Against nihilism: transformative human rights praxis for the future of global health
If we recognize that global health has colonial origins, we must also acknowledge that it remains deeply embedded in, and shaped by, interlocking systems of power.
In commemoration of Dr. Paul Farmer, who recently passed away at the age of 62, we would like to re-share this article to uphold the legacy of his work on public health and human rights.
The sweeping devastation wrought by the COVID-19 pandemic creates an imperative to disrupt ‘business as usual,’ especially for health and human rights advocates. Transformative human rights praxis relies on forging new strategies when old ones fall short, which in turn requires critical evaluation of the ideologies that undergird our responses to the social problems of our time.
In relation to the right to health, if we recognize that global health has colonial origins, we must also acknowledge that it remains deeply embedded in, and shaped by, interlocking systems of power—patriarchy, racism, coloniality, neoliberalism, and exploitative commerce, among others. These systems are reflected in laws and policies, as well as in research, programming, and clinical practices, and they breed a pervasive nihilism about our capacity to effect rapid and meaningful change. Even now, well over a year since COVID-19 was declared a global pandemic, the greatest obstacles to health justice stem not from a novel pathogen, but from the pathogenic forces of apathy, cynicism, marginalization, and historical amnesia that drive us to accept the suffering of the poor as inevitable misfortunes to be endured, as opposed to injustices to be cured.
‘Speaking truth to power’ demands an understanding of the evolving nature of power, and the uneven ways in which it sustains human rights abuses. Pathologies of power generate scandalous inequities in health not only—or even primarily—through observable rights violations committed by tyrannical governments, but through more insidious, structural means. Strategies that rely on denouncing overt abuses of power or urging governments to adopt “human rights-based approaches” to health are thus ill-suited to challenging the opaque mechanisms through which global health agendas are set and our collective imaginations colonized. To subvert such mechanisms, we must first interrogate how “truth” and “knowledge” are constructed in global health, and what purposes their construction serves. Second, we must resist top-down, technical fixes and call for collective action that spans disciplines, movements, populations, and borders.
‘Speaking truth to power’ demands an understanding of the evolving nature of power, and the uneven ways in which it sustains human rights abuses.
During the COVID-19 pandemic, we have seen stunning levels of public health nihilism in the United States. Tried-and-true tools of public health, from contact tracing to supported isolation and quarantine, were summarily dismissed as “too late” and “too difficult” to implement, despite evidence of their utility in settings across the world. Neither the federal government nor the overwhelming majority of state governments invested early in shoring up public health systems, which had already been enfeebled through decades of underfunding. Instead, passivity prevailed, allowing the virus to invade the cracks and fissures of society and leaving the poor and otherwise marginalized to fend for themselves.
The arrival of safe and effective vaccines for the prevention of COVID-19 has inspired hope in a time in which it’s sorely needed. But this optimism is tempered by vast disparities in access to these tools, and by the emergence of a nihilistic narrative arguing that poor people in poor countries should just be patient and wait for their turn, which will come once the rest of the world is vaccinated.
The COVAX facility, established by the World Health Organization and partners to pool procurement and coordinate distribution of COVID-19 vaccines has the goal of supplying up to 20% of need in 92 low- and middle-income countries. Yet even this limited goal may now be out of reach thanks to wealthy nations that have used their economic and political power to monopolize the global vaccine supply. Some have rightly recommended that wealthy countries donate excess vaccines to poorer ones. However, the “catastrophic moral failure” of vaccine nationalism reflects a much deeper injustice embedded within our global governance structures. A starkly colonialist mentality, institutionalized in the political economy of global health, endures in the rich world, emphasizing solutions based on charity alone, while obscuring ones rooted in justice.
The fastest way to accelerate access to COVID-19 vaccines is to dramatically increase their supply. This is eminently achievable if the know-how and incentive structures for manufacturing them were shared. The World Health Organization’s COVID-19 Technology Access Pool was designed to promote such sharing but has been sidelined by pharmaceutical corporations and the governments that have funded much of their research and development. As of this writing, over a hundred countries have backed a proposal for the World Trade Organization to temporarily waive intellectual property protections on COVID-19 vaccines, diagnostics, and therapeutics, and the Biden Administration has signalled its willingness to enter into text-based discussions on a waiver of patents on vaccines. The handful of governments that continue to block the waiver in its entirety are upholding a system of corporate monopolies that does not serve the interests of people in wealthy countries and denies the global poor access to life-saving clinical technologies in the midst of a global pandemic.
Just as our initial response to COVID-19 was impeded by nihilistic claims that it was “too late” to perform prompt testing and contact tracing, so too are we now hearing that it is “too hard” to boost vaccine production to meet the global need. This alleged impossibility lacks both moral and empirical backing. The US government alone has the power to incentivize transfers of know-how and expand vaccine production capacity significantly through the Defense Production Act, which it has already used domestically during the pandemic.
More broadly, the pandemic provides an opportunity to decentralize manufacturing capacity in global health, moving us closer toward a redistribution of power and resources, which should be the goal of health and human rights advocates. As Yale law professor Amy Kapczynski notes, transformative approaches to human rights require “attention to the structural changes that are needed to reform our political economy, and to provide the infrastructure for fair provision, locally and globally, that neoliberal legality has steadfastly opposed.”
We’ve been here before. Not long ago, the “expert” purveyors of the status quo argued that the delivery of antiretroviral therapy for AIDS was neither cost-effective nor feasible in settings of privation. But a broad coalition of actors—activists, clinicians, scientists, civil society, and, most of all, people living with HIV—refused to accept the prioritization of profits over patients and led a movement that secured needed policy reforms, changed national and global health institutions (while catalyzing the creation of new ones), and made AIDS medicines available to millions in the Global South. In the process, the coalition made a monumental contribution to the broader fight for global health equity: it elevated our imagination of what’s possible when nihilism is rejected in favor of a bold vision of social justice.
Today, COVID-19 reveals that we must do more than just build vertical programs to mitigate HIV or any other single condition. We must insist on robust health systems (public health and care) capable of attending to the complete burden of disease and of fulfilling their functions as core democratic institutions, including progressive public financing of health and social protection. Such efforts are far more likely to yield equitable improvements in population health than are myopic pandemic preparedness initiatives or sporadic humanitarian aid during crises.
Taking health-related rights seriously also requires us to fight the transnational dynamics across an array of policy areas that systematically undermine the well-being of populations in the Global South. We cannot limit our vision to schemes for interstate transfers of “aid,” which elide the structural injustices embedded in center-periphery dependence, as well as the history of colonial and neocolonial domination through which the North has prospered at the South’s expense. Historical amnesia clouds our capacity to see, and in turn redress, the enduring legacies of this history. Human rights activism should be centrally concerned with repairing our deeply unequal, global political economy and reimagining international governance to enable sustained Global Public Investment in domains ranging from global health to climate justice.
Alicia Ely Yamin is Senior Advisor on Human Rights and Health Policy at Partners In Health, Member of the GPI Expert Working Group, and Co-Chair of the GPIN Interim Steering Committee.
Paul Farmer is the Kolokotrones University Professor at Harvard University and co-founder and chief strategist at Partners In Health.