Monday, 14 December 2009

REFLECTIONS FROM KILIFI: ALTERNATIVE NARRATIVES OF PUBLIC HEALTH

By Melissa Leach

The Kilifi conference on the publics of public health is now complete, after two more intense days. Two dimensions of the contemporary world of public health have been particularly dominant.

First, the new global architectures through which so much funding and programming around health issues in Africa now takes place. The huge sums which are now invested through organisations such as the Gates Foundation and Global Fund, and PEPFAR bring new questions around governance, accountability and partnerships in their wake, while often constructing images of ‘predicament publics’ whose health needs can be addressed through the roll-out of standardised technological solutions.

What happens when such programmes reach the ground, and how community groups negotiate the new architectures through a variety of NGO mediations, was explored in revealing terms by STEPS members Hayley MacGregor and Jerker Edstrom in their study of Zambia, Kenya and Malawi.

Several papers also explored the ways in which foreign-funded medical research programmes are now also sites through which health treatment (for instance for HIV and malaria) takes place, related in complex ways to the protocols and precepts of particular trials. Yet the effect is often to produce well-provided enclaves of ‘high quality’ health provision, often geared to particular diseases, and sitting in sometimes uncomfortable relationship with underresourced government-run public health services outside the ‘experimental publics’ zone.

Second, we have explored a fascinating range of illustrations of what goes on within these ‘experimental publics’ islands. How do medical researchers, study participants and others in what Gemma Jones termed ‘research villages’ interact? How do they imagine each others’ lives and work? What aspects of the many inequalities between them – economic, social, power and status-related – are talked about, and which remain ‘public secrets’, known but not expressed, and therefore not (as Wenzel Geissler pointed out) easily articulated as rights and demands?

Rich and varied pictures emerged from cases as diverse as microbicide trials, in Zambia, malaria research in western Kenya, community engagement practices on the Kenyan coast, and others, with Erick Nambedha, Patricia Kingori, Shelley Lees,

The roles of research fieldworkers as creative brokers between scientists and communities emerges as key, along with public engagement methods and procedures including Community Advisory Boards. Reflection on and exploration of how such mediation across interfaces works in practice, what it enables and what it excludes, is becoming a rich field of inquiry and practice which at least at some level, is transforming the ways in which the social and ethical dimensions of research are understood and negotiated.

While this growing social science attention to ‘experimental publics’ is welcome, however, improving practices and effectiveness of medical research, as the conference drew to a close today many of us expressed concerns about the relative neglect of what goes on beyond the ‘research island’. Where is comparable attention (and funding) to wider health systems and their primary care publics? This relative neglect is despite international and donor claims to a renewed focus on universal access and ‘health for all’ thirty years after the original Alma Ata conference in 1978 and is, many participants expressed strongly, a balance which needs to be redressed.

As the conference moved into its final day, some overarching themes and dilemmas came into view. One concerned whether ‘publics’ should be conceived of as distinct collectivities of people, suggesting an endless and shifting multiplication of kinds of public, bounded in various ways. Yet as Nancy Rose Hunt had suggested to us in her evocative account of violence in colonial Congo, those in power may instead conceive of (and both repress and be nervous of ‘multitudes’, evoking a kind of non-publicness which in turn constructs a notion of ‘public’ more strongly associated with recognition, respect and rights in relation to states and other powerful institutions. And further, associations of public with a public sphere are also in evidence, contrasting, perhaps, with the private and the individuated.

Notwithstanding these definitional debates, a recurring theme concerns the ways that particular versions of publics and publicness are always co-constructed with particular networks, narratives, assemblages or contraptions. The relations within and between them deeply implicate politics – of knowledge, but also of political economy.

Some of our discussions turned from the past and present to possible futures, and scenarios which might include intensification of globalised and neo-liberal forms of health provision, along with a rise in ‘enclave’-type arrangements as foreign companies investing in Africa’s resources also provide welfare services, mimicking in new guises imperial schemes of old.
Epidemiologies may well shift, with the rising importance of chronic diseases and of new zoonotic pandemics both on the horizon. Meanwhile, uncertainties in both the natural and economic worlds look set to intensify. Amidst these complex and unpredictable changes, what kinds of new narratives, and associated pathways for public health, might we envisage?

Our final discussion began to point to some elements of an alternative narrative which many of us might share. This would refocus attention and investment on government-involved, primary health systems, envisaging ‘health’ in terms of basic care, and of broader social and economic wellbeing, of populations as a whole. This in turn would require new forms of research and of research-policy engagement to innovate in health service delivery, and understand how innovations might be scaled up while also adapting to diverse cultural settings and values, and ongoing uncertainties.

With questions of social justice centre stage, research and policy need to move from researching and intervening on, to working with, publics as a common ‘us’, while attending to social difference and positionality.

This take on the conference and its implications is only one amongst many which might be possible, and others will surely have different views. The papers are fascinating, and we will be making them available on the conference website shortly. Do have a read, and take the opportunity to add your comments and participate in the discussion on its forum, helping to take forward the debate of this last week around the new publics of public health.

No comments: