Episode 11: Prerna Singh on the Comparative Politics of Vaccination in China and India

In this episode of the Global Health Politics Podcast, I sit down with Brown University political scientist Prerna Singh to discuss her latest book project, Moral Vaccination: How Ideas and Institutions Controlled Contagion in China and India. Our wide-ranging conversation explores how states generate compliance with public health interventions, grounded in a comparison of India and China's efforts to eradicate smallpox. Her important work suggests the need to incorporate a broader understanding of human motivations that goes beyond economic rationality, drawing on insights from a range of academic disciplines. Dr. Singh is past President of the Comparative Politics Section of the American Political Science Association.

Transcript

Global Health Politics Podcast

Episode 11: Prerna Singh on the Comparative Politics of Vaccination in China and India

SPEAKERS

Prerna Singh, Joseph Harris

Joseph Harris  00:00

Welcome to the Global Health Politics Ppodcast, where we go beyond the articles and books and have real intimate conversations with people working in the field of global health today. I'm your host, Joseph Harris, Today, I'm really pleased to be here with Dr Prerna Singh, Mahatma Gandhi Associate Professor of Political Science and International and Public Affairs at Brown University. Thanks for coming to speak at the Global Health Politics Workshop and for joining the Global Health Politics Podcast.

Prerna Singh  00:42

Thank you for having me, Joe. You made really important contributions on the comparative politics of social, wealth, welfare institutions, nationalism, and ethnicity. How and when did you first become interested in global public health and what do you find political science offers studies these issues today? Well, you know, we've been talking about this already, but I think part of it, part of the way that I came to this project was through my first book, which was interested in health, but very much within the overall framework of social welfare and social policy. And so I think to me the entry into global public health and health more broadly has always been this question of variation. And so I'm a comparative politics scholar, and so I think the entry point has always been this question of comparison. Why does this country manage to put in universal health insurance, and this other country has has, you know, faltered on doing so, and not just, of course, at the state level in terms of the country level. My first book looked at and was really driven by this puzzle of differences in maternal and infant mortality rates and life expectancy. And so at some point, I just remember looking at some data which really corresponded with my experience visiting and growing up in different parts of India, which is just where you were born and where you lived, made such a huge difference, just even controlling for socio economic conditions and a bunch of other factors, just where you were born made such a huge difference on how you lived, how well you lived, how long you lived. And you know, I remember this particularly striking fact of how, if you were a woman in the rural countryside, and you happen to be born in the state of Uttar Pradesh, which is demographically, these are massive states in India. So Uttar Pradesh is like larger than Russia. And if you happen to be born in this North Central Indian part of India at certain points of time, I think the 1980s and the 90s, you were an average expected to live as a woman almost ten, and I think almost at some points, ten to 15 years less than if you were born in the southern state of Kerala, which is demographically about equal to Canada. And I just remember thinking, you know, that's just...it's just mind blowing that within the same federal country, with very symmetric electoral systems, legal systems, you have this huge differences in just sheer longevity. And so it's been that question of variation in social welfare policies, social welfare outcomes, and now increasingly in responses to infectious diseases and how people take on board and respond. So it's that question of kind of comparison that has always been to me the entry point and the driver of my interest in public health.

Joseph Harris  03:41

In my Sociology of Health and Healthcare class, we take up that issue quite often. And I think that one of the things that most often just breaks open students who've never been exposed to this is that the difference in life expectancy between someone living in Back Bay right here in Boston and Roxbury is 30 years. 

Prerna Singh  04:01

No!

Joseph Harris  04:01

Yes, and it's something that is always shocking to them. 

Prerna Singh  04:06

And to me, what's so crazy, of course, just talking about the US is how these variations. I mean, it's not just spatial variations, it's also differences in economic but also ethnic groups, right? And so to me, one of the most tragic, like talking about, like, important, salient, understudied issues in public health. I mean the fact that maternal mortality rates for certain groups of Americans, for instance, black women, has actually been rising. And I remember looking at some graph, and there was, I think, just the variation again, in maternal mortality rates and maternal mortality rates for black women across different states in India. I'm sorry, different states in America is almost as much as states in India. And there are many ways in which, and I feel a lot of scholars have now been talking about this, is that you can actually look at certain health outcomes in states in America, in the south, and if you just take them out of the context of being a part of the United States of America, they in global rankings, would be faring worse than many countries in the Global South. 

Joseph Harris  05:08

Yeah, quite so. It's true. You have a unique perspective on the field of political science. As president of the American Political Science Association's comparative politics section, what's your sense of interest in global health issues in political science these days?

