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COVID-19 demanded urgent responses by all countries, with wide variations in the scope and sustainability of those responses. Scholarship on resilience has increasingly emphasized relational considerations such as norms and power and how they influence health systems’ responses to evolving challenges. In this study, we explored what influenced countries’ national pandemic responses over time considering a country’s capacity to test for COVID-19. To identify countries for inclusion, we used daily reports of COVID-19 cases and testing from 184 countries between 21st January 2020 and 31st December 2020. Countries reporting test data consistently and for at least 105 days were included, yielding a sample of 52 countries. We then sampled five countries representing different geographies, income levels and governance structures (Belgium, Ethiopia, India, Israel and Peru) and conducted semi-structured key informant interviews with stakeholders working in, or deeply familiar with, national responses. Across these five countries, we found that existing health systems capacities and political leadership determined how responses unfolded, while emergency plans or pandemic preparedness documents were not fit-for-purpose. While all five countries were successful at reducing COVID-19 infections at a specific moment in the pandemic, political economy factors complicated the ability to sustain responses, with all countries experiencing larger waves of the virus in 2021 or 2022. Our findings emphasize the continued importance of foundational public health and health systems capacities, bolstered by clear leadership and multisectoral coordination functions. Even in settings with high-level political leadership and a strong multisectoral response, informants wished that they—and their country’s health system—were more prepared to address the pandemic and maintain an effective response over time. Our findings challenge emergency preparedness as the dominant frame in pandemic preparedness and call for a continued emphasis on health systems strengthening to respond to future health shocks and a pandemic moving to endemic status.

Frontline workers (FLWs) in the Global Polio Eradication Initiative go door-to-door delivering polio vaccine to children. They have played a pivotal role in eliminating wild polio from most countries on earth; at the same time, they face significant bodily risk. STRIPE, an international consortium, conducted a mixed-methods study exploring the knowledge and experiences of polio staff in seven countries (Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Indonesia and Nigeria). We surveyed 826 polio FLWs and conducted semi-structured interviews with 22 of them. We used a body work framework to guide analysis. Polio workers perform a different kind of body work than many other FLWs. Delivering a few drops of oral vaccine takes a light touch, but gendered spaces can make the work physically dangerous. Polio's FLWs must bend or break gendered space norms as they move from house-to-house. Navigating male spaces carries risk for women, including lethal risk, particularly in conflict settings. Workers manoeuvre between skeptical community members and the demands of supervisors which generates emotional labour. Providing FLWs with more power to make operational decisions and providing them with robust teams and remuneration would improve the likelihood that they could act to improve their working conditions.

IntroductionAcross a variety of settings, women in tenuous financial circumstances are drawn to community health work as a way to advance themselves in the context of limited employment options. Female Community Health Workers (CHWs) are often preferred because they can more easily access mothers and children; at the same time, gender norms are at the heart of many of the challenges and inequities that these workers encounter. Here, we explore how these gender roles and a lack of formal worker protections leave CHWs vulnerable to violence and sexual harassment, common occurrences that are frequently downplayed or silenced.MethodsWe are a group of researchers who work on CHW programmes in a variety of contexts globally. The examples here are drawn from our ethnographic research (participant observation and in-depth interviews).ResultsCHW work creates job opportunities for women in contexts where such opportunities are extremely rare. These jobs can be a lifeline for women with few other options. Yet the threat of violence can be very real: women may face violence from the community, and some experience harassment from supervisors within health programmes.ConclusionTaking gendered harassment and violence seriously in CHW programmes is critical for research and practice. Fulfilling CHWs’ vision of health programmes that value them, support them and give them opportunities may be a way for CHW programmes to lead the way in gender-transformative labour practices.

