Katherine Irene Pettus

One world, other planets: ethical edges of global health discourse

“The need to let suffering speak is the condition of all truth” Adorno 1973

December 6, 2012 12/6/2012

IntroductionA trope of contemporary globalization discourse is that human

society as a whole is rapidly advancing towards integration, thatthe previously fragmented Westphalian system is becoming ‘one world’ through inexorably universalizing and globally managed financial, communication, cultural, and (viral) disease meridians. Arguably, only global governance organizations and global health initiatives have sufficient scope to match the range and power of borderless capital, labor, and pathogens, and to manage the one world’s various sets of ‘stakeholders.’ This essay probes the ethical implications of one tiny gap in the discourse that narrates the progress of this ostensibly ‘flat’1 new world: the lack of literature on access to opioids for perioperative pain relief in low resource countries. Finding only a few random articles in a search undertaken for a

research project on global surgery,2 I wondered if the absence ofa literature means that surgical pain is so adequately controlledsuch that there is no need for research or reporting from the LMICs. Because I know something about the global narcotics control regime, international law and the maldistribution of opioids for palliative care worldwide, I knew that couldn’t be the case. So the question became why do mainstream global healthdiscourse and policy initiatives foreground certain (such as infectious disease3 and pharmaceutical) narratives while marginalizing narratives of suffering and vulnerability (such as those articulated by the specialties of global surgery and

1 Friedman 20062 Two chapters on pain management in low resource countries appear in a reportfrom the International Association for the Study of Pain, IASP, and two othersare general articles on pain management (Size 2007) and global opioid consumption that mention global surgery (Seya et. al 2011). The research gap was confirmed by personal and email conversations with several global surgeons(Adam Kushner MD, MPH, FACS, Kelley McQueen MD, MPH, Steve Bickler MD, and JimCleary MD, FRCAP, FAChPM) as well as palliative care specialists, some of whomare anesthesiologists from the LMICs participating in the Leadership Development Initiative course at the Institute for Palliative Medicine in San Diego, October 2012. Perioperative pain is controlled with whatever analgesicsexist in each country, district, or hospital. In many cases, that may be limited to Paracetemol.3 While “In African children over five, injuries claim more lives than HIV, tuberculosis, and malaria combined.” (Ozgediz 2008, e121)

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palliative care).4 From a political theory perspective these research and literature deficits are deficits of voice, and as such amount to legitimation deficits in the absence of a global demos5 that can hold the global health oligarchy6 accountable. Deficits of voice are epistemic deficits that have real consequences for effective and sustainable global policy.My assumption is that mainstream global health discourse

articulates the policy priorities of the self-appointed, largely unstructured global health establishment. In my reading of this literature, the global health establishment prioritizes strategies that seek to immunize the world from infectious disease threats and promotes an abstract, consistently undefined,conception of health as an optimal state of “Being,”7 rather thanengaging in a concerted praxis to alleviate suffering. In order to do the latter legitimately, global health initiatives would have to be informed by local (community) research priorities developed and published by the beneficiaries of global health initiatives themselves, rather than by an oligarchy of global planners.8 Ironically, this reading exposes the tension between 4 I distinguish mainstream from counter-narratives such as “Critical Public Health” and “Health and Human Rights” which provide important correctives to the positivist discourse. My analysis also differs from Shiffman’s (2009) important social constructionist perspective.5 See List 2010 on the possibility of a global demos. Clearly such an entity does not exist, and it is this institutional deficit that gives those I call the “global oligarchs” the “freedom”—since they are not accountable –to propose and enact policies that deepen (and silence) the vulnerability of already vulnerable global populations. 6 “Oligarchy” is rule by the select few, the wealthy, or the “well-born.” SeeAristotle, The Politics, (III.6.1278b8–10; cf. IV.1.1289a15–18).7 “Being” stands for the positive ontological order accessible to knowledge, for the infinite multitude of what “presents itself” in our experience, categorized in genuses and species in accordance with its properties.” (Žižekin Milbank et.al 2010 p.74) 8 See for instance Tollefson 2012 on the need for global surgery research and Derbew 2006 on the need for research in East Africa, and McQueen 2012: “While anecdotal reports of the successes of surgical intervention by international teams or short term missions are inspiring and contribute to the recognition of the abundance of unmet surgical need, these anecdotes are only the tip of the iceberg. As many epidemiologists are quick to point out, without outcome measures and follow up, little can be concluded accurately beyond the personalstories and photos of physically changed children. Therefore, more research isneeded to identify specific indicators to study the effectiveness and impact

