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Shaping the global: knowledge, experts, and U.S.
universities in the emergence of global health
To cite this article: Lydie Cabane (2022): Shaping the global: knowledge, experts,
and U.S. universities in the emergence of global health, Globalizations, DOI:
To link to this article: https://doi.org/10.1080/14747731.2022.2082130
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Shaping the global: knowledge, experts, and U.S. universities in the
emergence of global health
Institute of Security and Global Aﬀairs, Leiden University, The Hague, The Netherlands
The term ‘global health’has become the dominant way to describe worldwide
interventions on health since the 2000s. Despite signiﬁcant discussions about
the meaning of the term, there is still a lack of understanding about how it
came to dominate global thinking and the implications of such a shift. This
article traces the emergence and diﬀusion of ‘global health’as a concept. It
focuses particularly on the role of US experts and universities in shaping the
‘global’. It uses a combination of interviews, literature review and archives to
trace its apparition in expert discourses and diﬀusion in universities. It shows
that the deﬁnition of ‘global health’came out of and contributed to
American dominance in globalization. In addition to bringing a fresh
perspective on the origins of global health, the paper contributes to the
globalization debates by showing the co-constitution of scientiﬁc and
political ﬁelds in globalization.
Global health; globalization;
How do issues become accepted as global problems in being conceptualized and acted upon as
such? The mere idea of an issue being global is itself rarely a mechanical reﬂection of globalization
but instead reﬂects speciﬁc contexts, visions, and paradigms, themselves embedded in power
relations. Knowledge is essential to the deﬁnition and the politics of globalization. Various contri-
butions in IR, STS, or global studies have repeatedly emphasized the role of experts and epistemic
communities in diﬀusing ideas in global policy-making or creating models that frame objects, such
as climate change, as global. As a contribution to ‘globalisation debates’(Rosenberg, 2005; Roudo-
metof, 2021), this article examines the role of experts and universities in deﬁning global concepts
underpinning globalization.If much attention has been given to experts and global models, and the
origins of the globalization concept (James & Steger, 2014), there has been less focus on universities
as actors of global politics and the role of academic ﬁelds as an infrastructure of globalization. Yet,
as disciplines and universities are always embedded in national contexts, they also reﬂect speciﬁc
countries’concerns. In this article, I ask how the invention and the diﬀusion of ‘global health’con-
tributed to shaping a new domain of global governance. In trying to localize the origins of ‘global
health’, I show how knowledge was embedded in geopolitics and tied to the redeﬁnition of US
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CONTACT Lydie Cabane firstname.lastname@example.org
‘Global health’has become a well-accepted paradigm to describe health interventions in an
international context. Despite important continuities in international health interventions (Pack-
ard, 2016), the expression ‘global health’only really emerged in the 1980s–1990s. During the
2000s, it replaced ‘international health’as a conceptual and political paradigm for intervening
on the health of populations worldwide, supposedly in reﬂection of the globalization of health
and diseases. It served to indicate a pluralization of governance that was no longer only in the
hands of the World Health Organisation (WHO) and Western states but increasingly incorporated
many public and private actors.The term is now a well-established notion in IR used to describe
changes in global politics (Davies et al., 2014). The transition from international to ‘global health’
thus oﬀers a pertinent case to study what it means to label an issue as global and how such labelling
shapes global politics, as this shift was not just empirical but also cognitive. Rather than taking the
‘global’as a self-evident issue –the world has gone global, and so has health, and so should health
governance –the global oﬀers here a point of departure for an inquiry about the politics of becom-
ing ‘global’at the turn of the twenty-ﬁrst century.
By focusing on the origins of ‘global health’–as a concept and a paradigm –I suggest that the
‘global talk’about health (Hodges, 2012) is not intrinsically global but the result of a speciﬁc and
localized entanglement between knowledge and politics.More speciﬁcally, the article focuses on
how US experts and universities actively engaged in the practice of deﬁning and shaping ‘global
It argues that the framing of ‘global health’reﬂected the speciﬁc concerns, interests and
values of those who developed and promoted the notion. ‘Global health’consists of a speciﬁc pro-
blematisation of global politics, with its underlying power relations, inequalities, and postcolonial
visions. It emerged in response to a re-ordering of world politics that saw the aﬃrmation of U.S.
power and the structuring of neoliberal and economic globalization (Sparke, 2003).The deﬁnition
and adoption of the term resulted from speciﬁc concerns and changes at the turn of the noughties
in the USA, emanating from international public health and medical research seeking to reposition
itself politically, economically and scientiﬁcally.
To study the emergence of the concept, I follow a perspective inspired by science and technology
studies (STS) that focuses on how knowledge co-produces world orders (Jasanoﬀ,2004; Lidskog &
Sundqvist, 2014; Mayer et al., 2014). Such an approach builds upon the study of epistemic commu-
nities (Haas, 1992). However, it goes further by analysing epistemic practices, which means taking
into account not only networks and actors but also how discourses and ideas empirically shape
issues (and not just discursively) (Bueger, 2014). Additionally, it pays attention to how ‘infrastruc-
tures’of knowledge (Edwards, 2010) support global politics and build ‘global objects’(Allan, 2018).
