Season 2, Episode 6: James Pfeiffer on Debt, Austerity, and Decolonization

In this long-awaited episode, originally recorded in Fall 2022, Joseph Harris sits down with Dr. James Pfeiffer, Professor of Global Health and Anthropology at University of Washington. They talk about global health work in Mozambique; World Bank and IMF structural adjustment programs; debt and austerity and their impact on development; and the movement to decolonize global health.

Transcript

Global Health Politics Podcast

Season 2, Episode 6: James Pfeiffer on Debt, Austerity, and Decolonization

Joseph Harris  0:00  
Welcome to the Global Health Politics Podcast, 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. James Pfeiffer, Professor in the Departments of Global Health and Anthropology at the University of Washington in Seattle, and Director of the non governmental organization, Health Alliance International. Thanks for coming to speak at the Global Health Politics Workshop and for joining the Global Health Politics Podcast. 

James Pfeiffer 0:50
Great to be here. Thanks for the invitation.

Joseph Harris  0:54  
Well, James, you've made major contributions in your career on primary care, health systems, HIV, AIDS, international aid, austerity and debt. How and why did you become interested in these issues in global health?

James Pfeiffer  1:07  
So, long story short, I was very involved in the 1980s in the anti-Apartheid movement, which led me to join an organization called the Mozambique Support Network. Mozambique, at the time, was what's called a frontline state and the struggle against Apartheid and was being undermined. The Apartheid regime was funding an insurgency that was devastating the country, and I connected with some health professionals who were working in solidarity with Mozambique, working with the Ministry of Health and the National Health System that they were building after independence in 1975 one thing led to another, and we were able to - my wife and I - to move to Mozambique and work on the project that they had organized, called Health Alliance International, working closely with the National Health System in Mozambique. And Mozambique, when we got there in the early 90s, had recently signed on to what's called a "structural adjustment program" with the World Bank, and part of that program was because Mozambique was heavily in debt because of the war they had been engaged in. 

And part of the structural adjustment agreement was cutbacks in health and education, other social services in government budgets. And so when I arrived there, the National Health System was reeling. It was quite a well developed system, well organized and designed, but very, very much underfunded. It brought basic primary health care services all throughout the country through about 1000 different health posts and rural health centers, but was understaffed, underfunded and was struggling, and we were an NGO funded by various funders, including UNICEF as well as USAID, to do mainly maternal child health and community work, but in close association with the health system itself, in contrast to many other NGOs who were arriving in the country during the sort of the post war period. 

The war in Mozambique ended in 1992 apartheid was ending, and there was foreign aid started to come into the country, and pretty big chunks of funding coming to health work, but most of it was going to NGOs and not the health system. And I've kind of thought, well, this is weird. Why is that happening? Isn't the health system where people are supposed to be getting their care? Why are millions and millions of dollars going to American NGOs running around doing kind of random projects? 

And I learned at that time with my other colleagues that because of structural adjustment, the national health budget was constrained. It was capped. They weren't allowed to take foreign aid money to hire more health workers. They were being told to keep salaries low, to keep the number of health workers low. There was very little investment, even though the country was rebuilding after a war, and I learned more and more about what structural adjustment meant and what austerity meant and what debt meant to a country very, very poor country. At one point, I think Mozambique was considered the poorest country in the world. When the war was ending there, I thought, this seems wrong, and I learned a lot more about austerity and structural adjustment, and realized that it was something happening in many, many countries around the world, especially Sub Saharan Africa, and that it was a huge problem for building and improving public health, not just in health systems, but structural adjustment was impeding public investment, public finance for all kinds of social services and all kinds of public efforts to improve health and population well being so that's why I got very interested.

Joseph Harris  4:36  
It sounds like good reasons for you to be motivated to study those issues. Now, when I invited you to the Global Health Politics Workshop, you mentioned that it's an exciting time and an important moment to talk about these issues, being global health politics. What's particularly important about this moment, as you see it, to do work on the politics of global health?

James Pfeiffer  4:56  
Boy, it's just been such a tumultuous. Was couple of years we've had the combination of the pandemic, of course, but part of that was the George Floyd uprisings. And even before the George Floyd events, there was a growing call emanating from the Global South to decolonize global health, which means a lot of different things to different people, but the idea that the Global North and institutions in rich countries are dominating and set the agenda in a way that Global South partners are not setting priorities and not making the decisions and not getting the resources, and that had already been burgeoning. 