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the discipline of global “health” and the practice of “healing.” What I discern as the exclusion of the subject(s) who need(s) “healing” from the mainstream global health literature raises ethical questions about her/their status and value from the perspective of global health policy and challenges global health institutions and discourse to become more inclusive, for pragmatic, consequentialist reasons. I conclude that this is a “political” issue in the classic sense of the term.9

In the spirit of global health’s pluralistic invitation to interdisciplinary collaboration, I write as a critical theorist.10 This essay is an exercise in ethical immanent critique, meaning it measures the pretensions of global health against its own articulated consequentialist standards.11 The sources of the substance of my critique are, paradoxically, constituted by emptiness –the structured and eloquent silences within the global health narrative. Just as “the music is the silence between the notes,”12 the ethical and political edges, the frontiers, of global health discourse emerge from the gaps inthe literature. Those edges, the boundaries that delineate whereit doesn’t go – into truly embodied vulnerability –mirror the current weaknesses of the discipline.

of surgical interventions.”9 “The words ‘public,’ ‘common’ and ‘general’ have a long tradition of usage which has made them synonyms for what is ‘political’…from its very beginnings in Greece, the Western political tradition has looked upon the political orderas a common order created to deal with those concerns in which all of the members of society have some interest.” (Wolin 1960, 9)10 Briefly defined: Critical social theory addresses why hunger, poverty, and other forms of human suffering persist despite the technological and scientific potential to mitigate or to eliminate them altogether. Stanford Encyclopedia of Philosophy. See also Geuss 2005, 111-130 “Suffering and Knowledge in Adorno.” See also Fidler 1997, 46-50 on Critical International Theory, which this paper does not subscribe to. 11 These are generally expressed in the broadly accepted definitions of globalhealth such as Macfarlane 2008 “[G]lobal health is about worldwide improvementof health, reduction of disparities, and protection against global threats that disregard national borders,” and Koplan 2009 [Global health is]…'the areaof study, research and practice that places a priority on improving health andachieving equity in health for all people worldwide'.12 Achille Claude Debussy, As quoted in Turning Numbers into Knowledge: Mastering the Artof Problem Solving (2001) by Jonathan G. Koomey, p.96

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The gap appears in the context of the literature on the global burden of (untreated) surgical disease, a comparatively well documented13 narrative of the suffering of people whose lives (and deaths) in resource limited countries are globalization’s negative integer, and who might as well live on another planet. The normative claim of the paper is that the gap exposes an ethical deficit that runs through the academic discipline of global health as a whole and that the institutional source of that ethical deficit is the corresponding lack of a robust institutional connection between the global health establishment and the populations it seeks to serve: the “unhealthy” and unconstituted global demos. 14 One way to begin meeting that gap, given that there are no traditional elected/representative institutions to hold the global oligarchy accountable, is to build a robust, locally generated literature that could provide at least discursive legitimation and constitute a hermeneuticallyethical basis for policy and funding initiatives. Section I introduces the global burden of surgical disease and

briefly lays out the problem of access to opioids for both surgery and palliative care. Section II lays out the theoreticalclaims of the paper, defining the concepts of vulnerability and suffering, and contrasting them with the instrumental rationalityof the extant global health establishment. The essay’s very modest ambition is only to probe the rationale of a double 13 I say “comparatively” because most the most common complaint in the global surgery literature from providers and advocates is the lack of research regarding the global burden of surgical disease. Just about every article on global surgery begins with a paragraph like this: “Information regarding surgical capacity in the developing world is limited by the paucity of available data regarding surgical care, infrastructure, and human resources inthe literature.” See Chao et al. 2012, Tollefson 2012, and Taira 2009 “Little is factually known about the burden ofsurgical disease and less is known about global surgical provision of care fordiseases that may be treated, cured, orpalliated by a surgical intervention.”14 It is beyond the scope of this brief essay to do anything more than gestureto the growing literature on this subject. The authorities are Buchanan, Allen. 2002. “Political Legitimacy and Democracy.” Ethics 112(4): 689–719.–––. 2003. Justice, Legitimacy and Self-Determination. Oxford: Oxford University Press.Buchanan, Allen and Robert O. Keohane. 2006. “The Legitimacy of Global Governance Institutions.” Ethics and International Affairs 20(4): 405–437.

