BOOK REVIEW
Adamu Addissiea
a MD, MPH, MA, PhD, Associate Professor, Addis Ababa University; Program Leader for Gender, Health, and Theology, Ethiopian Graduate School of Theology (EGST), Ethiopia
Global health can help to ensure its relevance and effectiveness by continuing to monitor not just what happens to people, but especially what those people think about what’s happening to them. In other words, listen. Is it possible for global health, as an enterprise, to listen to what people think and want, and blend its expertise with that? Or is it too late?1
In Global Health Means Listening, Dr Raymond Downing illustrates how listening in global health is important and timely based on his many years of experience as a physician and educator in Africa. All in all, it is a terrific resource for any global health expert and specifically for those with faith-based values. Dr. Downing, according to his own words, is someone “stuck” in his version of global health—living where he works (not just visiting), working for health systems (not introducing new ones), and personally cooperating with colleagues (not just introducing programs and surveys). Drawing from his observations at two international conferences, he describes the majority of global health programs to be also “stuck” in a technical, scientific, vertical, even imperialistic approach. Though he is an expatriate Caucasian-American, his over 30 years of lived and reflective experience in remote and rural parts of Africa make him a person worthy of being listened to when he writes about his perspectives on global health.
The book is structured into four sections. Part I has chapters with reflections on global health: its definitions, understandings, and evolution. All the chapters in this part are stories and reflections on global health from the author’s own experiences in Africa and observations at global health conferences. Part II deals with reflections on global health based on the author’s readings and experience related to his AIDS work. This part has more of an academic element. Part III contains reflections based on the author’s 10-year engagement in initiating, running, and teaching a Family Medicine training program at Moi University in Kenya, and is based on dialogue with a student from Duke University. While the earlier three parts are applicable to global health in the broader sense, Part IV is dedicated specifically for spiritual reflections on global health, biblical mandates, and reflections from the perspective of a medical missionary.
Two major themes guide the whole evolution of the book, “global health” and “listening.” The author discusses and illustrates what global health is and demonstrates the importance of listening in global health. He gives an introduction to global health concepts and terminology as well as to listening in global health followed by an overview of the whole volume. In the various sections and chapters, he discusses the evolution of terminology in global health over the years and illustrates it from his experiences. The book is a contribution to a re- definition of global health. Many attempts to re-define global health have been made, for better or worse. Whatever the intentions, there seems to be a growing consensus that global health needs re-thinking to enable appropriate responses to health realities in the world. Dr Downing makes an excellent contribution to that end.
Dr. Downing presents his thoughts about the need to listen in order to understand the other, i.e., the people whom we intend to serve in all the cycles of health and disease, between “global health scholars and activists in the West and those in receiving countries.”(p 37) His major point is that there is an absence of listening in contemporary global health practices, especially between Westerners and Africans. According to him, the listening approach is meant to be a natural way of doing global health and actually is not something new. It is a living principle from long ago which over time has become neglected and undermined. He emphasizes both why we need to listen and how to listen in global health. This is illustrated well with living examples of real stories about real people.
The beauty of the book is that it is written on the basis of about three decades of personal reflections. This is a book not of theories but of praxis and life reflections. As I was reading his reflections, I was imagining him walking, talking, discussing, treating, etc. I felt like I was on a journey with him, at times laughing, at times questioning, and at times arguing with him. He mixes academic and journalistic styles of writing. I am convinced that readers of all walks of life such as practitioners, managers, and medical personnel will enjoy reading the book for its style, respecting the writing for its content, and strong, troubling, and challenging message.
He combines a particular style of personal reflection with personal encounters from working in global health and based on his reading over the years. He begins the book with a compelling story. This illustrates how listening operates within a culture in an institution, but also at an interpersonal level, and shows the need for mediation and inner, deeper listening in the business of saving lives.
While enjoying the flow of the plots in each of the chapters and the style of writing, I also was trying to grasp the point he was making. Accordingly, I was able to personally gather three key messages from the book. The first was the fact that global health is beyond numbers and statistics. It is about people with real stories, about lives changed, and human nature, emotions, culture, and feelings. Health defined to mean wholeness is the aim of global health—saving lives which cannot be done fully without paying attention to the deeper roots of the dangers at personal and societal levels beyond the viruses and the bacteria causing diseases. Disease is beyond biology and the physical body. It is social, emotional, spiritual, economic, and cultural. Healing also needs to address the whole, complete cycle of disease and its dimensions.