I know that the Harvard School of Public Health, their students organized a decolonizing Global Health Conference in 2018 the tragic events around the George Floyd moment, the so called racial reckoning, you know, that came after, really transformed, in my experience, anyway, the way in which people in global health are talking about global health. It centered anti-racism, and it's centered ideas around decolonization in a way that I haven't seen in 30 years of being involved in global health work. And I thought finally, we're getting to have a real discussion about this. And so right now, as we're sort of emerging from the pandemic, although it's fall [2022], we don't know if the pandemic is over yet, but we're not quite out of the woods. But given the experience we've just had, there's upheaval happening on many levels. 

You know, how do donors think about funding Global Health going forward? What are the what are our priorities? We're heading into very, very challenging economic times, which are going to challenge our priorities and how funding flows to things like public health and global health in this country, in the US, as well as globally. So it is a fraught time. The politics, I think, are intensifying. I'm not sure where politics are leading us in terms of the funding that will be coming out of wealthier countries to support global health. At the same time, we have very vocal Global South, voices, actors, colleagues, calling for a change in the way we do business. 

And I would say that, in my opinion, I think it's shared by a lot of folks. The pandemic has been an epic public health fail, especially in the United States. You know, some countries have done actually pretty well, but we've done horribly: we have the highest mortality rate in the in the wealthy world, the egregious racial and social class disparities and the experience of it, but it's a huge, epic fail for the Global South, where Africa, I think basic vaccination, across the entire continent, is maybe 25%. I'm not sure what the latest numbers are. 

Some areas where, you know, regions where there's almost no vaccination available, I would say that most of the Global South, especially Sub Saharan Africa, is still not even close to being prepared for the next pandemic. The pandemic is a learning moment in principle, will we? Will we? Will we learn anything from it? But I think it's an opportunity for people that are interested in a social justice frame for global health to get as active as possible now and to be speaking out. So I'm excited about that. I think there's potential for change. We can always fall back on cynicism and hopelessness, but I think that is the most defeating, self defeating approach, and we have to take advantage of the fact that the conversation has changed, and there's a potential opportunity to move the needle a bit,

Joseph Harris  8:31  
And yet, at the same time, it's a worrying time, because I don't think ever has the word neoliberalism so well fit this moment in public health history. You know, this is in the context of decades of under investment in public health, right?

James Pfeiffer  8:46  
And so I think that is key to understanding what happened in the pandemic is, you know, basically since about 1980 we have been in a period of increasing disinvestment, underinvestment in basic public services everywhere, growing inequality, severe inequality, and having then the pandemic land on that world has revealed the damage that was done. In many ways. That's what makes this moment so poignant. And you know, are we still? I know that scholars of neoliberalism, are asking: are we still in the period of neoliberalism? I think we are, in its essence. 

But with so called right-wing populism, can we just call it fascism on the rise? You know, how will that change the way so much of this is done? You know, neoliberalism was active engagement in pushing free markets and small government we can continue on that path. Is it just kind of chaos right now? What are the roles? Of course, IMF and World Bank have been central actors in imposing neoliberalism since 1980 interestingly enough, their roles are being questioned now in the new global regime and in. It has to be said, I think here that China is a new actor and relatively new actor in this space, and is changing things now, whether that's for the better or the worst, we don't know, but China has become an important creditor and a real important actor, especially in Africa, in my experience, and that has changed things a bit as well. And so I think there are challenges to basically Western hegemony of the global economy right now, which are interesting, and it's hard to know exactly where this is going to go.

Joseph Harris  10:32  
Yeah. I mean, this has been something I've really struggled with as someone who's been really curious about this movement at the global level for universal coverage, and yet we've seen the elimination or reduction of funds to deal with a pandemic here in this country, a miserable public health response, as you say. And it's a real struggle to understand what it all means, how this fits together.