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negative: the flat world’s marginalization of global surgery as an urgent public health priority despite the convincing body of increasingly exasperated articles by global surgeons drawing attention to the burden of surgical disease, and the dearth of research on access to opioids for perioperative pain relief for what surgery does take place in the LMICs.15 If by synthesizing these two concerns it allows “suffering to speak” even faintly, and inspires further research by ethicists, students, or practitioners, so much the better.

I. Global Surgery and the Opioid GapI only noticed the “opioid gap” in the global surgery literature because I am all too familiar with the problem of lack of access to of opioids for palliative care in the LMICs,16 and was curiousto learn how surgical teams in low resource counties manage acutepain without strong opioids. Why should such a gap in the literature raise ethical concerns? First of all, because according to the United Nations Special Rapporteur on the prevention of torture and cruel, inhuman, or degrading treatment or punishment, and Special Rapporteur on the right of everyone tothe enjoyment of the highest attainable standard of physical and 15 Based on surgical data for 56 (29%) of 192 WHO member states, Weiser et.al.(2008) calculated that in 2004, 8.1 million surgical procedures (3.5 % of the global total) took place in the poorest countries, which account for 34·8% of the global population. The study combined data for middle and high income countries. “This study has, without question, major limitations that make ourestimates necessarily provisional. The fact that less than a third of countries could offer data for surgical volume is an indication of not only how difficult making an accurate global estimate of surgery is, but also how inadequate present health-care surveillance is.” See also Bickler et.al (2010)16 See for instance, See International Narcotics Control Board, Report of the International Narcotics Control Board on the Availability of Internationally Controlled Drugs: Ensuring Adequate Access for Medical and Scientific Purposes5 (2010), available at http://www.incb.org/pdf/annual-report/2010/en/supp/AR10_Supp_E.pdf (last visited Aug. 28, 2012); Easing the Pain; successes and challenges in international palliative care Open Society Foundations (2010) and Allyn L. Taylor “Addressing the Global Tragedy of Needless Pain: rethinking the United Nations Single Convention on Narcotic Drugs” Research Paper No. 6. (January 2008) Georgetown University Journal of Law, Medicine, and Ethics 556 (2007) and “Please do not make us suffer any more; Access to Pain Treatment as a Human Right; ” Human Rights Watch 2009

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mental health, “The failure to ensure access to controlled medicines for the relief of pain and suffering threatens fundamental rights to health and to protection against cruel, inhuman and degrading treatment.”17 Second, because in the words of philosopher Cornelius Castoriadis, referenced in Bauman (1998, 5)

… the trouble with the contemporary condition of our modern civilization is that it stopped questioning itself. Not asking certain questions is pregnant with more dangers than failing to answer the questions already on the official agenda…The price of silence is paid in the hard currency of human suffering.

The global surgery literature itself provides examples of that hard currency in the statistics regarding morbidity and mortalityfrom trauma, obstetric complications, and other treatable conditions in the LMICs: more than 500,000 women die each year from complications of pregnancy and childbirth, deaths that are largely attributable to an absence of surgical services and othermeans of stopping post-partum hemorrhage. 18 Yet in Farmer’s (2008) words, surgery remains the “neglected stepchild of global health,” there is no global funding organization focusing on the provision of surgical care or anesthesia, and none of the major donors are willing to support and acknowledge surgery and anesthesia as an imperative part of global public health. The result is gross neglect of surgical need for the poor around the world.19 Surgery is not part of President Obama’s Global Health 17 Letter to the Chairperson of the 52nd Commission on Narcotic Drugs from Manfred Nowak and Anand Grover Special Rapporteur to Her Excellency Ms Selma Ashipala-Musavyi, p. 4. 12.10.2008. See also Brennan (2004)18 World Health Organization (2005) “World health report 2005: making every mother and child count.” Cited in Farmer 2008. Equally unattended, among the very poor, are motor-vehicle and farm accidents, peritonitis, long-bone fractures, and even blindness. According to Farmer (2008, 533) in some settings, surveys reveal that surgical disease is among the top 15 causes of disability, and surgical conditions account for up to 15% of total disability adjusted life years (DALYs) lost worldwide. 19 “Background document for world health assembly resolution for surgical careand anesthesia” www.adamkushnermd.com/.../WHA-SCA_draft_background Accessed 12/1/2012

