And I would try and do it, or
be part of a team that does it, or fields questions from
people who might be affected. And so that’s why
I would, again, try to shut up and
hold my tongue, and sort through
something that involves celebrity-based addressing of
our attention deficit disorder. So social suffering,
and poverty, and structural violence. And again, I know that’s
not a short answer, but I’m just explaining
my own caution. When you say, well, the beast
has never been in the cage and we all need to address it,
another way of saying it is– and President Obama said this
at the end of his service– is that we really need
to be happy warriors. Like we’re fighting
for social justice, our own grumpiness is
not really the point. He didn’t say all
that, but that’s how I would interpret it. And I would say the same about
celebrity-based ADD treatment. It doesn’t last
long, but sometimes you get a chance to pull
a lever where people– I’m more comfortable working
with activists, who are going to be at this for years. Thank you. So no more questions. I thank you for your– I’ll stay around, though. For those of you standing,
I’ll stay around. I didn’t mean to interrupt you. Thank you for your attention. I think– [APPLAUSE] Part of what I would say is that
all of us have a role to play. And sometimes before critiquing
other people’s roles, we need to step back
and look at our own. And you don’t always know
another person’s heart, or mind, or intent. And it’s actually together,
that we’re able to accomplish. There’s a saying I
got from my mother. That “I” is like the “I”
in the word “individual.” And “we”– W-E– is like the “we” in power. And it’s when the
“we” come together that you can actually have
the power to create change. And so it’s how do we work
together to create the change. And so I want to thank Paul. I want to thank my
friend for this. I want to thank Harvard and
[email protected] for this opportunity for us to have this dialogue. And I’m going to
end with a quote from somebody that, in no way,
makes me think of disparities, bias, or social justice. But they said something
that I think makes sense. And I’m going to
quote Henry Ford. Doesn’t come to
mind in this space. And Henry Ford said, “Whether
you think you can, or you think you can’t, you’re right.” And we’ve talked
about these, what can seem daunting problems
and daunting issues. And part of this is
your frame of mind. Part of this is being
a happy warrior. Part of this is
being willing to take on the problems and
issues, and create the change that’s needed. And that’s what we
all need to be about. Thank you, Paul. [APPLAUSE] You’re welcome.

Daniel Yohans

2 thoughts on “[email protected]: Disparities & Bias in Global Health

  1. Ana Carolina FigueMe says:

    I want study in harvard,is a dream

  2. Service Center Gurgaon says:

    The world is facing disease outbreaks like Ebola, measles, drug-resistant pathogens, health impacts of environmental pollution and climate change and multiple humanitarian crises.

    https://www.youtube.com/watch?time_continue=47&v=fw83yTt8OPs

Leave a Reply

Your email address will not be published. Required fields are marked *