Prerna Singh  05:26

So it's a great question, Joe. I think on the one hand, there is this increased, intense, unprecedented attention to public health, global public health, of course, because of the ongoing COVID-19 pandemic. But in some ways, that is not an interest that I feel really predated the pandemic, and therefore I'm concerned that it will not be sustained beyond it. I hope it will be, but I think if you just kind of go back pre-pandemic, so before the pandemic, I had agreed to write an article for the Annual Reviews of Political Science, which is, you know, one of the kind of flagship ways that the discipline kind of reflects on its own contributions to a field. And I was struck by the fact that about 10 years ago, in the same journal, the Annual Reviews, Dan Carpenter at Harvard had written an article in which he had said, I think he'd used a life cycle analogy to say that the study of health policy is very much at a at a kind of, you know, very immature stage. And to me, it was just striking that writing in the pages of the same journal ten years later, it was not as if I could say, "Oh, we've made huge strides, and that there's a wasp scholarship that I'm reviewing" because at least for me, within comparative politics, so on the one hand, there's a lot of great work on understanding the institution of health policies as part of larger social welfare policies, like I could just rattle off so many names of so many amazing scholars in Western Europe, in Southeast Asia, you know, in South Asia, who, in Latin America, who have done absolutely path breaking work in terms of trying to understand what are the conditions under which certain policies get passed, and what the structure of those policies are, like yYou know, for instance, do they support the aging population more? Are they more geared towards women and children? So that has been, I think, a topic of long standing interest, and there have been important contributions to that field. On the other hand, the subject of my present work, which is really on infectious diseases and control of infectious diseases, I would say so little. Almost all the work has been on HIV/AIDS within that almost all the work has been on Africa. And there has been...there have been some exceptions, you know, your work, Evan Lieberman's work, that have tried to put HIV AIDS policy and comparative perspective across regions, but I think, for the fact that this is empirically, such an important, topical, urgent subject, and for the fact that, for me, theoretically, it has this possibility to make important contributions to the study of state-society, relations and state capacity. It's a it's a topic that is crying out for kind of more sustained engagement. And you know, as I said, I am concerned that after everyone's written their COVID paper, they will not really engage substantively with the many other issues in public health. But I but I also hope that they might, you know, the best thing would be if the pandemic kind of allows people to see just what a central topic of research there should be. To me, one thing is that I think people haven't quite appreciated just how important questions of the study of of disease and of health are to those kinds of bread and butter issues that animate the disciplines themselves. You know, like the core foundational questions of comparative politics, of comparative sociology. To me, health is there, but people haven't quite been able to appreciate that. So when I think of health, and I think of, you know, public health, you know, just that term itself, right? Public Health. Now, public health is usually, though not exclusively, initiated by states, but it is public health, you know. So it even in the term itself. It's all about like the engagement with the people and the people coming on board, cooperating, resisting, with these interventions. And that, that question of state-society relations of how the public relates to the government, those are like bread and butter issues. And to me, I think part of perhaps the neglect has been that we haven't fully appreciated how study of compliance with public health interventions might really allow us to understand questions of, under what conditions are states able to mobilize their citizens? And we were talking about this, but to me, the analogy between vaccination and taxation and conscription is is just fundamental, because in all cases they are collective action problems. They are all instances of states making costly demands upon their citizens, asking citizens to sacrifice in the name of a kind of collective good, and in all cases, your most rational strategy would be to free ride on the contributions of others. Don't sign up to fight because you might be losing the most precious of all things your life. Let someone else fight your war. Don't pay your taxes. Free ride on the piped water the pavements, and don't get vaccinated because every intervention, including vaccines, do carry certain risks, even if they're small, and why don't you let other people bear those risks and the effort of getting vaccinated, and you free ride on herd immunity. And so in all cases, you are being asked to do something, an intervention into the body, a parting of your money, a possible parting of your life, in the case of joining an army, and you're doing this because of, for me, a moral contract between states and societies and and that, to me, that question of, how do we think about the conundrum of this collective action problem and how to transcend it? And that's why it's so hard. That's why you know, to me, vaccine hesitancy has the gravity, is such a grave challenge, is because it's a big ask, and I think to try to kind of be able to link it to and allow it to be informed by what we know about the conditions under which people pay their taxes or join the army. I mean, there's, there are ways in which I feel as if there's a really fruitful conversation to be had, and we are missing the opportunity to have it. And so that's kind of sad, and I feel as if people don't realize that bringing in public health into the picture would actually allow us to have new insights on these foundational questions for our discipline. So that's, I think, part of, like my part of the reason for why it is that it is neglected and part of why I'm so sad that it is.

Joseph Harris  12:24

I love that those thoughts you share, I think that they get it central concens of both our disciplines. You're talking about state capacity. Yyou're talking about state building. Yyou're talking about collective action problems. Well, I look forward to hearing more in a minute about how your book addresses some of these issues. How does work outside your discipline inform the kind of work that you do?

Prerna Singh  12:48

The work that I read in political science is usually not on health. It's usually on these other more fundamental questions, which my discipline in comparative politics has done a really tremendous job of looking at, questions of state-society relations, but often that question has been explored, as I said, in studies of taxation and studies of, you know, joining an army, or in studies of economic development and other other measures of state capacity, or the more conceptual scholarship and state capacity when it comes to health, much of my reading is in medical anthropology, in area studies. The book itself looks at China and India. So I read very heavily in that, but also increasingly, as this argument about the moral basis of vaccination, morale has taken root. It's been in neurobiology. It's been in philosophy. It's been in religious studies. A lot of it, a lot of my work does draw on my micro foundations in psychology. So I think psychology and sociology and comparative politics, I often see that line is quite blurry, and so definitely a lot in kind of sociology as well. But, but to me, the argument has really emerged from an immersion into these other disciplines, seeing what they have to offer, and science and technology studies I've read quite widely in STS, as well as behavioral economics, so I...I really, I think that that's the part of the project, and I think that's kind of part of it, is that it's all linked, and to be able to kind of approach health, not just by reading public health studies, which, of course, you do, but also from seeing what insights these other disciplines can bring to bear on questions within public health, but are central to comparative politics that's that's kind of my thinking about it. 

Joseph Harris  14:41

Yeah, and I think invigorating our own disciplines when you do do that. What do you find to be the most interesting and important areas today to make theoretical, empirical contributions to global health politics?

Prerna Singh  14:57

So I think, as I said, we've done remarkable work in trying to understand the determinants of state policies, the role of political elites, the nature of political competition, the nature of electoral competition. My own previous work has dealt with how solidarity and community influence social policymaking. But I think to me, while there has, on the one hand, been a lot of attention to this question of health policy, there has been less work, at least within comparative politics, on what are the conditions under which these health policies are more or less enthusiastically accepted or resisted on the ground. A lot of sociologists have called this "the last mile problem." It's where the rubber hits the road. And so I think, for me, the area of research that I think would be so well served by having a lot of interesting new work on it would be this question of: how do these social policies, health policies, public health policies, policies to control disease, how are they received on the ground? How do people engage with these policies, that more public part of public health? I think that kind of bottom up perspective. And again, as I said, you can clearly see that there is now research on it because I think we have seen through COVID and vaccine hesitancy, how important that part is. We've rolled out vaccines, and we invented the vaccines first of all. Right, so first it used to be, or you have to kind of have the right technology, and it turned out that we made unbelievable advances and had vaccines within a matter of few months. And then, you know, states across the world, including many in the Global South, rolled out these vaccines with amazing efficacy, and they were soon available across the world. And then you began to realize that much of the problem was not the invention of the technology, and not even so much the provision or access to it, but the fact that many people who had access to this kind of state of the art intervention for free were not willing to take it. But I think this question of you know, under what circumstances do people come on board with this is is, to me, the kind of that area that I am most excited about seeing new work in. 

Joseph Harris  17:27

We've talked so far about disciplines, both your own and other ones. But what about practitioner organizations, activist organizations? Are there groups whose work is, you know on your mind, or that's influenced the way that you think about these issues?

