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Critical global health or, when geography meets anthropology
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This commentary critically engages with the argument that climate change is the greatest threat to global health in the twenty-first century. A review of climate-health examples suggests that although it is important to be aware of the risk that climate change presents, health status is caused and mediated by multiple exposures. The current evidence suggests the impact of climate change over the next 30 years is not going to be catastrophic for health, and positioning it as the greatest threat – instead of other important factors such as poverty and health inequalities – could obscure the potential of current global health measures and reduce focus on other health risks such as non-communicable diseases and HIV/AIDS. Although climate change mitigation is vitally important to reduce far-future harm, the policymaking community should focus on current interventions that reduce populations’ exposure to climate change, boost populations’ ability to adapt, and reduce health inequalities.
Anthropological approaches broaden and deepen our understanding of the finding that high levels of socioeconomic inequality correlate with worsened health outcomes across an entire society. Social scientists have debated whether such societies are unhealthy because of diminished social cohesion, psychobiological pathways, or the material environment. Anthropologists have questioned these mechanisms, emphasizing that fine-grained ethnographic studies reveal that social cohesion is locally and historically produced; psychobiological pathways involve complex, longitudinal biosocial dynamics suggesting causation cannot be viewed in purely biological terms; and material factors in health care need to be firmly situated within a broad geopolitical analysis. As a result, anthropological scholarship argues that this finding should be understood within a theoretical framework that avoids the pitfalls of methodological individualism, assumed universalism, and unidirectional causation. Rather, affliction must be understood as the embodiment of social hierarchy, a form of violence that for modern bodies is increasingly sublimated into differential disease rates and can be measured in terms of variances in morbidity and mortality between social groups. Ethnographies on the terrain of this neoliberal global health economy suggest that the violence of this inequality will continue to spiral as the exclusion of poorer societies from the global economy worsens their health-an illness poverty trap that, with few exceptions, has been greeted by a culture of indifference that is the hallmark of situations of extreme violence and terror. Studies of biocommodities and biomarkets index the processes by which those who are less well off trade in their long-term health for short-term gain, to the benefit of the long-term health of better-off individuals. Paradoxically, new biomedical technologies have served to heighten the commodification of the body, driving this trade in biological futures as well as organs and body parts.
Life has been problematized anew by recent social change and scientific innovation. There are important and little studied geographical dimensions to any such understanding of “the politics of life itself,” however. A geographical perspective involves, first, highlighting the spatial aspects of both states and capital, two rather neglected dimensions of vital politics. Elaborating the geographical constitution of vital politics entails further describing the related powers of knowledges and practices. Reflecting on the geographical dimensions of longevity and health leads directly to a recognition of the ethical implications of the geographical luck of birth and residence. Taking up this ethical challenge requires specifying at least six components of geographical justice: culpability, fairness, care, state failure, human rights, and solidarity with environmental and social justice.
This article explores contemporary biopolitics in the light of Michel Foucault's oft quoted suggestion that contemporary politics calls `life itself' into question. It suggests that recent developments in the life sciences, biomedicine and biotechnology can usefully be analysed along three dimensions. The first concerns logics of control - for contemporary biopolitics is risk politics. The second concerns the regime of truth in the life sciences - for contemporary biopolitics is molecular politics. The third concerns technologies of the self - for contemporary biopolitics is ethopolitics. The article suggests that, in these events, human beings have become `somatic individuals': personhood is increasingly being defined in terms of corporeality, and new and direct relations are established between our biology and our conduct. At the same time, this somatic and corporeal individuality has become opened up to choice, prudence and responsibility, to experimentation, to contestation and so to a politics of `life itself'.
David Stuckler and Sanjay Basu comment on a study by Carl Lachat and colleagues documenting the lack of policies addressing noncommunicable disease prevention in low- and middle-income countries and outline steps for making such policies accessible, effective, and transparent.
