Displaced Children: "Adverse Childhood Experiences Amongst Refugees from the Horn of Africa: Influences on Development, Attachment, and Risk/Resilience"
by Segen Zeray
Changing Conditions of People's Lives More Broadly
Professor Dredge Byung’chu Kang‘s research focuses on beauty and love as they intersect with race, class, gender, sexuality, globalization, and structural violence in body modification and interracial relationships. Dr. Kang teaches courses on love, beauty, race, gender variance, sex work, sexual health, global health, inter-Asian / transnational Southeast Asian studies, and the Korean wave. This summer, he will leading a Global Seminar course in Thailand that focuses on sex, gender and health within the context of this country.
Dr. Kang is currently teaching Global Health courses such as ANSC/GLBH 148. Global Health and Cultural Diversity and ANSC/GLBH 146. A Global Health Perspective on HIV.
We had the opportunity to sit down and discuss his approaches to global health regarding HIV/AIDS, sex, gender and structural determinants in global health.
Interviewed by: Anh Vo
“What I really want students to get is global health is not just about doing medicine or doing public health, but it’s about changing conditions of people’s lives more broadly.”
1. Please tell us about your background and how you came to choose your profession/field.
My background is actually in Public Health work. I was working at non-profit organizations, and at a certain point when you reach a certain level in non-profits, all you do is fund-raise; you either write grants or you network with donors, mostly private donors, for funds. And I really did not like that, because you’re constantly asking for money and because they are giving you money, you have to play these “games.” And one of them is that, in relation to the #MeToo movement coming out and its widespread, wealthy people often feel that they have the right to manipulate you in any which ways they want. So after a while, I decided that this was not for me, so I went back to go to graduate school and do something else.
2. Why did you choose your particular field of study, or more specifically, medical anthropology/global health?
Initially, I was going to do specific research on HIV. And I had worked at UC San Francisco running an HIV research program before, and because of that I knew what kind of disciplines were involved in HIV research, and I also knew which ones I did not want to be involved with. In general, I got along best with the anthropologists, amongst the psychologists and epidemiologists who I work with. But I knew that I needed to learn epidemiology so I could speak the language of epidemiology when I am in a room with epidemiologists, however I knew that I did not want to purse epidemiology; so I did get an MPH studying epidemiology, but I did it just because I want to be able to be at the table and to speak in a way that earn respect from others. Because if you do not know what everyone else is talking about, you are going to be automatically dismissed. And then, I knew that the psychological framework was also not what I was interested in, in part because I am more drawn towards social & structural factors related to risk and vulnerabilities, as opposed to individual factors, and so I felt that the psychological approach was often to reductive in terms of how they look at risks.
“…one of the most important things about Global Health is respect for difference.”
3. How do you define global health from your perspectives? And how do you think it should be approached?
I think one of the most important things about Global Health is respect for difference. Traditionally, before global health, there were international health, and before that came tropical medicine. The history of it is basically to keep white people who traveled to the colonies from getting sick, and keep the people who were working for the colonies from dying to increase their product and work time for these colonizers. In this tropical health paradigm, there were in part missionary goals to Christianize the colonies, etc. Then, the paradigm for international health is more about saving and helping people, in which case it was about rich countries giving money and doing things to help the poor and needy in other places. I think how that has shifted recently, in part due to the impacts of HIV/AIDS, promotes the sense that things are not necessarily top down or about rich vs. poor countries. For instance, global health now is looking at transnational issues such as migrant/refugee health, or things that affected rich countries such as the emergence of infectious diseases. This is unfolding in a way that is considerate of cultural differences.
Another way that global health has changed in its approach is the focus on structural inequality. Before, there was this notion that the differences that we see is due to people having different beliefs, which lead to differences in their behaviors which were bad for them without them knowing. So the solution were that we just need to better educating them, then things would just be better; as opposed to looking at social structures and how those impact people’s risks, and what they can or cannot do, in regards to that individual’s agency and constraints.