This perspective also contributes to the rich IR literature on global health (Davies et al., 2014) that
has insuﬃciently discussed the role of knowledge and expertise in the emergence of ‘global health’.
Below, I examine how ‘global health’was ﬁrst coined as a concept, how it circulated and became
dominant as an academic ﬁeld and a way to think about health worldwide.The article combines
archival research, an analysis of institutional reports and the scientiﬁc literature, as well as a few
interviews with global health experts from Harvard University. As a whole book would be necessary
to give a deﬁnitive account of this history, I focus on selected meaningful moments, places, and
actors. A systematic literature review of the origins of ‘global health’helped me identify the key
institutions and actors I then focused on.
First, I review the diﬀerent explanations of the origins of the concept and subsequently develop a
theorization of the role of experts and universities in shaping ‘global health.’s The second part ana-
lyses how the idea was coined in the Americas in the 1990s. Criticisms of international health in
Latin America converged with concerns about globalization, security and development in the
U.S. to deﬁne ‘America’s vital interests in global health’. The third part delves into the institutio-
nalization of ‘global health’in U.S. universities in the 2000s and how it constituted an architecture
for ‘global health’–in other words, how U.S. science and experts shaped the very understanding of
‘global health’by contributing to its global expansion and institutionalization in the U.S.
Theorizing the role of experts and universities in shaping global health
Explaining ‘global health’
Various explanations have been put forward as to why ‘global health’replaced international health.
The ﬁrst and most common is ‘globalisation’. This view considers ‘global health’seen as a response
to structural transformations generally coined under globalization, reﬂecting changes in health
conditions and international political and economic structures. An objectivist version of this argu-
ment claims that health is global due to the acceleration of globalization to unprecedented levels at
the turn of the twenty-ﬁrst century. Diseases and health conditions, such as AIDS, Ebola, corona-
viruses, chronic diseases like diabetes, or non-transmittable diseases like cancer were quickly
becoming more global. Countries increasingly shared economic, environmental, and social con-
ditions that shape health. The globalization of health determinants, the circulation of diseases,
and shared health outcomes called for new political, economic, and medical forms of interventions.
Global health actions are, in this perspective, a logical consequence of this epidemiological globa-
lization. In short, ‘global health’primarily reﬂects current health conditions. A constructivist ver-
sion of this argument, often found in IR (McInnes & Kelley, 2012), contends that transnational
actors, such as doctors, activists, policy-makers or pharmaceutical companies, shaped health as a
global issue. For example, Brandt (2013) argued that AIDS laid the foundations of ‘global health’,
not only because it was a worldwide pandemic but also because of the new forms of transnational
activism, funding, philanthropic interventions and private actors it triggered. The limit of globali-
zation arguments, whether objectivist or constructivist, is that they do not suﬃciently explain why
the term ‘global health’was used, where it originated from, and how it circulated.
An alternative explanation examines how ‘global health’epitomized a redeﬁnition of security
and states’interests in international relations (Rushton & Youde, 2017). This genealogy points
to the role of U.S. virologists, immunologists, and international health experts, who, during the
1990s, warned the American public and policy-makers in Washington of the danger of new ‘emer-
ging infectious diseases’such as AIDS and Ebola. In their view, these pandemics, potential or real,
compromised America’s security and ability to trade and prosper alongside economic globalization.
Notably, the 1997 report of the Institute of Medicine, America’s Vital Interest in Global Health, best
captured this ‘worldview’(King, 2002) and formalized a deﬁnition of ‘global health’. This focus on
the role of experts, knowledge and parochial concerns in Washington points to signiﬁcant connec-
tions between expertise and US hegemony in the invention of the notion. Yet, it provides fewer
clues on its diﬀusion, particularly beyond biosecurity issues and broader global governance circles.
Global health entailed not only a discursive change but also signiﬁcant transformations in insti-
tutions, tools, and actors (Gaudillière et al., 2020). In that sense, governance dynamics provide
another explanation. In particular, historians have pointed out how the changing context of inter-
national organizations in the 1990s led to global governance. Brown, Cueto and Fee (2006) argue
that the WHO devised the notion of ‘global health’in response to growing competition from other
players in the ﬁeld of international health –an argument echoed by others (Birn, 2009; Chorev,
2012; Cueto et al., 2019). The World Bank challenged the WHO’s leadership in 1993 when it
dedicated its annual report, the World Development Report,to‘Investing on Health’. The report
promoted new economic measurements of health, and deﬁned health as a prerequisite for econ-
omic development, rather than the contrary –development for health –which was the WHO’s tra-
ditional position (Gaudillière, 2014). The WHO found itself amid a legitimacy crisis, in addition to
budgetary crises (following budget freezes by the U.S.) (Chorev, 2012), and calls for a redeﬁnition of
its mandate (Antezana, 1997; Godlee, 1997; Lee et al., 1996; Stenson & Sterky, 1994). ‘Global health’
oﬀered the WHO an organizational survival strategy: it acknowledged the existence of the numer-
ous actors and organizations now intervening in world health while legitimizing the need for an
experienced coordinator and leader. Yet, the WHO itself did not invent ‘global health’. Instead,
it reﬂected conceptual transformations, changing public and international health paradigms.
