S2 Ep 10 - Katherine Furman on 'The Philosophy of Public Health'

"Philosophers of science are really good about thinking about causation and trying to figure out what the mechanisms are that make something work"

Today we welcome Katherine Furman, who talks to Indi about the philosophy of public health. Katherine is a lecturer of Philosophy, Politics and Economics at the University of Liverpool. She is currently on research leave to work with the SOCRATES project in Hanover, Germany.

Katherine explores with us the intricacies of implementing public health measures in the face of epidemics. When there is resistance to these programs, the cause is rarely as simple as an information deficit. Katherine draws on her South African background in her focus on the South African AIDS epidemic and how various case studies of rejection of public health programs may be applicable to the wider philosophy of science.

Transcript of the episode available here: https://www.hpsunimelb.org/post/katherine-furman-transcript-s2-e10

Resources related to the episode:

Katherine's Website: https://katherinefurman.com/

SOCRATES Centre: https://www.socrates.uni-hannover.de/en/ 

Maya Goldenberg's Book: Vaccine Hesitancy: Public Trust, Expertise, and the War on Science

Benjamin Black's Book: Belly Woman: Birth, Blood & Ebola - the Untold Story

Article on Ebola: Ebola: failures, flashpoints and focus | | Africa at LSE

Jonny Steinberg's Book: Three Letter Plague

Heidi Larson's Book: Stuck: How Vaccine Rumors Start - and Why They Don't Go Away

Thanks for listening to The HPS Podcast with current producers, Samara Greenwood and Carmelina Contarino. You can find more about us on our blog, website, bluesky, twitter, instagram and facebook feeds. Music by ComaStudio.

This podcast would not be possible without the support of School of Historical and Philosophical Studies at the University of Melbourne.

HPS Podcast | hpsunimelb.org

Transcript

Hi all! From the team here at The HPS Podcast, we welcome you to a new episode. I'm Indigo Keel, your host, and my co producer is Samara Greenwood. Today we welcome Katherine Furman from the University of Liverpool to the podcast. 

Katherine explores with us the intricacies of public health initiatives, and reasons why they may not be received well by the people they're designed to serve.

She draws on her South African history in her focus on the South African AIDS epidemic and how various case studies of rejection of public health programs may be applicable to the wider philosophy of science. 

Hello, Katherine, welcome to the HPS podcast. 

[00:00:45] Katherine Furman: Hi, it's so great to be here. 

[00:00:47] Indigo Keel: So grateful for you joining us all the way from Germany. I'll get started, as we always do on this podcast, which is asking you about your connection to HPS. 

[00:00:55] Katherine Furman: I'm a philosopher of science, more specifically a philosopher of social science, and even more specifically than that, a philosopher of health policy sciences. But the way that I work is very case based.

So, I'm really interested in getting all the details about the cases. As a result, I end up needing to be kind of a methodological magpie and I end up drawing a lot on medical anthropology and medical sociology, because I do very little of my own primary research. To get all the details of the cases, I then end up needing to read loads of sociology and anthropology, the people who've really been on the ground doing the work. So, it ends up being this weird mishmash of philosophy of science, but also social sciences. Trying to get this really detailed understanding of the cases. I start with the cases and then build the philosophy upwards. 

I'm South African, as you might've got from the accent. I did all my early philosophical background training in South Africa, not that far after the end of apartheid. Far in one sense, but not that far in another, 10 years into democracy. 

It's kind of difficult in retrospect to know if this is true or not, but I felt like there was a lot of moral and political philosophy when I was an undergrad in South Africa. There was a sense that philosophers are funded by taxpayers and so they need to do something that is really socially relevant in a new democracy. Figuring out how to live together seems really important. Figuring out how to reimagine the state seems really important. And so, lots of moral and political philosophy was happening.

I never encountered any philosophy or history of science until I ended up at the London School of Economics doing a master's degree in philosophy and public policy. I ended up in Nancy Cartwright's evidence module, which is a bit legendary in the LSE circles. It's really a module on how philosophy of science can do policy better. The thought being philosophers of science have thought a lot about things like causation and evidence and how to put evidence together, so this is really how to make policy be better. 

That module was transformative. I ended up doing my master's dissertation with Nancy Cartwright on AIDS denialism, and then ended up going back and doing a PhD also on AIDS denialism.

That was the entry point into using philosophy of science and social science to figure out how to do policy better. And that's what I've ended up doing ever since. 

[00:03:05] Indigo Keel: Beautiful. So, what do you see as the value of HPS coming at it from your background in philosophy of science? 