Prerna Singh  17:47

Absolutely. I mean, I think mostly because a lot of at least my field research and my first book entirely was on South Asia, I think of a number of organizations that are working in public health in the South Asian context, many of whom I learned from because, without having the fancy theory, they have found what works on the ground. And just to me, the selflessness and the dedication and commitment with which you know volunteers, people...I mean, this is actually, in some ways, I'm glad you mentioned this. It's kind of seeing the zeal of a lot of these workers that makes me realize that the story in public health is not about money or monitoring or, you know, these people are not doing it because they're being coerced into doing it, and the incentive structure does not support them doing the kind of work that they do, and yet they do it. And so it's almost as if, like, I, you know, it's that kind of wisdom of just like witnessing and just how inspiring it is. So I mean, I could name a whole lot of organizations. There's one actually, that actually, you know, my father's been involved with in, and therefore I know the work quite closely, that has done so much in vaccine hesitancy in some of the most backward, in terms of socioeconomically backward, areas in Rajasthan that have, which is a state in the northwest of India, bordering Pakistan, that and especially among indigenous populations, but just seeing the creativity and the joy with which they have, you know, absorbed cultural traditions, song, repertoires, and again, the dedication and non-judgment with which they have approached a lot of these issues around vaccines. I mean, so the organization itself, which is called Dusrada Shah, actually is mostly for education. It's for the education of girls from ten, from age ten to 20 - that's the Dusrada Sha, the second decade of their lives, when, in some senses, they're let down by the secondary school system. But to see lots of these associations and activist organizations also pivot during the pandemic and see how effective they can be has also made me realize, again, this point about, you know, public health can learn. And these organizations, for them, there was no clear demarcation between education or working with migrant workers or doing vaccination, you know, it was all they approached it as a whole. And I think that's part of why it was also so successful. So yeah, I mean, and of course, lots of global organizations that continue to inspire. 

Joseph Harris  20:22

Tell us a little bit about your current project. I understand it's a historical project that relates to vaccination campaigns in the two largest countries in the world, China and India.

Prerna Singh  20:32

Yeah. So this project actually looks at the world's first vaccine which gave rise to the term vaccine, which comes from the term variola vaccine, which was cow pox, the cow pox vaccine, which was against smallpox, which has now been eradicated. So in some ways it is the world's most successful vaccine, because and you can, I think you can appreciate the scale of the achievement when you look at the COVID vaccine today, and so this wasn't just herd immunity. This was like, you know, you had to hit above 90% vaccination across the world for a disease that was, had killed mankind in the hundreds of thousands. It was called a slate wiper disease, in that it would kind of go across the globe and just destroy millions. I mean, it destroyed the virgin populations of North and Central America. The indigenous people did not have resistance to smallpox, and so by some accounts, something like 90% of indigenous populations were decimated by the arrival of smallpox through the Spanish, so it's a deadly disease that we now barely know of. When my daughter was born, I remember, like flicking through a pediatric pamphlet at Brigham and Women's when I was teaching at Harvard, and it was actually showing practitioners, clinical physicians how to distinguish chicken pox from smallpox. Because at that time, you know, especially since post-9-11 there had been this specter of the use of disease as a agent of bio-terrorism. And when smallpox was eradicated, one strain was kept in the CDC in Atlanta under like seven locked doors. And then one strain, because it was eradicated in the Cold War context is somewhere in Russia. So that's always been kind of terrifying, but, but you know all to say that now we don't even like now clinicians have to be taught to identify this disease, but it was a huge disease, and it was eradicated. So it follows the invention of the vaccine, which I prefer to call the discovery, because it really built on a lot of knowledge associated with the practice of variolation, on which vaccination was built. I won't get into the details, but it's a fascinating but also somewhat tragic kind of co-optation that Jenner is said to have invented vaccines when actually he really built on indigenous knowledge from China and India. But it follows the trajectory of this vaccine and tries to understand how, in the countries of China and India, but also in subnational units, so cities within these two countries, what were the factors that led to the more or less enthusiastic adoption of this vaccine? And so the idea is that, I think you know, humans are the same, even if vaccines have changed. And some of the insights that we can gain from looking back in time can actually help us understand the present and possibly also think about the future, insofar as neither infectious diseases, nor vaccines, as our primary and most effective line of defense against them, like that's going to remain. And so the general idea is a kind of historical analysis but very much with the hope that it will be able to speak to present challenges. 

Joseph Harris  23:52

That's fascinating. What drew your interest to these issues?

Prerna Singh  23:55

I think in many ways, a dissatisfaction with the existing ways that we think about compliance with public health interventions, which seems entirely saturated by this idea of Homo Economicus or rational actor models, and so the idea that, Oh, we will take on board public health advice to wash our hands, to wear a mask, to socially distance to take the vaccine, if it if we think it's in our interest to do so, right? And so the general idea is that we either have to be told that we will be imprisoned or fined, or some other kind of, you know, coercive stick will be there as a threat to force us into doing this or that we are incentivized. And so there's a whole scholarship on the use of fiscal and non-fiscal incentives to kind of encourage compliance with public health interventions. And then the other side of that is kind of, you know, giving people positive incentives or carrots. So, you know, trying to encourage them into taking on board everything from mosquito nets to, again, vaccines. And to me, it just is a very frugal...it's, you know, homo economicus is a very familiar way. The rational actor model is a very familiar way of thinking about humans. It's also very frugal way because we know that we are, you know, driven by emotions and by norms and values and worldviews. And these are not captured by this kind of interest maximizing strategic actor model, you know, the questions of importance of trust between providers and the state and people. And so the general kind of way that I got to it was to say that there's a story here that does not only look at decisions in terms of, oh, I had no choice, because otherwise I was going to have to face the coercive arm of the state, or that I did it because, you know, I made a rational decision to do so based on incentives and information, but to realize that we do things because we also have all of these ways of being in the world, which are moral ways of being in the world. And at the same time, as I was beginning to look at the historical archives, and so this project involved like archival analysis across Guangzhou and Shanghai and Beijing and Delhi and Kolkata, but also Geneva, the WHO archives, and all of India's smallpox eradication archives are in the WHO and so, you know, I was looking at all of these range of different kinds of documents, and reading all these historiographies and histories of the smallpox eradication, but also earlier in the 19th century. And I kept kind of looking, I kept kind of realizing that there is a kind of story here for the way in which people are viewing this intervention that isn't saturated by rational actor models. And at the same time, I was beginning to be involved in this quite inspiring set of collaborations around what is called a new model political economy. And so people like Anne Marie Slaughter and Hilary Cottam were talking about this idea of Sapiens Integra as an alternative to homo economicus. And so what's also been called Homo Morales. And so they were not talking about public health at all. They were just talking about the ways in which we might think of public policy more broadly speaking, if we center an understanding, a theoretical understanding of humans, not as homo economicus, but as Sapiens Integra more integral humans, and that, I think, gave me the theoretical hook and prism through which to understand this history that I was reading and engaging with in 19th century China and India. 

