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Here is an edited transcript of the podcast with Dr Rachel Hall-Clifford.
Before Dr Rachel Hall-Clifford moved to Guatemala to study childhood diarrhea, she could not fathom why many kids were dying from the disease. Oral Rehydration Therapy (ORT) has helped prevent millions of deaths from diarrhea for over half a century.1 Compared to other public health interventions, it is fairly easy to provide.2 Yet, diarrhea remains the third leading cause of death in children under five globally.3
As Dr Hall-Clifford spent time in Guatemala, she realized that low ORT use was just one symptom of a public health system in crisis. Socioeconomic disparities and neoliberal policies, among other factors, have led to poor health outcomes, with the country’s indigenous Maya communities disproportionately bearing the brunt.4
In her book Underbelly: Childhood Diarrhea and the Hidden Local Realities of Global Health, published in 2024, Dr Hall-Clifford explores how international development and global health programs have been inimical to health equity and access.5 Despite their seemingly good intentions, they often cause harm by not considering communities’ lived experiences, unilaterally imposing ‘solutions’, and prioritizing technocratic approaches at the expense of primary care. [See glossary for details]
I spoke to Dr Hall-Clifford to explore how we can make international health programs more responsive to marginalized communities’ needs, how public health professionals from high-income countries can promote global health equity, and her co-design initiatives for improved maternal and child health in Guatemala.
When I started university, I planned to go into medicine. However, I majored in anthropology and was interested in different cultures and places. I took a course on medical anthropology and suddenly, everything made sense to me. I understood that while I was passionate about health, I didn’t want to be a health provider — I wanted to work on health at the population level. So, I further studied medical anthropology and trained in global public health.
In graduate school, I got interested in childhood diarrheal disease because it seemed like a problem that we should have been able to solve. The solutions appeared so simple and within our grasp, but it turned out that they can be incredibly challenging. Global health is like pulling a loose string on a sweater — everything is connected. If you work on one issue, you quickly recognize how interconnected it is to others.
So, my work on childhood diarrheal disease led to issues of water quality, nutrition, maternal health, and equity. In rural Guatemala’s Maya communities, we see the embodiment of marginalization. There are incredibly high rates of chronic undernutrition and stunting [see glossary for details]. Due to intergenerational impacts, the Maya population is shorter today than when colonization began 500 years ago.6
The height differences between indigenous populations and others are not genetic, but socially prescribed. This is heartbreaking, but also compelling because we can change and improve these things. And that’s where my career has led me.
In my book Underbelly, I tried to link local experiences of global health with global health’s meta-structures — particularly with respect to oral rehydration therapy, but a host of other programs too.
Many development professionals work in distant places from where programs are implemented. Global health starts from offices in Geneva, Atlanta, London, etc., but I argue that it should begin with communities. We need to change global health frameworks to recenter communities and their on-ground realities because our current approach is entrenching asymmetrical power dynamics. It replicates colonialist structures and also leaves big gaps. As a result, programs aren’t as effective as they could be.
I’ve been fortunate to live and work in Guatemala for much of the last 20 years. I’ve gotten to know the country well and I love it very much.
In Guatemala, as in much of the majority world [See glossary for details], colonialist dynamics are still in play in terms of who is setting the agenda and who creates programmatic priorities. In our contemporary capitalist economy, the majority world is still used for resources. A majority of profits is extracted to high-income countries, which, in many cases, are former colonizing powers.
There’s a lot of fine-grained economic debate we could get into here, but the US certainly has that sort of neoliberal, neocolonial relationship with Guatemala. The largest contributor to Guatemala’s economy is remittances from the US.7 There is a reliance on a very fraught migration to the US to support life and communities in Guatemala. This kind of clientelism is unfortunately a result of its colonial past. It also places the US in an incredibly powerful position in terms of dictating policies and priorities.
Global health and development programs establish relationships of what I call ‘problematic gratitude’. The recipient countries are in a position where they can’t or don’t say no to any foreign aid and can’t dictate or even negotiate the terms of that aid. That leads to what I call ‘development dumping’ — lots of uncoordinated programs coming in through foreign aid. Public health programs constantly come and go, leading to fragmentation of the ground. This creates problems for health workers, but more importantly, for heath-seekers. In an ever-changing landscape, they find it difficult to get care that is geographically, financially, and culturally accessible to them, which prevents effective health-seeking behavior
This fragmentation also replicates a neoliberal model where everything is a marketplace. In Guatemala’s health system, the quality of care has become conflated with cost. And so, people delay care hoping that they can save or raise money to get private treatment.8 However, the country has a government health system, which, on paper, guarantees the human right to health and access to healthcare for all citizens.9 But there are gaps in the system and people fall through.
I love the opportunities I’ve had to work in global health, but as a White lady from Tennessee, USA, I shouldn’t be leading them. The experts who have lived in and trained in the majority world and represent the population they are working with should be our leaders.
I have enjoyed recent conversations about decolonizing global health and often think about how we can move from conversations to action. I have tried to address that in my work through co-design. My approach to co-design is that I do not take on projects that don’t originate in the community. The community could be a village, social group, or even at the national level.
I absolutely should not be sitting in my nice office at Emory University and thinking of interesting ideas to try out elsewhere. I should be contributing to the efforts identified by a community, perhaps by facilitating resources or expertise. That’s the role I can play, given my training and positionality.
