Global health is more than just ‘Public Health Somewhere Else’

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Turcotte- TremblayA- M, etal. BMJ Global Health 2020;5:e002545. doi:10.1136/bmjgh-2020-002545
Global health is more than just ‘Public
Health Somewhere Else’
Anne- Marie Turcotte- Tremblay ,1 Federica Fregonese,2 Kadidiatou Kadio,3,4
Nazmul Alam,5 Lisa Merry6
Commentary
To cite: Turcotte- TremblayA- M,
FregoneseF, KadioK, etal.
Global health is more than just
‘Public Health Somewhere
Else’. BMJ Global Health
2020;5:e002545. doi:10.1136/
bmjgh-2020-002545
Received 29 March 2020
Accepted 6 April 2020
1School of Public Health,
Université de Montréal,
Montreal, Quebec, Canada
2Research Institute of McGill
University Health Center,
Montreal, Quebec, Canada
3Institut de Recherche en
Science de la Santé (IRSS),
Centre National de la Recherche
Scientique et Technologique
(CNRST), Ouagadougou, Burkina
Faso
4Institut de Recherche pour le
Développement, Ouagadougou,
Burkina Faso
5Department of Public Health,
Asian University for Women,
Chittagong, Bangladesh
6Faculty of Nursing, Université
de Montréal, Montreal, Quebec,
Canada
Correspondence to
Anne- Marie Turcotte- Tremblay;
annemarie. turcottetremblay@
gmail. com
© Author(s) (or their
employer(s)) 2020. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
Summary box
►Global health can be anywhere as it often focuses
on large- scale health inequities that are rooted in
transnational determinants.
►Some global health initiatives and actors aim to nd
solutions to domestic problems.
►King and Koski’s denition of global health may
exacerbate inequities by reserving the right to call
oneself a global health researcher to those who are
privileged and have access to funding that enables
them to travel to other settings.
►An inadequate denition of global health based on a
‘here’ vs ‘somewhere else’ dichotomy could result
in less funding for a eld already characterised by
limited resources.
►The decolonisation of global health requires promot-
ing and valuing reexivity, critical approaches, equi-
table partnerships and accountability.
INTRODUCTION
King and Koski1 recently published a bold
commentary in BMJ Global Health that defines
global health as ‘public health somewhere else’.
It raises important concerns about the justi-
fication, scope, efficiency and accountability
of the field. We appreciate that the commen-
tary compels us to reflect on the definition
of global health, its application and how the
field could be improved. We also agree that
many of the issues highlighted by the authors
(ie, political priorities driven by the North,
expertise from the North being overvalued)
do exist in some global health interventions.
Many of us have heard of or witnessed disas-
trous situations caused by seemingly well-
intentioned people. However, the problems
described are not unavoidable or intrinsic
characteristics of global health. Moreover,
we believe the proposed definition of global
health is not adequate to conceptualise the
field. Rather than prompting improvements,
it could result in mistrust towards global
health and be a step backwards for the field.
In the following, we contend that global
health is more than just ‘public health somewhere
else’ and argue that an inadequate definition
entails risks for the field.
GLOBAL HEALTH IS MORE THAN JUST ‘PUBLIC
HEALTH SOMEWHERE ELSE’
First, we argue that King and Koski’s1 defini-
tion is not adequate, because global health
is not always ‘somewhere else’. According to
Koplan et al,2 the term global refers to the
scope of problems, not their location. In
fact, we believe that global health can be
anywhere. This field of research and practice
often addresses problems that are rooted in
transnational determinants or ‘supraterrito-
rial’ links3 (eg, war, climate change, natural
disasters, colonisation, international trade,
forced migration, international policies) and
that have negative effects on national and
local determinants of health (eg, employment
conditions, access to healthcare, income
differentials). The populations of interest in
these instances can be anywhere (low, middle
and high- income countries) and include
anyone affected and facing health inequities
due to these transnational or global issues.
The solutions can also be global or transna-
tional in nature.
The coronavirus pandemic is an example
of a global health problem that is affecting
people everywhere, especially vulnerable
groups. Due to the ever- increasing move-
ment of people across borders, viruses like
covid-19 can spread easily and quickly around
the world and affect anyone, irrespective
of whether they are in the global North or
South. A global health response involving
most countries that includes data sharing
and coordinated efforts to stop the spread,
find treatments and a cure as well as protect
vulnerable groups (eg, elderly, migrants, pris-
oners, homeless) is therefore necessary.
Second, we disagree with King and Koski’s1
statement that ‘a person engages in global health
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2Turcotte- TremblayA- M, etal. BMJ Global Health 2020;5:e002545. doi:10.1136/bmjgh-2020-002545
BMJ Global Health
when they practice public health somewhere—a community, a
political entity, a geographical space—that they do NOT call
home’. To us, this is an oversimplified statement. Several
of our colleagues, and we as well, have received funding
to engage in global health in places we call home. For
example, KK has conducted research on social protection
policies in Burkina Faso, her home country. Similarly, NA
has conducted research on the health of migrant workers
in Bangladesh, where he lives. We should be applauding
and valuing global health initiatives that are led by local
researchers/practitioners rather than excluding them
from the definition.
Moreover, King and Koski’s1 definition is not adequate
because some global health initiatives are aimed at finding
solutions to domestic problems, whether it be in a high,
middle or low- income country. For example, Grand Chal-
lenge Canada funded the adaptation and transfer of inno-
vations from low and middle- income countries to make a
difference in Canada. While the innovations come from
abroad, the primary focus or end goal of such initiatives
is quite local. This also highlights the fact that solutions
for health problems in the North and South sometimes
stem from expertise in the South.4 5 According to Syed
et al,4 global health partners are increasingly seeking a
mutuality of benefits across countries.