Joseph Harris  27:51

One of my favorite things to do when I read a book is to read the acknowledgements because you often get to see the lineage of the ideas, and so I love to hear you reflect a bit on, you know, you're interlocuters and how they informed your thinking. I was curious. You know, as I understand it, this is still a book in progress. But  would you say that there are lessons that we can draw from that that apply to our current dilemma today with respect to vaccine hesitancy?

Prerna Singh  28:24

Yeah, it's a really good question, and it's something that I think about a lot. I mean, the one is, I think that parts of the book are being borne out by the way that I read the scholarship on vaccine hesitancy, specifically for COVID, and the fact that again and again, the role of trust, which I think of as very much in that bucket of kind of moral factors, broadly defined in that it's not reducible to a kind of strict rational calculation. And so to me that the work of so many people has shown again and again, this importance of trust, in your provider, in the state, that to me is in some ways, I don't want to say vindication, because, you know, but it's a kind of, I think it resonates with the argument I because I was taking this opportunity to come to Boston, even though I live very close by in Providence, I had I met some of my best friends, one of whom is the union organizer from Guatemala, and the other one actually works at BU and he's from Chile. And so he was asking me what my talk today was on. And he was like, I'll tell you an anecdote. His mother lives in Chile. And he told me that he was just talking on his on the phone with his mother, just, you know, in Chile. And she said, "Oh, I got the vaccine." And he said, "Oh, really, you got the vaccine. Which one did you get?" And he said, you know, she had basically no idea which vaccine she got. And the way that it happened was that she was just out and about. Her friends told her, Oh, the vaccine is being provided. It was at a center she trusted. And he was talking about how even and that, I think is the part of this that I, that I really want to emphasize, is that, you know, we struggle with this in North America, in the US, but in many areas of what we might call the Global South, there are deep model relationships between states and societies, even in conditions where other ways of thinking about state capacity, like per capita GDP, might not look so great and and so he said, "You know, there's so much trust between the state and in particular the domain of public health, that his mother didn't even bother checking which vaccine it was. It turns out there were a few different ones available in Chile at the time, and she just saw a sign that said, 'Vaccines available,' And her friends said, 'Oh, let's go get the vaccine.'" And so, you know, here where I was having such detailed conversation with friends who were like, "I will only take the Johnson and Johnson." And you know, you were kind of like, it was such a it was such a fraught decision for so many of us. And I think that it really gets to these very fundamental differences in the relationship that people have with their states and and that, I think, is the fundamental insight about the project, that I think is vindicated in the case of COVID, is that you can, you can provide the vaccine, you can bring it to people's doorsteps. I mean, in the US, I don't think it's so much an access situation. It's really about how do the people think of the state? How? I mean, there's obviously a partisan element to that as well, but I think there's a more fundamental element of, you know, should the state be doing this? Does the State belong in the domain of health? And I think for many Americans, because of the history of the American state and the privatization of health, there is a way in which it's just normatively incongruous to see the state involved in health in the way that in many other parts of the world, the state is a very normatively accepted actor under conditions of universal health insurance. You know. So to me, there is a connection between the absence of universal health insurance, and that interaction with the state as a healthcare provider in the way that you know, even just a few years in the UK as a student, the health service is the National Health Service. I knew I was interacting with an agency of the state when I went for my annual checkup, and that, I think you know that that kind of close intermeshing of states and societies around around health has created legacies of trust or mistrust, as the case may be. And so that, I think, is a fundamental argument of the book that I think is very valid and is kind of playing out today, often tragically.

Joseph Harris  32:39

Yes, yes. And it's so interesting. I think we talked a little bit about this in the workshop today. These ideas of what the state is and its appropriateness being very different, let's say in Florida versus Massachusetts. 

Prerna Singh  32:57

Absolutely.

Joseph Harris  32:58

The next couple questions I have to ask you are more about the research process and invite listeners to sort of learn how you think about research. What would you say are the most meaningful parts of the research process to you?

