Health Equity is a Front Line for Social Justice
By Salmaan Keshavjee
Although growing up in Canada seems far from the front lines of the struggle for equitable health care and human rights, I learned there that even in communities striving for equity, huge gaps exist between people who need care and those who receive it. From the health of First Nations Peoples in Canada—who have 300 times the risk of getting the disease tuberculosis (TB) than non-indigenous persons—to addressing health inequity among people who are unhoused, people incarcerated by the state, recent immigrants, groups that have been racialized, and individuals and families living in poverty, I realized that health equity was a “front-line” for social justice, and a critical component of a just society.
Many of these ideas crystalized for me as a graduate student when I spent a summer working in a poor urban neighborhood of Dhaka, Bangladesh. In the midst of unimaginable poverty, food and water insecurity, and housing precarity—where people were taking shifts sleeping in make-shift settlements—I was part of a team trying to understand why poor women from the community were unable to complete their tasks as unpaid community health workers providing basic health education to other people who were also living in abject poverty. My gut instinct was to ask why, in the midst of such resource-deprivation and hardship, where tangible health care was desperately needed and not being delivered, health education was seen as a bedrock intervention? Was it lack of knowledge that led to people dying from malnutrition, the effects of dirty water, pneumonia, and lack of access to life-saving medicines? I felt even more nervous asking why vulnerable women were being asked to work for free, when even I, a summer intern, had funding. These questions plagued me throughout my time in Dhaka, and moreover, were not met with much enthusiasm from the colleagues with whom I was working. The persistence of these questions did, however, drive me into the fields of Anthropology and Medicine. Later, after working in Central Asia, these very questions drove me to write Blind Spot, a book aimed at understanding how social and economic forces in the 20th century had constrained our collective ability to provide care to vulnerable populations.
As I was on this journey of understanding why health care was not being delivered to those in need, in the mid-1990s I had the good fortune of meeting Paul Farmer, Jim Kim, and Ophelia Dahl, and working with Partners In Health (PIH), the global solidarity organization committed to improving health care delivery in areas where there are health equity gaps. Working with PIH has been a balm to my soul because the goal of working in solidarity for health equity has, to put it in Paul Farmer’s eloquent words, offered “the privilege of reasserting our humanity. . . . Against a tide of utilitarian opinion and worse, we are offered the chance to insist, This is not how it should be done.”
With PIH, we started working to improve TB care in Peru, Russia, and Lesotho — work with which I have been engaged over the past 20+ years. Without a doubt, TB is a disease with a complex biology, but one that has been largely curable since 1948. The tools to drive down TB rates exist — they have been used in the US, Canada, and other wealthier settings, but have yet to be deployed fully in the rest of the world where TB rates remain high. The result: TB remains a leading infectious killer in the world, with more than 4,000 people dying every day.
And while it is important to spend time thinking about the bacteria that causes TB and its complex immunological interactions, this disease also forces us to think about inadequate health systems, as well as the role of poor nutrition, sub-standard housing, and air pollution as drivers of disease production and suffering. Fighting TB demands that we examine health and health care among people who are incarcerated, who are unhoused, or who live in overcrowded conditions. It demands that we understand how supply chains work, how drug prices are determined and how medicine itself is a “force of production” in the neoliberal economy. Essentially, a disease like TB forces us to think seriously about gradients of power and social processes through which people become sick and, most importantly, the social change required for healing. We are forced to fight against what Paul Farmer called the “the fixing of protocols and policies based on a lower standard of care.”
Knowing that we have tools on hand to ensure that people receive care when they are sick — that we can prevent suffering — is a driver for me in the fight for health care and human rights. Their deployment will require that we recognize gaps in the way we think about health care and the approach to health care delivery, understand the reasons why they persist, and work in solidarity to fix them. For me this is one path through which we can repair the world. Paul Farmer once said, “To be horrified by inequality and early death and not have any kind of plan for responding – that would not work for me.” Thanks in large part to Paul, it also does not work for the many people who benefitted from his example of how to act in this world. Years into this work, I recognize that the struggle for health equity will require the commitment of many. Thanks to Paul’s great efforts and vision, we have an army committed to this work, and a path for what this struggle should look like.
Rest in Peace, Paul. Your light shines bright. For the rest of us, we have miles to go before we sleep.
Salmaan Keshavjee is Professor of Global Health and Social Medicine at Harvard Medical School, and director of the School’s Center for Global Health Delivery. He teaches in the Department of Anthropology at Harvard, serves as physician and Associate Professor of Medicine at Brigham and Women’s Hospital and Senior TB Specialist at Partners In Health, and is Faculty Dean of Adams House at Harvard College. He is the author of Blind Spot: How Neoliberalism Infiltrated Global Health.