4. What do you think is one of the most pressing issues in global health today?
I would say that we should not be focusing on a single health issue, because there are many contenders for those, such as infectious diseases, malaria, or neglected tropical diseases, etc. But for me, the most important thing in global health is thinking of new ways to fund global health programs. We should think about our priorities when it comes to how to do the funding, and where the funding should come from. The way which funding has been done is, I think, inadequate, but at this point, there is not a political will to do something different. There have been game changers in the field like the Gates Foundation, but I still think there needs to be different model for how we get funding from public sources.
“…even though there is the myth that because everyone is at risk for HIV, everyone is at equal risk, and that is clearly not true….the ways that the disease transmits and spreads in a population are highly specific, whether if it is in the US, Africa, Southeast Asia, or anywhere else. And the populations that are most impacted…are key populations that are particularly vulnerable and are often marginalized from society.”
5. You will be leading a Study Abroad Global Seminar course this summer in Thailand, which will be focusing on gender, sexuality and health inequity. What is unique about the structure of this course and why do you think these topics are important?
One thing that is unique about this course is that it is based on my expertise. Other Global Seminars may not be based on the professor’s expertise but on the destination. This course is special to me because it is from the place where I do my research as well as being about my specific research work, so it matches well with my background and expertise overall.
The site lends itself to this kind of work. Thailand is a country known for its gender diversity, it recognizes sexes more than male or female for instance, and it also has a higher social tolerance for gender difference within the country. This does not mean that it is great or perfect for people who are not male or female, but just that there are more tolerance and acceptance of it within compare to other places. This makes Thailand unique, since this is not common throughout the world, and this is also something that is relatively prevalent in Southeast Asia in particular.
The other piece is about sexual health, which I think Thailand in many ways has been a model for in the developing world. They went from a very high birth rate to a very low birth rate within a very short period of time. Family planning took off very quickly, and in terms of HIV they are considered one of the two star models in the developing countries, the other being Uganda in Africa. There is a lot of discussion around how successful the Thai model for HIV prevention was, and what people generally point to is the 100% condom policy for brothels, which I think was important to reducing the AIDS epidemic in Thailand. But there are a lot of things which people do not consider regarding this model; for example, the 100% condom policy, in my mind, is only effective in Thailand because (1) prostitution is illegal, (2) the police are corrupt, and (3) because Thailand was under a military dictatorship at the time. So the only reason that the policy was enforced was because the government could do whatever they wanted, which is not necessarily the model of global/public health that aim to engage local populations.
Because most of my work has been in HIV specifically, the population that HIV touches on are groups like sex workers, gay men, trans women, injection drug users, and in places like the US, it’s racial minorities. So even though there is the myth that because everyone is at risk for HIV, everyone is at equal risk, and that is clearly not true. And there is a reason why people put that message out before, which was to draw attention and care about the disease. But the ways that the disease transmits and spreads in a population are highly specific, whether if it is in the US, Africa, Southeast Asia, or anywhere else. And the populations that are most impacted, except in Sub Saharan Africa where the epidemic is more generalized, are key populations that are particularly vulnerable and are often marginalized from society. So those are the populations that I am most interested in, and these populations are also most affected by the structural issues that I think are really important to global health.
Do you think that this HIV/AIDS situation has been improving due to the insurmountable funding and focus that has gone into the disease, or has it just been leveling off?
I think it has leveled off in many ways, particularly because people do not think of HIV as a crisis anymore. And when it does not feel threatening anymore, there is less interest in it, even though people are still getting infected and dying. And it is not as “spectacular” now like it used to be, because before, you would visibly see people wasting away: you can see extremely thin people with lesions on their bodies, and you could “see” AIDS in a sense. But now you don’t really see this in the same way as people are increasingly going into treatment, and generally in places like the US, you don’t see people “dying” of it in the same way that you used to. So it does not have the same potency as something like Ebola, or different kinds of diseases that prompt an outbreak, which have people really scared and panicked, so there is a more dramatic response to it.