Prerna Singh  33:15

I think, well, I want to say, thanks for asking such a question, because I don't feel we reflect on it enough, you know, like we just kind of do it, and then we hear these, like, in some ways, packaged talks, right? And, I mean, so now I'm going to out myself as someone who did not come to this question specifically through public health. I mean, it's funny how you kind of end up in the same neck of the woods one way or the other, because there's a part of you that's there even when you're not there. But this project really began in on the streets of Beijing in the aftermath of the Beijing Olympics. And as someone who had grown up in India, I was just struck by the degree of again, this what I call a very thick relationship between state and society, in that there were these people, and just in the process of conversing and getting to know them, and at that point I was learning conversational Chinese, I realized these are mostly volunteers, older volunteers, who were helping people do everything, like negotiate the public transport system. And these volunteers different age group, younger that time had been the backbone of the Beijing Olympics. And at the same time, India was having a kind of huge public relations disaster in that the front page of number of British newspapers and the colonial angle was not lost, were showing these, not just these collapsing stadiums, but empty stadiums in the Commonwealth Games in Delhi. And of stories of volunteers who had made off with their, you know, the kits, their uniforms and their flags. And part of being a volunteer is you show up for these, like, you know, fencing, you know, 101, kinds of qualifying tournaments, and there was no one in the stadiums, and it was a disaster. And to me, the disaster was, "Well, why is it that, you know, these two states are not like...what explains the differences in the organization of these sporting events, but less from the point of the organization of the sporting event, but more a question of, like, popular engagement with it, because clearly there was a lot of kind of pride that led people to kind of be a part of the Olympics and to work for the Olympics in the way that clearly there had been very little such pride that had driven either popular participation more broadly, or even the volunteers to actually show up to do their jobs. And so that's why I wrote this paper when I was an Assistant Professor at Harvard for for a conference organized by Peter Hall and Bo Rothstein, in which I tried to kind of make a link, saying that this, the difference in these two sporting events said something very deep about the relationships between states and societies, and that it did not have to do with regime type. So, you know, political science and the discipline is completely about like regime type looms in everywhere. And so I wanted to say this does not have to do with the coercive power of an authoritarian communist state in China. And actually, most scholars who work on China will agree with that. And that was not what I saw, but that it really has to do with some kind of obligation to a state in the way that growing up in India, as a citizen of India, I definitely did not have, or at least I had not witnessed, and so that's how it kind of began. And so I think all this is to say that for me it was, it was an insight, like I had an inkling about something way back, like 10 years ago. And then, of course, the project went nowhere. And then I finished my first book and did a whole lot of other things, but I think this was in my head. And then one way or the other, I came back to health. So the first book had been about health and education, and I realized I really wasn't interested in the organization of sporting events at all. It had just been for me, that kind of very clear manifestation and the arrival of an insight that I realized actually helped explain something in health and so then I was just kind of reading around, just this question of, as I said right at the beginning, my entry point into it is always this question of variation. And growing up in India, you always kind of hear of how China is doing a lot better. And in particular to me, what was interesting were those early years of the People's Republic of China and the early years of India after independence, because India gets in Independence in 1947 China in 1949, so both enter very close together, kind of as sovereign states. And even though they have different trajectories after that, it, you know, China, on many accounts, is poorer. India inherits an institutional apparatus through the British. And on many counts, you would imagine that India might have been better placed at doing a lot of these kind of developmental interventions, as compared to China and so that kind of was linked to the first book, is that, how at the national level, there was very little...Community development was much less of a success of the Nehruvian state, as you might have hoped. And so then it kind of, I began to kind of release. So it began in the 1950s in which I realized, I began to read about the Barefoot Doctors. Then I realized that actually, much of this eradication, like, you know, just happened, like in China, they managed to immunize to such a vast population so rapidly, and it was mostly through a kind of volunteer army, a lot of CCT, CCP cadres. And then I just became obsessively interested in this patriotic health campaign. And in my first book, the argument...The book is called How Solidarity Works for Welfare: Subnationalism and Social Development in India. And the idea was that states in India that have much more cohesive subnational identities based around a common and distinctive language were more likely to have an idea of the common good. But the argument itself is really not just about regionalism. It was about nationalism. So this idea that if you can go back and look in Western Europe after the Second World War, nationalism is a big driving force for the institution of welfare states and of national health services in Europe. And so I had been interested in nationalism, and here I was reading about a patriotic health campaign that I did not know much about, that had essentially been responsible for the eradication of one of the deadliest diseases without the kind of institutional apparatus that many advanced industrialized countries had had. And so I realized there was something here about the way in which patriotism or nationalism had been mobilized in service of a public health campaign. And it made me realize that there's clearly something here about affect and the role of emotion. And I just happened to be reading, you know, Martha Nussbaum, and a lot of I began as a political theorist, and so I always like bedside reading for me is a lot of political philosophy. And so I was reading this whole work, and then I was reading Damasio about that railroad worker who has the pole through his head, and, you know, his cognitive abilities are intact, but he can't make any decisions because he doesn't have like...it's the emotional part that's affected. But, you know, it clearly shows that emotions are involved in decision making. And so I was reading all this neurobiology and philosophy on the role of emotion in decisions. And then I was reading about how people's decisions to vaccinate or not were really influenced by being seen as a patriotic duty or not. And I was beginning to think about in a way the kind of deficit of nationalism and patriotism in India in the 1950s. It's kind of ironic because India gets its independence through this kind of hugely successful non-violent movement led by Gandhi. But at that point, I have colleagues who were beginning to kind of write about the point that actually India's nationalist movement was much thinner than people give it credit for. And the fact that I was reading Nehru's own papers, and the fact that he really bemoaned the collapse of the Congress. He kept saying, you know, I can get hundreds of thousands people to come out and hear me, but I don't have a party to work with. The Congress has disappeared. So the Congress, kind of, like the rank and file of the Congress, kind of evaporates after 1947, and so I was kind of, you know, thinking about the frontline bureaucracy and, you know, how does it work? And do you have a party that supplements the frontline bureaucracy, thinking about the kind of, you know, where the state meets the street? And then I read this article about smallpox and Canton and how they'd embedded the incision into acupuncture. And for a while that remained completely separate from the patriotic health campaigns, because they felt so different. And then at some point, I realized, no, it's the same. There's something happening about this kind of affective motivation to vaccinate, whether you know that, I think so. You know, it's kind of like deep moments of self doubt about, like, where is this going? But I think it's, to me, it's a lot of iterative reading between, kind of, like conceptual theory that you don't even know if it's actually going to make it into the book, but I think it's important, and then a lot of kind of just reading a lot of history around it. So it's a terrible answer to your question. 

Joseph Harris  33:51

I think it's a wonderful answer. I mean, I feel like you've described the process of coming to these a-ha moments about how the world really works, or generating some understanding of that that's better than we we currently have and, you know, and the way we sometimes back into that, right? I love the way that you, you started on the streets of Beijing after the Olympics. I mean this, you know, we get there sometimes in funny ways. 

Prerna Singh  42:55

Yeah. I just remember thinking, you know, in India, like, I just, like, pictured that someone who was just doing this because of, like, you know, that sense and but, you know, so, yeah, it all blew back into it. For a long time, I'd been interested in this question of, we're so obsessed with rights. This is my right, but I had always kind of thought, especially because in India, we have to recite the preamble to the Constitution of India. And, you know, there's a whole section of fundamental rights, but there's also a section on like fund...on duties. And I don't know, as a kid, I was always kind of also fascinated by their duty section, you know, but the duties are non-enforceable in a way, right? And I was always interested in that non enforceable part of duties, you know. Like, why do people do this? In a way, it kind of gets to your point about the activist organizations, you know. Like, why do people like act in all these ways that are like in some ways? You might think it's foolish for them to do it right, but they do it and we, and to me, those are very powerful drivers. And weirdly, the neurobiologists like have said that they are, but us as social scientists have been so kind of blindsided by this focus on economic rationality that we're almost not able to hear what the neurobiologists are telling us about ourselves. But then my point is, you know, it's not just neurobiology. A lot of this is constructed, right? So it's also about how the state constructs its relationship to society. And then I kept going back and reading like, you know, these boring documents, which I find endlessly fascinating, of like training manuals for community health workers in India and and the fact that, you know, they're just never able to create this sense of, you know, oneness, this kind of being able to speak to the health providers and and for them to be able to speak to the people. It remains a very top-down kind of, you know, almost new colonial relationship in the post-colonial period and, you know, yeah, so it's a but I just wanted to say one thing, which is that, for me, it's also the one thing that I just want to say is that I think there's no one a-ha moment, you know, yeah, I think that's the thing is you kind of realize that every a-ha moment is also inevitably followed by the ah moment right, in which you're like, "Oh, no, shit! I thought I got it, and then I haven't, and there's this, and there's that." So I think it's more just like, I think what I've realized is it's just you kind of have to keep working at it and just kind of keep going and faith. You just have to have faith. 

