Issue: Spring/Summer 2014
Caitlin (Cleland ’10) Whittemore
Across a dimly lit table, a young global health professional asks,“Did you hear about the issue with female condoms here?” We were at a local restaurant in Swaziland’s Ezulwini Valley, sipping on tap water while waiting for our meals to arrive. We were a party of five, and we had all been working in global health for several years. A conversation about condoms didn’t feel strange at all, and in a way we knew what might be coming next. She began by explaining that female condoms have been heavily promoted for a long time as a part of HIV/AIDS programs but haven’t yet been widely adopted. Thus, it was surprising to her organization when they came across rapid increases in sales of female condoms. “We were floored!” she said. “We went into the community to better understand the reason for the increased uptake, but when we talked to women, they didn’t seem to even know what a female condom was and had certainly never used one before. Then, as we were walking through the community, we noticed that many women were sporting a white plastic bracelet. Upon closer inspection, we realized that they had been using female condoms, but as a fashion statement instead of a prophylactic!” Laughter erupted around the table as we all acknowledged the perfect punch line to a classic global health mishap. The story was told for comedy, but the humor hinges upon a heartbreaking truth about global health: it fails often.
The use of female condoms as bracelets may seem fairly benign, but the costs of failure quickly add up. There are, of course, monetary costs. Depending on the scale, this program could be using hundreds of thousands or even millions of dollars of taxpayer and philanthropic funding. The program participants may also suffer economically if they dedicate time and resources to a failed program. There are reputational costs. Often, implementing organizations that report failure lose funding and may have to scale down local operations. Staff may be let go; donors may lose confidence; but the ultimate and most serious cost is paid by the communities whose health and livelihoods hang in the balance.
With the cost of global health program failure being so high and the incidents of failure being so frequent, two pertinent questions emerge. First, a question of ends: can we really hope to bring health to all people in this broken world where health threats and inequalities are ever-present and emergent? Second, a question of means: should we continue to rely on a failure-prone system like global health?
I believe that the life of Jesus Christ provides a model for how to respond to health threats and inequalities. His is a mission of holistic restoration with a special attention to society’s most vulnerable and marginalized. It is true that health threats will always exist. It is equally true that injustice will never be eradicated through human effort. The goal of global health is not to eliminate all sickness. It is to bring about human thriving, perhaps not to everyone, but to more people today than yesterday.
Global health is about much more than vaccinations, clean water and mosquito nets. It has meaning within my own family, my own neighborhood, my city. I talk to my family about eating more plants. I volunteer at my local community garden in D.C. I provide gentle hints to my elderly neighbors about smoking cessation. These efforts meet with failure constantly. It’s the nature of human behavior: we resolve and we regress. We are wonderfully unpredictable.
When you take these efforts to change human behavior from a small scale to a large one, complexity expands at a rapid rate. Global health is a house built on sand. Human behavior forms the shifting foundation. An intricate series of programming activities build the shaky frame. The house is battered constantly by a storm of endlessly varied sociocultural- economic contexts. It sinks and warps as the months and years pass.
Even the best designed and most expertly implemented global health program faces challenges at every turn. The female condom promotion program was well-funded, well-designed, and implemented by an organization with a reputation for excellence. Who could have predicted such an outcome?
Fortunately, accurate prediction isn’t necessary for a successful global health program, but agility is. My work in global health is focused on helping organizations embrace complexity and learn from failure. We must encourage the practices of better documentation, iteration and critical thinking. We must ask “why” and “how” and not just “how much?” The house remains on the sand, and the storm is still raging outside, but we’re picking up the broken boards and hammering in the loosened nails. Global health is a broken system, but I hope that my efforts are making it more effective for future generations. If the global health system of the past could eradicate smallpox, vaccinate 85 percent of children under 12 months against measles, and save 3.3 million lives through malaria interventions, what more will we be able to accomplish in the future?