Global health can be understood as part of a larger history of global cooperation that reflects and enacts uneven politics, power, and privilege on an unequal earth. Global health emerged in the early 21st century when the groundswell of money for HIV/AIDS transformed the field, and a global orientation, as opposed to one of international relations or modularity, took hold. It is rooted in a long history of wealthier countries intervening in poorer countries with the stated aim of improving health—often with other goals, including economic power or winning hearts and minds. This history has been told by historians of medicine, as well as anthropologists. The idea of “global health” references the fact that health problems are concentrated not only in poorer countries, but rather around the world in resource-constrained settings, including rural areas and those that have been systematically cut off from services. The infusion of money for HIV, largely from wealthy nations, including the United States, positioned decision-making in global power centers that reflected a holdover from previous epochs of international health and colonial medicine. As in earlier eras, the period of global health was one where the focus was often on short-term, measurable outcomes achieved through top-down programs that sidestepped government infrastructure and development. This lack of sustained attention and support for national governments’ ability to build sustainable, broad-based health systems underlines long-standing concerns around the utility of technical solutions for health problems when long-standing social and economic political and policy problems are overlooked.

Using international collaborations to develop educational materials presents several challenges but offers enormous benefits in gleaning a wealth of information, perspectives, and context. The global course that resulted from this collaboration mirrors the goals of implementation science more broadly—to bring the findings of research into routine practice to improve health services., Key Findings Using international collaborations to develop educational materials is an effective approach to obtaining a wealth of information, perspectives, and context and to facilitating local and global ownership and uptake of the educational materials.While these collaborations can involve challenges for curriculum design, content development, and team cohesion, in-person meetings and early recognition of institutional hierarchies can mitigate challenges and enhance team strengths. Key Implications Collaborations should plan for and adjust approaches for hierarchies ahead of time and ensure significant in-person meeting time to make the most of international collaboration., Lessons learned from one global health program can inform responses to challenges faced by other programs. One way to disseminate these lessons is through courses. However, such courses are often delivered by and taught to people based in high-income countries and thus may not present a truly global perspective. The Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) is a consortium of 8 institutions in Afghanistan, Bangladesh, the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria, and the United States that seeks to carry out such a transfer of the lessons learned in polio eradication. This short report describes the collaborative process of developing content and curriculum for an international course, the learnings that emerged, the barriers we faced, and recommendations for future similar efforts. Various parts of our course were developed by teams of researchers from countries across South Asia and sub-Saharan Africa. We held a series of regional in-person team meetings hosted in different countries to improve rapport and provide a chance to work together in person. The course content reflects the diversity of team members’ knowledge in a variety of contexts. Challenges to this effort included team coordination (e.g., scheduling across time zones); hierarchies across and between countries; and the coronavirus disease (COVID-19) pandemic. We recommend planning for these hierarchies ahead of time and ensuring significant in-person meeting time to make the most of international collaboration.

The practice of assigning grades is a universal quality of educational institutions, but the effects of biases in grading as well as its potential to distract from actual learning can make grading particularly problematic in the context of global health education. Ungrading is an anti-oppressive strategy to teaching which seeks to promote students as the experts of their own learning. It de-emphasizes grades and focuses on improved student engagement over time facilitated through thoughtful instructor comments and ongoing conversations. We implemented ungrading in two graduate-level global health courses at the Johns Hopkins Bloomberg School of Public Health; this manuscript documents the implementation process, the teaching teams’ experience, and student evaluations related to ungrading. Overall, quantitative course reviews were much improved from previous year(s). Qualitative responses revealed that students across both courses felt that ungrading improved their ability to focus on learning course material without anxiety about GPAs. Ungrading also encouraged students to embrace comments for learning, take risks, and leverage their lived experiences in responses. The teaching team felt students put in more effort, not less, and enjoyed a transformation in interactions with students—away from grades and toward content. Ungrading is a promising approach in graduate global health education that can facilitate inclusive and reflexive learning spaces.

Ayaz Qureshi. 2018. AIDS in Pakistan: Bureaucracy, Public Goods, and NGOs. Singapore: Palgrave Macmillan. 217 pp. ISBN 978-981-10-6219-3.