Joseph Harris  43:01

Yes. I mean, you know, I'm glad you mentioned that, because it's so counterintuitive. You know, no one talks about that. I think in the social science, faith is really required to do this work.

Prerna Singh  45:26

It's essential. 

Joseph Harris  45:38

You know, that seems like an odd thing to say, both for the amount of time it takes, but also, you know, I remember in my dissertation, you know, struggling with a lot of self-doubt. One, because not only did busy people have to give me the time of day in order for my research to succeed, which they didn't have to, but they had to then say something that was interesting and/or novel enough for me to be able to write something new, and that seemed to require a tremendous amount of faith, and I didn't have it at the time. But, you know, here we are. 

Prerna Singh  46:14

No, I think it's a kind of daily renewal. I think it's the daily renewal of faith and the kind of, you know, at least a commitment to a daily or, you know, regular writing habit that I feel.

Joseph Harris  46:27

Yeah, yeah. And the other thing you were saying was this idea of altruism producing a kind of does not compute, does not compute moment, in particular political science, where, you know, the rational homo economicus, as you talk about, kind of dominates. I mean, that's a really interesting kind of, I think, moment.

Prerna Singh  46:49

Yeah, and that's where, you know, talking about the acknowledgements and the interlocutors, the fact that a large number of the interlocutors for this project have not worked on health at all. And it's, you know, it's you know, it's not just altruism. It is the fact that, you know, we have broader, I mean, if you kind of go back to the Weberian understanding of rationality, it's actually, you know, we are value rational. We are rational in so many ways, right? So in some ways, to me, it's also just the kind of equation of rational with this very narrow cost-benefit calculation. I mean, you know, it's rational for me to do this because it gives me a lot of, you know, satisfaction, but that satisfaction, you know, so, and we know this from, like, you know, just life, yeah, right, like we know that we don't just derive satisfaction from those things that give us...

Joseph Harris  47:37

Put it in our model.

Prerna Singh  47:38

Exactly, yeah. So that, I think that's kind of part of it is, is Yeah, is to just realize that we are all driven by a range of motivations and and to me, it's important that scholarship begins to take note of them, to emphasize them, and to center them because, you know, it's a vicious circle. If you think we are only driven by narrow rationality and the institutions are only structured to cater to that kind of rationality, then in a sense we know that it kind of exercises that rational muscle, because that's what we're seeing around us, right? In some ways, it's the kind of it's a hegemony of neoliberalism. It becomes the water that you swim in, no? So for me, it's like in not just having the quote, unquote, non rational moral be the residual, you know, the error term in the equation. But it's actually that, you know, this is quite central to how people think. Yeah, it's not just that part when they're not thinking, actually, this is, this is just how we think. And so I think, to me, it's, it's, you know, it's also about kind of creating the conditions for institutional change, so that the institutions are not just catering to a version of us that is so impoverished and does not bear resemblance to us, you know. So what would public policy, public health policy, look like if we realized that actually people are driven by a whole range of motivations that are that are not kind of strictly interest maximizing.

Joseph Harris  49:02

Yeah, and it would seem, I mean, I'm a sociologist, not political scientist, but that there's a lot of opportunity within political science to build new kinds of models in this in this way, right? Am I wrong? 

Prerna Singh  49:14

I wouldn't say a lot. I would say that I'm certainly standing on the shoulders of giants in terms of everyone who's been involved with this kind of new moral economy project, and my association with it has been through Margaret Levi's leadership of the Center for Advanced Study at Stanford. But I think that there is a growing community of people. You know, seeing a community of incredible people, you know, Dani Rodrik here, all kinds of amazing people like really try to center this idea of, you know, what would moral motivations look like? Daniel Allen, and I think that has been kind of inspiring. And then I think of it as obviously within the context of health. But then you also read all these kind of clinicians' accounts of how you get people to comply with tuberculosis DOTS [Directly Observed Therapy Short-Course] programs, right and/or diabetes medication. And you see again and again, the kind of importance of these kind of relational dynamics. And it's not just about giving people information leaflets and saying, you know, if you don't complete this TB DOTS program you might actually develop, you know, it's not, it's kind of being able to appeal to something that's beyond that. And so I think, on the one hand, it, you know, there's a whole community of really amazing scholars working on it. On the other hand, you know, those people who actually do health work, you know, the Judith Tendlers, frontline health providers, they know what it takes. So in India, smallpox eradication campaign, there's a great work by Frederick Apfel Marlene, who's an anthropologist who wrote this book. The problem was that these vaccinators, who were often foreign in terms of not being from the city, would not take their shoes off when they entered a house, you know, because they were, like, you know, basically brown babus, you know, like the they were trained in a colonial bureaucracy, which had basically just passed on to Indians, but they kept their shoes on. They had shirts. They were dealing with, like, you know, these rural ignoramuses, and they would go in with their shoes. They they felt they didn't respect the elders. And so a lot of this, you know, and, and the kind of irony in all this is that the WHO comes in, which is its own kind of incredible story, and Larry Brilliant, who had an opportunity, who's kind of a public health great, you know, he, I was talking to him, and a lot of people in India spoke to me about how he was a devotee of this Neem Karoli Baba, who's an amazing mystic, who was also Steve Jobs' guru, but an amazing kind of healer. But he spoke about the importance of creating these Shitala Mata statues, you know. So when he took these teams, and he became very quickly critical to the WHO campaigns, he's written this very dry book called The Eradication of Small Pox in India, which is the main book about the kind of way in which it was eradicated, most of it is just tables of the number of trucks and gas and vials and, you know, but it's dedicated to his guru, but he talks about how critical to the WHO's campaign was that they began to organize these smallpox vaccination campaigns within the precincts of the temple to Shitala Mata, who is the deity associated with smallpox because they wanted to be very clear that they were saying that they were devotees of the Goddess, and not, you know, not offending her in any way. And so, no, it's true. I mean, I'm always struck by how so many of these people, Bill Figge, who was another big person, you know, son of missionaries there. There is some kind of, at some point, I want to kind of create a dataset of people in international bureaucracies who have come from kind of religious backgrounds interesting because there is something...I don't know. It's an observation. I don't know who...a path that maybe somebody else can take.