Third, there are many public health researchers and
practitioners working ‘somewhere else’, in a place that
‘they do NOT call home’, whose work does not qualify as
global health. They do not view themselves as part of the
global health community, nor do they actively participate
in global health activities. Their practice and research
would also not be eligible for global health funding. For
example, a Canadian medical student’s clinical place-
ment in a public health unit in Belgium is not automati-
cally considered training in global health simply because
it is done in another country. Therefore, referring to
global health merely as public health ‘somewhere else’ is
not useful.
Fourth, we consider that King and Koski’s1 commen-
tary and definition discredit the field of global health
and fail to recognise its added value. While it is crucial
to reflect on limitations, it is also important to highlight
the field’s strengths, best practices and success stories.6 7
There are examples of global health research and inter-
ventions where countries and communities have worked
collaboratively and shared expertise, cultural knowledge
and other resources to develop appropriate and effective
solutions.8–10
Moreover, while global health is considered one of
the multiple branches of public health, the literature
does suggest there are differences among them.11 For
example, global health tends to have a broader focus (ie,
health for all worldwide), a greater emphasis on health
inequities, more interdisciplinarity2 and more ‘bridging’
between cultures and communities. Practitioners and
researchers working in global health also face unique
ethical challenges (eg, power differentials between
parties) and require that some key competencies be
further developed (eg, cultural safety and inclusion, part-
nership development).6 11 12
Recognising global health as a field in its own right
is crucial to ensure there are dedicated resources for
training and forums where the global health community
can exchange and share knowledge, so that best practices
can be further promoted, especially among students and
emerging researchers and practitioners. It is also vital
that global health be recognised as a distinct field so
that resources will be made available to support global
health initiatives that can promote the human right to
health and help meet the global pledge to ‘leave no one
behind’.
THE RISKS OF USING AN INADEQUATE DEFINITION
The proposed definition by King and Koski1 entails
several risks. First, accepting the definition proposed
would mean that global health initiatives led by local
actors or community leaders in low or middle- income
countries, or by indigenous or migrant communities
in high- income countries, would not be acknowledged
and considered global health. This in turn could lead
to devaluing their contribution as global health actors
and limiting their access to resources to support their
work, despite there being significant needs. Therefore,
rather than moving us ‘towards an eventual decolonisa-
tion of global health’, the definition by King and Koski1
might actually reinforce the problems they highlight in
their article, including inefficiency, lack of accounta-
bility and uncritical faith in Western expertise, because
only ‘foreigners’ would be acknowledged as doing global
health.
Second, the definition may exacerbate inequities
by reserving the right to call oneself a global health
researcher, and the related expertise, exclusively to those
who are privileged and have access to funding that allows
them to travel and practise or conduct research in other
settings that they do not call home. Third, the definition
would limit the scope of problems and solutions consid-
ered, possibly neglecting global and transnational issues.
Fourth, if global health is conceptualised as public health
elsewhere, what interest would countries and communities
have in investing in global health? This could result in
less funding for a field that already faces the challenge of
limited resources.
Lastly, the definition and commentary imply that
working somewhere else is somewhat problematic and
negative. We are concerned that this view is divisive and
dangerous. It could contribute to ethnocentrism and
ultimately limit the sharing of knowledge and expertise
across groups. A ‘here’ versus ‘somewhere else’ dichotomy
seems counterproductive. We live in a globalised world,
and more than ever we are interconnected and inter-
dependent. Everyone in high, middle and low- income
settings has a vested interest in attaining health for all and
reducing health inequities. Concerns over pandemics
(covid-19!), global warming, environmental degradation
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BMJ Global Health
and potential misuse of technological advances (the easy
spread of fake news!) affect us all. Protecting the most
vulnerable is beneficial for everyone—for our economic,
social, mental and physical well- being. As a Burkinabé
saying goes, ‘we are together’.
CONCLUSION
Currently, global health may not be perfectly practised,
but we need inclusive definitions, frameworks and
training programmes that set the standards towards
which we should all strive. We can have transparent
discussions and be critical of global health academic
programmes, research and practices, while sharing an
adequate definition. We should condemn bad practices,
rather than condemn the whole field. True partnerships
across disciplines and geographic boundaries, which
have resulted in meaningful projects, exist and can be
further promoted.9 13 We need to promote the strengths
and best practices of the field and value success stories
while learning from failures.
Ultimately, the decolonisation of global health
requires training programmes that teach reflexivity, crit-
ical approaches, equitable partnerships and account-
ability. Such training programmes, and all global health
initiatives more broadly, should include participatory
approaches and ensure there are benefits for all stake-
holders involved. Resources should also be expended
equitably. These are all good practices that are attainable.
This is the morally ‘right way’ to do global health, and
also a more effective way to achieve ‘health for all’.
Twitter Anne- Marie Turcotte- Tremblay @AnneMarieTrem
Acknowledgements This commentary was written by members of a global health
community of practice, which is supported by the Global Health Research Axis and
the Global Health Research Capacity Strengthening Program (GHR- CAPS) of the
Quebec Population Health Research Network.
Contributors AMTT conceived the main idea presented. All authors contributed to
the conception and writing of the commentary.
Funding We thank the Quebec Population Health Research Network for its
contribution to the nancing of this initiative. Moreover, AMTT received a training
bursary from the Canadian Institutes of Health Research (CIHR). LM was supported
by a research scholar junior 1 award from the Fonds de Recherche du Québec-
Santé (FRQS).
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
Data availability statement No data was used for this commentary.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non- commercial. See:http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
ORCID iD
Anne- MarieTurcotte- Tremblay http:// orcid. org/ 0000- 0002- 6138- 9908
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