Why are non-communicable diseases (NCDs) near the bottom of the list in terms of global health funding and political priority when together they account for the most death and suffering globally, particularly amongst the world’s poorest populations? The dissertation engages this puzzle by analyzing the work and impact of two model public health programs, one which succeeded in making legible the problem of NCDs as understood and experienced by citizens in the Global North in Finland and one which is challenging that understanding, based on the experiences of the poor in the Global South in Sierra Leone. The North Karelia Project, launched in eastern Finland in the early 1970s, generated science and practice that was taken up by the World Health Organization (WHO) (Puska 2002) and has become hegemonic, dominating global NCD public health discourse and rendering understandings of alternative causes and potential interventions invisible (Weisz and Vignola-Gagné 2015). The integrated NCD clinic at Koidu Government Hospital is the first clinical program to treat ongoing chronic illnesses—an issue that is frequently assumed to be too expensive for poor governments to address—in post-conflict and post-Ebola Sierra Leone, which hosts one of the weakest health systems in the world but which is part of a broader movement to challenge the dominant WHO NCD policy (PIH 2019; NCD Synergies 2015). Drawing on theories from medical sociology, science and technology studies, and global and transnational sociology, I use this comparison to explore how and why some understandings of NCDs prevail and why others fail. I also use it to gain leverage on three important related questions: (1) How are depictions of the burden of NCDs and their severity constructed in different material and social settings? (2) How do those depictions become stabilized (or not) in the global discourse about global health priorities? And, (3) What are the implications of such contrasting stabilization processes?
I approach these questions by using a triangulated qualitative comparative case study research design (Bartlett and Vavrus 2016; Rihoux 2006), building on existing models of comparative research in the field of Science and Technology Studies (STS) (Knorr-Cetina 1999; Crane 2013). I conducted participant observation at organizational headquarters and clinical settings; semi-structured interviews with leaders, researchers, and clinical staff; and critical discourse analysis of the scientific literature, reports, and other historical and organizational materials generated by the actors. Each component compares the two cases (North Karelia Project, Finland and Koidu Government Hospital, Sierra Leone) along the lines of material setting, discourse, and science-making practices. Differences in epistemic practices reveal how power and politics are enacted and reproduced through public health science.
I find that public health scientists in both cases must work to quell, or neutralize, persistent sociological ambivalence – irreconcilable tensions in values, interests, and politics – to solve local public health problems and produce science that can travel beyond the local. Ambivalences inherent in local public health science-making are quelled in patterned ways, shaped by an institutional field of struggle and strategies of accumulation of scarce symbolic and material capital. The North Karelia Project exemplified a public health social epistemology that I term “UHC-Insulated Population Optimization” which deployed three tactics for quelling persistent ambivalence such as offloading obligations, epistemic normality, and utilitarian construction. Conversely, the integrated NCD clinic at Koidu Government Hospital’s public health social epistemology, characterized as “Attending to Undone Care”, utilized other strategies for quelling ambivalence: making preferential option for the poor obligations, hybrid methods, and polar distinctions. The field of global health struggle, and the doxa on which it rests, is rooted in principles of distinction and hierarchy built from the legacies of extractive colonialism which remain powerful today in maintaining enormous health inequalities between the Global North and South. This dissertation and the comparison on which it rests opens new ground on the material conditions for epistemic justice and the material reparations necessary to ‘decolonize global’ health. / 2025-09-21T00:00:00Z
| Identifer | oai:union.ndltd.org:bu.edu/oai:open.bu.edu:2144/46991 |
| Date | 21 September 2023 |
| Creators | Shaffer, Jonathan D. |
| Contributors | Harris, Joseph |
| Source Sets | Boston University |
| Language | en_US |
| Detected Language | English |
| Type | Thesis/Dissertation |
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