I argue for a conception of health as a person's ability to achieve or exercise a cluster of basic human activities. These basic activities are in turn specified through free-standing ethical reasoning about what constitutes a minimal conception of a human life with equal human dignity in the modern world. I arrive at this conception of health by closely following and modifying Lennart Nordenfelt's theory of health which presents health as the ability to achieve vital goals. Despite its strengths I transform Nordenfelt's argument in order to overcome three significant drawbacks. Nordenfelt makes vital goals relative to each community or context and significantly reflective of personal preferences. By doing so, Nordenfelt's conception of health faces problems with both socially relative concepts of health and subjectively defined wellbeing. Moreover, Nordenfelt does not ever explicitly specify a set of vital goals. The theory of health advanced here replaces Nordenfelt's (seemingly) empty set of preferences and society-relative vital goals with a human species-wide conception of basic vital goals, or 'central human capabilities and functionings'. These central human capabilities come out of the capabilities approach (CA) now familiar in political philosophy and economics, and particularly reflect the work of Martha Nussbaum. As a result, the health of an individual should be understood as the ability to achieve a basic cluster of beings and doings-or having the overarching capability, a meta-capability, to achieve a set of central or vital inter-related capabilities and functionings.
Current definitions of 'global health' lack specificity about the term 'global'. This debate presents and discusses existing definitions of 'global health' and a common problem inherent therein. It aims to provide a way forward towards an understanding of 'global health' while avoiding redundancy. The attention is concentrated on the dialectics of different concepts of 'global' in their application to malnutrition; HIV, tuberculosis & malaria; and maternal mortality. Further attention is payed to normative objectives attached to 'global health' definitions and to paradoxes involved in attempts to define the field.
The manuscript identifies denotations of 'global' as 'worldwide', as 'transcending national boundaries' and as 'holistic'. A fourth concept of 'global' as 'supraterritorial' is presented and defined as 'links between the social determinants of health anywhere in the world'. The rhetorical power of the denotations impacts considerably on the object of 'global health', exemplified in the context of malnutrition; HIV, tuberculosis & malaria; and maternal mortality. The 'global' as 'worldwide', as 'transcending national boundaries' and as 'holistic' house contradictions which can be overcome by the fourth concept of 'global' as 'supraterritorial'. The 'global-local-relationship' inherent in the proposed concept coheres with influential anthropological and sociological views despite the use of different terminology. At the same time, it may be assembled with other views on 'global' or amend apparently conflicting ones. The author argues for detaching normative objectives from 'global health' definitions to avoid so called 'entanglement-problems'. Instead, it is argued that the proposed concept constitutes an un-euphemistical approach to describe the inherently politicised field of 'global health'.
While global-as-worldwide and global-as-transcending-national-boundaries are misleading and produce redundancy with public and international health, global-as-supraterritorial provides 'new' objects for research, education and practice while avoiding redundancy. Linked with 'health' as a human right, this concept preserves the rhetorical power of the term 'global health' for more innovative forms of study, research and practice. The dialectic approach reveals that the contradictions involved in the different notions of the term 'global' are only of apparent nature and not exclusive, but have to be seen as complementary to each other if expected to be useful in the final step.
The term global health is used rather than global public health to avoid the perception that our endeavours are focussed only on classical, and nationally based, public health actions. Global health builds on national public health efforts and institutions. In many countries public health is equated primarily with population-wide interventions; global health is concerned with all strategies for health improvement, whether population-wide or individually based health care actions, and across all sectors, not just the health sector.
Research implies the importance of developing the evidence-base for policy based on a full range of disciplines and especially research which highlights the effects of trans-national determinants of health.
Action emphasises the importance of using this evidence-based information constructively in all countries to improve health and health equity.
This paper describes accelerating development of programs in global health, particularly in North American academic institutions, and sets this phenomenon in the context of earlier programs in tropical medicine and international health that originated predominantly in Europe. Like these earlier programs, the major focus of the new global health programs is on the health needs of developing countries, and perhaps for this reason, few similar programs have emerged in academic institutions in the developing countries themselves. If global health is about the improvement of health worldwide, the reduction of disparities, and protection of societies against global threats that disregard national borders, it is essential that academic institutions reach across geographic, cultural, economic, gender, and linguistic boundaries to develop mutual understanding of the scope of global health and to create collaborative education and research programs. One indication of success would be emergence of a new generation of truly global leaders working on a shared and well-defined agenda--and doing so on equal footing.