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Initiative, and the US and WHO refused to support a WHA resolution calling for a new Department of General Surgical Care and Anesthesia.20 According to Hedges (2010, 2003) “Emergency and essential surgery (EES) remains a low priority on global health agendas even though a growing body of evidence demonstrates that EES is a cost-effective public health intervention and that it holds the potential to prevent a sizablenumber of deaths and disabilities. The inferior status of EES should be considered, in part, a political problem and subject topolitical analysis.”The fact that there is no global surgery literature that

specifically addresses the (policy) issue of access to opioids for perioperative pain in the LMICs means that I must extrapolatefrom the palliative care literature to assemble a provisional picture of the constraints of global surgery vis-à-vis control ofacute pain. That effort in itself raises ethical and intellectual red flags. The development of palliative medicine in the last two decades of the twentieth century and the advocacyefforts of palliative care activists around the world who have researched and published data and policies on access to opioids has exposed what the European Society of Medical Oncologists ESMOrecently called a “worldwide public health pandemic” of untreatedpain. Tragically, the numbers are mind boggling: 5.5 billion people

(83 per cent of the world’s population) live in countries with low to non-existent access [to pain medications]; 250 million (4 per cent) have moderate access; 460 million (7 per cent) have adequate access; and for 430 million (7 per cent) insufficient data are available.”21 And… “WHO estimates that every year untreated or undertreated moderate to severe pain results in the suffering of 5.5 million terminal cancer patients and 1 million end-stage HIV/AIDS patients, as well as many other people with chronic, non-malignant pain. These figures include 800,000 patients with lethal injuries caused by accidents and violence, patients with chronic illnesses, patients recovering from surgery, women in labour (110 million births each year) and

20 Personal correspondence between the author and global surgeon Adam Kushner 21 Ibd. P.4

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paediatric patients.”22 Obviously these numbers do not the millions of include untreated surgical cases – the pain suffered by those individuals bearing the unadressed burden of surgical disease. Based on surgical data for 56 of 192 WHO member states (29%),

Weiser et.al. (2008) calculated that in 2004, 8.1 million surgical procedures (3.5 % of the global total) took place in thepoorest countries, which account for 34·8% of the global population. 23 Yet insofar as published research into appropriatemanagement of acute perioperative pain in is concerned, the surgical teams who performed those eight million or so proceduresmight as well live on another planet. Given that the general surgery and anesthesia literatures emphasize the clinical and ethical importance of perioperative pain management24 the epistemic gap is even more startling.

McQueen 2010 puts the case clearly and is worth quoting at length:

Current global health disparities in surgical care are staggering. For example, a comparison between high- and low-income countries suggests an estimated 1-2 million avertable injury deaths/year in severely injured patients alone and that 90% of those injury deaths occur in low-income countries. However, only a third of injured patients in rural low-income countries are able to obtain care. In many LMIC settings, thereis a lack of functional prehospital and other emergency care systems to provide care. Meanwhile, 99% of maternal deaths, at least partially avertable through access to emergency obstetriccare inclusive of caesarian section, occur in low-income countries. Nevertheless, interim evaluation suggests that the

22 Ibid.23 See also Bickler et.al (2010)24 See for instance Beyaz et. al. (2011) “One of the most important causes of postoperative morbidity and mortality is insufficiently treated pain. Postoperative pain that could not be treated sufficiently leads to problems like reduction in vital capacity and alveolar ventilation, pneumonia, tachycardia, hypertension, myocardial ischemia and infarction, conversion to chronic pain, delay in wound healing and prolonged hospital stay.”

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Millennium Development Goal to reduce maternal mortality is unlikely to be met.