BackgroundIn India and other low- and middle-income countries, multiple family and community members are influential in caregivers’ perceptions of vaccination. Existing literature indicates the primary caregiver, typically the mother, is instrumental in vaccine decision-making, but this may vary in contexts. We investigated the role of stakeholders in India who influence caregivers’ vaccination perceptions, as this is essential to developing strategies to promote vaccine acceptance and improve uptake.MethodsThis research was conducted in 2019 in Mewat District in Haryana, an area in India with extremely low vaccination coverage. We conducted six focus group discussions with 60 participants in the following categories: fathers of children under-5 years old, expectant mothers, mothers-in-law, community health workers, and community influencers such as locally elected officials and religious leaders.ResultsOur results highlighted four themes that influence vaccine uptake. First, while caregivers associated vaccination with reductions in specific diseases, they also noted that vaccination services brought broad health gains, including improved nutrition, antenatal guidance, and social support. Second, community health workers critically influenced, positively or negatively, caregivers’ vaccination perceptions. Third, community health workers faced gaps in their education such as limited training on vaccine side-effects, placing them at a disadvantage when dealing with families. Finally, we found that mothers-in-law, fathers, and religious leaders influence caregivers’ perceptions of vaccination.ConclusionsCommunication of broader benefits of vaccines and vaccination services by community health workers could be impactful in increasing vaccine acceptance. Vaccine uptake could potentially be improved by facilitating community health workers’ ownership over vaccine acceptance and uptake by involving them in the design and implementation of interventions to target mothers and mothers-in-law. A ‘bottom-up’ approach, leveraging community health workers’ knowledge to design interventions, and giving a voice to key members of the household and society beyond mothers alone, may sustain health improvement in low vaccine coverage areas.

Across the literature on CHWs globally, the role of CHWs' families remains largely unexplored. This article focuses on ASHAs and Anganwadi Workers in a town in rural Rajasthan, India. We interviewed all twenty ASHAs and Anganwadi Workers in this town, and ten of their families; we also conducted participant observation in Anganwadi Centers, health centres, and family settings. ASHA and Anganwadi work was in high demand, despite being low paying, because of an overall lack of jobs for educated women. Every aspect of CHW work, from recruitment to selection to training to the number of hours spent on the job, was heavily determined by families. Women's mobility, income, and workload was tied up in family structures. ASHA and Anganwadi Work increased the mobility and autonomy of the women who held those jobs in significant ways. But mostly, women stayed in these extremely low paying jobs because they and their families hoped that one day they would become permanent jobs with salaries and benefits. By providing honourable work, and keeping the idea of permanent employment in view but always just out of reach, the ASHA and Anganwadi programmes both exploited and strengthened gendered inequalities in the rural Rajasthani labour market.

IntroductionThe debate over the impact of vertical programmes, including mass vaccination, on health systems is long-standing and often polarised. Studies have assessed the effects of a given vertical health programme on a health system separately from the goals of the vertical programme itself. Further, these health system effects are often categorised as either positive or negative. Yet health systems are in fact complex, dynamic and tightly linked. Relationships between elements of the system determine programme and system-level outcomes over time.MethodsWe constructed a causal loop diagram of the interactions between mass polio vaccination campaigns and government health systems in Ethiopia, India and Nigeria, working inductively from two qualitative datasets. The first dataset was 175 interviews conducted with policymakers, officials and frontline staff in these countries in 2011–2012. The second was 101 interviews conducted with similar groups in 2019, focusing on lessons learnt from polio eradication.ResultsPursuing high coverage in polio campaigns, without considering the dynamic impacts of campaigns on health systems, cost campaign coverage gains over time in weaker health systems with many campaigns. Over time, the systems effects of frequent campaigns, delivered through parallel structures, led to a loss of frontline worker motivation, and an increase in vaccine hesitancy in recipient populations. Co-delivery of interventions helped to mitigate these negative effects. In stronger health systems with fewer campaigns, these issues did not arise.ConclusionIt benefits vertical programmes to reduce the construction of parallel systems and pursue co-delivery of interventions where possible, and to consider the workflow of frontline staff. Ultimately, for health campaign designs to be effective, they must make sense for those delivering and receiving campaign interventions, and must take into account the complex, adaptive nature of the health systems in which they operate.