Most people threatened by AIDS, tuberculosis, and unsafe drinking water are poor and have little or no influence over the global politics of public health.
Structural violence refers to the social structures that put people in harm's way. Farmer and colleagues describe the impact of social violence upon people living with HIV in the US and Rwanda.
When People Come First critically assesses the expanding field of global health. It brings together an international and interdisciplinary group of scholars to address the medical, social, political, and economic dimensions of the global health enterprise through vivid case studies and bold conceptual work. The book demonstrates the crucial role of ethnography as an empirical lantern in global health, arguing for a more comprehensive, people-centered approach. Topics include the limits of technological quick fixes in disease control, the moral economy of global health science, the unexpected effects of massive treatment rollouts in resource-poor contexts, and how right-to-health activism coalesces with the increased influence of the pharmaceutical industry on health care. The contributors explore the altered landscapes left behind after programs scale up, break down, or move on. We learn that disease is really never just one thing, technology delivery does not equate with care, and biology and technology interact in ways we cannot always predict. The most effective solutions may well be found in people themselves, who consistently exceed the projections of experts and the medical-scientific, political, and humanitarian frameworks in which they are cast. When People Come First sets a new research agenda in global health and social theory and challenges us to rethink the relationships between care, rights, health, and economic futures.
This article discusses the emergence and maturing of Global Health as a sub-discipline within International Relations. It directly addresses three questions. First, it discusses how International Relations? scholarship can deepen our understanding of global health. Second, it asks what the study of global health can tell scholars of International Relations about contemporary world politics. And finally, it examines how the discipline of International Relations might contribute to the improvement of global health outcomes.
Countries in sub-Saharan Africa were once dismissed by Western experts as being too poor and chaotic to benefit from the antiretroviral drugs that transformed the AIDS epidemic in the United States and Europe. Today, however, the region is courted by some of the most prestigious research universities in the world as they search for “resource-poor” hospitals in which to base their international HIV research and global health programs. In Scrambling for Africa, Johanna Tayloe Crane reveals how, in the space of merely a decade, Africa went from being a continent largely excluded from advancements in HIV medicine to an area of central concern and knowledge production within the increasingly popular field of global health science.
Drawing on research conducted in the U.S. and Uganda during the mid-2000s, Crane provides a fascinating ethnographic account of the transnational flow of knowledge, politics, and research money—as well as blood samples, viruses, and drugs. She takes readers to underfunded Ugandan HIV clinics as well as to laboratories and conference rooms in wealthy American cities like San Francisco and Seattle where American and Ugandan experts struggle to forge shared knowledge about the AIDS epidemic. The resulting uncomfortable mix of preventable suffering, humanitarian sentiment, and scientific ambition shows how global health research partnerships may paradoxically benefit from the very inequalities they aspire to redress. A work of outstanding interdisciplinary scholarship, Scrambling for Africa will be of interest to audiences in anthropology, science and technology studies, African studies, and the medical humanities.
http://www.cornellpress.cornell.edu/book/?gcoi=80140100922670
This paper surveys the return to materialist concerns in the work of a new generation of cultural geographers informed by their engagements with science and technology studies and performance studies, on the one hand, and by their worldly involvements in the politically charged climate of relations between science and society on the other. It argues that these efforts centre on new ways of approaching the vital nexus between the bio (life) and the geo (earth), or the ‘livingness’ of the world, in a context in which the modality of life is politically and technologically molten. It identifies some of the major innovations in theory, style and application associated with this work and some of the key challenges that it poses for the practice of cultural geography.
Thinking is neither a line drawn between subject and object nor a revolving of one around the other. Rather thinking takes place in the relationship of territory and earth... involving a gradual but thorough displacement from text to territory.