According to WHO, the realization of the Millennium DevelopmentGoal 8, “providing access to affordable essential drugs in developing countries,” is likely to be farther away for opioid analgesics than for any other class of medicines. (Seya 2011) Yet the WHO regards morphine as a gold standard for the relief ofmoderate to severe pain associated with cancer and has included morphine in its Model Essential Medicines List since 1977.25 And… “Pain relief is now recognized as part of the human right tothe highest attainable standard of mental and physical health, orto some extent a human right on its own.”26 The ethical dimensions of this crisis of pain are succinctly addressed in therecently released “Morphine Manifesto” which has been signed by leading organizations and foundations from around the world, including cancer, pain management, and hospice & palliative care organizations:27

Prolonged unrelieved pain destroys the mind; destroys the body;destroys families. Inexpensive and effective immediate-release morphine can relieve most of such pain. We cannot call ourselves a cultured or ethical society if we deprive this relief to those in pain; or worse yet, benefit financially fromthis suffering by forcing expensive, unaffordable alternatives on them.

25 “Of all pain medications, opioids represent the gold standard for severe pain, usually linked to end-stage cancer and HIV. Opioids are considered essential for the treatment of moderate to severe pain, both acute and cancer-related, and are sometimes recommended for the treatment of chronic non-cancerpain in some patients. Suitable alternatives to strong opioids for the treatment of moderate to severe pain have not been found, despite a century ofresearch in medical chemistry.” United Nations Commission on Narcotic Drugs 2012 (Promoting adequate availability of internationally controlled narcotic drugs and psychotropic substances for medical and scientific purposes while preventing their diversion and abuse Report of the Executive Director 54th Session p.3) 26 Ibid. see also Brennan 2007 on pain management as a human right.27 See http://palliumindia.org/manifesto/press/ for full text and a comprehensive list of sponsors.

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According to Brennan (2007), “Medicine is at an inflection point,at which a coherent international consensus is emerging: the unreasonable failure to treat pain is poor medicine, unethical practice, and is an abrogation of a fundamental human right.” (Brennan 2007)It is beyond the scope of this paper to lay out the historical

and political genealogy of the barriers to opioid access for acute and palliative pain in the LMICs. The barriers have been officially documented and analyzed.28 The claim to a human rightto pain relief has been made. As such, a first step has been taken toward laying the epistemological and legal groundwork for public health policy initiatives to make strong opioids availablefor palliative care and surgery in the LMICs. There is an important analytical distinction, however, between official documentation of a problem and interest groups’ abilities to marshal the political, social and economic wherewithal to solve it.29 What is encouraging is the proliferation of truly committed, transnational, largely privately funded, small-scale collaborations between health professionals at the community level around the world – an alternative register of “globalization” –that configures a parallel ethical universe of dedicated praxis

II. A theoretical perspective: vulnerability and suffering; health and healingThe central, and very limited claim analytical claim of this essay, is that the overwhelmingly positivist, empirically oriented mainstream global health literature reproduces 28 See supra Note 11 and Pettus 2012 29 See Speigel 2012: With regard to the power of the actors, the global surgical community has yet to coalesceinto a unified front. Hedges et al. [31] stated that ‘‘organizational fragmentation within global surgery effortsimpedes large scale action’’. Framing the issue remains a challenge, as there has been a lack of consensus in defining ‘‘surgery.’’ From the standpoint of political context, the surgical community has been unable to successfully linksurgical care with a ‘‘policy window’’ such as the Millenium Development Goals. Finally, the inability to capture the burden of surgical diseases with existing metrics has hindered our ability to draw attention to the magnitude of the problem and to facilitate comparison between the surgical burden and that of competing health priorities.”

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narratives of “health” and immunization (metaphorical and literal)30 and marginalizes (unarticulated) narratives of vulnerability and suffering for reasons that will be outlined below.31 This analytical claim is based on a critical theoretical perspective that does not accept the hegemonically promoted yet rarely defined goal of “global health” as self-evident. It proposes that “health” is only legitimately defined and promoted by Allowing discourse of vulnerability will reveal its own vulnerability?Projects its power – self legitimating? Shabby gesture of reparations for the ravages of colonialsm? The concept of vulnerability is derived from the Latin word for wound – vulnus – and in its modern usage vulnerability has come to denote the human ability to be open to suffering, to physical, psychological, social and moral injury (Wainwright and Williams 2005). Moreover, I argue that cultivation of this susceptibilityis essential to resilience and robustness as ‘the peculiar beautyof human excellence just is its vulnerability’ (Nussbaum, 1986: 2). By marginalizing and actually banning narratives of vulnerability,32 mainstream global health discourse, and the discipline itself, is less excellent in the classical sense,33 isunnecessarily weak, and will always fall short of its (literal and metaphorical) millennial goals. As I argue in Section III, including the voices of vulnerable populations in agenda setting will strengthen the discipline epistemologically and ultimately render it more legitimate and resilient. Clearly this depends onthe willingness of the (institutionally uncoordinated) global health establishment to be transformed and to undergo structural change.