There is a growing critical social science literature on volunteering in health programs in non-western, low-income countries, yet few have mixed quantitative and qualitative methods to examine the psychological and social wellbeing of unpaid community health workers in such contexts. We address this issue with data from unpaid community health workers (CHWs) and other women who comprise Ethiopia's state-organized Women's Development Army. We draw on qualitative and cross-sectional survey data collected between 2013 and 2016 to test links between various aspects of psychosocial and economic wellbeing and volunteer status in a rural context. We surveyed 422 adult women in Amhara state, 73 of whom were unpaid CHWs in the “Army”. We also conducted interviews and focus group discussions with health officials, salaried Health Extension Workers, volunteer CHWs, and other adult women. Analyses of our qualitative and quantitative datasets show that volunteer CHWs are actually worse off than their peers in various psychosocial and economic respects, and that CHW recruitment processes are the most likely explanation for this difference. Additionally, the unpaid CHW position adds work to already burdened shoulders, and makes women—especially unmarried women—vulnerable to negative gossip and high levels of psychological distress. To a limited extent, the volunteer CHW position also bolsters married women's subjective socioeconomic status and confidence in achieving future gains in status. By showing that unpaid CHWs do not necessarily enjoy psychosocial benefits, and may experience harm as a result of their work, these findings reinforce the recommendation that CHWs in contexts of poverty be paid and better supported.

Of the millions of Community Health Workers (CHWs) serving their communities across the world, there are approximately twice as many female CHWs as there are male. Hiring women has in many cases become an ethical expectation, in part because working as a CHW is often seen as empowering the CHW herself to enact positive change in her community. This article draws on interviews, participant observation, document review and a survey carried out in rural Amhara, Ethiopia from 2013 to 2016 to explore discourses and experiences of empowerment among unpaid female CHWs in Ethiopia’s Women’s Development Army (WDA). This programme was designed to encourage women to leave the house and gain decision-making power vis-à-vis their husbands—and to use this power to achieve specific, state-mandated, domestically centred goals. Some women discovered new opportunities for mobility and self-actualization through this work, and some made positive contributions to the health system. At the same time, by design, women in the WDA had limited ability to exercise political power or gain authority within the structures that employed them, and they were taken away from tending to their individual work demands without compensation. The official rhetoric of the WDA—that women’s empowerment can happen by rearranging village-level social relations, without offering poor women opportunities like paid employment, job advancement or the ability to shape government policy—allowed the Ethiopian government and its donors to pursue ‘empowerment’ without investments in pay for lower-level health workers, or fundamental freedoms introduced into state-society relations.

BackgroundMass campaigns are a key strategy for delivering life-saving interventions under Global Health Initiatives, especially in weak health system contexts. They are frequently designed parallel to the health system to rapidly achieve programme targets such as vaccination coverage, but we lack quantitative evidence demonstrating their impact and effect mechanisms on health system performance at sub-/national level. This longitudinal study responds to this gap through an analysis of polio eradication campaigns in Nigeria.MethodsUsing four rounds of Demographic and Health Surveys in Nigeria between October 2000 and December 2017, we created a longitudinal dataset containing 88 881 under-5 children/pregnancies. We estimated the relationships between individuals’ campaign exposure and health system performance indices (full RI schedule attainment, maternal healthcare services utilisation and child survival) using multilevel, mixed-effects regression models applied nationally and stratified by the six geopolitical zones in Nigeria.ResultsNationally, high-frequency mass campaigns had detrimental health systems effects that potentially left 3.6 million children deprived of full immunisation. The frequency of campaigns was most concentrated in regions with weak health systems, where the operations of RI were disrupted, alongside negative effects on child survival and institutional delivery. In contrast, regions with relatively strong health systems and few campaigns experienced beneficial effects on maternal healthcare service utilisation.ConclusionsAs we provide evidence that well-functioning health systems can benefit from mass campaigns under Global Health Initiatives, our work also challenges the established wisdom to intensify mass campaigns in weaker health systems to bypass service provision bottlenecks. Mass campaigns do not inherently benefit or damage a health system, but frequent campaigns in weak health system contexts can impede service provision. We call for an additional burden of proof and active efforts to integrate mass campaigns into routine health services by harmonising implementation plans and service delivery in weak health system contexts.

