 August, 2007
Global health agencies such as the World Health Organization, wholly governed by the laws of epidemiology, are clinically ineffective, and are not able to intervene at the human level. The actual practice of global health is a mechanistic explanation of the determinants and distribution of diseases using descriptive and inferential epidemiology. The problem is that epidemiological data about a disease is meaningless unless undertaken with a bearing on the established actions and interactions that produce knowledge about health of an individual in a specific location. There are important features of knowledge about health of an individual in a specific location, such as growing pyrethrum in the backyard, which operational principles of epidemiology do not reveal. Because of this problem, epidemiological principles do not account for failure and ultimate breakdown of health of individuals in specific locations. For example, Kenya has the best epidemiological data on malaria; yet Kenya is one of the countries with the highest mortality due to malaria. The logical structure of global health must consider the integrated knowledge processes of all stakeholders of global health. The discipline of systems thinking provides the ability to visualize the detail and dynamic complexity in this relationship. Local nationals of economically disadvantaged countries are significant because they account for as much as 84% of world population, and 93% of the worldwide burden of disease. By contrast, they represent only 18% of global income and 11% of global health spending. One could define the relations by which activities of the local nationals, the diaspora nationals, the governments, the business, and the international development communities integrate to produce health of an individual in a community, and hence global health. In global heath, the narrowed view of health results in actions that are least leveraged, based on inadequate knowing, targeting events, rather than the structures driving the events. Rapid upswings of the incidence of the condition that they tried to solve consistently follow such actions in a typical fixes-that-fail system archetype. The recurrent fixes-that-fail is puzzling to the development community, and results in an increased desire by the members of the international development community to take away the burden of development, poverty reduction, and dealing with the diseases from the hands of the local communities who seem incapable and helpless. Taking away the burden of disease, and poverty from the hands of the local nationals is a classic example of shifting-the-burden of development to the international development community. Breach of Processual Integrity in Global Health The basic structure of tacit knowing involves two terms: a proximal and a distal term. From this insight, Polanyi postulated that human beings “know the first term only by relying on our awareness of it for attending to the second term.” Hence, in tacit knowing, human beings attend from the proximal term to the distal term. Polanyi argued that “the proximal is that term we know and we cannot tell;" and the “connection between the first and the second term remain tacit.” The increase in mosquito population in a region forms the first term of tacit knowing, and illness and death from malaria forms the second term. From this perspective, human beings in sub-Saharan Africa attend from the changes in mosquito populations to illness and death due to malaria. Indeed, human beings attend from changes in mosquito populations, by planting pyrethrum, an insecticide-producing herb, to illness or death due to malaria. Pyrethrum kills the mosquitoes, the intermediate host of plasmodium the malaria-causing parasite (Jovetic). Elimination of mosquitoes in an environment prevents the occurrence of malaria. In communities in sub-Saharan Africa, the connection between planting of pyrethrum and death due to malaria remains tacit. Effectiveness in actions against malaria from global health perspective comes from being aware of the tacit connection between the proximal term (e.g., planting of pyrethrum), and the distal term, (i.e., incidence, prevalence, burden of disease, or mortality); or understanding the joint meaning between pyrethrum, and malaria. Malaria control and planting of pyrethrum naturally belong together. Alienation, which results in separation of things that naturally belong together, breaches processual integrity. For example, the World Health Organization’s (WHO) strategies for fighting malaria produced actions and interactions that inhibited the flow of relevant knowledge from people living in developing countries to the WHO. In this case, the WHO did not have a process to know about the production of pyrethrum by local nationals living in the highlands of East and Central Africa. SC Johnson (SCJ), a multinational corporation, knew about the production of pyrethrum from the highlands, and collected the pyrethrum extract from poor farmers. SCJ did not help the farmers to repackage pyrethrum for malaria control. On the other end, the WHO imported synthetic pyrethroids to help the poor farmers fight malaria. Although SCJ and WHO were dealing with the same individual—the poor farmer who is struggling with malaria and poverty—they did not communicate with each other. The relevant knowledge about the importance of natural pyrethrins in malaria control did not flow among the three stakeholders: the farmer, the people at SC Johnson, and the members of the WHO. In the effort to help the farmers, the WHO undermined the productivity of the poor farmers by flooding the market with the synthetic molecule. The structure of alienation resembles a tragedy-of-the-commons systems archetype in systems thinking (Figure 1). The tragedy of the commons occurs due to absence of flow of knowledge from one stakeholder to the next. Tragedy of the commons occurs because the basic structure of the interrelationships that controls behavior is tacit and subtle. The actors are part of the structure, although they are not aware of it. 