The second point was the need for being deliberate and intentional about listening in global health. Dr. Downing remains critical of the persistent superiority complex by global health practitioners over the beneficiaries, which is, at its heart, a result of lack of listening. On the contrary, listening requires humility, under-standing, conviction, determination, and sacrifice. Listening is arriving there with one’s whole self, ears, intentions, body, mind, sensitivity, and imagination. One needs to arrive primarily for fuller meaning, understanding, and informed action. Listening is not spontaneous, but needs active effort. It does not happen passively.
The third message goes to the faith-based element of global health. The last section of the book offers reflections and perspectives, as well as practical challenges to the faith-based global health community. Missionary medicine and colonial medicine have failed to listen to the traditional African forms of healing over the years, and the global health trend needs to take a better approach than that. Listening creates synergy between our contributions and the existing reality, including the spiritual.
There are also three areas where I would offer some critique. The first is the question of generalizability of the reflection to global health. Though originally from a Western setting in the USA, Downing’s lived experiences are mostly from his focused years providing medical missionary services in Eastern Africa—specifically Kenya. As someone coming from a different country in the East African region, I can very well agree with his thoughtful and contextual reflections, especially as these observations explain concepts very close to my setting. This makes me believe that his reflections apply mainly to the Sub-Saharan African context but may not fully apply to other settings.
A second critique involves the varieties and levels of listening in global health in various forms. The best listening needs to be a two-way process where communication is reciprocal and complete. By the same token, listening in global health would entail listening not only from the perspective of the recipients and partners, but also the recipients listening to what global health workers bring of value. Dr. Downing has made good reflections on the locals’ understandings in his own words, but I wondered if added perspectives might have been evident if their own words and expressions had been used. Additionally, there is listening from beyond the practitioner such as from policy makers and the leadership of international organisations and actors in global health.
Last, but not least, one could ask for strategies for listening in global health. Are there practical tools for listening? I would have preferred a section with practical suggestions on how to listen. This made me think of a book on a similar theme by Sussan Vitalis, a medical missionary, on how to hear God’s direction at life’s cross roads. She included practical levels of listening to the will of God in her vocation and ministry.2 I understand that it is difficult to prescribe methods for listening to the multifaceted levels and dimensions in global health. It is also to be noted that this may have been beyond the scope of the book. Possibly other experts will complement this in the future.
My reviews above and conclusions below are possibly influenced by who I am, a medical doctor who worked in East Africa for most of the two decades of my professional life as a clinician, then as a public health practitioner and academician. By way of conclusion, finding the right balance is my approach. The Western approach to global health and healing medicine has been useful and will continue to be useful but needs to be complemented with local knowledge and supported by the existing resources to strike the right balance. I am not arguing that the traditional African approach to healing is better than the Western one. Rather both have their pros and cons. Thus, the best approach will be to cross fertilise and find a model of care where the global is married to the local, and both are listening. This seems a very romantic idea but it is not an easy task. We all are fascinated by the importance of listening in other aspects of life such as family, work, etc. But often we fail to realise that listening is a task which does not happen by merely wishing. One needs to work intentionally to develop listening skills depending on the context, the language, and the prevailing communication techniques used locally. According to the book, listening in global health is listening to the global and the local, and requires the right attitude and intentional emotional readiness from the global health practitioner.
I recommend that this book be read by all actors in the field of global health, government officials, multilateral organisations, academic entities, mission agencies, local NGOs, and, last but not least, the African or developing world practitioners and decision-makers who need to be heard. I end with a quote from one of the well-read contemporary management and leadership writers, Steven Covey. I do wish the grace and wisdom of listening for all of us engaged in the global health arena.
To relate effectively… we must learn to listen. And this requires emotional strength. Listening involves patience, openness, and the desire to understand—highly developed qualities of character. It is so much easier to operate from a low emotional level and to give high-level advice.3