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Int Health 2018; 10:63–65
doi:10.1093/inthealth/ihy010 Advance Access publication 8 March 2018
On the meaning of global health and the role of global
health journals
Seye Abimbola*
School of Public Health, University of Sydney, NSW, Australia and The George Institute for Global Health, Sydney, NSW, Australia;
Editor in Chief, BMJ Global Health
*Corresponding author: E-mail: seye.abimbola@sydney.edu.au
Received 16 January 2018; editorial decision 24 January 2018; accepted 24 January 2018
Whenever I hear the term ‘tropical medicine’or see it in print,
what often comes to mind is, ‘how delightfully quaint!’Quaint
because it is dated, reminiscent of the colonial origins of global
health. And delightful because it brings to mind how unremark-
able it has become to recognize that global solidarity is necessary
for health; that ‘we’re in this together’.Globalhealthdidnotbegin
that way. Indeed, my first challenge 2 years ago when I was
appointed the inaugural Editor in Chief of BMJ Global Health was
how tricky it was to define global health. It is an ongoing struggle.
In this editorial I describe where I am on that journey and how a
well-considered meaning of global health could transform global
health practice, research and journals.
To define the remit of the journal, I had to first define global
health—what should qualify as a global health paper and what
should be the markers of quality of a global health paper. I
recalled a BMJ blog with a set of caricature definitions of four eras
in the history of global health
1
: global health 1.0 as tropical medi-
cine, beginning as an effort to keep white people and subse-
quently the labour force alive in thecolonialtropics;globalhealth
2.0 as international health, which was about clever people in high-
income countries (HICs) helping people in low- and middle-
income countries (LMICs); global health 3.0, which is (note the
change in tense) about people from HICs leading health pro-
grammes in LMICs; and global health 4.0, which is about people
from LMICs leading health programmes in LMICs.
While these definitions offer truth by way of caricature, they
say little about the why and how of global health, except for global
health 1.0, which began with a clear goal and continues today in
efforts to keep people alive by developing drugs and vaccines to
tackle largely infectious diseases. I wondered, for example,
whether global health 4.0 differs in any way from day-to-day pub-
lic health work done by nationals of LMICs in their own or neigh-
bouring countries, and whether such work only becomes ‘global
health’when it is done by a person or with funds from HICs. The
definitions also made me wonder if there was any difference
between international health (global health 2.0) and global health
3.0 or 4.0. What about the health of disadvantaged groups in
HICs? Is addressing high HIV prevalence among Hispanics or
African Americans in the USA global health? Is intervening to
improve the health of indigenous peoples in Australia or Canada
global health?
These are important questions, not only for a journal editor, but
also for all of us who work in global health. We need to be able to
articulateclearlywhatitisthatwedo.However,globalhealthis
often defined by how it differs and departs from international
health, the difference being a focus on health equity and issues
that transcend national boundaries, being multidisciplinary and
embracing the role of non-state global actors such as philanthro-
pies.
2
But there is much in the ‘international health’eratosuggest
that this is a false distinction: international health went beyond
bilateral relations (e.g., in efforts to eradicate smallpox), focused on
health equity (e.g., in the Alma Ata declaration), was multidisciplin-
ary (e.g., academic departments of international health were often
multi-disciplinary) and embraced and involved the role of non-state
philanthropies (e.g., the Rockefeller Foundation).
3
So is this distinction between international health and global
health in name only; differing brands, but the same substance? I
found my answer in a description of global health by Farmer et al.,
as ‘not [an academic] discipline but a collection of problems [that]
…turn on the quest for equity’.
4
This is, for me, the distinction
between international health and global health—while inter-
national health focuses on helping LMICs, global health is about
health equity everywhere, including within HICs, such that a paper
addressing, for example, indigenous health equity in Australia is eli-
gible for consideration in a global health journal. This is my favour-
ite characterization of global health, as it makes no pretences
about global health being defined by global cooperation, national
boundaries and specific categories of actors. Nonetheless, this
description deserves further consideration—what problems define
global health and why is global health not (yet) a discipline?
For me, there are two kinds of problems: problems of discovery
and problems of delivery. Problems of discovery are about finding
EDITORIAL
©The Author(s) 2018. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved.
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technological innovations to improve global health equity, for
example, new vaccines for infectious diseases like HIV and mal-
aria, drugs to control non-communicable diseases or a new app
to connect patients and providers. The disciplines responsible for
finding solutions to these problems either predate or would exist
without global health, so they cannot be what defines global
health. On the other hand, delivery problems are encountered in
efforts to make innovations work in practice. Unlike discovery pro-
blems, which belong in the basic sciences, delivery problems
require the social sciences, first to understand and then to address
the information and motivation problems that may prevent or
constrain delivery.
5
They highlight the failure of governments,
non-governmental organizations, the private sector, service provi-
ders and communities to put in place or demand equitable health
systems.