Brown and his colleagues suggest that the concept was developed around that time in a few pub-
lications related to debates about global environmental change, medicine or health systems (Gellert,
1990; McMichael, 1993; Roemer & Roemer, 1990). But they remain silent about the notion, its gen-
ealogy, reception, and further circulation. In brief, this argument account for the institutionaliza-
tion of ‘global health’but not for its invention.
Relatedly, scholars have emphasized the close links between ‘global health’, global governance
and neoliberalism (Cueto, 2020; Sparke, 2020). This argument further underlines the role of econ-
omic rationalities (Kenny, 2017) and neoliberalism in paving the way to ‘global health’(Gaudillière,
2014). According to that perspective, ‘global health’signalled a shift in health interventions from
social development to economic growth, from equity to cost-eﬀectiveness, from primary healthcare
to disease-oriented technical solutions, from WHO and publicly-funded interventions to public-
private partnerships, and from public health to economics (Chorev, 2012; Gaudillière et al.,
2020, 2022). The 1993 World Bank Development Report was a telling sign of the rise of economics,
which developed tools, such as the Global Burden of Disease, to globally compare the impact of
diseases and the health of populations (Kenny, 2015). Changes in economics and public health
paradigms accompanied the rise of a neoliberal agenda led by the World Bank, private actors, pub-
lic-private partnerships and philanthropies (Youde, 2013). This argument combines structural
transformations with changes in knowledge paradigms and r33einforces the idea of the prominent
role of the United States in promoting a concept that supported its political agenda. It led to strong
criticisms of the concept as a reﬂection of neoliberal hegemony (Birn, 2011), and an homogeniz-
ation of history (Anderson, 2014) that neglects political ideology and economic contexts.
Theorizing the role of knowledge and experts in shaping global health
The above arguments provide valuable explanations of the origins and diﬀusion of global health.
However, they do not oﬀer speciﬁc grounds for the term’s invention and have diverging accounts
of its ﬁrst uses –at the WHO, the US Institute of Medicine, or in speciﬁcﬁelds of knowledge. To
tackle these limitations, I turn the focus to how science shapes understandings and the politics of
globalization through the invention and diﬀusion of concepts, such as ‘global health’. I combine
STS works on the role of knowledge in the coproduction of political orders, and constructivist
IR perspectives on the role of expertise.
In IR, Haas demonstrated the importance of epistemic communities in transnational politics and
how their control of knowledge enables them to deﬁne problems, policies and solutions in inter-
national policy coordination (1992). More recent approaches have either focused on discourse
and power (while neglecting the speciﬁc role of expertise) or insisted on how knowledge empirically
shapes practices (Bueger, 2014). Others argue that there has been a turn in how IR considers
expertise: after focusing on experts, it is now looking more at the constitution of ‘objects’(Allan,
2018). The notion of object is helpful in global contexts constituted by a collection of diverse insti-
tutions, actors, networks, practices or ideas. According to such a perspective, knowledge and the
deﬁnition of concepts by actors are essential in shaping the global objects and, consequently, global
This last theory rejoins a ﬂurry of works in STS on the constitution of world orders. STS theories
of coproduction provide crucial insights to grasp the entanglement of science and politics in glo-
balization dynamics. The basic tenet of coproduction is that science shape politics and vice versa. It
invites an examination of knowledge production and how it deﬁnes global objects and, thus, shapes
political interventions. Jasanoﬀand others have demonstrated how science is a ‘political agent’in
global politics (2004, p. 14), notably by providing a cognitive architecture that constitutes issues as
global. Most famously, in the case of climate change, scientists played a crucial role in forming this
global object through knowledge infrastructures (Edwards, 2010), or the constitution of a discipline
(climate science) and an institution (the IPCC) that was essential in framing the problem (and its
solutions) as global (Aykut, 2020; Miller, 2004). Yet, such constructions ‘always take place some-
where’(Blok, 2010, p. 901). In other words, it matters to localize the global.
Combining Allan’s analysis of the role of expertise in shaping global objects and STS analysis of
the role of science in co-producing the global, I study the formation of ‘global health’both as a
scientiﬁc and a political category to understand its emergence and institutionalization. To do so,
I consider two constitutive epistemic moments. First, I stress the importance of deﬁning global con-
cepts themselves. Although much has been said about how knowledge shapes global politics, there
has been less attention to the invention of global concepts, and how their deﬁnition structures glo-
bal politics in ways that reﬂect the visions, values and interests of those who invent them. This argu-
ment builds on recurrent claims about how power in the ﬁeld of health is co-constructed by
knowledge (Fillol et al., 2021; Gaudillière et al., 2022; Moon, 2019; Shiﬀman, 2014). Put diﬀerently,
by providing a genealogy of ‘global health’, I illuminate the role of concepts, how they embed actors
and politics and participate in broader transformations. Second, I focus on the role of universities
in institutionalizing the concept through their research and teaching activities. The point here is
that the structuration of disciplines and programmes in universities provides a knowledge infra-
structure and resources to the larger ﬁeld of ‘global health’, which also reﬂects the geopolitical con-
text in which those universities are embedded. At the same time, the institutionalization of
academic notions in politics further stimulates the growth of such academic activities by providing
resources and legitimacy. Deﬁning the ‘global’required a cognitive architecture provided by science
and institutionalizing these categories in politics to validate them.