[00:03:12] Katherine Furman: I think HPS gives people a more critical lens to view the world through. I get that everyone who works in any subdiscipline in the humanities or social science will say exactly the same thing. You know, medieval literature will give you a more critical lens to see the world through. 

But I think HPS is distinct because so much of our lives are structured by science and then even more so when we are expansive and include the social sciences. So, everything from what medicine do I take to how do I educate my children? We want it to be science informed and science based, and we have a sense that science is given to us almost from the gods, that it's not something that you can challenge. But once you've done even a little bit of HPS, we start to see that the sciences are a human endeavour done by actual human beings. As a result, that gives us a route to be a bit more critical of the results of that whole human process. Humans are messy. They make mistakes. 

I don't think that leads us into a position where HPS students end up being crackpot denialists about everything, because also HPS gives us this wonderful view of the miracle that is science. The extraordinary things that people have been able to accomplish.

So, on the one side, it allows us to be more critical because we can see that there are actual human beings doing this, in this kind of messy, piecemeal way. But on the other side of things, it's kind of miraculous, like, look at all the amazing things that we've done. We've discovered that there are microbes and as a result, we can take antibiotics. It's all super cool. 

[00:04:33] Indigo Keel: Oh, absolutely. This is me cheating a little bit because we were chatting about this before we started recording the podcast, but I was wondering if you could tell the audience a bit about what your current work is. I think they'd really love it. 

[00:04:47] Katherine Furman: Right. So, I'm currently in Hanover at the SOCRATES Centre. 

SOCRATES is the ‘Social Credibility and Trustworthiness of Expert Knowledge and Science-Based Information’, but they've managed to get that into this super cool acronym. And essentially, I'm doing work on public distrust in science. I've been working on this for a long time now, and what I'm looking at is how ordinary people relate to health policy interventions in particular. What I'm really interested in is where people actively resist health policy interventions. 

I know that lots of people in philosophy of science and social science have been working on this. Maya Goldenberg has this wonderful book on vaccine hesitancy that came out recently. Lots of people are interested in distrust in science, but I'm really interested in when people actively resist health interventions.

I'm into AIDS denialists. I'm into people who, when AIDS treatment became available in South Africa, didn't go and get tested to get treatment. I'm interested in people during the West African Ebola crisis who didn't participate in the interventions, and it got so extreme that people were burning down clinics.

So, I'm really interested in resistance to health policy interventions given that we think that health is a really good thing and people should surely want more of it. And it does seem that people do want access to healthcare. So, what's going wrong when people don't take up those opportunities for health? How does that go so wrong? 

[00:06:03] Indigo Keel: Interesting and extremely relevant given the last couple of years that we've had. 

[00:06:07] Katherine Furman: I think people have become way more interested in this since COVID. It seemed like a parochial, far away issue that people were actively refusing health care in some distant corner of the world. But when people started to see anti lockdown marches in their town centres, it suddenly really hit close to home. Weirdly, I've done very little writing on the COVID pandemic. I mean, I use it as examples, but I'm still really interested in these African cases. 

[00:06:30] Indigo Keel: And I think that leads quite nicely into my next question, which is - what is a topic that you wanted to talk to us about today?

[00:06:37] Katherine Furman: The topic I really want to talk about is thinking more about public distrust in science and people who resist health interventions. I think that this is an issue of obviously crucial concern, not just to all of us trying to figure out when to trust the experts and when not to trust the experts, but organizations like the World Health Organization, MSF, which is Doctors Without Borders.

These issues come up all the time in their reports. There was a report on trust and health policy interventions from the World Health Organization. People who work in these areas are really desperate, I suppose, for better theories and better concepts to help this go along. Maybe they don't think of themselves as being desperate, but it seems to me that this is the case.

And so, I'm really interested in trying to understand how public distrust in science works and why people don't trust health policy interventions. I think that this is a key topic. And I think that it's really easy when we read the popular press to think that when people are distrustful of health policy interventions, it's because they're cranks or tinfoil hat wearing conspiracy theorists.

But I think that actually being overly dismissive of people who hold these views then doesn't give us a way to communicate with them or draw them into the health policy space. I think that once we pay really close attention to what's going on in these cases, they're substantially more complicated. And so, I start from the presumption in these cases that people are not obviously irrational or obviously crazy, or obviously doing things that are incomprehensible to outsiders.

But if we start from the lay perspective or from the ground level, we can try to figure out where people are coming from. Developing our theories of distrust that way I think things are really complicated. 

