Q&A With Gregg Gonsalves: Global Health Justice Now

BY KARINA XIE

Gregg Gonsalves (PhD) is a longtime HIV/AIDS activist who started working with ACT UP in 1990 and founded the Treatment Action Group. He now teaches at the Yale School of Public Health and Yale Law School, where he is the Co-Director of the Global Health Justice Partnership. The Yale Global Health Review had an opportunity to sit down with Dr. Gonsalves and discuss his work towards global health justice, gaining insight on both the importance of such interdisciplinary work and the tools used to solve global health challenges.

How did you transition from the early stages of activism to your current work?

When I started working for ACT UP, I dropped out of college and committed myself to HIV/AIDS activism. In 1996, we had an international problem because drugs were not available around the world. It took a long time to get scientists and policymakers working together to get drugs to people and make sure people with HIV got the support they need. At the same time, I worked on educating communities on HIV and TB. I applied to Yale to ask for a financial aid package that would let me complete my college degree. At Yale, I studied biology, and a group of students and I started a Global Health and AIDS Coalition. We protested Obama when he didn’t keep his campaign promise on HIV and AIDS. And then, after college, I was going to go to Paris for a PhD, and do more benchwork research, when I was approached by two people—Albert Ko, who works on leptospirosis, and Jerry Friedland—both of whom are here at the School of Public Health. They asked me to stay at Yale to launch a new initiative merging science, public health, and justice. Then we recruited Ally Miller from the University of California at Berkeley and we formed the Global Health Justice Partnership. We work on Ebola, the United Nations’ role in cholera in Haiti, drugs in Connecticut, tuberculosis in prisons. We believe public health problems are also social justice problems. Fixing people’s health is not just one problem. Doctors and epidemiologists have only part of the tools. If you’re building a house, you need all the tools.

Can you describe your work with the Global Health Justice Partnership?

The Global Health Justice Partnership aims to promote and protect people’s health. We want to bridge the worlds of health and human rights by answering questions ranging from HIV to refugee and immigrant health. We use the tools of science to answer some questions, but we also describe the world around us using tools of sociology. We figure out a problem about the real world. If there’s a problem, what’s the expertise we need and how can we get the people we need? To put it together, we bring people from different departments. They come into the office and use all their faculties and senses to answer questions. Interdisciplinary work is very hot right now but also very hard. When you apply for a grant from the National Institute of Health, it’s very biomedically oriented. But you may also need some expertise from the law. We have a lecture at noon today with two lawyers and two epidemiologists on the panel, and they’re discussing the cholera epidemic in Haiti. Law won’t answer every question on refugees and immigrant rights, or every question of sexual violence and rape in Cape Town, South Africa, but neither can science. That’s why we’re bringing people from different backgrounds to work together.

Can you tell me more about your project on sexual violence against women in Cape Town?

Women have to go and use the facilities. They’re living in shacks in townships, and if they want to go to the bathroom, they have to walk three blocks to go to a portable toilet in the middle of the night, and they’re subject to sexual violence. So we did a model of the city of Cape Town, showing how the city pays a lot of societal costs in terms of violence against women. And we showed that if we have more toilets, we have less sexual violence. And that makes intuitive sense. Instead of walking five blocks, they walk across the street, and there’s ten times as many toilets. And so we put that model together with a friend of mine from the Social Justice Coalition. When we were done with the study, we sent it to the Social Justice Coalition, and they sent it to the city of Cape Town, where advocate groups put it in the newspapers. We wanted to bring to the surface and address the first-person reality of these women in the township, and of other people on the ground and in the front lines. Whether they’re women facing sexual violence or miners with TB, we ask, “What’s the problem, how can we address it with all the tools—public health and science and managing resources?” When you use modeling, even if you can’t address something in an experimental way, you can still simulate it.

How are mathematical models used in global health?

Infectious disease modeling has a long history that stretches back into the 20^th century. The people I study with come from a field called operations research. There’s David Paltiel, who’s down the hall, and Ed Kaplan, who’s at the SOM [School of Management], who’s written on in vitro fertilization, HIV prevention, and public housing. Ed is a genius. If there’s a problem, he thinks, “I can make it into a mathematical model,” which allows him to say something important in a great analytical, quantitative way. Ed teaches a course here called Policy Modeling which is at the SOM. Ed’s really powerful. He can answer questions about people—about in vitro fertilization, terrorism, about HIV prevention—with these simple mathematical models. He can formulate it in a way that means something in the real world, like the toilet and sexual violence paper. What is a woman’s risk a function of? The function of the distance between her house and the toilet, how long she walks, how often she has to use the restroom, the level of crime in the immediate area? Then you can set the parameters: X equals this, Y equals that. And you have a formula that shows the less you have to walk, the less sexual violence you face. Ed teaches you how to translate policy questions into mathematical terms. Ed has taken a field that has been used for military and even business and supply chains and has used it for the public good. He has been an important mentor in teaching me about looking at health policy through mathematical modeling.

