In this spotlight, we talk to Raphael Frankfurter about how to incorporate a critical anthropological perspective into global health practice and his experience working in Sierra Leone before, during, and after the Ebola outbreak.
Erin: What first interested you in the GHP program?
Raphael: My freshman year I took a medical anthropology class with João Biehl and found myself interested in the cross-cutting topics of global health from an anthropological point of view. This class was my first step toward developing the serious critical thinking skills required to think about global health problems and how people experience disease. I also became involved in João Biehl’s interdisciplinary Grand Challenges research group. I thought the Global Health Program offered a unique way of approaching topics and methods. These topics included the complicated politics and roles of unregulated NGOs working in global health; critically examining how programs and successes are “measured”, what embedded assumptions, politics, and ideologies are included in measurement tools; the ways in which global politics and history determine health inequities around the world; who gets left out of universal treatment programs; the many steps, challenges, and complexities between developing a pharmaceutical and it reaching people on the ground; and so many more. The whole orientation of the Global Health Program applied critical thought to global health problems and it paved the way for how I oriented myself in the field.
Erin: As an undergrad, what did you value most about the GHP experience?
Raphael: The way it supported and challenged us to do serious research—and then how the program followed these immersive research experiences with longer-term mentorship and integration with academic reading, critical thinking, and classes. Sometimes programs encourage [a form of] health tourism—[a sort of] dabbling in health problems. But the Princeton GHP summer experience is not “one-off” or disconnected from the academic experience—it’s integrated into the program and the research informs dialogue and classroom engagement which informs how we engage in future fieldwork. The way Princeton encouraged us to engage was longitudinal. It involved mentorship from many professors and they helped impart values of research integrity and cultural engagement.
Erin: Can you tell me more about your work in Sierra Leone as an undergrad?
Raphael: I first became involved in through my relationship with João Biehl— an alum had a research project in Sierra Leone. I worked with a post-doc—Peter Locke—and the research project was to interview and spend time with people who had been amputated during the civil war and try and understand how they experienced psychological pain related to the war and physical pain related to amputation. My first summer in Sierra Leone, I felt like I was being thrown into a different world, and I got a sense of how much people had suffered—but I also uncovered how ethnographic methods provide insight into how people understand their condition and make meaningful lives for themselves. I was shocked by deep poverty, but I was excited to return and gain a deeper sense of the complexity of poverty.
My sophomore summer, I got a small grant to do an agriculture project, this was my first experience in implementation. I returned each summer and I gradually began working for the Wellbody Alliance year round. In the US, I was writing grants, publicity materials, building a donor base, and getting others involved.
Erin: How did your continued and different types of engagement in Sierra Leone affect your approach to global health work?
Raphael: Professor Biehl and Peter Locke helped me develop a “reflexive” approach—to embrace and constantly reflect on and re-evaluate my own uneasiness about the ethics and problematics of "doing" global health, of "intervening" or of "implementing,” (as if I am researching myself, so to speak) while also learning something in the process. I also came to recognize how important it is to attend ethnographically to the ‘targets’ of global health programs as individual people with emotional, cultural, social and personal complexities. There is a way in which the technical and abstracted perspective inherent to (and types of research and data valorized in) much high-level global public health work can efface the fact that ultimately health programs are trying to improve the lives of real people inhabiting difficult and complex contexts. This was a critical perspective that was imparted to me through the GHP. So we thought a lot about how to build more humanistic, decentralized, and ethnographically attentive health programs at Wellbody Alliance that could be both large-scale and “people-centered”—particularly during the Ebola outbreak. I feel very grateful that I started my global health ‘work’ as a student intern on-the-ground and worked my way up to a higher-level management position.
There was also an inherent uneasiness on my own end about what it means to do research and also try to intervene as I did, in a way, becoming a big part of this global health organization's administration as a student. In college, you're supposed to focus on your intellectual development into a complex and effective thinker, not be an NGO administrator. And the challenge was to maintain a critical skepticism, nuance, and pragmatism but not produce a cynicism so intense that the underlying motivation to engage and help the world is lost. That's an intellectual exercise that colored my work with Wellbody and Partners in Health going forward and my current academic path.
Erin: How did your role with the Wellbody Alliance change after graduation?
Raphael: After I graduated from Princeton, Wellbody was ready to start a US office. I worked full time for the organization in Boston with another GHP graduate, Shirley Gao. We built out the team there and helped develop a substantial fundraising and financial plan by partnering with organizations working at a higher level and building and cultivating relationships with foundations and other funding groups. One of the challenges to fundraising was that we had an entirely local staff in Sierra Leone, which we strongly felt we wanted to maintain. But maintaining an autonomous, indigenous and locally-managed health organizations is challenging given that sustaining the work involves connecting and networking with larger donors and when the norms and terms of budgeting and accounting are developed in Geneva, London, or DC conference rooms or academic halls. Shirley helped a lot with building donor relationships and developed an organizational strategy and priorities. We were able to expand from solely offering primary care to also supporting a community center, 24-hour maternity care, and an ambulance system. We also prioritized strengthening relationships with the government health system at multiple levels and strengthening relationships with supply organizations in order to stave off any supply chain challenges.