6. At the moment, do you have any research or projects you are conducting? And what are they if you do not mind sharing?
One of the things that I am looking at now, which is once again specific to Bangkok, is PrEP use (Pre-Exposure Prophylaxis for HIV), and there is a unique situation in Bangkok regarding this. I’m interested in the circulation of PrEP in particularly gay male communities in Asia. Part of my work is on how Bangkok itself is a hub for gay men in Asia, where people go to meet each other, and where large parties are happening. And because Thailand being a hub for tourism, and a hub for sex tourism, Bangkok has become a hub for gay tourism as well. As Thailand was so traumatically affected by HIV in the past, Thailand is one of the few countries that is allowed to make generic HIV medications, amongst few other places like India, Brazil, etc. Because of that, the cost of HIV drugs in Thailand is much lower than it is in other parts of the world, because it isn’t a for-profit venture so to speak. And that is only possible because Thailand has a declared national state of emergency around HIV, which allows them to be exempted from certain international copyright laws and patent laws. Here, if you are a UCSD student and you have the SHIP insurance, it is free, which most student do not know about. In the US in general, if you are paying off-the-shelf prices however, it’s $1000/month, because it’s Truvada, which is a patented brand-name drug. Truvada as of this year will go off patent, but the manufacturer has already created a tweak in the formula so that it is going to be re-patented right after this patent expires, which means that people will not be getting a generic version in the US for a while longer. What that means is in developed countries such as Taiwan, Korea, Japan, Singapore and other developed regions like Hong Kong, they have to pay the same price as the market rate in the US ($1000). In the US, depending on your health insurance, you can get it through your health insurance with a co-pay of in between $25-$50/month, which is much more affordable. In many of these Asian countries, people do not have prescription access to Truvada through their medical system, so that means they have to pay the full price if they want to buy the medicine. Besides being expensive, this is something that most people would not be able to pay for on their own. In Thailand, because they can manufacture generic Truvada, it costs $30/month for the same supply. The way that PrEP works is that you have to be tested for HIV to make sure you are uninfected and you can get a 3-month prescription. So if a person from one of these developed regions in Asia flew to Thailand, which a round-trip plane ticket is around $300 around these places, then you can get a 3-month prescription for PrEP for $90, and in the process you can save yourselves several thousands dollars. So this is creating a new demand for medical tourism to Bangkok specifically amongst gay men, in order to access PrEP. So there are now clinics that are now opening up in Thailand specifically dealing with tourists who are coming for things like PrEP.
This is all created because of the different history of Thailand compared to the region, and the kinds of infrastructures already available there, and the state of emergency that allows for the generic production of the drug.
“…global health should be about changing the conditions that allow for those diseases to exist, or to cause illnesses and premature deaths of people who have the diseases in the first place.”
7. Do you have any advice you can give to students that want to pursue the global health field?
When I’m teaching global health, the thing that I am really trying to emphasize is the social justice aspects of health. What I really want students to get is global health is not just about doing medicine or doing public health, but it’s about changing conditions of people’s lives more broadly. That’s I want the takeaway message of my classes to be. Because it is easy to think about global health as something like a vaccine, a pill, or some other interventions that you do in a place for a population to take care of a certain diseases. And for me that is not what global health is about, global health should be about changing the conditions that allow for those diseases to exist, or to cause illnesses and premature deaths of people who have the diseases in the first place.
In terms of advice, there are so many different ways and avenues to pursue global health, and it’s really open. But the thing I’ve always told people is: ask questions, particularly to the populations that you are working with. Often people who are running programs think they have the answers, and they just need to get somewhere and implement their solutions. But I think the most important thing is to ask what the local populations’ priorities are and what they think should be done to deal with their priorities problems, as opposed to going in with your own idea and say “this is what we are going to do.”