Do mathematical models produce direct effects on health policy?

A friend of mine, Bernard, gave a talk a few days ago about health and politics, specifically the smoking ban in China. Cigarette production in China is more than the next 25 to 30 countries combined. Bernard showed that the pollution created by smoking is fifty times worse than Beijing on a smoggy day. People continue to smoke despite knowledge of all the data correlating lung cancer with smoking. What he had to do was to craft an argument to the Chinese government that would focus more on the politics of China and less on the health outcomes. Bernard crafted a method meant to appeal to the government, which didn’t want a two tier system where the elite could smoke in their offices and everybody else couldn’t. Joe crafted this method to determine what other evidence was needed so that Beijing as well as Shanghai could institute a smoking ban. Health policy work in China was about creating a message using what smoking means in terms of society. Scientific evidence is just one piece of the mix; you need clever communications people, and you need activists to push the government to do the right thing. At the same time, you use scientific tools to answer these very important questions.

What do you see as the intersection between science and politics?

Climate change is one place where scientists have done their work measuring carbon dioxide levels and temperature changes in countries around the world. A lot of climate scientists feel their work is incredibly political. There was all this climate data that scientists downloaded from NASA before the Trump administration because they realized that science is not neutral. Even if the science is rigorously proved, it may not convince the BPA [Bonneville Power Administration]. Science is one part of the puzzle. With climate science, public health, reproductive health, you’re in in the world, on the edge of wars, entangled with politics.

What is the role of raising the voices of individual people in achieving global health justice?

Think about all the social advancements in the U.S. and around the world. Women’s rights, civil rights, and gay rights were achieved by people saying, “Enough. I want the right to vote. I want my vote to count. I want to get married.” One thing about HIV is that the drug is really expensive anywhere outside of the US, and especially for people Asia and Africa. People in Thailand, Brazil, and South Africa said they would fight for these medicines. They would fight these drug companies. They would fight the US. And now ten million people are on these HIV drugs while a couple hundred thousand were on them in 2000. All the HIV activism in South Africa was done by poor women in the township who were arguing for better sanitation. They had been involved in a history of political struggle. They had overthrown the white Apartheid government and weren’t powerless. In 1996, newspapers were flooded with articles about how HIV had new medicines that raised people from their deathbeds. At the same time, many people in South Africa were watching their neighbors and their friends die. Ordinary people started saying this wasn’t right and got together to ask, “What can we do about this?” Then lawyers and doctors came into the mix and said, “With the law you can sue the drug company, and from the medical side, you can definitely deliver these drugs even if you don’t have a HIV specialist.” Then 40,000 South African women from the township marched on the South African Parliament. They fought and they won. Political mobilization is a potent force in changing health and public health law. The resulting public health measures produce architectural changes, such as better sanitation and ventilation, which work to improve the lives of people over the course of a century.

Can you tell me more about your course on global health justice?

The purpose of the course is to help students work with people in the field. We want to give students a connection to the outside world, to achieve health equity through real world work. We have three projects going on right now. One is on drug pricing in CT and MD, one on maternal health in Georgia, and one on abortion and the Zika virus in Colombia, Costa Rica, and Brazil. There’s a drug pricing bill that’s going to happen in Connecticut over the next few weeks, so law students are doing research on drug costs, debates around drug pricing, and the legal ramifications. Over spring break, one team is going to South Africa, one is going to Georgia, one to Latin America. They’re talking to minors, doctors, lawyers, and government officials. Our students are sitting in classrooms, but they’re also going outside. They’re running along with current events with outside partners.

What is informing the future direction of your projects?

I’m thinking about what’s happening now politically and what effect it’s going to have on people’s health. A lot of people are looking at the Affordable Care Act and Medicaid. I’m interested in what’s going to happen now to the health of migrants, immigrants, and refugees, and if can we measure that in the short term. I’m drawing inspiration from people like Forrest Crawford, who works just downstairs, measuring hate crimes with stochastic modeling. Public health has given clinical medicine and basic science the need to be public.