As readers begin to read this entry on global health, they may be looking for a definition of this relatively new concept in the health field. However, we believe it is impossible to propose just one, as it is labile and controversial. If we take up the three dimensions of a concept (meaning, term, referent), we are still sorely lacking in clarity and precision regarding global health. Yet, “only a concept that is adequately constructed and operationalised can contribute to a cumulative scientific production of quality” (Daigneault and Jacob, 2012). We could even propose that it is of such a level of immaturity (Morse et al., 1996) that it would be risky to venture into a definitional suggestion. Instead, we will propose a critical analysis of this term and the underlying issues it raises.
The field of health, like many others, is full of malleable concepts and evolving terms, according to international declarations, scholarly discourse, and public interventions. We will not discuss the concept of health (Roy, 2018), but rather those associated with the contexts in which health interventions are implemented. Thus, laypeople can quickly get lost in understanding the differences and similarities between global health, international health, one health, health in all policies, international health cooperation, primary health care, and health promotion. We could multiply the examples of this diversity of concepts that change according to history and according to the people and organizations which propose them or impose certain adjustments. However, since the microbial unification of the world, which dates back to at least the 14th century, and the globalization of trade, is health not global in essence?
A field embedded in a politic and historical context
The concept of global health is relatively recent. In particular, it emanates from the need of certain North American and European actors to qualify their public health actions/ information in a context outside their national borders (King and Koski, 2020). Some people place global health at the end of a continuum of historical public health practices from tropical health (especially during colonial periods) to international health and today as “a field of study, research and practice that prioritises health improvement and health equity for all people of the world” (Koplan et al., 2009). A recent systematic review of the literature identified four complementary themes of the field of global health (Salm et al., 2021): i) an orientation towards improving global health; ii) an ethical vision guided by principles of justice; iii) a mode of governance that aims to identify and decide on problems, policy decisions, and resource distribution; and iv) an awareness of a vague and multifaceted concept. Therefore, it is more an attempt by academics to globalize semantics of international health practices and teachings (beyond their national boundaries) than a policy paradigm shift in the sense of Hall (1993). Instruments, ideas, and objectives do not seem to have changed much as we do not see anything new in the definition proposed by Koplan, whose reiteration and improvement may give the impression of a new fragmentation of global health approaches. Indeed, most of the articles published in so-called global health journals deal with health problems specific to so-called low-income countries (Abdalla et al., 2020). The contribution to scientific production called for by Daigneault and Jacob (2012) when mobilizing a concept seems less present than that of wanting to exist in an academic field (as in the 1970s/80s for the field of evaluation). Indeed, international health approaches have sometimes had difficulty shedding the trappings of colonial medicine. In 2020 (this has just changed to 2021), the French public health society still publishes a scientific journal with a section devoted to Africa that is not coordinated by a person from that continent. In France, a think tank called “Global Health 2030” has been set up without any representative of the diversity of national society and people from the countries it is committed to defending, and with a vision centred on low-income countries (international health) and not on a global scale (Ridde, Ouedraogo, and Yaya, 2021). Doesn't the city of Antwerp in Belgium still have an Institute of Tropical Medicine where students from Central Africa come to do a Master's degree in public health? Some will argue that global health is primarily concerned with equity issues in all countries of the world, while international health is concerned with equity only in low-income countries (Abimbola, 2018). But this noble quest for global equity is not new for health actors. One need only recall the Ottawa Charter of 1986, which makes equity the central objective of health promotion research and interventions (Ridde, 2007). What if these attempts to define global health, which some people call global health but which always focus on the “South”, were simply an attempt to legitimize Northern institutions that want to continue to offer public health training/interventions concerning “Southern” contexts? Why is it relevant in 2020 for a Canadian, Belgian, or French university to offer public health training to students from Africa or about health systems in African countries? Why does it make sense for Canadian or European taxpayers to fund health system reforms in Africa? Beyond the definitional issues, the question of powers is central to this reflection.