So, it's not just about getting people access to the right information about the sciences. It's not just about giving people more leaflets. ‘Have you heard the good news? Like, there's an Ebola treatment centre down the road.’ But we also need to understand things about the emotional landscape in which people are operating. People have just found themselves in the middle of an epidemic, perhaps. Their friends are dying. They're trying to figure out whether or not they're going to take their sister to the Ebola treatment centre. All of that is terrifying. Perhaps people are super angry because they don't have access to proper medical care. And so, all of this emotional stuff is playing a role. Values play a huge role. 

This is something that philosophers of science are really very familiar with, thinking about the value turn in philosophy of science. And so, sometimes people's values are very much at stake in these issues. This makes our picture of what we're dealing with a lot more complicated than ‘we need to get people access to the right information’, because often in these cases, people have access to the right information. They're going to workshops, they're receiving educational flyers, there are hotlines that they can call to get access to all of the information.

And so, it seems as though what's going wrong is not informational. It's all of these other contextual factors, which means that we need this more complicated theory to understand what's happening on the ground. 

[00:09:21] Indigo Keel: Yes, absolutely. I was hoping that you could talk us through a couple of case studies. 

[00:09:25] Katherine Furman: I love case studies. I've recently been rereading a book, Johnny Steinberg's Three Letter Plague, which was released in 2008. Johnny Steinberg was a political theorist by training. He did his PhD at Oxford in political theory. So, he's kind of a philosopher, but doesn't really do theory anymore. He does these really incredible detailed ethnographies. 

Three Letter Plague is about the South African AIDS crisis and particularly the moment where people finally got access to treatment, the mid 2000s. It seemed initially that even though people finally had access to treatment, that they weren't showing up at the treatment centres, that they could go and get tested so that they could finally access the treatment. This was going to be a huge tragedy because South Africa has an incredibly high HIV rate. 

So, he went to this very rural area. In fact, not that far away from where I grew up. He learned the language, met some locals. He ends up becoming good friends with this guy that he named Sizwe throughout the course of the book. He tries to figure out why Sizwe is not getting tested so that he can tell the whole story of the AIDS crisis around Sizwe's decision around whether to test or not to test. It immediately becomes apparent that this is not an informational problem. MSF is working in this village. There are little workshops. People can go and get all the information they need about AIDS testing and treatment. Sizwe is suspicious, but also there are really good personal reasons for why Sizwe is not going to get tested. And so, it ends up being really not informational at all. 

I think as philosophers, we really like things to be informational because we're very good at doing epistemology. We are like, ‘Oh yeah, what we need to do is figure out the right way to package the information.’ But actually there's all of this other stuff going on in people's lives that impact whether or not they're going to participate in your health policy campaign. 

[00:10:58] Indigo Keel: The social side of things is often just as important, if not more than the epistemic side of things when it comes to getting people to trust in what experts are saying.

[00:11:06] Katherine Furman: I've done some writing on the Ebola crisis in West Africa. So that was kind of from 2013 to 2016, depending on how you divide it up. Different people have different dates for this. It was the biggest Ebola outbreak we'd ever seen. So, there have previously been other Ebola outbreaks, but mostly on the opposite side of the African continent. They were kind of small and the thought was Ebola was never going to be a big deal precisely because Ebola is so deadly. Ebola is super deadly and is very quick. So, people don't have a lot of time to travel around infecting other people. Unlike HIV, where if you have HIV, you can be fine for 10 years.

So, the thought was Ebola was never going to be a big deal because people don't have an opportunity to travel before they die. It's super infectious, but also super deadly. And so, they deemed these ‘little mini explosions’ of Ebola in the African continent. People hadn't taken it really seriously because of that.

Then you had this big Ebola outbreak in West Africa and suddenly, because it was so large, the international community sat up. Mostly because they were worried that Ebola was going to reach the rest of the world, not because they were that worried about Ebola in Africa, but that's a whole separate discussion.

So suddenly the whole international community descends on West Africa to intervene and to help people. Everyone is there, the World Health Organization is there, Doctors Without Borders is there, the British army has a presence there. The best description I've read of this is that ‘the alphabet soup of world organizations descended upon West Africa.’ 

These Ebola treatment centres were set up, immediately large intervention. But large intervention didn't come with large scale participation in the program. So, in all three countries that were affected, Sierra Leone, Liberia and Guinea, people resisted to various degrees. Some people responded by keeping sick relatives at home and not taking them to the treatment centres. Others were performing secret burials. The bodies of people who've had Ebola are really very infectious, so not having the proper hygienic burial is a real problem. 

