What makes health ‘global’? This is the question I have addressed in a recent article in the journal Developing World Bioethics. I am afraid, however, that I don’t have an answer. Nor was answering the aim of the article. After all, many definitions of ‘global health’ exist in the literature and most of them are as good an answer as any other.
Or are they? The actual title of the article is, rather rhetorically, “what in the world is global health?”. This might give away its sceptical take on the increasingly pervasive terminology of ‘global health’. However, the scepticism is not an exhortation to drop that terminology. Rather, the article wants to make explicit and raise some criticism of the ethical values that the terminology of ‘global health’ risks leaving implicit.
For instance, during the COVID-19 pandemic, arguments for wealthy countries’ duty to distribute COVID-19 vaccine doses to low and middle-income countries (LMICs) were typically presented as a matter of ‘global health’ and in opposition to ‘vaccine nationalism’. However, the ‘global’ qualification seems to simply assume that COVID-19 vaccine distribution is a matter of collective or global responsibility of some wealthy countries. These are ethical and political claims, subject to disagreement. What type and level of benefit for some LMICs justifies the cost of international vaccine distribution for high-income countries? Is that cost justified at all? Where do such obligations come from? Adopting the ‘global health’ framework risks bypassing that discussion.
It is quite telling that most definitions of ‘global health’ include the language of equity. The most widely endorsed definition is as an “area of study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide” (Koplan et al 2009). The problem is that what counts as equitable – who owes what to whom – is an ethical issue and, as such, subject to critical appraisal and disagreement. Making the concept of ‘equity’ part and parcel of the meaning of ‘global health’ risks ruling out from the realm of equity different approaches that do not conform to a ‘global’ agenda, but that might have some ethical justification. Those who support vaccine nationalism, after all, are not against equity. They simply interpret equity in a way that doesn’t involve the same global responsibilities. They might think that equity requires a government to prioritize its own citizens way beyond the level that a ‘global health’ approach seems to presuppose. This is questionable, of course. But the point is precisely that there is a reasonable ethical-political question to be asked about obligations in a pandemic. The ‘global’ terminology risks overshadowing such question. Areas of reasonable disagreement are thus avoided by way of terminological exclusion from the discipline, rather than explicitly addressed through dialogue within it.
To an extent, but to an extent only, this discussion mirrors an analogous one we might be having about public health. After all, what makes health ‘public’ is itself something that turns on ethical and political values. The term ‘public’ can either qualify public health in opposition to private health, to indicate health issues that significantly affect third parties, such as communicable diseases; or indicate whose health we are talking about – that of the whole public, rather than that of individuals, for instance the prevalence of a certain disease in a population; or, again, categorize a certain health issue as a matter of Government policy (Coggon 2012). In all such cases, what makes health ‘public’ is itself contested and, ultimately, an ethical-political issue – for example, are vaccination or antibiotic use a private choice, or primarily a matter of Government regulation? What population group constitutes the relevant ‘public’ for any health condition? These are ethical issues that are not solved simply by dubbing them as ‘public health’.
In the article I have provide a roughly equivalent conceptual map for the possible meanings of ‘global health’. In particular, I distinguish between a sense of ‘global’ that refers to the actor designing or implementing health policies, for instance some international organization like the WHO; and a sense that refers to the target of such policies, for instance local communities mostly in LMICs (for some reason, global health seems to exclude local communities in HICs), or perhaps the entire world population. Both senses come with their own version of the problem outlined above: the term ‘global’ embeds implicit ethical values about appropriate, or equitable, health actions across cultural contexts and by certain actors.
There seems to be a relevant difference between public and global health, though. A well-developed field called “public health ethics” exists, where many of the values that the terminology of ‘public’ presupposes – equity, solidarity, collective responsibility, and so on – are made explicit, analysed, criticized, debated. As a result, public health seems to be characterized by a higher level of internal disagreement than global health. In the latter, a wide agreement exists on the ethical priority of a certain understanding of equity as expressed, for instance, by terms like “health for all”. The worry is that that type of agreement results from a failure to ask the relevant questions about the ethical goals of global health – for instance, what type of equity? “Health for all” at what costs, and for whom? – rather than from a convergence on the answers.
Would it be desirable, then, to have more ethical disagreement within global health around its goals and identity? Perhaps this is the actual question that, retrospectively, this article wanted to answer, and probably did.
The article is available Open Access at this link. It has greatly benefited from formal and informal interdisciplinary discussion around global health within the TORCH Medical Humanities Hub, including very helpful feedback on an early draft by Utsa Bose, Erica Charters, and Tolulope Osayomi
Coggon, J. (2012). What Makes Health Public? A Critical Evaluation of Moral, Legal, and Political Claims in Public Health. Cambridge University Press
Koplan, J. P., Bond, T. C., Merson, M. H., Reddy, K. S., Rodriguez, M. H., Sewankambo, N. K., & Wasserheit, J. N. (2009). Towards a common definition of global health. The Lancet, 373(9679), 1993-1995.