By Beryne Odeny (Washington University in St. Louis, Department of Surgery) and Julia Robinson (PLOS Global Public Health) The first in-person CUGH…
By guest contributors Madhukar Pai and Katri Bertram
“There is no thing as a single-issue struggle because we do not live single-issue lives” – Audre Lorde
In 2014, during the height of the West African Ebola crisis, Liberian nursing assistant Salome Karwah was profiled on the cover of Time Magazine as person of the year. Three years later, Time Magazine reported that Ms. Karwah had died in childbirth.
Ms. Karwah’s survival from Ebola, but tragic death from childbirth complications, is not a unique case. During the Covid-19 pandemic, many people who survived the virus died from other diseases and complications as health systems became strained or collapsed. Every primary health care worker will have a story to share about a child surviving measles or malaria thanks to vaccines or timely emergency care, but suffering from or succumbing to malnutrition, violence, or mental health problems.
A focused push for progress?
To address new or diverse health challenges, global health advocates play a big part in influencing global health practice. All of us are advocating for something or another. There are situations when we advocate for a single issue or cause because the issue is urgent, or because we really care about it.
For example, AIDS activism played a massive role in turning the tide on the HIV epidemic. It is widely hailed as a success story in activism, and held up as a model for other areas. Advocacy also played a key role in the eradication of smallpox, and in greatly reducing the burden of polio. During the Covid-19 pandemic, many of us advocated for Covid vaccine equity because billions of lives were at risk, and we needed to vaccinate the world.
But single-issue advocacy comes with some dangers. First, when we advocate for single issues, we sometimes lose sight of the broader context that erodes progress in our area. For example, even when Covid-19 vaccines were more easily available, their uptake was blunted by weak health systems, health workforce shortages, vaccine hesitancy, broken supply chains, and competing needs.
Second, when we are laser-beam focused on a single issue, we can end up competing instead of collaborating. For example, we end up pitting one area against another (e.g. HIV funding matters more than funding for TB or malaria) because we think our specific issue or cause is more important than others. We see this reflected in how people advocate: “disease X kills more people than TB, AIDS and malaria combined.” Paul Farmer had cautioned about this scarcity mindset which pits disease A against B. He encouraged us to ‘counter failures of imagination’ and demand for more resources, instead of competing amongst ourselves.
Third, single issue advocacy ignores the realities of people. As Audre Lorde put it, “we do not live single-issue lives.” (“Learning from the 60s”, Sister Outsider, 138) All of us have intersectional identities and multiple health needs. In fact, multi-morbidity is common, especially for vulnerable people such as those in conflict settings or living in poverty, but also for all of us as we grow older.
For example, people with TB are often co-infected with HIV, and tend to be malnourished or have diabetes. So, what happens when someone with TB needs nutritional support or anti-retrovirals (ARVs) or mental health services? Will advocating for TB alone solve those issues? Imagine curing TB but not being able to provide them ARVs for HIV, or insulin for diabetes? And among people living with HIV, TB is the leading cause of death. And yet, it is not uncommon to see HIV advocates and experts say nothing about TB!
Fourth, single-issue advocacy imposes a tunnel vision, and that comes with the inability to expand the scope for solutions. We push for capacity and funding for narrow silver-bullet solutions, and believe that things will be fine, if only we can fix this single problem in a complex world.
Frequently, we find that fixing one issue merely shifts the problem to another part of the system. For example, advocacy and projects to scale-up malaria rapid testing did reduce unnecessary use of anti-malarial medicines but focusing only on a single disease simply led to untargeted overprescribing of antibiotics.
Climate justice activists warn us about the dangers of being tunnel visioned and only focus on carbon emissions, without addressing the social, economic and political structures that have put our futures at risk. “Trapped by tunnel vision, the chance to imagine radical solutions for sustainability is stolen from the collective imagination by those benefiting from the current economic system,” they argue.
How do we deal these perils of single-issue advocacy?
There are no easy solutions, but one approach is that all of us can advocate for universal health coverage (UHC), stronger health systems, and greater investments in issues that affect health outcomes overall, in addition to advocating for whatever we are most passionate about. This is, in fact, an urgent issue. New data by the World Bank show that after an initial strong response to the Covid-19 pandemic, health spending is for many governments no longer a priority – putting at risk global health security and progress toward the health-related SDGs. So, without addressing this big issue of under-investment in health, progress in all areas will be stalled.
UHC is the one thing that grows the pie and unites us all, regardless of which area or population group we care about. There is no area in global health that will not benefit from UHC and a stronger, more equitable health system. Every area will function better with good primary care and resilient health systems as the backbone. The primary principle of UHC is universality – that all people are covered. Advocacy for UHC is people-centered, not focused on specific population groups or health interventions. While every disease or interest group is quick to emphasize that their area is critical for UHC, they also need to shift their single-issue advocacy to cover UHC and stronger health systems. In short, everyone in health must become an advocate for health as a human right.
For example, those who advocate for global surgery are aware that surgery cannot be performed safely without a decent health infrastructure that includes anesthesia and post-operative support. So, merely advocating for surgery is insufficient. Global surgery enthusiasts must also advocate for UHC. This logic extends to every area. Tuberculosis will greatly benefit from a stronger primary care system since most people with TB first seek care at the level of primary care. Diagnostics for cancer will improve when countries adopt a broader essential diagnostics list and include them in national UHC benefits packages.
To improve health outcomes for all people, including the individual issues we are passionate about, we need to understand the importance of bigger systemic changes and other issues that impact our focus area. We need to read beyond our narrow areas, meet with people with diverse expertise and experiences, and learn how to shape a broader agenda.
Global health is full of false dichotomies. We must not create yet another false dichotomy between single-issue vs broader advocacy. We need to use both approaches and smartly. This requires changes to how we communicate, fundraise, and advocate in global health. A better understanding of the possibilities and perils of both approaches could help all of us navigate this dilemma we all face daily.
Madhukar Pai is a Canada Research Chair of Epidemiology and Global Health at McGill University, Montreal. He is an Editor in Chief of PLOS Global Public Health. He can be found on Twitter at @paimadhu
Katri Betram is a senior global health consultant and founding partner of Partners for Impact. Katri can be found on Twitter at @KatriBertram
Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.