In places like Guinea, stuff got super violent, particularly in an area called the Forest Region, where people were burning down clinics, people were cutting down rope bridges to prevent the medical teams from getting access to them or logging trees so that they would block off the roads so the medical teams couldn't get access to them. This reaches a kind of violent crescendo where eight members of a medical team are murdered by a community to prevent them from getting access after they'd been warned not to enter the community. 

I obviously don't think anyone should be murdering medical teams. This is a horrifying story, but then there's the question about, well, what happened there? Because again, we kind of have this presumption that people should want healthcare when it's on offer. Why wouldn't you want it? Why would you act in such a violently resistant way?

So, I think that's a super interesting case study. Again, we start from the presumption that people are trying to do the best for themselves and their families. What's going on? And it turns out that when you start to read the ethnographic stuff about what's going on in these cases, it turns out to be super complicated.

There are political stresses between people in the Forest Region of Guinea and their government. There were loads of conspiracies and rumours that this was a plot by the government to take out a troublesome marginalized group. People were also very afraid in all three countries because who wouldn't be? Ebola is not a friendly disease. It's really terrifying. 

When you speak to the doctors who are involved in these processes, they agree that it would be terrifying coming to the Ebola treatment centres, because, if you were sick with something else and you ended up being quarantined, you might become infected, even if you were sick with something else.

There's a really interesting book written by a doctor who was working for MSF. He's an obstetrician and he was in Sierra Leone, not to work on the Ebola pandemic, just to be an obstetrician and Ebola ends up in the place where he's working. At the time he had this incredible blog in which he was detailing what it was like being an obstetrician during an Ebola outbreak. He would need to make calls about whether or not what he was looking at was a really complicated pregnancy case, in which case people would need to go into get emergency medical care and obstetrics, or if he was looking at an Ebola case, in which case they would need to be quarantined. They couldn't go anywhere near the other pregnant women because they would infect them and then we would have more of an outbreak. He was, on a daily basis, needing to make these calls about whether or not what he was looking at was a really complicated pregnancy or an Ebola case. If he made the wrong call, people would die. He had this incredible blog. This has now come out as a book called Belly Woman, in which he talks about that period of time.

People, in some sense, are not wrong about being afraid of going and receiving treatment under these conditions where if you're incorrectly classified, you might end up dying as a result of that. And so, I think there's just so many of these different factors that are really complicated and people are not responding in obviously crazy ways.

[00:15:39] Indigo Keel: Yes, absolutely. Epidemics are terrifying.

[00:15:42] Katherine Furman: Part of what's so interesting about the Ebola case is, because there was such an international presence, there was lots of really good information available to people about Ebola and how the treatment centres worked and how the disease worked and what the best practice would be under the circumstances.

So again, this was not an informational problem. This was a problem about uptake. You also saw interestingly, local celebrities getting involved. And so, they would have really catchy pop songs that had all of the information you needed about Ebola happening at the time as well. So, information campaign wise, things were really good, but happening on this backdrop of people having mistrust for the government, people having mistrust of international presences in their locations. People being really suspicious of what was going on and sometimes really rationally suspicious, which is why I told the whole story of the obstetrician. It wasn't always a safe option to go and seek medical treatment. 

[00:16:34] Indigo Keel: And why do you feel this topic is so important? Why is this the work that you do?

[00:16:39] Katherine Furman: Trying to get health policy cases, in particular, right is super important because it really has an impact on who lives and who dies. I think part of the lesson of all of this is that getting health policy right isn't just about getting clinics in places where there need to be clinics and doctors in places where there need to be doctors. 

Of course, that's going to be necessary. I come from South Africa where there aren't always clinics in places where people need them and doctors in places where they need them. So, all of that is necessary, but it's not sufficient. We also need to be paying very careful attention to where all of this is going on. Because if these background conditions are all going badly wrong, then people are not going to show up at the clinics, even if they're there.

I think getting health policy cases right, in particular, is super important because it really impacts on people living and dying. It's kind of existential in this way. I think all policies are really interesting when we dig into the weeds of how they operate. But I think health policy cases have this existential threat aspect, which makes them even more important. 

I grew up in a region of South Africa called the Eastern Cape, which is the poorest province in the country. The AIDS crisis really hit my region very badly. So I grew up in the midst of the AIDS crisis, sort of at the tail end of people not having access to treatment.