30 See Esposito, R. (2011). Immunitas: The Protection and Negation of Life. Polity31 But see Amin et.al.201132 I did a word search for “vulnerable” and “vulnerability” in Fidler’s (1997)paper on the globalization of public health. He used the words nine times, butalways in the context of how societies are vulnerable to disease and threats, not how individual people are vulnerable to suffering. I use the word in the latter sense in this essay.33 “Excellence” as “arête,” or virtue. See Aristotle, Nichomachean Ethics and MacIntyre, A.: 1984, After Virtue: A Study in Moral Theory, 2nd edition (University of Notre Dame Press)

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Perhaps the global health literature can be excused for excluding specific narratives of pain because of pain’s resistance to language, its inherent unshareability: “Physical pain does not simply resist language but actively destroys it, bringing about an immediate reversion to a state anterior to language, to the sounds and cries a human being makes before language is learned.” (Scarry 1985, 4) It is practically a tropeof the pain literature that pain is notoriously difficult to diagnose and treat effectively. This does not mean, however, that it is impossible, and palliative medicine has made advances that were unimaginable only a decade ago. Yet the visceral particularity of pain is banned from the universalizing and totalizing narrative of globalization. For one thing, it is because the voices of pain and vulnerability are subtle, fragile,and so easily silenced that they are ignored both by the domesticand international health communities. For another, the globalized ear, tuned to aggregated frequencies based on instrumental rationality, is selectively deaf to pain. Tuning into it would disrupt the self-congratulatory charitable narrative of the global health establishment and draw attention to the historical and structural conditions that replicate the daily grind of suffering. In fact I wonder, and it is beyond thescope of this essay to do more than that, if the global oligarchy’s fixation on “health” policy, a comparatively easy (multi-billion dollar) target, relieves it of the much more onerous burden of dismantling those historically entrenched structures that guarantee ongoing health inequity.

Only the ear of the heart,34 inclined by a particular person or team that actually shows up to hear it, can discern and respond to the particular voice of pain. Unheard and uncommunicated suffering accumulates an escalating deficit in theessential political legitimation process of “communicative action.”35 In the absence of an even loosely organized global demos and corresponding political structure to hold it accountable, the global oligarchy is self-legitimating. It sets

34 Rule of St Benedict, “Listen carefully...and incline the ear of your heart.” 35 See Habermas 1984 for the classic discussion of the theory of communicativeaction and legitimacy.

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its own agenda. Clearly this is much easier to do if it can ignore, sideline, or banish certain voices outright.36 Communitybased research as the discourse/voice of the demos. Ptolomy project.37 “The Ptolemy Project attempts to bridge the gap betweenthe literature available to researchers in wealthy developed countries and that available to researchers in developing countries, where researchers are largely deprived of access to essential health information. The project's aim is to improve access for developing country researchers to peer-reviewed medical literature, as well as to journals and documents originating in their part of the world. The Ptolemy Project is anelectronic health information access tool designed to be effective, to be easy to use, and to satisfy the need for health information of surgeons in the developing world (K. Burton, A. Howard, M. Beveridge, unpublished data). Making any serious improvement in mortality, morbidity, and disability among the global poor will require more locally driven collaborative research and wider usage of the scientific literature [4]. The fundamental idea underlying Ptolemy is that it is African doctorsand researchers who know the right questions to ask in order to discover practicable solutions to the health problems of their regions. While Ptolemy alone is not sufficient to build a surgical research community, the electronic health information itprovides is a fundamental and necessary component to this transformation.” Derbew 2006 e.305In fact, I would dare to say that the global health

establishment has no need for the suffering “Other” who is a denizen of the periphery, who is “beyond the pale,” unless her health status (as producer or consumer) is essential to any of the multiple domains of globalized production or consumption. Ifit is not essential, and her body is not a disease vector, a threat to the health, security, and economic stability of the