Here we come to the core argument of this article: seeing the world as ‘global’, especially in the
context of health, was associated with a re-aﬃrmation and transformation of US power. This builds
on earlier comments by King, who pointed out the role of US security experts in shaping an ‘emer-
ging infectious diseases’worldview essential in deﬁning the security politics of ‘global health’(King,
2002)–however, neglecting the humanitarian component of ‘global health’(Lakoﬀ,2010). Sparke
(2003) also makes a similar point by asserting that ‘global health’is associated with a transform-
ation of the US Empire. I shift the attention to the speciﬁc role of US experts and universities in
deﬁning the concept of ‘global health’, providing a new explanation for the origins of the term.
This focus is further supported by the fact that US universities have signiﬁcantly contributed to
shaping knowledge production about the ‘global’through the internationalization of their research
and education activities (Kamola, 2019). Below, I emphasize two main places and moments when
knowledge and experts shaped ‘global health:’ﬁrst, the invention of the concept at the interface of
science and politics in North America in the early 1990s; second, its stabilization as an academic
ﬁeld connected to the market and politics of globalization in the U.S. in the 2000s.
Inventing global health: critiques and reconﬁguration of international health at
the turn of the 1990s
The emergence of ‘global health’as a concept in the 1990s sought to make sense of ongoing trans-
formations in the economy and global politics and shape these by transforming international
relations in the ﬁeld of health. New ideas coming from the Americas reﬂected concerns and inter-
ests about development, economic globalization and security.Experts circulating across networks
and political institutions deﬁned and spread the notion of ‘global health’in the early/mid-1990s at
the interface of U.S. interests and shifting geopolitics.
Redeﬁning international health in a globalizing world: the U.S. debate
By the end of the 1980s, international health –comprising of experts, doctors, and international
organizations intervening in the health populations in developing countries –faced multiple diﬃcul-
ties and criticisms. Neoliberal attacks on primary health care brought discussions about costs and
goals on the agenda. The U.S. froze its WHO budget, creating budgetary and legitimacy crises for
the organization (Chorev, 2012). The end of decolonization and the Cold War questioned Western
countries’supremacy and power to shape health interventions in the developing world. Economic
development, demographic transitions, and globalization were redeﬁning understandings of health,
which could no longer be neatly divided into health concerns of the North and diseases of the South.
In this context, various attempts to redeﬁne international health emanated from North America at the
turn of the 1990s. The notion of global health emerged from paradoxical concerns about, on the one
hand, security, economy and the place of the U.S. on a globalizing international stage, and on the
other hand, criticisms of the Western preeminence in international health.
A series of scientiﬁc and economic developments arouse American political interests in inter-
national health. The 1980s were times of considerable scientiﬁc advancement: the discovery of
recombinant DNA in 1976 and the subsequent development of biotechnologies generated hopes
of new treatments against infectious diseases. AIDS led to major scientiﬁc discoveries in immu-
nology and virology, contributing to increasing U.S. research capacities. The pandemic constituted
a source of anxiety for the US, which called for global solutions (Brandt, 2013). Following wide-
spread concerns about the nation’s decline in the 1970s, these developments appeared as an oppor-
tunity to revive the U.S.’inﬂuence through investments in biotechnologies and international
In 1985, a report from the Oﬃce of Technology Assessment of the U.S. Congress rec-
ommended increasing research funding and international collaborations in those ﬁelds.
during the Cold War, international health was tightly linked to foreign policy and development
assistance, globalization and the changing politics of the 1980s led to redeﬁning international health
as a security and economic interest, that oﬀered global markets to U.S. companies and science.
International health activities came to be seen as a resource that had to be promoted. In the
wake of these transformations, universities started to expand their international health research
and teaching activities (Godue, 1992). By the end of the decade, 24 schools of international health
were established. An International Health Medical Education Consortium (IHMEC) was created in
1991 to promote the internationalization of medical training in the U.S. (Stuck et al., 1995) and
support those economic developments.
As the scope of international health was evolving, debates about its meanings arose within the
US academia. Until then, the prevailing idea was that ‘international health’was a humanitarian
endeavour to extend the beneﬁts of medicine, anchored in the WHO declaration of Alma-Ata
and the promotion of primary health care (Velji, 1991). However, critics began to underscore
that international health remained ‘closely associated with aid and underdevelopment, with
the opening of a sociocentric gulf between “us”(the developed) and “the others”(the underde-
veloped)’(Godue, 1992, p. 120). In contrast to international health, which political ambitions
and cultural values reﬂected those of Western countries, ‘global health’appeared as an oppor-
tunity to rebalance relations between countries more equitably. In 1992, the Pan-American
Health Organisation (PAHO) published a critical report on international health that captured
The debate on the object of study has already started: a shift from a dissociative, sociocentric approach
to one that focuses on health at home. […] The term ‘global health’is being used to promote this new
trend and signal a break with the earlier sense of the term. (Godue, 1992, p. 121)
In the PAHO report, the idea of the ‘global’stemmed partly from a critique of the IMF interven-
tions in Latin America in the 1980s. The authors perceived economic instability and reduced public
health spending as detrimental to populations’health in the developing world. The post-Cold War
context called for a reconsideration of international health to overcome the divide between devel-
oped and developing countries. The shift towards global concerns intended to break the previous
association of international health with the tropics or Western humanitarianism and development.