Ethnographies of health systems are a theoretically rich and rapidly growing area within medical anthropology. Critical ethnographic work dating back to the 1950s has taken policymakers and health staff as points of entry into the power structures that run through the global health enterprise. In the last decade, there has been a surge of ethnographic work on health systems. We conceptualize the anthropology of health systems as a field; review the history of this body of knowledge; and outline emergent literatures on policymaking, HIV, hospitals, Community Health Workers, health markets, pharmaceuticals, and metrics. High-quality ethnographic work is an excellent way to understand the complex systems that shape health outcomes, and provides a critical vantage point for thinking about global health policy and systems. As theory in this space develops and deepens, we argue that anthropologists should look beyond the discipline to think through what their work does and why it matters.

Nearly all global health initiatives give per diems to community health workers (CHWs) in poor countries for short-term work on disease-specific programs. We interviewed CHWs, supervisors, and high-level officials (n = 95) in 6 study sites across sub-Saharan Africa and South Asia in early 2012 about the per diems given to them by the Global Polio Eradication Initiative. These per diems for CHWs ranged from $1.50 to $2.40 per day. International officials defended per diems for CHWs with an array of arguments, primarily that they were necessary to defray the expenses that workers incurred during campaigns. But high-level ministry of health officials in many countries were concerned that even small per diems were unsustainable. By contrast, CHWs saw per diems as a wage; the very small size of this wage led many to describe per diems as unjust. Per diem polio work existed in the larger context of limited and mostly exploitative options for female labor. Taking the perspectives of CHWs seriously would shift the international conversation about per diems toward questions of labor rights and justice in global health pay structures.

Little empirical research exists on the effects of health work on Community Health Workers' (CHWs') social relationships and status, yet these factors are important in understanding the broad social and behavioral drivers and impacts of CHW programs. This is particularly true for unpaid CHWs. Engaging with others as a CHW might help a worker to embody a valued role in society as a selfless, caring individual; or it might strengthen bonds with others and improve social networks and social capital. By combining qualitative, ethnographic, and survey data collected in rural Amhara, Ethiopia from 2013 to 2016, we evaluated the extent to which unpaid female workers in Ethiopia's Women's Development Army (WDA) were better able than their peers to achieve cultural consonance by building desired social connections or fulfilling locally salient models of virtuous womanhood. We conducted a cultural consensus survey (n = 74) and measured cultural consonance in a larger survey of adult women, including WDA leaders (n = 422). We also conducted participant observation and interviews with health officials, local health staff, and WDA leaders. In our study site, WDA leaders were more able than other women to fulfill the cultural ideal of having connections to various government officials. Yet these connections often did not lead to the benefits that WDA leaders hoped for. Also, in contrast to the findings of many other studies, achieving greater cultural consonance was not significantly associated with reduced psychological distress in this population. For women in this rural context, meanwhile, psychological distress is strongly associated with food and water insecurity, stressful life events, and social support. These findings point to the importance of social, economic and psychological support for rural women in Amhara, and specifically for unpaid CHWs.