Joseph Harris  53:09

We've already talked a bit about faith as it relates to the production of social science knowledge. Are there any other parts of the research process that you feel don't get enough attention, that we don't talk about enough?

Prerna Singh  53:24

I think one is just how solitary it can be. 

Joseph Harris  53:28

Yeah Yeah. 

Prerna Singh  53:28

I think, just looking around and just in the kind of present moment, and the kind of mental health crises of a lot of young people that we see around us, you know, again, it goes back to faith, but also, I think, at least being aware of both how solitary and how sometimes alienating it can be. You know, it's you, your work, your head, your thoughts, your words while you're still engaging. You know, you're engaging, but you know opportunities like this, of you know, being here at BU of actually having an in person event, especially after COVID. I mean, I wish I could say this is the norm, but, but it's not, especially in the production of research, that part of our kind of professional lives, I think, can be quite solitary. So I think not sure what the advice from that. One is just realizing that that is the case. And I think having networks, I had a writing group, I think, which was really quite invaluable to me in graduate school. But also, I think, yeah, I think discipline, I think it's something about faith and discipline too, is, I think just, it's almost like, you know, having a practice of yoga or, like, it's just kind of like, even if we're not setting high standards. So now I'm just like, I will just engage whatever that engagement is every day. That's what I try, but not always, that it happens, right, but I think, like knowing that I need to spend a little bit of time with the book every day and then just trying to, kind of, you know, find some time for deep work. I think deep thought for me, I know that you have all those 45 minutes, you know how to write your dissertation, 15 minutes a day, but I don't know for me, just like being able to carve out time to really get in, which is, of course, harder when you have people in your lives, particularly little people in your lives, but I think, I think, you know, both having those communities and and kind of actively trying to be part of them, but also kind of having your own discipline. I don't know if that makes sense. And I think questions in political science, there's an amazing revolution. There's a whole causal inference revolution, which is great. We have, you know, new, amazing, exciting work, but I see so much emphasis on, you know, trying to identify causality in terms of a particular, you know, either a regression discontinuity design or finding a kind of source of exogenous variation. And all of those are great. But I think to recognize that there's a place for asking the questions and that it's mutually complimentary.  You know?

Joseph Harris  56:06

Yeah, yeah. I think one inspires the other. Absolutely. If you didn't have one, the other would be meaningless. What would you say are some of your biggest influences in terms of writing research?

Prerna Singh  56:19

I mean, you know, we've spoken about how kind of solitary and alienating the process can be, but to me, it was also an incredible opportunity. You know, I grew up in India. I The idea that a university would give me five plus years of funding for me to be able to actually just learn and then work on something was a golden opportunity. I mean, it was just an opportunity that I was just so grateful to have. And so I think, I think not losing that gratitude, I think, and also that sense of awe, like, I mean, not to say that I like, went through graduate school with daily gratitude. I mean, there's certainly deep periods of being jaded and, you know, complaining, but I do think that at some point I began to really tire of a kind of culture of complaint that was happening around grad school, which I was embedded in. But I think just kind of realizing that it's also to me, it's like this opportunity to do what we love, and to be able to kind of, you know, engage with these big questions, and, you know, read scholars who inspire us, and to visit parts of the world and engage with people who are doing all this incredible work. And, you know, so and and to me, like, you know, my mentors in graduate school were a huge influence. But I've also been extremely lucky to have kind of mentors. You know, when I was an Assistant Pprofessor at Harvard, at Brown, you know, lots of folks in the moral economy network, you know, Margaret Levi and many others there. But you know, just to also to kind of see them at various life stages continue to produce really cutting edge research and to be able to move into new domains. But, um, so, yeah, I mean, I think also just kind of being like, I think just being grateful for, like, this life, the life of letters. I think that's, it's a huge privilege. It's, it's just, it's a great gift. And, you know, we know all gifts come with certain things. But I think, you know, the faith comes with the gift is, you know, you have, you have faith that this is all going to work out, and the argument and the empirics.

Joseph Harris  58:30

And you may have doubts!

Prerna Singh  58:32

For me, it's like most of the time, but then also kind of being really grateful that it like, you know, I don't have to talk in and you look at the world around us just like...

Joseph Harris  58:40

Yeah, you get to play with these ideas and they also may have practical importance. 

Prerna Singh  58:44

Oh, for sure. I mean, you know, the questions that drive it to me are, are questions that are unfolding in the world and have unfolded, yeah. And for me also I think a big thing is being able to learn from history and to realize that much of this, you know, the kind of Mark Twain history rhymes kind of thing, you know? So it's, yeah, I mean, most of my work is as much of my work is historical, but it's very much driven by like, you know, how can we think of these contemporary, vexing, urgent life and death issues and health and broadly so? Have you found your work to be taken up by practitioners, oOr have you had moments where you've had interesting conversations with people who are involved in practice, in the in the academic work that you're doing? Yeah, no, I think I've been quite fortunate in that respect. So the first book I remember, I have a friend from graduate school who once sent me, I mean, a friend from Delhi who, when I was in graduate school, sent me this clip of a chief minister who's the equivalent of, really the governor of a state in India called Bihar. And he used the word subnationalism, and it almost made me cry. But this particular state really understood, and this particular individual, Nitish Kumar, really understood this kind of importance of creation of a kind of subnational solidarity, and that was, I would say, the kind of most stark instance of an idea that I thought I had been putting forward for a long time being taken up. I'm not saying that it was my idea that he necessarily took up, but that it was out there, and that it resonated. You know, there were other people who were clearly making the same argument, and so I'm not saying he got it from the book or but so I think that is one instance when I really enjoy, again, speaking to kind of frontline bureaucrats and kind of activists. And for me, an endless source of inspiration, actually, this is an answer to your earlier question, are Asha workers? Asha workers are, you know, these kind of frontline health workers. My sister's a photographer. She photographed, I think it was for Time, these Asha workers who were being completely selfless. I mean, going out in the midst of the pandemic, the midst of the second wave of that terrible, deadly pandemic in India, to get food to people, to get COVID tests, to get people to hospitals. And, you know, there was no rational reason for these women to risk their lives. They had not been paid in months and so, you know, it wasn't so much that I felt as if they were, I mean, I drew inspiration from them to say, "Okay, this is an argument that needs to be made." Because it is not the case that these are people who are being driven by, you know, some of those interventions, their photograph is not being taken by a digital camera when they're clocking in to their you know, these various interventions to counter doctors and nurse absenteeism in India. They're not receiving any bonuses, quite the opposite, and yet they're showing up and and to me, that so it's, it's kind of it's both ways. It's, you know, not just how can my ideas be taken up, but to me, kind of being involved in public policies. Also, how can I showcase some of this that is happening? You know, people keep saying, "Well, why is it that certain front like, you know, why is it that certain service providers do better than others? Why are certain frontline bureaucracies more effective than others?" And to be able to see, you know, the role of that kind of non-bureaucratic component of bureaucracies, the kind of spirit they spoke about their, you know, this article spoke about just their uniform, the green coat, and about how, you know, for them, the people's trust in them, that people looked to them, their relationships with these women, that they so, you know. So I think it's both ways. It's both like, How can I influence public policy? But how can this last rung, you might call it of public bureaucracies, of service provision of activists and kind of state agencies, how can their work find its way into our theoretical models such that that, in turn, then hopefully influences, you know, kind of policy with the big P? 

