Global Health As a Term
The rise to prominence of the term “global health” has occurred in parallel with the popularization of globalization, an enhanced awareness of common vulnerabilities, and a feeling of increased shared responsibility for inequities present in the world today (Macfarlane, Jacobs, & Kaaya, 2008). For instance, let’s consider escalating health threats posed by climate change. By recognizing the role of globalization in driving greenhouse gas emissions, we realize how greenhouse gas emissions may impact population health not just in one region, but globally. We come to recognize how efforts to combat these issues will require substantial international collaboration. Within academia, these processes have produced a rise in the usage of the term “global health” (Macfarlane et al., 2008). Public health students today are more eager and feel better equipped to tackle the issues that global health is typically associated with. The evidence base for solutions has grown, and technological advances have facilitated easier collaboration between countries.
Ilona Kickbush (2006) is the director of the Global Health Programme at the Graduate Institute of International and Development Studies in Geneva, Switzerland, and she contends that global health refers to “health issues that transcend national boundaries and governments and call for actions on the global forces that determine the health of people.” Koplan and colleagues (2009) offer a different perspective and suggest that global health is “an area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide.” In addition, Beaglehole and Bonita’s (2010) publication favor a shorter definition: “collaborative international research and action for promoting health for all.” The viewpoint of Ilona Kickbush suggests that global health refers only to problems that cross national boundaries or governments, whereas Koplan et al.’s (2009) paper and Beaglehole and Bonita’s (2010) article do not impose this geographical limit. Whilst Koplan and colleagues and Beaglehole and Bonita explicitly state a goal (‘health for all’), only the former suggests that this should be achieved in an equitable manner. What may appear at first to be trivial differences, upon deeper examination reflects different perspectives on both the scope of the issues that global health should address and the ways in which it should do so.
Discussions on this theme have often entailed establishing where the boundaries between global health and preexisting disciplines such as international health, public health, and tropical medicine lie. Depending on the source, these fields have been described as overlapping with, separate from, or entirely subsumed in global health (Fried et al., 2010; Koplan et al., 2009). Currently, there is not yet an agreement on what, if anything, separates global health from these fields.
One approach for understanding why such apparent ambiguities exist would be to examine the contexts in which “global health” is typically encountered. Macfarlane and colleagues (2008) found that 87% of articles written by authors with an academic global health affiliation were from North American institutions. Only two articles, equating to 0.5% of the total number examined by Macfarlane et al. (2008) were from institutions in low and middle-income countries. In 2010, there were sufficiently many European research institutions concerned with global health issues to warrant the creation of the European Academic Global Health Alliance (Haines, Flahault, & Horton, 2011), which serves to promote collaboration between global health research institutions in Europe and to develop a European voice on global health issues. Beyond academia, the World Health Organization reported in 2009 that over 100 global health initiatives or partnerships had come into existence (World Health Organization Maximizing Positive Synergies Collaborative Group, 2009).
The diverse range of contexts in which the term is found emphasizes how interdisciplinary and multidimensional global health has become (Haines et al., 2011). The pace and ease with which this sense of familiarity has occurred, combined with a lack of a clear definition from the outset, has resulted in a situation in which the interpretation of the term “global health” varies based upon the perspective of the individual framing the context. For an academic, it may bring to mind broad international determinants for health, whereas for another person, it may be more about the threat of individual diseases such as tuberculosis and malaria. Kickbush has argued that this has resulted in global health becoming “a field of action where there is no common sense of purpose or direction” (Friends of Europe Development Policy Forum, 2010). This lack of clarity and coherence may contribute to the confusion found by producers of the recent PBS television documentary “Rx for Survival” while attempting to identify public perceptions of global health (Harrar, 2008). Through focus groups, they found that people consider anthrax and bioterrorism to be global health issues, but malaria and TB to be problems of the past; they remark on the difficulty they subsequently had in finding ways to “define” global health for their audience.
Why is This Important?
The lack of consensus as to what “global health” means poses a number of important problems, both for the present and for future generations. Koplan and colleagues (2009) suggest that the disagreement in definition may represent a lack of harmony in the aims of global health and what the objectives of global health research should be. Consider a lack of uniformity found in global health training programs and how, for graduates of such programs, the career pathways are less clear and consistent than those in related disciplines such as public health. In the United Kingdom, for example, doctors may choose to specialize in public health in the same way they might train in cardiothoracic surgery or psychiatry. There currently exists no such equivalent for global health.
A lack of consensus on aims means that it is hard to make appropriate comparisons between the increasing numbers of benchmarks that are used. How do we compare and prioritize between efforts to increase the resilience of vulnerable populations to climate change with efforts to reduce irrational antibiotic use so as to prevent resistance from developing? This problem is partly due to the quantitative methods available in global health, and how stakeholders place differential emphasis on different “values,” depending on their background. Finally, without a clear definition, it is all too easy for a short phrase like “global health” to obscure important and real differences in our thinking (Koplan et al., 2009). If we remain apathetic as to how it’s used, its use will increasingly be tailored to fit the needs of its user in any given situation.
A further issue highlighted by Macfarlane et al.’s (2008) publication is that the institutions of high-income countries frequently define global health in terms of their working relationships with low and middle-income countries; it seems that global health problems are identified and addressed through the lens of industrialized countries. An examination of recent definitions of “global health” in the literature shows that they are overwhelmingly written by authors from institutions in high-income countries (Beaglehole & Bonita, 2010; Koplan et al., 2009). If we continue to neglect input from low and middle-income countries in terms of global health research and discourse, we run the risk of making “global health” based on the perspectives of the industrialized world without considering the perspectives of the countries and populations from where many global health problems currently arise. Therefore, it seems like we are trying to define global health, develop “global health” initiatives, and engage in “global health” research without being global in our approach. We’re seemingly undermining one of the core principles to which those involved in global health aspire: that the relationship between richer and poorer countries should be mutual, a two-way flow in which all are considered equally valuable partners in addressing health issues worldwide. Instead, we perpetuate and lend credence to the contrary – that we are not equal partners.
What Can Be Done?
We can reflect on progress made in the emerging field of global health and together seek a more coherent sense of purpose and direction for the future. If we can do this through an equitable approach then the result itself may be more fitting to the needs of all stakeholders. The sense of cohesion that may emerge has the potential to aid those involved in global health practice and research and help the public to engage with and understand the vision underlying our approaches. It may be that we cannot develop a single definition of global health or agree upon its aims and principles. But nonetheless it is better to come to a consensus on this, than to lack any form of consensus.
It is important to engage in discussion and debate on the issues presented here. As students of global health at the Karolinska Institutet, we are planning a project that aims to prompt people to reflect on these ideas, and encourage further action to be taken. The aim of our project is to assess perceptions of individuals from all over the globe who identify themselves as studying or working in global health. By analyzing the responses to our questionnaire, we can perhaps obtain a more complete answer to the question posed in the title of this piece: what is global health?