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
I would say that much of what has happened in my career was unplanned. I started in AIDS and social justice activism, which lead to public health work as AIDS became mainstream and professionalized. I was working at non-profit orgs, and at a certain point when you reach a certain level in non-prof orgs, all you do is fundraise; 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, sexual harassment is pervasive. Wealthy people who are willing to donate money often feel that they have the right to touch or manipulate you in any way they want. You also lose contact with the very people that you want to work with and care about. So after a while, I decided that this was not for me, so I went back to college so that I could 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 research specifically on HIV. And I had worked at UCSF 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, more than the psychologists and epidemiologists who I worked with. But I knew that I needed to learn epidemiology so I could speak the language of quantitative methods when I am in a room with epidemiologists, however I knew that I did not want to purse epidemiology as a career; 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 earns respect from those who only care about quantitative data. 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 and structural factors related to risk and vulnerabilities, as opposed to individual factors, and so I felt that the psychological approach was often too 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 aspects about Global Health is respect for difference. Before global health, there was international health, and before that was tropical medicine. The history of it is basically about keeping Europeans who traveled to the colonies from getting sick, and keep colonized from dying to increase their productivity. This tropical health paradigm, in part, also had missionary goals to Christianize the colonies, through the beneficence of health. Then, the paradigm for international health is more about saving and helping people, in which case it was generally 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, which promotes the sense that answers are not necessarily top down or about rich vs. poor countries. For instance, global health now is looks at transnational issues such as migrant/refugee health, or issues that affected rich countries such as the re-emergence of infectious diseases. This is unfolding in a way that is cognizant of and considers cultural differences, though there is a lot more work to be done in this area.
Another way that global health has changed in its approach is the focus on structural inequality. Before, the primary thinking was that health differentials are due to people having different beliefs, which lead to their traditional behaviors, which were bad for them without them knowing. So the solution was that we just need to better educate 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 like HIV or 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 in which funding has been done is, I think, inadequate, but at this point, there is not the 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 a new model for how we get funding from public sources that are accountable to the broad public.
“…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 what makes sense for 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 also 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 pluralism. This does not mean that it is great or perfect for people who are not gender normative, but just that there is more tolerance and acceptance of it compared 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 more broadly.
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 among 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 essential to reducing the AIDS epidemic in Thailand. But there are a lot of factors which people do not consider regarding this model; for example, the 100% condom policy, in my mind, was 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 aims to engage local populations on their own terms.
Because most of my work has been in HIV specifically, the populations that HIV affects most, groups like sex workers, gay men, trans women, injection drug users, and in places like the US, racial minorities, are the ones I have the most experience working with. I also belong to many of these communities, so the stakes are also personal. 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 activists 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 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 the 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?
Global HIV funding has been decreasing in recent years, particularly because people in developed countries do not think of HIV as a crisis anymore. But addressing the problem actually requires more funding, especially as more people in underresourced countries get access to medications. Until there is a cure, a commitment to treatment is a commitment for life. But when it does not feel threatening anymore, there is less interest in it, even though people are still getting infected and dying. AIDS 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 increasingly go 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. Around 7,000 people still die of HIV related causes in the US every year, primarily because they do not have access to health care or the mental health and supportive services that make treatment possible. But these people are relatively invisible. So it does not have the same threat 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?
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 among 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. 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 has declared a national health emergency and is thus 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 and patent laws. Here, if you are a UCSD student and you have the SHIP insurance, PrEP is free except for the visit copays, 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 repatented right after this patent expires, which means that people may not be prescribed 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.
Because it is expensive, PrEP 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 screened for liver problems. Then you can get a 3-month prescription. So if a person from one of these developed regions in Asia flew to Thailand, 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 yourself 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 opening up in Thailand specifically dealing with tourists who are coming for things like PrEP. This is all made possible because of the different epidemic history of Thailand compared to Asian 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 that global health is not just about doing medicine or doing public health, but it’s about changing the conditions of people’s lives more broadly. That’s the takeaway message of my classes. 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 disease. 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, causing illness and premature death.
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 priority problems, as opposed to going in with your own idea and say “this is what we are going to do.” That’s not to say that global health can’t have an agenda, but that it always needs to be in dialogue and negotiation with the local populations that are affected.