Uncertainty in global health

by Halina Suwalowska, Epidemic Ethics / GLIDE, Nuffield Department of Population Health, Wellcome Centre for Ethics and Humanities, Ethox Centre, University of Oxford, Oxford, Oxfordshire, UK, Orcid number: https://orcid.org/0000-0003-4039-094X
 
Arsenii Alenichev, WEH / GLIDE, Nuffield Department of Population Health, Wellcome Centre for Ethics and Humanities, Ethox Centre, University of Oxford, Oxford, Oxfordshire, UK
 
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For many years, global health academics and practitioners have been showing that global health action does not exist in a vacuum (Biehl and Petryna, 2013). In the end, global health is largely about people, concepts and institutions jointly operating in concrete social, economic and historical settings. This, in turn, highlights the importance of taking wider social processes, tendencies and trends seriously for a more holistic understanding of global health and its overlooked dimensions and effects.
 
Uncertainty is one of those vectors of paramount importance, which seems to be burgeoning in numerous global contexts, affecting people and their life worlds on many levels. The recent COVID-19 pandemic has revealed pervasive and complicated forms of epistemological and ontological uncertainty in science, medicine and healthcare. In the course of this public health emergency, several questions have been raised about understanding the disease, immunity, treatment or outcomes. Those uncertainties have presented significant ethical challenges for policy makers, researchers, and healthcare professionals who have had to make decisions or provide advice when evidence was sparse, not conclusive or even conflicting.
 
For global health institutions, uncertainty is often an ordinary issue to be dealt with. Individual and collective human behaviours are often uncertain, so are cascades of complex molecular interactions unfolding in our bodies. In response, global health institutions draw on a host of techniques and methods from evidence-based medicine, statistics, sociology, organisational studies and futurology, to name a few. Such a wide tray of approaches allows for focusing on an uncertain and unknown context, generating evidence about it, which, in turn, is translated into concrete and tangible action. As a result, it might appear that global health is bringing order and stability to uncertain local contexts that have to be managed by the civilising and humanistic forces of global health. This seems to be a common and widely circulated understanding that is found in a myriad of texts, photos and images representing global health for the general public.
 
However, returning back to the first passage, global health does not exist in vacuum. It would be naive to assume that global health institutions and interventions that aim to deal with uncertainty are somehow immune to it in the first place. In the light of the globalised efforts to decolonise global health by ‘demystifying’ power structures, it is important to confront at least two powerful imaginations with regard to global health uncertainty. First, collective global health action may bring structure and stability to local contexts. This imagination subtly asserts that global health in itself is a seamless and smooth domain of practice as it deploys the civilised approach to counter the chaotic and unknown features of molecules, people and communities as well as other subjects of global health inquiry. This imagination directly mystifies and depoliticizes the functioning of global health and its ethical, social, cultural and political dimensions. By all means this is not a new phenomenon: similar tropes have been described by anthropologists systematically studying the global health’s older sibling- the international development, known for its attempts to reduce the complex reality into simple and easily manageable elements and drawing a false dividing line between ‘institutions’ and ‘contexts’, which in reality are deeply intertwined and co-produced (Lock and Nguyen, 2018). Moreover, mystification that has to be challenged is the understanding that global health action always decreases uncertainty, and that uncertainty is understood as something defaultly negative. Against this backdrop and with a nod to numerous social scientists studying ordinary dimensions of global health, we argue that 21st century global health could benefit from:
 

• Learning about how targets of global health interventions deal with uncertainty in their own way;


• Shedding light on uncertainty manifesting in global health interventions and institutions that are imagined to be the forerunners of certainty.


• Tracing ways in which global health interventions proliferate and exacerbate uncertainty under the banner of bringing certainty;

 
While uncertainty pervades the entirety of global health, its complications are clearly visible with regard to COVID-19 rules, e.g. to take COVID-19 vaccines, wash hands and wear masks. Such rules desire certainty; they are written in a short, laconic and concise form: simply wash your hands with soap and water, stay home, say the authoritative healthcare institutions. However, the reality, again, is uncertain. In order to wash hands - a seemingly easy act, a sophisticated infrastructure is needed, including access to running water and purchasing power to acquire soap. It gets even more uncertain with regard to the ‘stay home’ rule as, according to the UN, more than 1 billion people worldwide have inadequate housing, including lack of space, safety and risks of being evicted, coupled with a broader effect of globalisation neoliberalism on the quality of life of the world’s poorest. Whilst the Global Health community desires certainty by enforcing rules, the social life of such rules remains uncertain and often precarious, and should be taken seriously.
 
References:
Biehl, João and Petryna, Adriana. When People Come First: Critical Studies in Global Health, Princeton: Princeton University Press, 2013. https://ezproxy-prd.bodleian.ox.ac.uk:2102/10.1515/9781400846801
 
Lock, Margaret M., and Vinh-Kim Nguyen. An Anthropology of Biomedicine. Second edition. Hoboken, New Jersey: John Wiley & Sons, Inc., 2018.
 
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Halina is an Epidemic Ethics and GLIDE collaborative fellow at the Ethox Centre and the Wellcome Centre for Ethics and Humanities, University of Oxford. Her particular focus is on the ethical and social issues emerging in managing dead bodies during natural disasters and epidemics. Halina is a sociologist. She completed a DPhil in Population Health at the Ethox Centre in 2020. Her doctoral research focused on the ethics and politics of implementing Minimally Invasive Autopsy (MIA) in low-income settings.
 
Arsenii is a trained transdisciplinary global health scholar combining insights from biology, bioethics and medical anthropology. His academic focus is directed onto the overlooked- and often invisible- dimensions of public health interventions posing sharp challenges for theory and practice.
 
 

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