Figure 1. The effect of knowledge alienation presenting as the tragedy-of-the-commons: the total unintended impact of outside interventions affect the limited survival capacity of the local people who remain trapped between two global forces that are oblivious of each other’s actions.
Note. B= balancing loop; R=reinforcing loop. In the current practice, the WHO floods the local market with imported synthetic pyrethroids for malaria control, which depresses the market for local supply of locally produced natural pyrethrum. On the other hand, the SCJ buys local pyrethrum from the local producers for export products, and does nothing to encourage use of locally produced pyrethrum for malaria control. This market for SCJ product ingredients competes for pyrethrum supply for malaria control. The two global forces, the SCJ’s demand for pyrethrum, and WHO supply of synthetic pyrethroids, combine to wipe out local malaria control effort. Interventions by the WHO brought gain to the WHO as measured by the number of mosquito nets distributed, and the size of the target population. WHO focused on only one aspect of the society—to distribute imported anti-malaria products in the villages. This action created a reinforcing loop, which failed to address other fundamental needs, such as need for market for locally produced pyrethrum, which remained neglected. The ensuing diminishing local capacity for pyrethrum production led to poverty, in a negative feedback. In this negative feedback, WHO could have reacted by (a) stepping up effort, or (b) giving up. In this case, the WHO responded by stepping up. Actions by the SCJ brought gain to the SCJ, creating a reinforcing loop. SCJ focused only on one aspect of the society (i.e., buying the pyrethrum). People's other needs such as the need to control malaria remained neglected. A negative feedback from the diminishing capacity due to increased malaria in the community balanced the reinforcing loop. The SCJ could have reacted by (a) stepping up effort, or (b) giving up. In this case, the SCJ responded by giving up. The commons (or the limited capacity) in this case is the social well being, or capacity of the human beings to survive in a local community. Actions by both external actors (i.e., WHO and SCJ) affected the capacity of individuals to survive in the local community. The survival of individuals is desirable to both actors; the continued operation of the SCJ and the WHO within the community is a predicate of survival of local people. The SCJ needs the local people to continue producing pyrethrum, and the WHO needs the local people as a market for its services. Both organizations act in a fragmented way, and both may be convinced that their actions improve the lives of the people. Indeed, the human survival improves initially. Neither organization understands the adverse affects of the other. Each is inadvertently creating conditions that drive the others' interventions. In the long-term, their collective work end up causing social disruption, with negative effect on human survival among the local people. The difference is in the ultimate response of each intervener. In both cases, the local capacity continued to diminish. That is the tragedy. The structure of interrelationships that control behavior in global health is subtle. Human beings can only comprehend a subtle structure of a comprehensive entity by tacit knowing. In the case of malaria control, the failure to comprehend the subtle structure of interrelationships that control behavior in global health resulted in knowledge alienation. The WHO flooded local markets in developing countries with synthetic pyrethroids in an effort to fight malaria. This action done in good faith destroyed the market for pyrethrum grown locally, and caused local people to sink into abject poverty, exposing them to the same disease that the program was designed to protect. Poorer farmers could not protect themselves from mosquitoes, and became more susceptible to malaria. The mortality due to malaria increased from 250,000 in 1998 to 1.3 million in 2005. Macharia Waruingi MD, DHA Kenya Development Network and Consortium, and Ustawi International www.kdnc.org |
