What can fumigation backpacks in the Sierra show us about global health?

During this week of Global Health Bootcamp hosted by Compañeros En Salud (CES), we’ve been discussing macroscopic concepts and movements in global health. We began with a seemingly simple question: how do we define global health?

Our conversations have taken place at CES Headquarters in Jaltenango, Chiapas. Jaltenango is a mid-sized town where rebars reach to the sky from three story buildings and where pizza stores sit next to taquerias. From here, if you drive up unpaved roads to the surrounding mountains of the Sierra, you will find the communities served by CES, the pasantes (medical or nursing school graduates completing a required service year), and acompañantes (community health workers). These communities of several hundred to a couple thousand people are nestled in mountains dense with flora and interspersed with crops quilted across the landscape.

Coffee cultivation underlies the economic vitality in many of these communities. For me, a related and alarming sight around town was that of the bright green plastic fumigation backpack. Fumigation with organophosphates is used to combat la roya, a fungus that affects coffee plants and other crops in Chiapas. Walking around the community in the afternoon, you may see men returning from the fields with their backpacks in tow. These plastic backpacks also bounce around in the back of pick-up trucks next to families being transported to and from various parts of the district. At times, the fumigation backpack even becomes a toy backpack among boys trying it on for size.

To me, the fumigation backpack seemed like a sardonic facade to a serious health threat. My pasante has treated several organophosphate poisonings in her first six months of service, a condition I have never encountered in Boston. Some CES physicians also hypothesized that the organophosphates were responsible for the high number of patients with leukemias and lymphomas served by the tertiary referral program operated by CES. While seen as an essential tool for farming in order to make ends meet, there seems also to be a collective sense of the organophosphates’ inherent danger. My pasante shared with me that in her conversations with patients who have severe depression and suicidal ideation, organophosphate overdose is often proposed as the means by which one would consider suicide. The fumigator backpacks here are ubiquitous, and intertwined with peoples’ illness and health in complex ways.

Koplan et al define global health as “an area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide” (1). In our discussion in CES Headquarters, we discussed that operationally, global health often describes a unilateral flow of ideas and resources from high to low resource settings that are geographically distant; however, we can aspire to a definition of global health that is multi-directional and inclusive.

One aspirational characterization of “global health” that appeals to me is offered by Paul Farmer in the preface to the book Reimagining Global Health (2). “If global health is now merely a collection of problems,” he writes, “what might it take to forge a new discipline?” He goes on to argue for the necessity of an interdisciplinary approach to global health, and subsequent chapters of the book especially draw from the disciplines of anthropology, sociology, and history of science, among others. I would like to further Farmer´s argument by proposing that perhaps part of the path to forging this new discipline comes from dissecting the “collection of problems” that makes up our notion of global health today.

I wrote about the example of the fumigator backpack above because I think dissecting this object in Sierra life demonstrates some of the perspectives essential to crafting a new discipline of global health. I have outlined a few below:
– a medical perspective to determine the realm of health risks to humans (including carcinogenicity of widespread organphosphates) and to treat those lives affected
– an environmental perspective to reveal underlying causes of la roya and propose alternatives to heavy organophosphate use
-an economic perspective to delve into the price gouging practices of the “coyotes” (middle men who purchase coffee beans to sell to places like the United States) and offer ways to counter the financial fragility that many small coffee producers face when hit by la roya
-an anthropological perspective to learn more about how this ubiquitous symbol came to be and share the stories of those in closest contact with these organophosphates
– and many more

I think examining multidimensional examples like the fumigator backpack help us to identify what precedents we must summon in forging a new discipline of global health.

  1. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, et al. Towards a common definition of global health. Lancet. 2009;373:1993–5.
  2. Farmer, Paul, et al. Reimagining global health: an introduction. Vol. 26. Univ of California Press, 2013.

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