Many of medical anthropology's most pressing research questions require an understanding how infections, money, and ideas move around the globe. The Global Polio Eradication Initiative (GPEI) is a $9 billion project that has delivered 20 billion doses of oral polio vaccine in campaigns across the world. With its array of global activities, it cannot be comprehensively explored by the traditional anthropological method of research at one field site. This article describes an ethnographic study of the GPEI, a collaborative effort between researchers at eight sites in seven countries. We developed a methodology grounded in nuanced understandings of local context but structured to allow analysis of global trends. Here, we examine polio vaccine acceptance and refusal to understand how global phenomena-in this case, policy decisions by donors and global health organizations to support vaccination campaigns rather than building health systems-shape local behavior.

Drawing on ethnographic material collected in Pakistan, India, and Nepal, this article analyzes patterns of corruption in vaccination programs in South Asia. Corrupt practices-which required substantial work-were deeply shaped by both the money and systems of accountability of the global health system. Bilateral and multilateral donors provided substantial funding for immunization programs across South Asia. International agencies and governments instituted systems of accountability, including documentation requirements and a parallel UN bureaucracy in problematic districts, to try to ensure that health workers did what they wanted. Some immunization program staff skillfully bent these systems of accountability to their own ends, diverting vaccination funding into their own pockets. Corruption operates not in opposition to the official rules, but in spaces opened up by them. These practices sometimes transform Weber's rational bureaucracy into a sophisticated game with many players, whose aims are more complex than the stated goals of the bureaucracy.

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several propositions for further conceptual development and research related to the question of CHWs and accountability. publishedVersion

Background Many Community Health Workers (CHWs) experience the same socioeconomic and health needs as their neighbors, given that they are by definition part of their communities. Yet very few studies aim to measure and characterize experiences of deprivation, poverty, and wellbeing among community health workers. This study quantitatively examines deprivation and wellbeing in Ethiopia’s Women’s Development Army (WDA), a massive unpaid community health workforce intended to improve population health and modernize the country. Methods We conducted a survey of 422 volunteer WDA leaders and community members in rural Amhara state, part of a mixed-methods ethnographic study of the experiences of women in the WDA. The survey asked a variety of questions about respondents’ demographics, education, assets, and access to government services. We also used survey measures to evaluate respondents’ levels of household food and water security, stressful life events, social support, work burden, and psychological distress. Results Volunteer WDA leaders and community members alike tend to have very low levels of schooling and household assets, and to be heavily burdened with daily work in several domains. Large proportions are food and water insecure, many are in debt, and many experience stretches of time with no money at all. Our survey also revealed differences between volunteer WDA leaders and other women that warrant attention. Leaders are less likely to be married and more likely to be divorced or separated. Leaders are also more likely to experience some aspects of food insecurity and report greater levels of psychological distress and more stressful life events. They also report slightly less social support than other women. Conclusions In rural Amhara, women who seek out and/or are sought and recruited for leader roles in the WDA are a population living in precarity. In several domains, they experience even more hardship than their neighbors. These findings highlight a need for careful attention and further research into processes of volunteer CHW selection, and to determine whether or not volunteering for CHW programs increases socioeconomic and health risks among volunteers. CHW programs in settings of poverty should stop using unpaid labor and seek to create more paid CHW jobs.

Creating community health worker jobs in the public sector is a prominent goal in the global health development industry. According to industry leaders, Ethiopia’s government has created community health worker jobs at a scale and in a way that other countries can look to as a model. Based on extensive document review and interviews with district, national, and international health officials, we show that narratives about saving lives, empowering women, and creating model citizens in a context of resource scarcity allow Ethiopia’s ruling party to obtain international admiration for creating salaried community health worker jobs and to simultaneously avoid criticisms of its concurrent use of unpaid women’s community health labor. Public sector community health worker investments in the twenty-first century reveal the layered narratives inherent in global development practices that entangle states, international donors, NGOs, and citizens.