Joseph Harris  1:03:02

It improves our lives.

Prerna Singh  1:03:04

Absolutely, yeah, absolutely, you know, like, it's almost like they are Sapiens Integral, yeah. Like, I'm seeing this on the ground, right? Like, I'm seeing homo Morales. This is not homo economicus, and this is not the exception, right? You know, you have plenty of nurses who don't show up, and that's that kind of nurse absenteeism that finds its way into the data that we see on India. But there's also, equally, amazingly, plenty of this, I mean, Ann Swidler's work of, you know, the way in which these bureaucrats are advising or not advising, I mean, you know, so I think it's, it's also being inspired by that. 

Joseph Harris  1:03:40

Yeah, that's great. Last question: if you could give first year PhD students doing work on global health one piece of advice, what would it be?

Prerna Singh  1:03:51

I think one would be just in the context of the kind of ongoing pandemic and the interest in public health that it has sparked is is to kind of make sure that their engagement with it is not a kind of hot topic today. I mean, this gets to faith, It should be something that they deeply care about and is not, you know, not something that happens to be important today, but, uh, but I think, I mean, I think the one, I think, I guess the one piece of advice would be, choose something that's going to sustain you and that's going to nourish you, because this is going to be your life.

Joseph Harris  1:04:31

Yes! 

Prerna Singh  1:04:32

And so I think something that you really feel you can contribute to, but also something that will, in turn, help you grow. You know that this is a way in which you want to grow. I always, you know life always works out for the best. But I began my PhD thinking I wanted to do a project on kinds of movements against the state in many different parts of India, in particular in India's northeast, which are insurgencies that had been understudied. Indeed, as you know, I'm also interested in questions of ethnic politics and nationalism, but I spent one summer, thanks to Princeton's generosity, doing pre-dissertation field research there, and I realized that even though this was an essential, important, urgent question, I was not the person to answer it because just being there, realizing that I represented an oppressive, violent state, and that I would always be seen, not always, but I was, you know, people would say, "Oh, she's from India. I mean, you know, technically, this is a part of India, but you know, the fact that I would be marked as such, and that, you know, at 3pm in the afternoon, when it is pitch black because of the hegemony of Indian Standard Time. You know, this is way out in the east, but we are on Central Meridian Time in India, so the sun sets at 3pm in many parts of the Northeast. And you have these large trucks of commandos. And you know, this is a place where there has been basically a kind of state occupation and a crushing of a number of these insurgent movements. And I just realized that I didn't have, not only did I not have the stomach for this, I just like, this is like, I didn't, I could not do this. It was not me. It wasn't going to nourish me. And, in fact, like, because I was just so sad and just like, I couldn't write anything from it. And so I remember, like my dissertation advisor, being like, you know, you have something interesting to say about this. And I had met amazing people who had been fighting and fighting with arms, without arms, and I inspired, you know, that place always will have a very special place in my heart. But I realized that it was just too much for me to write about, like it was just almost too tragic. But there are people who do incredible studies of ethnic violence, of civil war, difficult ethnographies, and I have nothing but absolute awe and respect and admiration for them, you know. But I realized that I would not, I would, I could not do this, I, you know, and you could take it as a personal or a moral feeling or it, but it was also just self-knowing. And I actually kind of sometimes look at my like, you know, 22 year old self, and I'm like, you know, well done for just knowing. Yeah, that it, that wasn't me, yeah, you know, yeah. And other people have done incredible studies of that part of the world and and it will hopefully remain a kind of important topic of research. But I realized that that wasn't me. This wasn't going to nourish me, and I wasn't going to be able to kind of do with this what needs to be done. So, so I think that part of it is also kind of giving yourself a little bit of opportunity to feel around a little and see what fits, you know, and see what will sustain you and and what you know, where what can you be? You know, what is your value added? What are you best at? Also realize I'm just like I do much better with historical records and archives than I do with people. So I'm not a good interviewer. I'm not, and I think I'm a huge introvert, like, I would do one interview and then I'd have to take, like, three days off. And I realized that's not the most effective way to do fieldwork, and but I could be, you know, I was like, I could sustain, I could outsustain everyone else in the archives, you know. So I think it's also just kind of realizing that it's also a question of the fit between you as a human and the kind of method and research you want to do and so, I think, yeah, I think self, knowing, faith, big question, not doing something faddish, but something that's gonna, you know, be relevant six plus years later.

Joseph Harris  1:08:43

Prerna, this has been a wonderful talk. You have, I think, given so many nourishing thoughts to people who are aspiring to become social scientists. It's been optimistic, hopeful and just illuminating, so thank you. Prerna Singh is Mahatma Gandhi Associate Professor of Political Science and International and Public Affairs at Brown University, and she is also President of the American Political Science Association's Comparative Politics section. Thank you for sharing your insight. 

Prerna Singh  1:09:22

Thank you so much, Joe. It's been a pleasure.

Joseph Harris  1:09:27

This episode of the Global Health Politics Podcast was produced with the assistance of Bethany Hartman and Jane Pryma. Thanks for listening.