Jeffersonian Insights on Public Health

I recently gave a presentation to medical students and faculty at the University of Virginia organized by their Center for Global Health. UVA has a strong tradition in tropical infectious disease work in developing countries, with groundbreaking research addressing diseases such as leishmaniasis. However, like many other institutions, UVA has recently seen a broad swell of interest on a range of global health issues amongst its student population and I had been asked to address the medical school on thinking at Columbia about emerging challenges in the field.

I had anticipated that my slides arguing that chronic, rather than infectious disease stands to be the focus of greatest preventable mortality in the coming years to be the most controversial. But it was one of my slides in the section talking about globalization and the broader political and economic changes that are shaping the landscape of global health that drew the strongest reaction. Squeezed between slides depicting Chinese investment in health infrastructure in sub-Saharan Africa and material outlining development in communications technology was – for me – a ‘commonplace’ graphic. It depicted the decline in the health workforce across Africa since the year 2000, with international migration to the developed world one of the major factors contributing to a declining available capacity to address escalating needs.

Touched on briefly during Q&A, a moving email on the topic hit my inbox shortly after the lecture. It asked for a copy of this slide so that the writer – a medical student with experience of working in Uganda – could share this evidence with friends and family of the ‘north’ drawing resources from a ‘south’ that could so ill-afford such hemorrhage. I was touched by her commitment to advocacy and, if truth be told, a little envious of the clarity with which she saw a moral issue on which I have become somewhat jaded by complexity and pragmatism.

Coincidence makes bad science. But it can valuably fertilize the imagination. The following day I was touring the Monticello estate on the outskirts of Charlottesville, which has been restored to the condition in which Thomas Jefferson spent his retirement years. The house and gardens were wonderful, but it was the ‘Plantation Community Tour’ – visiting the remains of the homes and workshops of the slaves on whose labor the estate depended until the time of Jefferson’s death – that was most compelling. We had noted in the house how Jefferson had seen slavery as an "abominable crime" and a "moral depravity”. But he continued to hold slaves to the end of his life, with the crucial economic role they played in the operation of his estate and his deep indebtedness (which saw slaves sold on his death to pay creditors), clearly a major barrier to translating his moral conviction to economic practice.

There was much complexity and pragmatism operating in Jefferson’s 18th century calculus on the issue of slavery. 250 years later we recognize his moral impulse to be profoundly correct and his economic compromise to be profoundly indefensible. The voluntary movement of doctors and nurses from Africa to the developed world is a radically different phenomenon from the forced movement of Africans centuries before. But there are enough parallels in the hegemony of a political and economic order to cause one to wonder at the casual acceptance of gross inequality in the human experience. When visitors to a futuristic museum of global health in the 21st century learn that movement of doctors from settings where there is one physician for 50,000 people to settings where there is one for every 500 was seen as an inevitable consequence of our global economic system, how will they judge us? I fear my own rationalizations on the issue sound rather too like Jefferson’s on slavery. My hope lies in the passion of that medical student and thousands like her that see global health not as a career specialization but as a moral quest.

Alastair Ager is Professor of Clinical Population and Family Health at the Mailman School of Public Health, working with the Program on Forced Migration & Health. He serves of Executive Director of the Global Health Initiative.

The "Green" Agenda in Contemporary Brazil: Fact or Fiction?

The October 2010 elections in Brazil revealed the unexpected popularity of Marina Silva, a presidential candidate supported by the small Green Party. Due to the huge size of the country, its deep heterogeneity, the comprehensiveness of the process and the absence of any mandatory linkage between regional and national representatives, the 20 million votes received by Marina Silva as a president candidate did not translate to the Green Party’s overall performance. The Green Party was and is a small party, with a modest number of representatives in the Congress (15/513), without a single senator (0/81) or governor (0/27) elected in this round.

Brazilian campaigns are relatively small and cheap compared to their North American counterparts; partially due to the fact political parties have free time on both television and radio. Nevertheless, the scope and the costs of Brazilian campaigns have been increasing, due to an increasing population (~185 million people) living in a network of over 5,500 municipalities, as well as its increasing professionalization (e.g. involving political advisors, parties’ sponsored polls etc.). Big politics is translated, in Brazil as anywhere else, into rising costs and the need to use nationwide party structures. Half of the expenses of Marina Silva’s campaign were paid by the then vice-president candidate, Guilherme Leal, founder and chairman of Natura, the world’s largest company in the field of organic cosmetics.

Marina Silva’s 20 million votes should be viewed as resulting more from a combination of her personal leadership and the growing power of Brazilian companies committed to sustainable development than to a “green boom”. In the context of a harsh competition between the two major political coalitions (supporting the elected president Dilma Rousseff and her main adversary, Jose Serra), Marina Silva also appeared to be viewed as a new, “third” way.

In the second round of the elections both major coalitions stated they would incorporate the “green agenda” into their own plans. Dilma Rousseff was elected by a large political coalition and it is too early to fully understand the broad agenda to be followed by her presidency. The stage is set for the reemergence of the long-term conflict between the so-called “ruralists” (i.e. large farmers and leaders of agribusiness in Brazil) and the MST, the movement of landless peasants, as well as the conflicts between environmentalists and the supporters of accelerated development at the expenses of environmental degradation. Such conflicts tend to be especially violent in Brazil and it is no coincidence that Marina Silva’s regional leadership (in the state of Acre, in the northwest border of Brazil’s Amazon Rain Forest) is usually viewed as a leadership consolidated after the brutal murder of Chico Mendes, her former mentor and the late leader of the Brazilian rubber taper union (http://en.wikipedia.org/wiki/Chico_Mendes).

Brazil ranks nowadays as one of the main forces of agribusiness and the main producer of biofuels (especially sugar cane ethanol), worldwide. The country houses both the largest extensions of pristine forests in the whole world, as well as retaining the unfortunate record of having the fastest pace deforestation rate.
With an expected annual growth of its GDP of 7.5-8% in 2010, Brazil is an emergent partner in the complex and contradictory world agenda on global warming, protection of the environment, and biodiversity.

The world’s environmental agenda remains a big puzzle to be debated in the next rounds of the global diplomacy on the environment and climate changes. There is no consensus either within the US or between the US and its main partners, China and India. Much likely Brazil will have a central role in the global negotiations, depending on its own capacity to establish domestic consensus. Marina Silva is a key term in this global equation.

Global health is closely intertwined with environmental conditions in a broad sense and this interrelationship will undoubtedly become even more entangled in the coming years, with the increase of population, global warming, and scarcity of vital resources such as clean water and non-renewable energy. As a professional working in the field of global health, I see means of sustaining the ‘green agenda’ in Brazil, as globally, both increasingly politically complex and increasingly politically crucial.

Francisco I. Bastos, is a researcher at Fundação Oswaldo Cruz (FIOCRUZ) Rio de Janeiro, Brazil, working with Mailman School faculty to establish a GHI ‘Global Partners Alliance.’ As with all ‘Global Posts’ the views expressed are personal and do not reflect the institutional positions of either FIOCRUZ or Columbia University.