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 types and level of benefit for some LMICs justify 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, to what extent are vaccination or antibiotic use a private choice, and to what extent are they 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 provided 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.
Many years ago I recall an incident to do with two footballers (possibly the England team). One of them had an affair with the wife of one of his team-mates, who like him was in contention for the captaincy. That affair subsequently became public, but the footballer having the affair remained with the team, and the innocent party, unsurprisingly, left the team. At the time public media discussion was against the apparent offender, but the official line presented revealed the apparent offender had more value for the team. The offence in this instance was one of a breach of trust, both for a team-mate, two marriages and the endowed peer power. Yet the outcome was ostensibly reported as the perceived strengths of the footballer, rather than any moral/ethical interests of the team and group trust.
That type of real life scenario on the surface does not appear resonant with the arguments presented in the article, because both social trust and the team trust had been breached, yet the guiding principle towards resolution appeared to be skill or power. In the sense of Global Health or Public Health; If that type of principle is the main guidance publicly admitted as used by larger social groups, the message given is one of control rather than ethically or morally determined health, and that does resonate with the points in the article and the differences noticed between Global and Public. A ruleset which provides some clearer widely acceptable guidance avoiding the more extreme centric behaviours, from many perspectives clearly becomes necessary, but a fundamental and visible change beyond a mere ruleset agreed by experts in their area would be more valuable. And that appears to be something which at this stage does not appear feasible because most public discussions of that nature so frequently become no more than opinion markets.
Interestingly from a privacy perspective, the above described incident illustrated social and individual forgetfulness over time, where feelings like shame may form part of the relevant muting factors applying across the various worldviews involved.
I don’t doubt the concepts of global health or public health. They both surely exist. But the article is an opportunity to consider the differences between „private“ and „public“.
The relation between individual health care provider/worker and individual patient is surely private. There must be patient’s consent with the medical performance. There are only a few legal exceptions from this rule strictly defined by law.
The natural moral order for an individual is to take care about his/her own health. That means to eat healthy food, don’t smoke, to have some amount of regular physical activity, to have regular medical check-ups etc.
But the danger is when we start to declare that these private „instructions“ related to the individual‘s sphere shall be applied in the public interest.
In other words the politicians can start to declare that the orders of public bodies has its base in the individual freedom. The next step is that the politicians will say that the freedom of individual actually means to obey public orders. They start to say that the real and „the highest“ freedom means to sacrifice ourselves for the public welfare.
Suddenly there are no constitutional limits/boundaries for public power because breaking the privacy is legitimated (justified) by the public interest.
These statements might sound confusedly or illogically.
But if we look back to history we can see that all the dictatorships in the 20th century were established just on this. These regiems said that there is some public welfare and the only way to achieve it is to respect the public orders that in reality restricted the individual freedom.
Despite this it was proclaimed by the public power that when we reach the welfare also the individual freedom will be completely realised.
But a lot of times in history it turned out that it was a lie. Because the proclaimed welfare actually did not mean the public good. In reality it was only the plan of the dictator how to seize and keep his own political power.
It seems my comment and example may have possibly moved the debate into an unintended path. In summary: Global health does exist and is highly important, Public Health also exists but becomes simpler to apply because the immediate interests of a localised population may be shown to be being met.
Individual health applies at both levels. But at the global level becomes difficult to attach to the interests of individuals within localised populations. Hence, the comparison to levels of trust from marriage to team to endowed peer power, and how the ethical/moral components in each became ignored as a means of exercising control and power at the greater levels, seemingly indicating it is at those controlling social group levels (the ethos) where more focus/knowledge/comprehension about global ethics is required. That is the main message intended. Holding the focus on senses of fairness, injustice/justice at the individual level can show itself to be diversionary as that necessitates a focus upon leadership rather than ethical or moral values (think footballer and peer power example).
Another example: Individuals live within a sealed ecosystem; society, family, or nation state. As such they all rely upon environmental (physical and social) factors which themselves are affected by the wider environment. Taking major nuclear accidents like Three Mile Island, Chernobyl and Fukushima. The global and public messaging prior to and during early planning/construction phases was that the science applied in their construction meant there was absolutely no possibility of any accident under any circumstance. Because any such disaster would be so damaging to humanity over a long and protracted period of time, every possible human error and all major natural disasters were coped with in the designs. Those were global issues mainly being dealt with locally. Global to public. Yet the inevitable accidents created ongoing global problems (including health) and because that outcome is as it was/is, has created much public apathy around the subject.
The ethical/moral links to globally important issues become weakened at the local level by frequently relatively low level (or slow cumulative, seemingly unconnected) impacts competing against obviously observable local interests. Often resulting in the opinion markets frequently presenting local interests as applicable globally because that becomes perceived as answering their interests. In the individual that would be considered selfish, but for social groups with a common group interest selfishness is not perceived, with quantity becoming seen as volume and ethics/morality conditional matters pertaining to smaller member social groups rather than containing any inherently global aspects.
(The nuclear example is not intended to be accurate, merely a further attempt at an illustration of the created differences between Global/Public/Local interests. And the rest is simplified to a level where a great deal of important detail is missed. (i.e. Many would not be amused by the simplified description of leadership being disparate from ethical/moral value. Concepts which themselves require unpacking.)