James Pfeiffer   10:54  
Yeah, I'm glad you brought up universal health coverage, which is now being rolled out as part of the Sustainable Development Goals. And one of the things I'm interested in, and Joe, your scholarship is speaks directly to this. You know more about this, but what does universal health coverage mean? And I've always been fascinated by the use of the word coverage, and we used to call it universal health care, and I always thought that perhaps it signaled that let's think about insurance. And I know that USA ID and others have been pushing insurance as an alternative to having public sector national health systems to provide health care. And I guess since the insurance system has worked so well in this country, why don't we export it around the world? That's probably oversimplifying. But you know, how does this period of deepening debt created by the pandemic? We already had a lot of debt around the world, in global south countries that was making it difficult for them to increase public investment, but with the pandemic now on top of that, how does that jive with this global call for universal health coverage? And I think there's an awful lot of hand wringing, and, you know, struggle with how to square these things, and we're in such a strange economic moment globally that we just don't know where this is going to go. But on the positive side of that is what, when things are in turmoil in that way, where it's unclear where we're going, that's where a I think a strong global movement and activism can potentially have an impact. I don't want to be naive about what we can do, but I think it's a really important time for civil society and social movements to be activated around this.

Joseph Harris  12:39  
I do want to talk about social movements in just a minute, but I want to bring up that one of the pieces you've written about structural adjustment and health, called anthropological perspectives on structural adjustment and public health, with Rachel Chapman, was listed as the number one thing to read in a Washington Post article in 2015 that was titled five things you should read before saying the IMF is blameless in the 2014 Ebola outbreak. Have you seen any changes in the policies of the IMF and institution that's been known for promoting austerity since you wrote that piece in 2010?

James Pfeiffer  13:14  
I'm sorry to say, but I'm not sure that our piece had the effect we would have wanted to have on the IMF. Not sure whether the IMF folks read it, but it's an interesting story that in recent years, both World Bank and IMF have actually been changing their rhetoric and talking about a shift. And our colleague, Alexander Kentikelenis has written about this recently and has some great pieces out about are they? You know that there's this rhetoric about changing, sort of abandoning the hard austerity approach that they were known for through structural adjustment, and kind of embracing an idea of more targeted, well spent funding on public sector services, kind of recognizing that this is important change. And the claim that scholars who are really tracking the IMF and World Bank make is that it doesn't look like this, what they're going to do in practice, right? 

When it comes down to nuts and bolts of, you know, working with specific countries, that what we're seeing is kind of the same old, same old. So neoliberalism lives on through what's actually done there has been leading up to the pandemic, some countries saw some modest increases in public spending from very, very low levels in a piece that Kentucky has published in 2022 which may actually be outdated at this point, because the economic picture looks much more dire now than it did when I think they published this. But he was saying low income countries looked like in the next three to five years. Were looking at probably not too much more spending cuts, but staying at the low level they were already at, while a number of middle income countries. Were projected to face fairly major declines in public spending. So he was basically saying, in spite of the rhetoric and the universal health coverage sort of references, that they look like, they're going to be resorting to more or less the same old, same old. 

What I think is perhaps hopeful in this scenario a little bit is that all of the folks speaking out about this has at least penetrated enough that they know that they have to talk about this stuff differently. And then actually began in the 90s, when they abandoned the term structural adjustment, and then they adopted this thing called the poverty reduction strategies, and PRSPs or Poverty Reduction Strategy Papers, they call them. It's called Parpa in Portuguese, and Mozambique replaced structural adjustment programs, and they sort of had this surface difference in the way they did things, including civil society supposedly, in the processes locally to decide how is the government going to spend its money, but the budget envelopes were still being defined by the IMF World Bank, so people called it old wine and new bottles, right? And that's in the 2010 article that you mentioned. That's kind of been what's carried through is renaming it euphemistically Poverty Reduction Strategies. I mean, for those of us engaged in this, we think of them as poverty creation strategies!

Joseph Harris  16:22  
Orwellian.

James Pfeiffer  16:23  
It is very Orwellian, and that seems to be where we're headed now. The World Bank and IMF just had their October meetings two weeks ago. And the story coming out of that, especially from the civil society organizations, Bretton Woods projects and others that have been tracking what they're doing, basically, very disappointing, no major commitments to debt reduction. They have this thing called the common framework that they're working with the g20 and the Paris Club that is designed to try to alleviate debt in the poorest, the most debt distressed countries. That common framework, I think only three or four countries now have actually gotten through the first phase, and we're heading into what some people are calling a tsunami of debt in the Global South, and looks like the IMF World Bank have really not changed course at this point, to really abandon what they've been doing before. So unfortunately, our article, we tried, but it didn't create the change we hoped.

Joseph Harris  17:25  
Right? This is a common experience of academics, right? We often hope that someone's listening, but important contributions nonetheless and obviously ties to, you know, these efforts by social movements and people working at the international level. Now, one other initiative that you and you mentioned, Alexander Kentikelenis and other people like David Stuckler have been members of this new Collective on Political Determinants of Health that's run by Sakiko Fukado-Parr and Katareni Storeng, what can you share about your work in that initiative? How does what you've shared today connect to that?

James Pfeiffer  18:00  
Well, that grouping came out of a 2018 conference in Oslo, in which people gave papers from all around the world. It was part of a Lancet Commission. It has kind of roots going back to 2014 and very Europe based group of scholars concerned about how we frame and think about global health issues. And it was very exciting conference. And out of that came this, this group called the Political Determinants of Health Collective, and it is global. It tends to be Europe centered, and it's a place where people share their work. There is a regular blog that different members will talk about politically oriented aspects of global health. And I think it's having some success in shifting the frame away from infectious disease research, you know, HIV focused, single disease kinds of things in global health, to really saying we need to get very serious about the politics and the social context within which global health is being practiced and done, and the kind of power dynamics that are at work, and so it's exciting initiative. I know they have some things in the works for new conferences, and I think they have some funding to sponsor many conferences at specific universities. It is mostly academics. I think there are some folks from the WHO that are involved, but I think it's an exciting move, and hopefully we will see something grow out of that.

Joseph Harris  19:24  
Yeah, it sounds like another important space for expanding the conversation. Yeah, some of these issues that matter, right? Well, speaking of some of the different hats you wear, while you are a professor of global health and anthropology, you also run this interesting non governmental organization called the Health Alliance International that's affiliated with University of Washington. It's interesting to sort of see NGOs affiliated with universities we don't often see that model, at least here in the States. What does that NGO do? And how does it complement the work you do as a researcher?

James Pfeiffer  19:56  
Great and very poignant question at this moment. Moment so Health Alliance International began, actually as something called the Mozambique Health Committee back in 1988 when Mozambique was still engaged in a basically a proxy war that the Apartheid regime was funding an insurgency that was really destroying the country. Mozambique got its independence in 1975 from Portugal, immediately adopted an anti apartheid stand, as you can imagine, allied itself with the ANC, and therefore the apartheid regime tried to undermine that governance, what's called a frontline state. It shares a border with Mozambique, similar to Angola, and I had been involved in the anti apartheid movement with my wife, and we ran into folks in the US were part of something called the Mozambique support network. Had 25 chapters, a very interesting solidarity group around the country, trying to draw attention to what's happening in Mozambique and the United States, had been supporting the counter insurgency along with the apartheid regime. So we're raising awareness about that. 

As part of the anti-Apartheid movement, we met healthcare professionals, doctors and nurses that were based in Seattle, and a couple of them from Vancouver, who had been working with the Mozambique government for many years. Many of them had worked as doctors and nurses in the National Health System itself in solidarity as it was defending itself against attacks from the counter insurgency. They then decided in the late 80s that let's create an NGO. And so they created an NGO called Mozambique Health Committee that then morphed into the Health Alliance International. And because we had been working with these folks through the Mozambique Support Network, at one point, Rachel and I, we were PhD students, they said, "Hey, why don't you go to Mozambique and help run our projects, and you can do your research connected to our project?" And we said, "That sounds perfect!" 

So we ended up working for HAI for about four years in Mozambique, and HAI began to grow. Global Health funding started to grow. HAI was the founder, Steve Gloyd was faculty member in the School of Public Health with other faculty. So they did a very interesting thing where they created a 501c3 with one foot outside, but they had one foot inside, sort of a hybrid organization. As you said, it's an unusual arrangement. We had, not totally dissimilar from Partners in Health, which is a much bigger organization at Harvard, but sort of has one foot in, but also has independence. So in the countries where we work, we would work as an independent NGO, but it was really a faculty driven, in many, many cases, progressive faculty. So Hai had been around for about 30 years. We expanded into Cote d'Ivoire for a variety of reasons, and into East Timor. And had smaller projects over the years, one in Ghana, one in Nepal, but we never really aspired to become a big organization. We really wanted to focus on just a few places, and we became the, what's called the PEPFAR implementing partners in Mozambique and Cote d'Ivoire When HIV care was being scaled up through the President's emergency program for AIDS Relief called PEPFAR, big expansion of global health funding. 

So we grew as the funding grew, and again, we were embedded in the University of Washington was sort of its one foot out, and being an NGO allowed us to be more nimble in the kind of grants we would go after and to do the kind of work that we wanted to do. And we were very values mission driven. We wanted to support public sector, national health systems. We didn't want to do independent parallel projects. Our goal was to work closely, side by side, and usually in the countries where we work, we actually would get an office inside the Ministry of Health would be our main office. So we wanted to work side by side, trying to follow the priorities that they were asking us, you know, trying to fill the needs that they were saying they they had. Basically, we had about a 34 year history, and then at the beginning of the pandemic, one of the things that's happening right now in global health because of these calls for decolonization, is funding is is increasingly shifting from the big donors to local organizations and away from American and European NGOs, and we Were finding this is getting harder and harder for us to compete for all the right reasons. And we realized in early 2020, we said, You know what now is the time for us to jump in with both feet and hand over our work to local entities. And we had already been in in the process of creating local NGOs that were really going to be our staff that worked for hai Mozambique, for example, all Mozambicans, of course, that would then become their own independent entity, and we would help launch them. And we didn't know when this was going to happen, right? It's a very hard thing to do. There's a lot of hesitancy on the part of Global North donors to fund Global South agencies. 

There's, unfortunately, a lot of racism, assumptions that they're not capable, when in fact, of course, they are the most capable. So we had to fight against all of that, and we decided we'd jump in with both feet. We had enough funding in all of our countries to help really launch these in a very healthy way. So over the last couple of years, we decided that. We would hand over all of our projects, and in April, spring of this year, we actually closed our doors as Hai and handed over all of our work. Now we continue as faculty and students. We continue to have very close relationships, and we have students that are doing projects, for example, with these NGOs. We are channeling grants that we get, we subcontract them to the NGOs to help them thrive. Our Cote d'Ivoire group called Health Alliance, Cote d'Ivoire just received a big CDC grant through a consortium for HIV treatment that we helped them put that together. So we feel very excited about the work that's happening. There's some faculty that have NIH grants in our Department of Global Health that are now subcontracting those directly to what used to be hai. So that's what's happened to hai. We feel very proud of that, that we're kind of saying, hey, it is time. We don't need to be getting all this money in Seattle. And we did have to lay off staff. There are costs. But luckily, all of our staff members in Seattle actually landed on their feet and in great jobs. So we feel like that worked out well, and so we feel quite proud of that. 

Now there's a whole discussion about the shift to local funding Western NGOs and European NGOs. Is it the best practice to now fund a bunch of local NGOs? Is that truly creating more local autonomy, are they now just as easily controlled by the global north donor as a Western NGO? Whole other discussion, very important discussion, we would prefer that funding actually would be more channeled to national health systems, and hopefully that's a direction that we'll go in, but that's what's happened to hai. So I used to be Executive Director, and since 2013 I was the Mozambique country director from 2004 to about 2013 and then the founder stepped down, and said, Would you be willing to step into this role? And I said, Okay. And now we've landed the plane, and I'm no longer executive director of HAI but I want to be speaking about right we worked ourselves out of a job, which is the cliche, which isn't that worse what we're supposed to do. And in all the countries where we work, we have these just phenomenal people that are running these organizations, Mozambique, we have a country directors named Isaias Ramiro, who worked for 25 years the National Health System and has deep connections with with the National Health System, and is just brilliant. And so, you know, we're doing all we can to support him, back him up, and his team. And so that feels very exciting. So we feel good about that.

Joseph Harris  27:39  
That's really, truly exciting. I think it sounds like a model for you know, what many of us would say is needed at this current moment. Now, in your comments, you just talked a little bit about how the organization bears in relation to Partners in Health, in this sort of odd arrangement that's in and outside of a university, and I was hoping you could say a little bit more about that, but even more, how the organization relates to broader movements that have tried to promote ideas at the global level, like people's health movement, right?

James Pfeiffer  28:16  
Yeah, so starting with Partners in Gealth, right? Based here in Boston, we sort of thought ourselves as a in some ways, as a sister organization or maybe a cousin. We're a smaller Partners in Health. Of course, they had people like Jim Kim and Paul Farmer, big, super well-known people. We did not have those kinds of super well known rock stars, but we had similar models, similar politics, in many ways. And we collaborated with Partners in Health on creation of something called the NGO Code of Conduct, way back in the start 2008 The idea was to create to basically say, look, the NGO world, which is just, you know, exploded in this starting in really kind of late 80s and 90s, that with the global health increase in funding, most of this funding was flowing to global North NGOs. We saw this proliferation. I mean, literally hundreds of NGOs stumbling over themselves in places like Mozambique and Haiti. 

It was mainly HIV money after PEPFAR started in the early 2000s but even before that, in the 90s, you know, we saw this huge proliferation - some of the folks, you know, well meaning people, but an awful lot of harm being done. In reality, poaching people from the National Health System, doing parallel projects that just confused everybody, not listening to ministry of health priorities, just kind of doing their own thing, and really a parallel data systems, parallel nutrition projects, I can tell you story after story, and Partners in Health, I think, shared our commitment to supporting national public systems. And we said, you know, this is not what we should be doing in most cases. And let's have this NGO Code of Conduct at least to have a talking point, right? And think it had some success in generating a conversation that we need to be doing this differently. 

I'm afraid to say that the NGO industry has still galloped along, replicating many of its of its errors. It isn't necessarily even NGO's fault. It's really donors fault. We had a piece, I think, of 2014 or 2015 which was a follow on opinion piece about saying we need donors to embrace the NGO Code of Conduct. Yeah. And one of the co-authors was the head of the Africa health initiative of the Doris Duke Charitable Foundation, who shared our concerns. So it's kind of cool to have a donor, major donor in there, but sadly to say, they did not again. They did not listen to us as much as we hoped they would. But I think there is a growing awareness that public institutions around the Global South, I think we're seeing a modest shift, recognizing that we have to do this better. 

Anybody paying attention would know that the pandemic was worse in places where public institutions were weak, right? You can't get vaccines out, you can't get treatment out, you can't get public health messaging out, and I'll talk a little bit about Mozambique later today, but you have to have a robust, publicly funded finance, public health system, surveillance, messaging, getting vaccines out all of that, and because the US has the weakest public financing for health generally, I think that's one of the reasons why we had the highest mortality, why we did so badly, right? I think that we know that, right? And you talk to anybody in the CDC, and they've been underfunded. Public Health Surveillance around the country has been in our own country has been underfunded. Will we learn? This is the question.

Joseph Harris  31:53  
All right, and tell me about a connection to people's health movement, if there is one.

James Pfeiffer31:58  
Well, HAI was very proudly the North American representative for People's Health Movement. Now, that's a good thing. The downside is, is that the People's Health Movement is struggling. It's a good...it's a wonderful organization. David Sanders died, right? David Sanders died, and it's still out there. And I am a, you know, firm I have, I have the logo on my whenever I give talks, I always feature it. It is another space, you know, where people talk, you know, it's an activist space, right? And there was a conference when was it in Bangladesh. And so it's, you know, cruising along. But like much of the left and especially social movements around global health, things are quite fragmented. Sure, you know, even the international debt cancelation movement is some great organizations, but, but it's still, it still hasn't quite coalesced the way it did in the late 90s, around the Jubilee movement around canceling debt. So we still have a ways to go with that, but people's health movement is we've been members ever since they emerged, and David Sanders was was wonderful, and hopefully that struggle will continue.

Joseph Harris  33:12  
Yeah, hopefully! It's certainly needed. We've talked a little bit about social movements, we've talked about some of the important ideas that you've engaged with in your research. And next, I want to ask you about the research process itself, because I think some of our listeners would be really eager to sort of think about how you think about research and what you've enjoyed most about it. So what would you say has been the most meaningful parts of the research process to you? What's your favorite parts and why? Any stories you can share on this?

James Pfeiffer  33:42  
Yeah, great question. So with HAI, because we had one foot in academia and one foot out, we really thought of ourselves as implementers, you know, in solidarity with national health systems. And so we were always pushing, not only our department, but the work that we would channel through Hai was always about health system strengthening, which, of course, is a buzz word, like, what does that really mean, right? But in our case, it meant, what is the National Health System struggling with, and how can we help them do it better? So when they wanted to scale up antiretroviral therapy, especially in antenatal care and other things, you know, we did research around how to make that work in their system, what are the gaps? And then working, always, working in partnership with people from the public system. And so HAI helped something we're very proud of - helped set up something called the Beira Operations Research Center, which was centered in the center of the country, outside the capital, which gets all the resources. 

Of course, this was up in Beira, and we were able to basically finance it and create it, but it was part of the ministry system. And through that, then we were able to help train cadres of Mozambican researchers doing implementation science and health system, strengthening research in the National Health System. Self. And so that was the kind of research we were trying to promote and trying to push, you know, very applied. How do you strengthen service delivery in a public system in terms of global health work? My greatest fulfillment was working side by side with Mozambique and researchers, especially in this center in the National Health Institute, which is the name they have for their the research arm of the ministry. It was just the most rewarding, because that was where you're in actual health centers, where the action is working with health workers and figuring out, how do we do this better with the limited resources, and then trying to use that experience to scream and yell about austerity, right? So saying, "Okay, what we're seeing with HIV." 

You know, one of the things that Rachel and I wrote about, because we had an NIH funded grant to do trying out new models of antiretroviral therapy and antenatal care, because that's a huge issue, is, had you pregnant women coming in, getting tested for HIV, and then starting them in antiretroviral therapy in antenatal care. How do you do that? It's actually a complicated thing to keep people in treatment. And what we found along the Beira recorder, which is the epicenter of HIV and was hundreds of millions of dollars were going to American contractors like Abt and FHI 360 that were supposed to be supporting HIV care in exactly the places where we're doing this work. And you go, and you kind of go, Okay, there's one maternal child health nurse. There's no one else to help her out. She's got a lot of people waiting eight hours. We measured time-motion studies, how long it takes for people to get this was austerity, right? Yeah. Like, where's Abt? They have $50 million for these three central provinces. No sign of them. And they had these palatial, beautiful, this is all on record. I don't care. I'm gonna say it on the record: palacial, beautiful offices, you know, staff of a couple 100 people, no sign of them, in the most important health centers on the Bay Recorder.

Now, you know some of their funding was going to buy HIV meds and some of the equipment, all that kind of stuff. But it was like, something is wrong with this model. If you'd taken this 50 million bucks and invested it in the National Health System, trained more health workers, built out their rural systems, would have been transformational, but this funding did not go there, right? And I think this is one of the struggles. You know, I'm a supporter of PEPFAR. This is another discussion. Was great to have this additional funding, right? But it is gone. You know, 95% of it goes to American contractors. 

I mean, people don't quite understand that it's not going to build national health systems. So in terms of research, kind of trying to do research that has a direct impact, but also using that experience to highlight all that's going wrong in this enterprise. And luckily, at our Department of Global Health, to get back to the kind of academic setting, there was support for that, as long as we're publishing and bringing in grants and things. But most of our colleagues, many of them doing really important work, but are doing much more disease specific clinical trials, kind of NIH work, the kind of research that I think is becoming questioned now. And I think even within the NIH there are now big questions being raised. 

We have an experience in many African countries, is something people call pilotitis. You ever heard of pilotitis? Pilotitis is a particular research disease of having pilot projects, basically R ones that are funding a pilot trial, intervention trial, sometimes health system strengthening in principle, pouring $5 million into some somebody's idea from University of Washington or Harvard or whatever that gets funded by the NIH National Health System says, Actually, we're not interested in that, but if you've got the money, you can go do that. They do their pilot. The pilot is successful because they have $5 million as soon as it ends, nothing happens. We had a wonderful assistant professor NIH funded work in Kenya, and she did a map of pilotitus. She had little circles around dozens of projects that were funded mainly by the NIH that basically went nowhere. You know, very well done, very confidently done. Got a bunch of publications. They worked while the funding was flowing. But many of them just go nowhere. Now, some do contribute. Of course, I don't want to say that none of this is valuable. So that's, you know, I mentioned earlier in our discussion, the NIH just had what's called an RFI, or request for information, where they wanted input on how to promote equity and Global Health Research. And the responses, we tried to collate responses, or kind of put together a bunch of responses, mostly from our Global South partners, about what would they change? Everything was just about who's setting the priorities right. Often, NIH grants are not our priorities. 

If you want to know what's good for Mozambique, why don't we talk to Mozambicans, talk to the Ministry of Health, people, talk to the people in international and so on?...So, you know, hoping that there's going to be a shift that what we need to be doing, and amazingly, in our Department of Global Health, there is a lot of support for this among our faculty that kind of realizing we need to do a lot of this stuff differently. We need to be listening to Global South partners at a minimum and maybe having them at the tabling study section where proposals are being reviewed.

 You know, how much can we hope for in the real world? I mean, that's kind of the question. These are giant institutions and powerful, wealthy countries. I mean, are they really going to change? But if we can move the needle a bit, something can change. There is an amazingly talented director of the National Health Institute in Mozambique. Elsh Johnny, who has really learned how to navigate this world, and he's gotten very effective at how do you get those resources from Global North donors and channel them into stuff that they actually want? But it's tough, right? And it's often when your institutions are slow changing. When you're at the table and you listen to what donors sometimes say, you just serve in disbelief. It's like the Mozambicans actually know what they need and want. Why in the world don't you make that your starting place? Right? Not What You cooked up in Washington, DC or Atlanta, as well meaning and smart as those folks are, but if you want to do global health and health system strengthening, talk to the people in those countries.

Joseph Harris  41:28  
That's been such a theme of my global health politics, right? Yes, there's so much, so much reading that says why it has to be such a difficult discussion. So how does work outside the discipline of anthropology, inform your work today?

James Pfeiffer  41:41  
Oh well, hugely your work, for example. Siri Suh's work, for example. I'm always looking outside, frankly, like what makes me an anthropologist? Often in these spaces, I try to remind myself what I kind of land on isn't so much that I'm reading and working with what's developing an anthropology, but that I really value real world on the ground, ethnographic experience. So it's extent that even with NIH grants that Rachel and I were co PIs on, we brought an anthropological sensibility to that, really talking to health workers, talking to patients, working with our colleagues in sort of an anthropological way. But I've very much seen myself as an interdisciplinary researcher, and some of the boundaries between disciplines seem quite artificial. And so when I look at your work, resonates more with me sometimes than a lot of anthropology. But there, of course, are wonderful medical anthropologists doing similar stuff. 

I know that, you know, we have Emily Mendenhall, or just to name a few, and Adia Benton and others who are speaking the same language. I think that's what it has to be. Global health has to be interdisciplinary. I think my struggle for lack of better term in global health, my mission is to try to bring more social science, more broadly, not just anthropology, into global health. I'm surrounded by colleagues who I really appreciate doing really valuable work, but most are infectious disease physicians, doctors who often are approaching things in a narrower way, doing clinical trials and that kind of stuff, and so trying to bring not just an anthropological sensibility, but social context, political context, that this is if we're serious about health system strengthening, if we're serious about HIV treatment scale up. I mean, if you don't understand history, politics, context and cultural setting, you're going to fail. Yeah, we've seen failure after failure after failure, and I think it's as we all know, public health can really flatten things in public health, the standard is like, Oh, this week I'm in Indonesia. Next week I'm in India, and then I'm flying to Burma to do some work, and then I'll be in Burkina Faso. And I'm like, as an anthropologist, I kind of go, You know what? You're just skipping across the surface. And the best work is when you stick with one place. That's why I'm like, Sidney Mintz, one of my favorite anthropologists, Sydney Mintz, I saw a lecture of his once, and he said, what's his advice for young anthropology? Said, get to know one place really well. Yeah, yeah. And I think that is a good place to be, because the more time I've spent in Mozambique, the more I understand, how little I know. It's very humbling.

Joseph Harris  44:15  
I'm glad you ended on that note, because my last question is, if you could give first year PhD students doing work on global health one piece of advice? What would it be?

James Pfeiffer  44:25  
One piece? Oh, boy, and I'm going to be on the record with this, you know, given where we are in talking about decolonization, anti-racism, I think your own positionality is really important in this work. So if you're like me, coming from the Global North, the starting place is: why am I getting involved in this? How do I get involved in this? 

If you're coming from Global South, or if you're from underrepresented communities in the United States, that's a different positionality than coming from white, middle class background, which, you know, we still have a lot of people in  grad school. you've got to begin with understanding where you're fit into this world. What can you bring to it, and what value can you bring to it? I think now that has to be the beginning place, and then get to know one place really well, and then maybe that's your own community, increasingly, and I think in a very positive sense, doing work on our own communities.

Joseph Harris  45:20  
James, this has been so wonderful and insightful. Thanks so much for joining us.

James Pfeiffer  45:23  
Great thanks for the opportunity.

Joseph Harris  45:38  
This episode of The Global Health Politics Podcast was produced with the assistance of Bethany Hartman and Jane Pryma. Thanks for listening.