When I was a student in South Africa, the AIDS activist organization was taking the vice chancellor captive, kidnapping him to put pressure on the university to get access to AIDS treatment. So this was all super important stuff that was going on in our lives, on my university campus. This wasn't abstract philosophy, which is super interesting.

I mean, I think that issues of the philosophy of time are wildly interesting, but there's this existential dimension. The vice chancellor has been kidnapped so students can get access to healthcare on campus. This is really important stuff. And then finding myself only a few years later in Nancy Cartwright's evidence course, where you need to think really carefully about the evidence that ends up in policies was just serendipitous. 

[00:18:30] Indigo Keel: Experiential philosophy is just so captivating, pardon my pun. 

[00:18:35] Katherine Furman: It was sort of amazing because we had an incredible vice chancellor at the time who was really interested in trying to make the university a place for social change.

So, the student activists arrived at his office to kidnap him, to put pressure on the university to get access to AIDS treatment on campus. His response was, ‘I'd love to be kidnapped! Of course, I think that this is really important. Can I pack my stuff up so that I can come with you?’ So the vice chancellor was absolutely complicit in this kidnapping.

[00:19:01] Indigo Keel: What is it that you want people to be able to take away from the work that you do?

[00:19:07] Katherine Furman: I think the relevance to a wider audience is that we need to be careful about caricaturing people we don't get along with. I definitely think, particularly during the COVID pandemic, the way the press spoke about people who were concerned about lockdowns or concerned about vaccines was that these people were dangerous. These people were irrational. 

In some international press, these people were criminals. So, in the Netherlands, there were really violent anti lockdown protests. The response was that these were criminals who needed to be dealt with as criminals. For an ordinary person response to all of this, I think the wider applicability is to pause and think about the world from other people's perspectives and why they might be responding in these ways.

But even if we look beyond just ordinary people, I think lots of international organizations are very worried about these issues. The World Health Organization, Doctors Without Borders, they're often talking about concerns about trust, suspicion, public uptake of policy. So, this is really a very practical place where the large body of philosophy and HPS work that's happening on these issues is really applicable. Trying to help these international organizations do a better job and that, if they are intervening in people's lives, we should at least be doing that in a cautious and well informed way.

So I think the broader applicability here is that this helps ordinary people think about each other in a more sensible way, but also helps international organizations tailor their policy interventions so that they can be more effective. 

When we were looking at the COVID pandemic, at the beginning people kept on saying, ‘this is not our first rodeo friends. This is not the first time we've had a pandemic.’ In particular, how close that was to the end of the Ebola outbreak. The thought was that we would have learned some lessons from Ebola that we could then apply in the COVID pandemic. Although, the context was so different that it's not really clear how that would operate. But we've had all these lessons from previous big diseases like AIDS, like Ebola, that then become applicable as we encounter new infectious disease outbreaks.

And of course, COVID is not going to be the end of this, right? We're going to have more diseases in the future and more health policy interventions that will need to be dealt with in sensitive ways. 

[00:21:09] Indigo Keel: Absolutely. Hopefully we'll get to the point where we're able to learn from previous instances. 

[00:21:15] Katherine Furman: This is one of the real powers of something like HPS, particularly the history side of this. The history of science gives us all of these case studies that can help us understand new situations as we encounter them. The real magic trick though, is trying to make sure that your cases are actually applicable. 

Again, I keep on referring to Nancy Cartwright, who was clearly an outsized impact on my career. She's very cautious about saying, ‘Oh look, we have this thing that works. We can now just seamlessly implement it in this new intervention.’ Rather, we need to be really careful because what works in South Africa is not going to work in Sierra Leone. What works in Melbourne is not going to work in, I don't know, Liverpool. 

We need to try and figure out what makes things work in particular locations and what doesn't, which again, philosophy of science can help us with because philosophers of science are really good about thinking about causation and trying to figure out what the mechanisms are that make something work. I think that's all important. 

[00:22:01] Indigo Keel: Beautiful, and you drew it so nicely back to HPS. Thank you so much for coming on the HPS podcast, Katherine. 

[00:22:10] Katherine Furman: Thank you so much for having me and for letting me talk a little bit about my work. 

[00:22:16] Indigo Keel: Thank you all for listening to Season Two of The HPS Podcast, where we discuss all things history, philosophy, and social studies of science.

We want to thank the School of Historical and Philosophical Studies at the University of Melbourne for their support. To learn more, check out our website at www.hpsunimelb.org. There, you can also find links to our blog, our social media, as well as show notes for today's topic. I'm Indigo Keel, and my co producer is Samara Greenwood.

We look forward to having you back again next time.