In December 2012, militants began targeted attacks on workers going door to door in Pakistan delivering polio vaccine, including members of a community health worker cadre called Lady Health Workers (LHWs). Over the next several years, more than 50 workers, most of them women, were murdered as they worked. Media accounts frequently refer to these workers as “aid workers” or “heroes.” This paper complicates and theorizes this conception. Two conflicting moral economies around the work of LHWs existed before the targeted killings began; both have amplified since. One, shared among the LHWs themselves, centers around ideas of community health work as deserving of remuneration just like other government work. The other, promoted by the Global Polio Eradication Initiative at the international level, conceptualizes ground level workers like LHWs as “heroes,” not as labor—eclipsing the LHWs’ own discourse in the international sphere.

In this article, we use semistructured interviews and documents produced by Ethiopian government officials and international health donors to examine two key features of the nation's community health worker (CHW) program: (1) the process and criteria of selecting community health workers; and (2) policies, rhetoric, and experiences of payment and empowerment. We examine these from the varied perspectives of district health officials, Health Extension Workers, and leaders and members within Ethiopia's so-called Women's Development Army, whom we interviewed during 2012–14. According to national policymakers and policy documents, the goals of the Women's Development Army are twofold: first, to reduce mortality and second, to produce “model” women, who discipline themselves and their neighbors to enact healthy behaviors. The Army is supposed to simultaneously “empower” these women to be more autonomous from husbands and more active in development-oriented work. Yet one of the key criteria sought by district-level health officials—willingness to “accept what we teach them and implement what we tell them”—highlights that Army leaders are to remain subordinate to government health officials. Many female members of the Women's Development Army expressed ambivalence about their selection, particularly as the position was unpaid. Some questioned why women were expected to volunteer when men had previously been paid to do similar work. These data emphasize the differences in goals, aims, and experiences among various actors involved in CHW programs, and the need for researchers to address whether or not respondents are comfortable to express perspectives that might question dominant goals and discourses.

Community and health worker engagement will be key to polio eradication in Karachi, Pakistan. In this study, the authors conducted participant observation, interviews, and a document review in SITE Town, Karachi, an area that in recent years has harbored poliovirus. SITE’s diverse population includes large numbers of internally displaced persons who are disproportionately affected by polio and are more likely than other populations to refuse the polio vaccine. Vaccine acceptance and worker motivation in SITE Town were shaped by the discrepancy in funding and attention for polio eradication campaigns as compared with routine services. Parental vaccine refusals stemmed from a distrust of government and international actors that provided few services but administered polio vaccine door-to-door every month. Addressing this discrepancy could therefore be key to eliminating polio. The authors suggest short-term improvements to routine immunization and sanitation in key polio endemic areas, coupled with ...

Many actors in global health are concerned with improving community health worker (CHW) policy and practice to achieve universal health care. Ethnographic research can play an important role in providing information critical to the formation of effective CHW programs, by elucidating the life histories that shape CHWs’ desires for alleviation of their own and others’ economic and health challenges, and by addressing the working relationships that exist among CHWs, intended beneficiaries, and health officials. We briefly discuss ethnographic research with 3 groups of CHWs: volunteers involved in HIV/AIDS care and treatment support in Ethiopia and Mozambique and Lady Health Workers in Pakistan. We call for a broader application of ethnographic research to inform working relationships among CHWs, communities, and health institutions.

(2014). The Global Dreams and Local Complexities of Malaria Eradication. Anthropology Now: Vol. 6, No. 2, pp. 108-110.

Many of medical anthropology's most pressing research questions require an understanding how infections, money and ideas move around the globe. The Global Polio Eradication Initiative (GPEI) is a $9 billion project that has delivered 20 billion doses of oral polio vaccine in campaigns across the world. With its array of global activities, it cannot be comprehensively explored by the traditional anthropological method of research at one field site. This paper describes an ethnographic study of the GPEI, a collaborative effort between researchers at eight sites in seven countries. We developed a methodology grounded in nuanced understandings of local context but structured to allow analysis of global trends. Here, we examine polio vaccine acceptance and refusal to understand how global phenomena-in this case, policy decisions by donors and global health organizations to support vaccination campaigns rather than building health systems-shape local behavior. This article is protected by copyright. All rights reserved.