Instead, it sought to promote the idea that health was a shared problem globally, paradoxically con-
verging with economic processes that called for the globalization of health markets and US health
and medical activities. The report notably attributed a prominent role to universities in carrying out
this transformation (Auer et al., 2011).
A view from Mexico: the ‘new international health’.
Let us take a detour further South in Mexico. As Latin America was developing and changing fast in
the 1980s, new ideas and practices of international health ﬂourished and best articulated those cri-
ticisms about the ‘old’international health. In particular, Julio Frenk and Fernando Chacon from
the National Institute of Public Health in Cuernacava co-edited a series of articles (1991a,1991b)
that sought to deﬁne a ‘new international health’. They argued that it had become ‘necessary to
revise the perspectives and scope of health that enable us to understand the implications of the glo-
bal development on the economic and social processes internal to each country, and therefore, on
the health of the population’(Soberón & Chacón, 1991). Their argument underlined the anachron-
isms of borders in the age of economic globalization, growing heterogeneity inside countries, and
overly simplistic opposition between developed and developing countries. They formulated a frank
critique of Western ethnocentrism in health policies, and advocated for bilateral and multilateral
rather than unilateral interventions and a shift from dependence to interdependence, from techni-
cal assistance to cooperation. Their call for a ‘transition’to a ‘new’international health aimed at
reversing previous hegemonies, considering that ‘health problems as issues that are the responsi-
bility of all countries’(Frenk & Chacon, 1992, pp. 205–221). At the same time, they advocated
for the ‘emergence of a [new] paradigm of international health’as an interdisciplinary ﬁeld. This
conceptual redeﬁnition sought to promote their own work at a time when old paradigms were
breaking down and when there were opportunities for redeﬁning ‘global’politics.
These discussions were vital in bringing forward the notion of ‘global health’as they signiﬁ-
cantly inﬂuenced the PAHO report to which Julio Frenk contributed. Frenk, later recruited as a
WHO executive director between 1998 and 2000, before becoming Health Minister of Mexico
and later on a Harvard professor, played a critical role in disseminating these ideas. Through
his circulations, he connected the various institutions essential in the emergence of ‘global
health’,theWHO(Frenketal.,1997), the PAHO, U.S. universities and the Institute of Medicine.
This Latin American detour thus highlights the politics of the concept formation and the role of
expert connections in linking institutions discussed separately in the literature explaining the rise
of ‘global health’.
America’s interests in ‘global health’.
These debates converged in an inﬂuential report by the U.S. Institute of Medicine, America’sVital
Interest in Global Health, published in 1997. The report formalized the ﬁrst deﬁnition of ‘global
health’as ‘health problems, issues, and concerns that transcend national boundaries, and may best
be addressed by cooperative actions’. Until then, the concept had been used but not deﬁned. The
insistence on interdependence and cooperation reﬂected the criticisms of international health formu-
lated in Mexico. This was no coincidence since Julio Frenk was a member of the Institute of Medicine
International Health Board between 1992 and 1996. US experts credited him for having been the ﬁrst
to explain that ‘health is no longer international but global [but] a shared set of problems that are
faced by all the countries of the world’.
Yet, if for Mexicans and the PAHO, interdependence was
based on an explicit critique of Western interventions and called for more equitable cooperation
between nations, once in Washington, itbecame an argument for a renewedway of advancing ‘Amer-
ica’sinterests’in a post-Cold War, postcolonial, globalizing, neoliberal world.
Three aspects of that deﬁnition stand out.First, it remained tightly linked to fears among the
U.S. public and security experts about re-emerging infectious diseases. Relatedly, it provided a
rationale to invest in health, create markets for biosecurity technologies, and tackle security risks
(King, 2002), thereby promoting a strategic globalization of markets. The second striking feature
is that humanitarian concerns were no longer the prime reason for intervening on foreign popu-
lations’health but served to deﬁne American interests. The ‘global’appeared as a justiﬁcation to
preserve U.S. power and supremacy in a changing world:
The report argues that America has a vital and direct stake in the health of people around the globe, and
that this interest derives from both America’s long and enduring tradition of humanitarian concern and
compelling reasons of enlightened self-interest. Our considered involvement can serve to protect our
citizens, enhance our economy, and advance U.S. interests abroad. (p. V)
The third turnaround relates to science and technology that were progressively becoming the pri-
mary ‘basis’for intervening globally on health, and an ‘engine’of economic and political power.
