I am a PhD student working on discovering drug and vaccine targets of the malaria parasite. As a biomedical scientist, then, according to Jeremy Shiffman I’d be a “positivist” or “materialist”. And, after reading a bit about the two schools of philosophy, I’d have to agree that I am. I believe in the universality and the logic of the scientific method. I believe in proven truths or “facts” and “reality” and the testability of cause and effect. I do believe, specifically about global health issues, that many problems are known and defined (though perhaps with multiple distal causes—economic, environmental, etc) and that for many proximate causes, often there is already a known solution, but that the distal causes prevent the problem from being solved (lack of political will, infrastructure, corruption, etc). To me, it seems logical to say: People are dying of X. We can do Y to prevent people dying of X. Therefore, we should do Y—it is our moral imperative because health is a human right.
Yet Shiffman, as a practitioner of social constructionism or idealism, basically says that the only way to get any attention to a global health issue, let alone to get anything done, is to properly SPIN the issue “in ways that appeal to political leaders’ social values and concepts of reality”.
And this is exactly what I find so frustrating about policy—it involves politicians.
Now, of course there have been some great leaders over the thousands of years since the first governments. But, let’s face it—there have been an awful lot of bad governments in the world, too, or things like wars, genocides, massacres, environmental destruction, systematic torturing, marginalizing, and neglect of one’s people wouldn’t be so easily called to mind. But according to Shiffman, it all boils down to these leaders’ values.
Who are these leaders?? Sometimes they’re dictators. Sometimes they’re dynastic. Sometimes they’re democratically elected. But what do they have in common? Power. And the desire to maintain it, perhaps out of good intentions for their people, perhaps for the sake of power itself.
Even if we focus on our own democratically elected government, as Shiffman does in his argument, we encounter the problem that our political leaders (even if they have good intentions!) are subject to the whims of the voting populace, and, except for a few of us oddballs, the average voter probably puts extensively more thought into how many sugars make the best cup of coffee or if a man has a right to carry a gun to a political rally than into how many children in the world will die from preventable diarrhea today. Paul Farmer argues for a broader educational mandate on health and human rights issues, but acknowledges that for the general public, “the connection between health and human rights have not even been traced.” Which is why, I suppose, celebrity endorsement of an issue is considered important—if we can’t or won’t educate the public, at least to the point of caring a little bit, we can hope for emulation of celebrities.
In contrast to Shiffman, who is a proponent of working within the system of governments and international organizations, Farmer argues the opposite in part 5 of his 6-part prescription to change the health and human rights agenda. He maintains that the health and human rights movement must have independence from governments and bureaucracies because governments themselves (including our own) are part of the structural problems that perpetuate the distal causes of disease X. In his words, governments are “the perpetrators”. I imagine that for him (and possibly for me, as a scientist and materialist) that working within the governmental system would feel like sleeping with the enemy.
But what is one to do in order to best get something, ANYTHING done? Should one work within the system and spend a lot of time lobbying politicians and spinning the issues to gain money or international support? Or should one focus on building grassroots support for an issue with the voting population in order to “appeal” to the humanitarian side of a politician? But even if getting voter support works at creating a political mandate for international health action, in general, working with the large organizations may yield a globally applicable result, only to have local governments dilute the intended effect either intentionally (e.g. corruption) or unintentionally (e.g. poor delivery). Or, should one take matters into their own hands, and do something with a smaller scope, locally, but highly effective, in the Partners in Health model? I don’t know the answer about which is “best” but I’m attempting to learn the lay of the land.
But back to my frustration. Yes, I am a materialist. Yes, it’s annoying that politicians are by default part of the problem and the solution. But, ultimately, though, I’m frustrated by the fact that policy DOES largely operate in a social constructionist way, which is why I think scientists often shy away from getting into the fray—we view the social constructionism paradigm as part of the problem, too. Though I’m learning the policy language so that I could hop in bed with the enemy if that seems to be the best way, I strongly feel that one shouldn’t have to spin something that is a human rights issue, like health, and that leaders should always act in the absolute best interests of both their citizens AND the global citizenry. Perhaps this makes me a materialist-idealist. Or, perhaps, we should all reconsider the utility of benevolent dictatorships…