Delivery problems define global health. While the gulf between
discovery and delivery exists in other fields, what makes global
health peculiar is that discoveries and the decisions on whether or
how to deliver them are typically made at a distance, removed
from the realities of their targets or intended beneficiaries. They
are removed not only geographically, but also socially, culturally
and economically, even when geographically proximal. Notably,
the distance is not only between HIC and LMIC actors, it is also pre-
sent within HICs and within LMICs, especially across class, social
and ethnic divides. It is present when people with resources to
address delivery problems do not have the information or motiv-
ation to either make the discoveries available or tailor them to local
circumstances. It is present when feedback takes longer or does not
work at all; i.e., feedback between actors at the global and national
level,thenationalandsubnationallevel,orthesubnationallevel
and the community, or between any of the parties to these combi-
nations. It is present when there are asymmetries of power, motiv-
ation and information between the helper and the helped.
5,6
So, what do these mean for global health practice and research,
and for the journals that report them and seek to facilitate conver-
sations to improve them? First is the need to recognize an informa-
tion paradox at the heart of the delivery problem. On the one
hand, the only thing the helper in global health has more of than
the helped is power and resources. The helped have far more infor-
mation on how to get global health delivery right, on how to inter-
vene in their lives. But on the other side of the paradox, the helped
in global health (as individuals, households and communities)
often do not have the information to help themselves adopt
appropriate health practices, to help them hold their governments
and service providers to account. We helpers must acknowledge
and embrace our ignorance in our work and also reflect in our jour-
nal articles how we used information from the ground to inform
our work and how we in turn channelled new information back to
the people to help them hold their governments and service provi-
ders to account.
Beyond the methodological markers of quality, which are spe-
cific to each of the disciplines that feed into global health, journals
should require that the papers they publish are informed by,
framed by and reflect on delivery problems. Editors of global health
journals should demand of authors that the ‘so what?’of their
papers be articulated in terms of delivery problems, providing a
potential unifying framework for global health papers, thus helping
to fulfil the promise (hitherto unfulfilled in global health) of journals
serving as a forum for the different disciplines to speak to one
another. If we think of an academic discipline as a field in which
people share the same assumptions and engage in debates on
how to build on those assumptions
7
and the purpose of a journal
as a forum for such disciplinary conversation and debate, then an
important responsibility of global health journals is to foster, facili-
tate and forge a common language to link these disciplines that
will, potentially, allow global health to become a discipline rather
than only a collection of disciplines.
8,9
In the last two decades, health policy and systems research
(HPSR) has emerged as the multidisciplinary field that addresses
delivery problems in global health, but the field has so far not
moved towards becoming a discipline.
10
To create a discipline of
global health, journals should explicitly acknowledge this crucial
intersection between global health and HPSR. Beyond finding a
way for disciplines to speak to one another, global health journals
have a responsibility to make jurisdictions speak to one another.
This requires communication at a level of abstraction higher than
jurisdictional details and framing delivery problems at the level of
social phenomena. And therein lies a tension. Ensuring that
insights travel between jurisdictions requires abstraction, but to be
meaningful, published global health work requires a high level of
contextual detail. Balancing both demands is a challenge that edi-
tors of global health journals need to recognize and address, espe-
cially given the tendency of journals to require that authors limit
thelengthoftheirworkbasedonarbitrarywordlimits.
One way to encourage abstraction is to insist that research
papers identify the social phenomenon under inquiry and abstract
their research questions and/or their findings in terms of social the-
ories that have been used to study or explain similar phenomena
across disciplines. This may encourage deeper thinking and multi-
disciplinary analysis and reflection, and potentially advance the
fieldofglobalhealthasanacademicdiscipline.Inaddition,global
health journals should work together to develop guidelines for
structured reporting of context, even if in a regular appendix to glo-
bal health research papers. It is also important that global health
journals create a space and raise the profile of ‘practice’papers
dedicated to reports on implementation that may not achieve the
abstraction, theoretical sophistication and analytical rigour of a
research paper, but which may provide rich contextual detail and
transferable insight based on experience and descriptive data.
In conclusion, it appears to me that we have been looking in
the wrong places to definewhatisthecoreofourwork.Ifwetake
the meaning of our field seriously, and go where that meaning
leads, we will probably do things differently, as practitioners,
researchers and journal editors. If people who are the targets and
intended beneficiariesofglobalhealthworkweretodefine global
health and determine how it is studied, practised and reported, I
suspect it will not be about the global commissions, discussions
and debates of the day in Geneva, New York and London and on
Twitter, and the jostling of the privileged global elite for power and
position, but rather about the information and motivation pro-
blems that limit and constrain delivery, beginning at the local level.
I hope that we can begin to truly decolonize global health by being
awareofwhatwedonotknow,thatpeopleunderstandtheirown
lives better than we could ever do, that they and only they can
truly improve their own circumstances and that those of us who
work in global health are only, at best, enablers.
S. Abimbola
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Authors’contributions: SA undertook all duties of authorship and is
guarantor of the paper.
Acknowledgements: The author is grateful for comments and discus-
sions at the meetings and conferences where different stages and parts
of the reflections in this editorial were presented.
Funding: None.
Competing interests: None declared.
Ethics approval: Not required.
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