From material to epistemic power
There is no denying the desire of some global health actors to break out of these old patterns and to understand the power issues within the field better. Thus, there are more and more practical tools and proposals to decolonize global health. This decolonization is intended to be free not only from colonialism but also “from racism, sexism, capitalism and other -isms that are harmful [...] to health equity” (Büyüm et al., 2020). It is no longer just a matter of looking at how global health institutions unfold and the (direct) coercive modes of power between actors or countries. It is also about understanding how less visible processes, such as the establishment of epistemic, moral, or normative authorities, are conditioned by an unequal social order, and contribute to resource inequalities and processes of dependency and power. For example, while some African countries took early and effective measures against the COVID-19 pandemic, it was the expertise of scientists from North American or European countries that was called upon or put forward on the world stage (Dalglish, 2020). During the last Ebola crisis, African scientists were simply discredited because of their country of practice (Lauer, 2017). While not reaching the highest levels of political decision-making, this credibility gap, or epistemic injustice, also occurs daily in healthcare provider-client relationships, whether it is male doctors easing the pain experienced by women with endometriosis or female healthcare professionals dealing with migrants who do not speak the language or codes of the host country. In Montreal, for example, discrimination and racism are widely experienced by migrants when seeking care (Cloos et al., 2020). This racism is not to fall into a binary vision where some individuals would do “good” global health while others would only enrich power relations or be privileged. Most of the time, the processes leading to injustices, whether epistemic or social, are diffuse, are constructed in the daily life of actions and interactions and are rooted in structural determinants that are difficult to combat. Rather than singling out individuals (as was the case in the current COVID-19 pandemic), we should think about the influences of systems and structures: ‘Fighting health inequalities is not about helping the most vulnerable, it is about questioning the role of the privileged and challenging the social structures that create privilege and oppression’ (Nixon, 2019). However, it is surprising that international organizations, universities, and donors deciding on global health priorities in the so-called South are still predominantly male, from high-income, English-speaking, and economically advantaged countries (Global Health 50/50, 2020). No discourse with heterodox economic values is put forward, let alone considered legitimate. For example, only discourses that anchor climate change solutions in the capitalist system are present in the negotiations on the world stage. Discourses questioning the effectiveness of market-based governance or industrialization-based development and promoting equal burden-sharing on the planet are absent in these global negotiations (Stevenson, 2016).
Contempory issues of global health practices
Beyond questions of power, a myriad of other contemporary issues deserves to be addressed. We will begin by noting, of course, all the challenges posed by international (Vidal, 2014) and interdisciplinary collaborations in this context, where questions of inequality, discussed above, are consubstantial to this field. We will not revisit all the practices and strategies of adaptation that they provoke, as they are widely known, much studied but often hidden and little-discussed publicly (Ouattara and Ridde, 2013). Current debates on the decolonization of global health are more recent but do not yet seem to have fully permeated all stakeholders (Büyüm et al., 2020). Michel Foucault, Franz Fanon, Joseph Ki-Zerbo or Orlando Fals Borda are still little or not taught to global health practitioners and students. Interdisciplinary, participatory, and socially relevant approaches to research and interventions are not more present in the training of these people. The experts are still too often anchored in biomedical and epidemiological approaches to global health, omitting to insist on community-based, participatory and holistic approaches. This trend has been observed in recent epidemics (Carabali et al., 2020; Yoon, 2010) and the current COVID-19 pandemic (Paul, Brown, and Ridde, 2020), where the spectrum of solutions is too often oriented towards biomedical techniques, despite the social determinants of health. Community health training has virtually disappeared, including in Quebec (Ridde and Druetz, 2016). Public health that is concerned with equity, social determinants of health, policy issues, and power (to act) is theoretically nothing new. In practice, it should be the preservation of (truly) global health. The clinicians, virologists, and other infectious diseases specialists leading the fight against the COVID-19 pandemic in most countries of the world seem to be discovering what Ivan Illich, Pierre Aïach, or Michael Marmot have been saying for decades: the Pasteurists are still in power. Moreover, as long as the states of the South do not give priority to the health sector, international collaborations and their avatars will continue. For example, in Senegal, only 14.4% of health research projects in 2019 were funded locally. In Mali, the state devotes less than 6% of its annual budget to the health sector. In this context, the power struggles and their abuses can only continue. However, beyond the preconceived ideas about global health and the international collaboration it implies (Ridde and Ouattara, 2015), the abuses that these power issues engender are not exclusive to anyone. There are still researchers in the North who engage in scientific tourism: organizing their missions at the last minute, taking data from the South, and publishing without the collaboration of colleagues in the countries concerned. There are researchers in the South who use data whose collection has been funded by Northern colleagues and planned without asking their permission or involving them. Many case studies on these challenges (see: https://cjb-rcb.ca/index.php/cjb-rcb/cases) deserve to be analyzed without complacency but with the necessary critical distance for a better training of the new generation.
There is no doubt that global health can no longer avoid a (global) discussion on its decolonization, which the new generation will have to tackle head-on... since some of the older generations have somewhat missed out. Will the latter make way for the former? Another power issue!
This text is a traduction of a french original text : Ridde, Valery & Fillol, Amandine (2021). Santé Mondiale. Anthropen. https://doi.org/10.47854/anthropen.vi0.51161 available on https://revues.ulaval.ca/ojs/index.php/anthropen/article/view/51161