The U.S. global health policy needed medicine and public health to ﬁght pandemics that threatened
the U.S. population. Reversely, it provided support to expand the markets of a growing industry:
‘U.S. expertise in science and technology and its strength in biomedical, clinical, and health services
research and development are the engine that has helped power many of the advances in human
health and well-being of this century’(p. VI).
Hence, the transition from international to ‘global health’resulted from the convergence of pol-
itical, economic and academic interests and the American government’s strong interest in science
and biotechnologies in the 1980s. Earlier formulations of ‘global health’as a criticism of Western
domination were eventually overturned to provide a new legitimacy to the U.S. as a conductor of
global governance in the twenty-ﬁrst century. The praiseworthy attempts to redeﬁne international
heath in more equal ways converged with a general repositioning of U.S. interventionism: the end
of the Cold War called for rethinking U.S. hegemony since ﬁghting communism was no longer a
valid motive to support international aid. Designing a new role as global benefactor gave the U.S. a
self-interested moral superiority while securing markets, national interests, and soft power in
deﬁning international organizations’priorities, and conveniently relegating Europe to the back-
ward times of international health (Farmer et al., 2013).
Albeit being about the role of the US in the world, those debates were not limited to Washington
DC. One of the preparatory reports of the IoM report was dedicated to ‘Perspectives from inter-
national organisations’(Bryant & Harrisson, 1996). WHO experts, who were also at that time
thinking about ‘global health’, were interviewed, including Derek Yach, whose role is mentioned
by Brown et al. (2006) as central in devising global health at WHO (see also (Yach & Bettcher,
1998a,1998b)). These circulations suggest that the emergence of ‘global health’took oﬀbecause
it could articulate diﬀerent visions, from powerful countries and international institutions to the
criticisms of the previous colonial and development period.
The deﬁnition of ‘global health’was thus an attempt to shape global governance in ways that
conveniently served (North) America’s interests. The notion originated from various debates but
was formalized and deﬁned in the US context. Circulations between institutions and countries
were essential to the emergence of the notion but embedded in hierarchies and power relations.
As in other domains (Goldman, 2006), criticisms of Western hegemony and acknowledgement
of interdependence and equality between countries were incorporated into the global governance
mainstream of the 1990s and turned into an economic project.
Diﬀusing global health: the role of U.S. science and universities in shaping global
How did ‘global health’become accepted as a concept to think and act upon health worldwide? How
did it travel out from the original context in which it emerged to become an uncontested concept and
international framework? This part argues that the anchoring of ‘global health’in the US academia
was essential to its broader diﬀusion. Empirically, US universities have become actors of ‘global
health’politics through their education and scientiﬁc programmes or by supporting global organiz-
ations with their research. Theoretically, such a focus can be justiﬁed by the ‘coproduction’argument
(Jasanoﬀ,2004), according to which the stabilization of knowledge within a ﬁeld of study is tightly
linked to its institutionalization in politics and policies. Furthermore, as Kamola argues, US univer-
sities were, ‘at the turn of the 21st century […] actively engaged in the […] imagining of the world as a
vast, interconnected global space’(2019, p. 2) in response to funding constraints and changing econ-
omic conditions that called for embracing ‘global’opportunities and discourses. This part examines
how the institutionalization of ‘global health’within the US academia through the constitution of an
academic ﬁeld dominated by the U.S., its anchoring in economic and political dimensions of the U.S.’
insertion in the globalization, and the shaping of policy through networks and lobbying.
U.S. domination in ‘global health’research
The rise of ‘global health’in world politics was paralleled by an increase in research in ‘global
health’, especially in the 2000s (Figure 1). Yet, most of this growth came from U.S. universities
(Byass, 2013). In 2008, almost nine out of ten articles published on ‘global health’in scientiﬁc
journals came from North American institutions (Macfarlane, Jacobs et al., 2008). In 2018,
slightly more than half of the articles came from North America, and about 70% from the
U.K., US, Canada and Australia (Figure 2). The top 10 publishing institutions in ‘global
health’were all located in the US, Canada and the U.K. (Figure 3). Most global health partner-
ships came from Western universities, mostly based in the U.S. (Herrick & Reades, 2016).
Therefore, the activity of producing knowledge about ‘global health’is highly localized in
The development of ‘global health’programmes, institutes, initiatives, and partnerships
throughout the 2000s largely supported this supremacy. Whereas 24 ‘global health’programmes
existed in 2002 in the U.S., this number reached 52 in 2009 (Merson & Chapman, 2009). In
2015, 88 North American universities were aﬃliated with the Consortium of Universities for Global
Health, the organization that federates ‘global health’academic programmes in the U.S.
opment of an academic infrastructure supporting ‘global health’knowledge thus reﬂects the same
ambiguities as the concept. The ‘global’in ‘global health’indicates ﬁrst and foremost the geographic
extent of those activities carried by U.S. actors and universities rather than a global activity. What
drove such growth and built the US hegemony in ‘global health’?
‘Global health’as an academic engine
In 1999, the University of California San Francisco created an Institute of Global Health, one of the
ﬁrst in the United States to use ‘global health’to designate its activities (Macfarlane, Agabian et al.,
Figure 1. Number of ‘global health’publications in PubMed.