This article addresses anthropology's engagement with the emerging discipline of global health. We develop a definition for global health and then present four principal contributions of anthropology to global health: (a) ethnographic studies of health inequities in political and economic contexts; (b) analysis of the impact on local worlds of the assemblages of science and technology that circulate globally; (c) interrogation, analysis, and critique of international health programs and policies; and (d) analysis of the health consequences of the reconfiguration of the social relations of international health development.
The post-2015 development agenda will build on the Millennium Development Goals (MDGs), in which health is a core component. This agenda will focus on human development, incorporate the components of the Millennium Declaration, and will be made sustainable by support from the social, economic, and environmental domains of activity, represented graphically as the strands of a triple helix. The approaches to prevention and control of non-communicable diseases (NCDs) have been elaborated in the political declaration of the UN high-level meeting on NCDs and governments have adopted a goal of 25% reduction in relative mortality from NCDs by 2025 (the 25 by 25 goal), but a strong movement is needed based on the evidence already available, enhanced by effective partnerships, and with political support to ensure that NCDs are embedded in the post-2015 human development agenda. NCDs should be embedded in the post-2015 development agenda, since they are leading causes of death and disability, have a negative effect on health, and, through their effect on the societal, economic, and the environmental domains, impair the sustainability of development. Some drivers of unsustainable development, such as the transport, food and agriculture, and energy sectors, also increase the risk of NCDs.
This article reflects on the increasing use of the term geopolitics in discussions of disease. It notes that although the term geopolitics has been used increasingly often, its precise meaning has not received sustained attention. Neither has it been conceptualized in relation to the extensive literature in critical geopolitics. To lay the groundwork for a more considered understanding of geopolitics in relation to disease, the article elaborates upon the senses in which geopolitics has been invoked in recent literature and links them with themes in critical geopolitics. It identifies three intersecting themes, in connection with which issues of geopolitics have been raised: the spatialization of governance, biopolitics and transnational political economies. In discussing these themes, the article identifies a number of questions and avenues for further research. Overall, it argues that there is considerable scope to investigate further the ways in which disease becomes geopolitical. In conclusion, the article raises a series of questions that may serve to connect research on the geopolitics of disease with debates taking place in and around critical geopolitics and geography more generally.
This paper examines the lessons learned from the 2009 H1N1 pandemic in relation to wider work on globalization and the epidemiology of inequality. The media attention and economic resources diverted to the threats posed by H1N1 were significant inequalities themselves when contrasted with weaker responses to more lethal threats posed by other diseases associated with global inequality. However, the multiple inequalities revealed by H1N1 itself in 2009 still provide important insights into the future of global health in the context of market-led globalization. These lessons relate to at least four main forms of inequality: (1) inequalities in blame for the outbreak in the media; (2) inequalities in risk management; (3) inequalities in access to medicines; and (4) inequalities encoded in the actual emergence of new flu viruses.
At an understaffed and underresourced urban African training hospital, Malawian medical students learn to be doctors while foreign medical students, visiting Malawi as clinical tourists on short-term electives, learn about “global health.” Scientific ideas circulate fast there; clinical tourists circulate readily from outside to Malawi but not the reverse; medical technologies circulate slowly, erratically, and sometimes not at all. Medicine's uneven globalization is on full display. I extend scholarship on moral imaginations and medical imaginaries to propose that students map these wards variously as places in which—or from which—they seek a better medicine. Clinical tourists, enacting their own moral maps, also become representatives of medicine “out there”: points on the maps of others. Ethnographic data show that for Malawians, clinical tourists are colleagues, foils against whom they construct ideas about a superior and distinctly Malawian medicine and visions of possible alternative futures for themselves.
In the wake of the report of the World Health Organisation's Commission on the Social Determinants of Health, Closing the gap in a generation (Marmot 2008), this invited commentary considers the scope for geographical research on global health. We reflect on current work and note future possibilities, particularly those that take a critical perspective on the interplay of globalisation, security and health. © 2011 The Authors. The Geographical Journal © 2011 Royal Geographical Society (with the Institute of British Geographers).
The Monster at our Door: The Global Threat of Avian Flu
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Reimaging Global Health
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