We spent the first two years after graduation going back and forth between the US and Sierra Leone and worked to raise money for the organization—quadrupling funds raised and the operating budget in two years.
Then the Ebola outbreak happened—which brought its own challenges.
Erin: What were your roles and the organization’s response to the Ebola outbreak in Sierra Leone?
Raphael: Then Ebola...almost all clinics shut down at the beginning of the outbreak—while we weren’t initially treating Ebola patients we wanted to keep the clinic open and help with supply chain management to keep some health care services open. We also strengthened community programs in order to engage people who may have had exposure to Ebola and encourage them to get care. As things get more out of control, Partners in Health (PIH), an organization with which we had had a long-term partnership, was drawn to get involved (and ultimately become a leader in) Ebola care in West Africa. We partnered to facilitate PIH’s entrance into Sierra Leone and we expanded to operate an Ebola treatment center (in a different region then Kono where Wellbody Alliance is located). In the Kono region, we expanded the community health worker training and started offering remote community care facilities where people could be tested and treated for Ebola closer to the home.
Erin: What was your specific role in coordinating Ebola care and responding to the crisis?
Raphael: My role was to negotiate a partnership with PIH and design and manage the CHW response system and its relationship to other community care services.
PIH was the only organization that was staffing Ministry of Health run Ebola Treatment Units in Sierra Leone clinics rather than building their own tent city and their own clinics. We [Wellbody Alliance] were independently running our clinic, one of the only clinics in eastern Sierra Leone to maintain essential primary healthcare services throughout the outbreak. But we also worked to support with material, staffing, and technical support public clinics and the hospital in the region. We were committed to standing alongside the local clinics. Fortunately, none of our clinic staff contracted Ebola even though we had a number of Ebola positive patients come through our clinic (they were properly isolated and referred for testing and treatment). This just reinforced our stance that it was possible to provide routine healthcare safely during an Ebola outbreak with proper material and human resources and infection control systems. Nationwide, most public clinics were abysmally under-resourced and many, many Sierra Leonean nurses and doctors passed away after contracting Ebola while doing what they could to keep treating patients.
Erin: What are you up to now?
Raphael: I’m in an MD PhD program, I just finished two years of medical school at UCSF and took boards and started my PhD work at UC Berkeley. I wasn’t totally sure what I wanted to do after graduation, but I am drawn to help individual people and there is a power to helping people through medicine in a different way than just managing programs. But I also came to value serious critical thinking and thought and what anthropology can contribute to medicine and care—these are values I developed through GHP—and I wouldn't be satisfied just as a doctor. With this dual program, I will hopefully be able to maintain both sides of my interest and ultimately get an academic position where I can write, do academic, clinical, and global health work.
Erin: Have you decided where the anthropology part of your PhD research will focus yet?
Raphael: I'm interested in working in the remote region where Ebola first emerged to gain a critical perspective of what the reality was and is in this "Ground Zero" of Ebola, the focus of so many major global health institutions. Although money had been reaching unprecedented levels in global health, often this money was delivered in a vertical and technical, disease-specific manner rather than investments into health system strengthening, but then this epidemic blew out of control. I want to spend time seeing what the reality was in the “Ground Zero” of where the Ebola epidemic began and what reforms have been made to the health system and how things have changed or not changed.
Erin: You’ve worked mostly in Sierra Leone and now you are engaging the US health system more through medical school which gives you a little bit of an “outsider’s perspective”—if you could take anything from Sierra Leone’ s health care system and implement it in the US what would that be?
Raphael: Within Wellbody Alliance and Partners in Health, we really tried to put the onus on us as health workers to improve patients’ health situation—if patients are struggling with adherence, or coming to the clinic for appointments, or complicated social or economic situations we viewed it as our responsibility to work with them to develop solutions. This inspired our community health worker program, our integrated social support initiatives alongside the clinical care we provide, etc. This type of a perspective is also, of course, relevant in the urban hospitals in which I’ve trained in the US, and parts of the home-based care model we were using in Kono could certainly play a role here (and there are plenty of people in the US who are working on this!)
Erin: Any final thoughts, advice, words of wisdom for current GHP students?
Raphael: I would emphasize doing actual field research where you engage with people and then seriously reflexively think about those experience. The GHP support for these experiences is unique and it changed my life. The relationship with anthropology and the GHP is also very cool. It demonstrates to natural science students the value of layering in a different approach. I think that the GHP program and my relationship with Professor Biehl made my Princeton career.