36 See Bachrach and Baratz classic (1962) article “The Two Faces of Power” American political science review, 56(04), 947-952 about the power of agenda setting and limiting decisions to relatively non-controversial issues. See also Schattschneider 1960, 71: “All forms of political organization have a bias infavor of the exploitation of some kinds of conflict and the suppression of others because organization is the mobilization of bias. Some issues are organized into politics while others are organized out.” (Italics in original.)37

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globalized center, the metropolis, it is basically irrelevant. Her body represents “bare life,”38 and is beyond the reach of global health discourse or ethics. In direct etymological contrast to the “wound” of

vulnerability, the word for “health” comes from the Indo-Europeanroot kailo, meaning whole, intact, uninjured.39 Health (as “soundness”) means “undamaged,40” a concept with clear normative associations – think of its inverse, “damaged goods.” Accordingto a recent definition, global health is “an area for study, research, and practice that places a priority on improving healthand achieving equity in health for all people worldwide.”41 Because the author doesn’t bother to define “health” though, he raises more questions than he answers. I suggest that improving health – particularly when it is based on the WHO (Ottowa) definition "a resource for everyday life, not the objective of living… a positive concept emphasizing social and personal resources, as well as physical capacities" – is analytically distinct from the praxis of alleviating suffering. The latter can, of course be both a goal of medicine (Cassell 2004) and, in that suffering is a predictable outcome of pathological systems, an appropriate topic for global health research and action. As Giacaman notes in a 2009 Lancet editorial though,

…the notion of suffering is no longer fashionable. It is not ascientific word; it seems vague and old-fashioned, harking back to a time of clinical impotence, when patients had to endure and tolerate pain without respite or relief. Science aims to deliver the means to eliminate much of what once

38 See Giorgio Agamben’s discussion of “bare life” in Homo Sacer Sovereign Power and Bare Life Meridian (1998) 39 http://www.etymonline.com/index.php?term=health accessed 12/2/201240 “The ancient origin of this word sound is obscure, but it can be traced to the 12th century Old English word gesund and its West Germanic precursor gasundaz. Modern relatives include German gesund and gesundheit (Dutch gezond and gezondheid), healthy and health. The inherent relationship between soundness and health is also found in Latin. Three Latin roots stemming from the prehistoric [sol-] (whole) give rise to Latin words that become the English solid, safe, save, salutary and salubrious. The Greek word holos (fromwhich we get holo- and catholic) is derived from the suffixed form [sol-wo] ofsame prehistoric root.” http://donnal.net/health/defining/soundness.htmlAccessed 12/2/201241 See Koplan note 10, supra. See also Giacaman 2009

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passed for human suffering…But as the opening article in our Series on health in the occupied Palestinian territory shows, dimensions of suffering, especially at the community level, are measurable and often severe. Science has not eradicated suffering, despite its enormous power to deliver technologies to improve health. Being more humble about the experience of individuals,rather than simply drawing up reductive report cards of their health status, opens up the possibility for a more realistic understanding of what it means to be healthy. The fact is thatone cannot be healthy in an unhealthy society.

Giacaman qualifies (against the classic 1946 WHO definition) that“[h]ealth is not a “state of complete physical, mental, and social well-being.” Nor is it “merely the absence of disease or infirmity.” (my emphasis) Health is not a fixed entity. It variesfor every individual, depending on their circumstances. Health isdefined not by the doctor, but by the person, according to his orher functional needs. The role of the doctor is to help the individual adapt to their unique prevailing conditions.”Global health discourse, which is empirical and positivist,

resists narratives of suffering because its function is to express the priorities of globalization, whose imperatives are structured by instrumental rationality. Instrumental rationalityis characterized by consistency between ends and means, standardization, and uniformity and rejects their opposites: particularity, plurality, affectivity and indeterminacy. By definition, instrumental rationality is inhospitable to “irrational” and site specific (in the body and geographical) “non-standard” suffering whose relief is often provisional and depends on one-on-one (intimate) conversation and skilled clinical discernment. Globalization discourse cannot translate, let alone assimilate, intimacy, language, and praxis that falls short of technocratic standards. The EES conditions and (usually terminal at diagnosis) NCDs

that call for palliative care – including opioids to treat pain –although amendable to standard diagnosis are, by definition, particular to the individuals they afflict. As such, assimilatingthem to standardized diagnosis and treatment will never be