Note: For Figures 1–3, searches were carried in English, which may bias the results. However, combining various languages would be
diﬃcult given that the databases enabling such comparison include more English publications, reﬂecting wider structural inequalities.
Besides, English is the predominant publication language, especially in medical ﬁelds, even outside English speaking countries. Besides,
globalization has also generated a diﬀusion of the term, incentivising other countries to adopt the term ‘global health’to position
themselves in this ﬁeld. Therefore, the measures, albeit imperfect, give a good indication of current trends.
10 L. CABANE
Figure 2. Top ten publishing countries in ‘global health’.
Source: Web of Science, 2018.
Figure 3. Top ten publishing institutions in ‘global health’.
Source: Web of Science, 2018.
2008). Launched in the heart of the biotechnology revolution, the Institute aimed at ‘harnessing the
positive powers of globalisation, the explosion of biomedical science and technology, the revolution
in information technology’.
Its programmes included research on evidence-based health policy,
the development of vaccine markets for developing countries, and the analysis of health risks. It
launched ‘Global Health Forums’to foster health leaders networks, and headquartered a working
group of the WHO Commission of Macroeconomics and Health. ‘Global health’positioned univer-
sities at the intersection of markets and politics, and provided an opportunity to work worldwide
under a renewed legitimacy:
Rather than repeating the colonial approach of the early days of tropical medicine, or the development
aid approach of international health, the increased connectedness of the twenty-ﬁrst century provides
academic institutions around the world the opportunity to work collaboratively to develop research
programmes to redress health disparities and education programmes to nurture global health leaders
capable of tackling looming global threats wherever they occur. (Macfarlane, Jacobs et al., 2008)
This aﬃrmation expresses best the complexities and ambiguities of ‘global health’. On the one
hand, the new label sought to aﬃrm a postcolonial mode of intervention based on partnerships
that would seek to acknowledge disparities and redress them through equitable relations with part-
ners (Crane, 2010). On the other hand, ‘global health’appeared as a proﬁtable academic endeavour
anchored in the U.S. economy. It deﬁned health problems as global threats or opportunities from
the U.S. point of view, thus embedding those partnerships in an inevitable unequal power relation
(Crane, 2013). Strikingly, ‘global health’was an academic project as much as an economic one. In
2009, the Global Health Institute of the Universities of California realized a study of the economic
impact of ‘global health’in California: for the year 2007, it estimated that business activity related to
‘global health’generated 49,8 billion dollars, including 4 billion by the Universities of California.
Academics and universities considered ‘global health’as a proﬁtable ‘academic enterprise’
through international clinical experiments, research partnerships (Petryna, 2009), or international
Global interventions in the ﬁeld of health became a strategic economic asset. As an ‘academic
enterprise’(Adams, 2010), ‘global health’made markets and academic research the prime source
of power for the U.S. under the ‘global health’paradigm. This reversal of values is part of a broader
movement that saw American universities become over the past 30 years ‘economic engines’inte-
grated into the market, massively beneﬁting from private funding, and widely seen as catalysts of
economic growth (Popp Berman, 2012), thereby transforming conditions of knowledge production
(Kamola, 2019). In the case of ‘global health’, the myriad of international research, education, and
care partnerships participate in a larger transformation of international politics, in which states act
alongside economic and academic actors, NGOs. In a nutshell, the diﬀusion and institutionaliza-
tion of ‘global health’went hand in hand with the aﬃrmation of new actors in global health politics
and a renewed U.S. supremacy through markets and science.
‘Global health’, advocacy and politics
The development of ‘global health’in the U.S. academia contributed to its diﬀusion by creating cog-
nitive tools and research infrastructure to support ‘America’s interests in global health’.‘Conver-
ging interests’(Siegel et al., 2013) between U.S. academia and global politics did not only result
from structural factors; they were also the product of close connections between political interests
and universities. These networks materialized in two ways: as a response to increased funding,
12 L. CABANE
whether public or private; and through universities’advocacy, which co-constructed political
understandings of ‘global health’.
The development of ‘global health’ﬁrst responded to the U.S. government’sﬁnancial and pol-
itical interests in global health to support U.S. foreign policy. The U.S. has become the main con-
tributor to development assistance for health over the past two decades.
In 2015, the federal
budget dedicated $8 billion to global health against $1 billion in 2000 (Ravishankar et al.,
U.S. presidents initiated and drove this rise in ‘global health’funding, particularly with
the President’s Emergency Plan for AIDS Relief (PEPFAR), created by George W. Bush, and con-
tinued by Barack Obama. In 2009, the U.S. government launched a six-year $63 billion Global
Health Initiative to coordinate agencies and make global health action and funding more visible
(Bendavid & Miller, 2010). In 2017, despite the changing political climate of the Trump presidency,
‘global health’still represented the ﬁrst component of U.S. foreign assistance (24%).
largely irrigated universities thanks to the National Institute of Health research or educational
grants, USAID partnerships, or ‘global health’partnerships eligible for development assistance aid.
