Barbara Bush, the rise of global health & white privilege

As difficult as it is to engage with Nick Kristof’s latest column A Millennial Named Bush on George Bush’s daughter Barbara Bush without getting a little bit sick in your mouth (we are still talking about the Bush family...), there is quite an interesting statement in the text that triggered some broader reflections on global public health, international development and increasing elite professionalization:

Her (Barbara Bush’s) passion for service certainly echoes widely in her generation. Dr. Paul Farmer, the globe-trotting co-founder of Partners in Health, emailed me from Rwanda (where he was working with Global Health Corps fellows) to say that when he was going into medical school there was little interest in global health. Now young people are passionate about getting involved.
“Looks from my vantage point that the ‘me generation’ (mine) has been replaced by a millennial generation much more focused on others,” he wrote.

Particularly Kristof’s point about the millennial generation-development-medical school link deserves further attention.

I agree with Kristof that ‘global health’ has become a powerful, well-funded discourse inside the development industry. The promise of large, measurable impact (after all RCTs were pioneered in the medical field), buy-ins from multinational companies with very deep pockets and philanthrocapitalistic frontrunners meet perfect volunteering opportunities-after all there is practically no way you don’t make an impact if you are a medical professional working in a small health post in POORCOUNTRY.

But the story about Barbara Bush is also a reminder that ‘global health’ (which I will use as a singular term for the purpose of my argument in this short blog post) often comes in the form of WWW: well-educated white women. That’s generally a growing and important demographic in development, but I also believe that the rise of ‘global health’ raises some difficult questions about broader health and medical education issues.

The challenges and changes of medical school admission
Western/Northern/North American medical schools are among the, depending on your political view, most prestigious or elitist professional schools in many universities. Based on my own insights into a Canadian medical school I would argue that there is a ‘pipeline’ of young, well-educated global citizens that bridge the time between their undergrad degree and the application for medical school by engaging in ‘public health’ – it clearly shows your interest in ‘health’, builds on your knowledge gained from your undergrad degree and gets you into POORCOUNTRY which should help to facilitate a story or two for a great application essay.

A 2013 study (published in 2015, ungated version) by a Dutch medical school already indicates that ‘extracurricular activities’ should play a more prominent role in the selection process and this study from Europe did not find a bias with respect to ethnicity or social background:

This study has some practical implications for medical schools that aim to increase the diversity of their student populations. A first recommendation would be to include non-academic criteria in the selection procedure. Selection on the basis of the quality and quantity of extracurricular activities before application showed no bias with respect to ethnicity or social background. In addition, previous research has shown that success on our non-academic selection criteria was related to better performance during clerkships (p.131).

Another article from the same journal, this time written by Canadian scholars (ungated version), is more vague, but also indicates that more ‘inclusive’ admission structures to medical schools should looks beyond traditional forms of ‘excellence’-community or ‘public health’ engagement should most likely be one of those added components:

Moving from agency to structure, what can this critical discourse analysis teach us about improving inclusiveness? We recommend that the processes of developing policy to address issues of diversity and equity in medical school admissions explicitly recognise the power differentials that exist between the profession and excluded groups, and build in the consultative participation of such groups as policies are developed. For greater inclusion, we suggest a transformative model for the discourses of selection to value multiple excellences rather than one hegemonic definition of excellence. Through this multipronged approach based upon our research evidence, we call for the profession to courageously make explicit the hidden aristo- or elitist aspect contained within the merito- of the cherished notion of the medical meritocracy (p.46).

I don’t want to take this post too far down the academic route, but this 2013 article from Canada (sorry, link to gated version) is an important reminder of how complicated the relationship between privileged groups, medical education and public health is-and how the hype in global ‘public health’ risks to replicate inequality and power discourses: 

This Foucauldian analysis raises challenges in defining the concepts of equity, excellence, and diversity, and how these words may have specific meanings for different individuals and/or groups depending on their particular or local histories. Designing health policies with respect to medical education, including the selection of students, is ultimately an act of power, with both positive and negative, intended and unintended consequences for the institutions involved. One detrimental effect of rhetorical constructions—such as the one presenting the present situation as a new crisis—is that they may divert attention from the root causes of a given situation. Our analysis in fact suggests that deeper structural changes, beyond the regulatory bodies considered here, are required to address these problems. To contribute constructively to the situation, we query how best to incorporate marginalized viewpoints within the design and development of policy, and have a new appreciation of how texts about underserved or underrepresented groups might actually serve to continue to unintentionally exclude these groups from positions of power relative to health and the medical system (p.179).

As with most of my musings on the development industry, global precariat and ‘posh white blokes’ there is no radical ‘this is wrong and should be stopped’ lesson, but hopefully some food for thought as more young, white, privileged men and women aspire to become ‘leaders’ in global health.

Diversity in international aid work has always been an issue and I think the risk is that the ‘global health’ discourse will tie elite education practices further to development.

Are we all doomed then?
As much as I think the ‘global health’-elite education nexus needs further exploration from a non-medical perspective on development professionals and professionalism, I certainly want to acknowledge some of the nuances and complexities.

The medical and ‘global health’ industry have tremendous experience in fundraising and re-allocating some funding from ‘cancer research’ or other trendy, expensive projects to more development-oriented work is not the worst idea.

From a communication perspective I also find it important that medical professionals can use their development and ‘global health’ insights in their communities, private practices, hospitals or other organizations where many will end up working when they need jobs to pay for the student loans and medical professional lifestyles. And as much as one can criticize the elite recruitment patterns of medical schools, small local organizations or large NGOs will get a pool of very well educated volunteers or short-term international health workers that will most likely make some kind of difference.

At the end of the day I am always a bit concerned about the increasing professionalization of development work; there is a risk that the (stereo)typical economist may be replaced/accompanied by a (stereo)typical public health specialist – keen to use (big) data, scientific methods and a socialization from very prestigious/elite institutions that will have detrimental effects on diversity and knowledge production in development.

Besides the name and super-well-connected family, do we need 33 year-old white, Yale-educated ‘leaders’ in global public health like Barbara Bush-and what does that say about the increasing popularity of ‘public health’ and the discourses of power, knowledge and practices they (re)produce?