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completely successful.42 Although surgical conditions such as traumatic injuries, cancers, or obstetric issues suffered by individuals can be estimated and described in epidemiological aggregates, this particular cancer, or that particular fistula always pertains to a particular person situated in a particular culture and country. Because the condition does not replicate, because it is not a discernible, targetable vector, its very existence is a challenge to contemporary global health initiatives as they are currently structured and managed. This observation does not imply that well-designed and

coherently implemented global health policies cannot fund, manage, and ensure the availability and fair pricing of essentialpharmaceuticals and medical devices, support educational programsfor clinical providers in the LMICs, and improve basic hospital and transportation networks that could alleviate the global burden of surgical disease. While these types of initiatives would go a long way toward mitigating workforce, supply, and infrastructure deficits, global health initiatives encounter the necessarily limiting political geography of local and national authority structures and professional competences insofar as treating and managing NCDs (including surgical conditions) on theground is concerned. Frank discussion of these types of constraints, which reflect entrenched power relations and (national and international) political arrangements, are absent from the global health literature. Because the global health oligarchy does not adequately fund or support ‘indigenous’ research in low resource countries that analyzes local conditions, infrastructure and specific disease burdens from the local perspective, the epistemic gulf between center and periphery only widens, perpetuating suboptimal outcomes on the ground. This remains the case notwithstanding careful (underfunded and unsupported) efforts of global surgeons and their local colleagues to document their (collective) efforts.

42 This is not to say, of course, that the social determinants of health (SDH)that underlie much of the adverse epidemiology cannot benefit from a systems approach, only that individual bodies in pain resist that approach. And indeed, global health literature has taken a robust approach to the SDH for that very reason.

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ConclusionBack to immanent critique theme – does it deliver?Stakes of the Epistemological and Legitimation Deficit Solly?“A reconceptualized critical theory of power: linguistic/discursive power. Critical researchers have come to understand that language is not a mirror of society. It is an unstable social practice whose meaning shifts, depending upon thecontext in which it is used. Contrary to previous understandings,critical researchers appreciate the fact that language is not a neutral and objective conduit of description of the “real world.”Rather, from a critical perspective, linguistic descriptions are not simply about the world but serve to construct it. With these linguistic notions in mind, criticalists begin to study the way language in the form of discourses servesas a form of regulation and domination… particular hegemonic/ideological message into theconsciousness of the reader. This is a process often referred to as the attempt toimpose discursive closure.” 291 KINCHELOE AND MCLAREN CRITICAL HERMENEUTICAL METHODS OF INTERPRETATIONThese concerns with the nature of hermeneutical interpretation come under thecategory of philosophical hermeneutics. Working this domain, hermeneutical scholarsattempt to think through and clarify the conditions under which interpretation andunderstanding take place. The critical hermeneutics that grounds critical qualitativeresearch moves more in the direction of normative hermeneutics inthat it raisesquestions about the purposes and procedures of interpretation. Inits critical theorydrivencontext, the purpose of hermeneutical analysis is to develop a form of culturalcriticism revealing power dynamics within social and cultural texts. Qualitativeresearchers familiar with critical hermeneutics build bridges between reader and text,

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text and its producer, historical context and present, and one particular social circumstanceand another. Accomplishing such interpretive tasks is difficult, and researcherssituated in normative hermeneutics push ethnographers, historians, semioticians,literary critics, and content analysts to trace the bridge-building processes employedby successful interpretations of knowledge production and culture. 294 (Gallagher, 1992;

Kellner, 1995; Kogler, 1996; Rapko, 1998)Critical research can be best understood in the context of the empowerment ofindividuals. Inquiry that aspired to the name critical must be connected to anattempt to confront the injustice of a particular society or public sphere within thesociety. Research thus becomes a transformative endeavor unembarrassed by the labelpolitical and unafraid to consummate a relationship with emancipatory consciousness.Whereas traditional researchers cling to the guard rail of neutrality, criticalresearchers frequently announce their partisanship in the struggle for a better world. 300

The music that emerges from the “silences” between these notes isa dirge, a tragic evocation of the suffering borne by those people and societies who have “lost out” on a grand scale in global game of modernity. It is tragic because the winners in that game have means – material, technical, and human (as in educational resources) – to remedy the deficit and provide the requisite healthcare, surgery, and pain management. What they lack is the ethical perspective and political will to do so.

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