Co-design is one of many tools we need for more equitable global public health. It involves working with the community to identify problems together. So instead of a professional coming in and saying, “You need ORT here,”, the community must identify the challenges they want to address. There are always multiple challenges, so having the community prioritize and set goals is essential.
In recent years, we’ve seen movement in global health toward community engagement efforts. But too often, those just comprise a single meeting where there’s already a pre-formed project and project managers try to convince people it’s what they want. Co-design, on the other hand, says, “Let’s have everyone at the table before we get started.”
The community should lead the way. So, after they decide to focus on a certain issue, we can identify existing technologies, prototypes, etc that can help solve the problem. What I typically do is present these options back to the community and let them decide how they want to proceed based on what they find appealing and accessible. The solution is developed, iterated, and implemented collaboratively.
Each component of the co-design process is based on agile design methods, so that you can do trial-and-error with end users to arrive at a workable solution, which can then be implemented more broadly. Ongoing feedback from and engagement with end users has led to improvements in project sustainability as well because it’s their idea and it’s their project. So, once the solutions are in place, they are more likely to maintain them.
It’s important to be clear with co-design partners in terms of what’s scientifically possible and what the standards are. I never want a co-designed effort to be less than other programs or lead to poor-quality healthcare. I’ve learned that you have to be upfront with the community about this goal. There is also sometimes a limitation in terms of what aspects of a program can be co-designed.
Safe+natal is a peri-natal monitoring toolkit co-designed with lay Guatemalan midwives — Kaqchikel-speaking Maya women who are birth attendants. The toolkit is powered by a smartphone and has peripheral devices, such as a blood pressure cuff and a one-dimensional Doppler ultrasound.
Midwives use it during pre-natal visits to identify the standard World Health Organization checklist of pregnancy complications in pregnant women. With the peripheral devices, we can identify hypertension, preeclampsia, and fetal growth restriction. This helps us prepare for a safe birth.
There’s a strong cultural preference for home births in the central highlands of Guatemala. We support that, but we also identify pregnancies likely to need facility-based care, either during pregnancy or childbirth. Our project partner, Wuqu’ Kawoq or the Maya Health Alliance, is an outstanding example of a local health-provider organization that has been doing this work. The network of midwives that use the safe+Natal toolkit liaise with local providers operating within the Maya Health Alliance to quickly facilitate transfers for facility-based care.
Through this project, we’ve seen incredible reductions in perinatal complications and maternal mortality10 and it’s been running for a decade. So, I think of this as a real co-design success story.
It also has pushed back against the received wisdom in global health that technologies should only be in the hands of skilled end-users. Our co-design partners are Kaqchikel-speaking Maya midwives and have low literacy levels. Some had never used a smartphone before participating in this project, but now use it effectively. That’s been exciting to see!
A key reason for the success was the co-design of the mobile app itself, which is pictogram-driven and uses audio instructions in the Kaqchikel language. Midwives designed it for their own use. So, they added visual guidance and one of their colleagues provided the audio instructions. That makes it intuitive and accessible for them.
This is a work-in-progress project in partnership with Universidad del Valle and EcoFiltro, a water filtration social enterprise, in Guatemala.
Philip Wilson, a colleague and friend at Ecofiltro, first thought of a point-of-use water-quality testing device that community workers can use to show the need for water purification. He said, “Rachel, I need to be able to just point my phone at a glass of water and see if it’s contaminated.”
I thought that’s a tall order. But we started surveying available technologies and looked for something that was easy to use and didn’t involve a complex training process or supply chain, like microscopy tools. Now, after a few years’ work, I think we are close to a solution.
We are still working on the hardware — essentially a microscope that clips onto a cell phone camera. We have a protocol for collecting water, fixing a sample onto a slide, putting the slide into the microscope, and taking the picture. And then, we use AI object detection to look for E. coli in the sample.
Unfortunately, E. coli is present in up to 98% of Guatemalan drinking water sources and largely accounts for diarrheal disease in the country.11 So, it is exciting to co-design this project with Guatemalan partners and see if we can improve the real-time water-contamination detection. This will help drive water purification in households and enable citizen science for water systems advocacy.
Through her co-design projects, Dr Hall-Clifford demonstrates how we can take steps towards making global health programs more equitable and responsive to the needs of marginalized communities. While scholars and public health professionals have voiced concerns about the current frameworks of foreign aid and international development programs, conversations around the issue need to result in concrete action. Those who work on such projects must be mindful of entrenched inequities and hierarchies and work towards involving communities, overcoming fragmentation through greater collaboration, and challenging existing power structures.
A technocratic approach gives weightage to narrow technical skills and expertise. In healthcare, it has been criticized for promoting the objectification and alienation of patients12 and undermining the social determinants of healthcare.
Primary healthcare seeks to bring services for health and wellbeing closer to communities through integrated health services that meet people’s health needs throughout their lives and by addressing the broader determinants of health through multi-sectoral policy and action.13
Majority world Dr Hall-Clifford uses the terms high-income countries and majority world instead of Global North/South; developed/developing; high-income/low and middle-income; global minority/majority to “intentionally foreground the prevailing wealth of a few countries within a supposed system of mutuality that perpetuates inequality”.
Stunting is when a child’s height is low for their age. It is largely irreversible and can have lifelong adverse health effects.
The mission of the Boston Congress of Public Health Thought Leadership for Public Health Fellowship (BCPH Fellowship) seeks to:
It is guided by an overall vision to provide a platform, training, and support network for the next generation of public health thought leaders and public scholars to explore and grow their voice.
