Invisibility in global health: a case for disturbing bioethical frameworks

In recent years, the global health community has been increasingly reporting the problem of ‘invisibility’ as aspects of health and wellbeing that are often overlooked and ignored, and predominantly affects the most marginalized and precarious people. However, it is unclear how to realistically manage global health invisibility and move forward. In this letter, we reflect on several case studies of invisibility experienced by people in Brazil, Malaysia, West Africa and other transnational contexts. Highlighting the complex nature of invisibility and its interconnectedness with social, political and economic issues and trends, we argue that while local and targeted interventions might provide relief and comfort locally, they will not be able to solve the underlying causes of invisibility. Moving forward, we argue that in dealing with an intersectional issue such as invisibility, twenty-first century global health bioethics could pursue a more ‘disturbing’ framework, challenging the narrow comforting solutions and sociomaterial inequalities of the sociopolitical status quo. We highlight that comforting and disturbing bioethical frameworks should not be considered as opposing sides, but as two approaches working in tandem in order to achieve the internationally set global health milestones of providing better health and wellbeing for everyone. In doing so, we call for taking seriously insights from sociology, anthropology, postcolonial studies, history, feminist studies and other styles of critical reasoning that have long been disturbing the grand assumptions about people and their conditions, and, practically, to rediscover the ethos of the WHO Alma Ata Declaration, calling for cooperation and support beyond the narrow market logic that dominates the landscape of contemporary global health

Minimally invasive autopsy - navigating uncertainties of death in the Global South

In recent years, global health practitioners and policy-makers have been confronted with the complex challenge of identifying and quantifying the causes of death of the world’s poorest people. In order to address this cause-of-death uncertainty and to minimise longstanding sensitivities and reservations about full autopsies in the Global South, funding bodies such as the Bill and Melinda Gates Foundation have advocated minimally invasive autopsies (MIA) as an alternative. MIA is a technology that involves using hollow needles to collect samples from key bodily organs. It has the potential to be more acceptable and less invasive than a full autopsy, which requires opening the cadaver. While the global development and introduction of MIA is growing, little attention has been paid to the ethical implications of its introduction in the Global South. This DPhil project aimed to provide a greater understanding of the various motivations underlying, barriers to, and debates about the development and implementation of MIA technology in the Global South. These include the various social, ethical, and political implications of this technology. In this thesis, empirical data that I collected in a range of contexts and countries is used to demonstrate that a core problem exists in current understandings of death in global health. Death is unavoidable; this is certain. However, at global and national levels, persistent uncertainty surrounds the exact numbers of deaths occurring and the causes of these individual deaths. The findings demonstrate the complexities in closing this information gap and shows a plurality of uncertainties underlying and contributing to the above-mentioned issue. I show that while MIA technology has been introduced as a solution to this enduring cause-of-death uncertainty, the development and deployment of technologies such as these always constitute interventions in complex social and moral worlds, and, in this respect, are both solutions to and causes of new problems. Therefore, MIA inevitably creates new kinds of uncertainties that need to be addressed. I deconstruct the ways in which these different dimensions and levels of uncertainties have been articulated, experienced, and approached, and the ways the uncertainties relate to each other. Finally, I argue that given the radical uncertainty of the future, the full impact of MIA technology is unknown

The invisible body work of ‘last responders’ – ethical and social issues faced by the pathologists in the Global South

This paper utilises empirical data to explore the value of ‘body work’ performed by last responders charged with the duty of dead body management, with a focus on the Global South. While frontline staff work to save lives, little is known about the experiences and roles of those who care for the dead in global health in times of crises and even during normal times. This paper discusses ethical and socio-cultural challenges pathologists face in ‘working on the bodies of others’ while conducting any form of post-mortem procedures – necessary for ascertaining and recording the causes of death. Identifying and reporting the cause of death have significant public health benefits and provide closure for bereaved families. Despite the foregoing, the pathology field does not attract funding from governments or donors, and it is overlooked compared to other disciplines. Autopsy procedure bears social stigma – as it is associated with body mutilation and therefore disrespecting the dead; certain cultural beliefs or taboos about impurity and death persist, further raising some social and ethical tensions. As a result, the dearth of autopsy procedures contributes to the cause of death uncertainty in global health

Navigating uncertainties of death: Minimally Invasive Autopsy Technology in global health

Global health practitioners and policymakers have become increasingly vocal about the complex challenges of identifying and quantifying the causes of death of the world’s poorest people. To address this cause-of-death uncertainty and to minimise longstanding sensitivities about full autopsies, the Bill and Melinda Gates Foundation have been one of the foremost advocates of minimally invasive autopsy technology (MIA). MIA involves using biopsy needles to collect samples from key organs and body fluids; as such, it is touted as potentially more acceptable and less invasive than a complete autopsy, which requires opening the cadaver. In addition, MIA is considered a good means of collecting accurate bodily samples and can provide the crucial information needed to address cause-of-death uncertainty. In this paper, we employ qualitative data to demonstrate that while MIA technology has been introduced as a solution to the enduring cause-of-death uncertainty, the development and deployment of technologies such as these always constitute interventions in complex social and moral worlds; in this respect, they are both the solutions to and the causes of new kinds of uncertainties. We deconstruct the ways in which those new dimensions of uncertainty operate at different levels in the global health context