Moreover, the rise of public-private partnerships and foundations in global health boosted univer-
sities’activities (Rushton & Williams, 2011). The most prominent actor is the Gates Foundation, cre-
ated in 1994. It dedicates a signiﬁcant part of its budget to research organizations and universities in
rich countries, which turned it into a major sponsor of ‘global health’on American campuses (Sridhar
&Batniji,2008). For example, when Harvard University started its ‘global health’activities in 2000,
the Gates Foundation donated 44 million dollars to its Global Health and Social Medicine department
to build its international programmes.
It also funded one of the ﬂagship projects of ‘global health’,
the Global Burden of Diseases. This project, initiated at Harvard University, was then supported by
the World Bank, the WHO and later became a self-funded project (the Institute for Health Metrics
and Evaluation) (Gaudillière & Gasnier, 2020), illustrating how the connections between philanthro-
pic foundations, international organizations, and leading U.S. academics sustained the existence of
‘global health’as a worldwide activity, and an element of U.S. global activities.
These ﬁnancial ﬂows do not simply indicate a mechanical response to ﬁnancial incentives and pri-
orities deﬁned by political powers. Inﬂuential ‘global health’U.S. academics shaped these political
‘interests’through their research and advocacy –as in other ‘global’academic ﬁelds (Kamola, 2019).
The most notable case is that of Harvard ‘global health’scientists who often occupied eminent advisory
or decision-making positions in government or international organizations, such as the WHO. A tell-
ing example was Paul Farmer, one of the most outspoken advocates of ‘global health’and a professor of
social medicine at Harvard. Farmer’sinvolvementin‘global health’incarnatedthosesameambiguities
characteristics of ‘global health’: through its NGO Partners in Health, Farmer was a critical advocate of
equality in global health and launched successful tuberculosis and AIDS programmes in Haiti, Rwanda,
and Russia. Yet, he heavily relied on business and political connections, the same ones at the source of
the inequalities he criticized. Despite an approach rooted in anthropology, Partners in Health worked
simultaneously on replicating case studies and standardizing interventions worldwide (Kim et al., 2010;
Weintraub et al., 2011).Finally,theappointmentofDrJimYong Kim, co-founder of Partners in
Health, as the head of the World Bank in 2014 illustrates further the close connections between
U.S. experts and global governance and the co-institution of science and politics in global health.
By enlightening the debates and conditions in which the notion of ‘global health’emerged, this
article has shown how, far from simply reﬂecting global conditions and modes of governance, it
was part of a re-ordering of world politics. At a time when global governance and globalization
were emerging, the deﬁnition of a category to describe worldwide interventions in the ﬁeld of
health served to redeﬁne and legitimise the U.S. position and power in global aﬀairs. The article
demonstrated how the co-institution of political interventions and academic research in the US
was essential in deﬁning it, thereby providing new explanations for the rise of the notion. The
acknowledgement of interdependences between countries emanated from criticism of international
health in the early 1990s and sought to recognize developing countries’agency. Yet, the term came
to legitimise U.S. supremacy, merging of postcolonial concerns with security concerns and neolib-
eral market forces. This movement was supported by and beneﬁcial to U.S. universities, which
institutionalized ‘global health’and diﬀused it through their advocacy and research activities, trans-
forming it into a successful global academic enterprise. The extraction of the term from its original
production context and successful diﬀusion eventually obfuscated the politics of inequalities it
initially intended to tackle, reproducing asymmetries of power, albeit in a transformed way.
To conclude, I would like to stress two points. First, this article has called for taking more sys-
tematically into account the role of universities and experts in ‘global health’and more generally, as
actors in global politics. It showed how concepts and disciplines are tightly linked to the consti-
tution of world orders through knowledge production and diﬀusion. This perspective opens new
scope for global health research in IR: for example, how U.S. academics’connections with private
philanthropies and policy actors shape U.S. and international policies; how scientiﬁc concepts
become frameworks for international health actions, whether through or international organiz-
ations. More generally, this perspective showed the relevance of coproduction in understanding
the framing of globalization, and the importance of analysing the constitution of global ﬁelds of
knowledge in parallel to politics.
Second, this article’s other contribution lies in showing how the deﬁnition of the global
(in health) stemmed from U.S. parochial concerns and ideas. The history of how international
health became ‘global’provides a relevant example to question how we think of processes as global.
This episode is an important reminder that the notion of the ‘global’is not ﬁxed. Instead, it reﬂects
power relations; the ability to deﬁne what is global is a power to shape global governance. Acknowl-
edging and re-situating these processes contributes to pluralizing understandings of the global, and
shows the necessity of deconstructing the notion of the ‘global’to uncover knowledge and power
1. To make clear that I focus on the invention of ‘global health’as a concept, I keep the expression in
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14 L. CABANE
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The author thanks the reviewers and the various colleagues who gave valuable input this paper.
No potential conﬂict of interest was reported by the author(s).
This work was funded by post-doctoral fellowships from the University of Bordeaux (2013) and the Institute
for Research on Innovation in Society (IFRIS) in Paris at CERMES3 (2014-2015).
Notes on contributor
Lydie Cabane is an Assistant Professor at the Institute for Security and Global Aﬀairs, with an interdisciplin-
ary background in sociology and political science.
Lydie Cabane http://orcid.org/0000-0002-0696-6725
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