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Shaping the global: knowledge, experts, and U.S. universities in the emergence of global health

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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.
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Globalizations
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Shaping the global: knowledge, experts, and U.S.
universities in the emergence of global health
Lydie Cabane
To cite this article: Lydie Cabane (2022): Shaping the global: knowledge, experts,
and U.S. universities in the emergence of global health, Globalizations, DOI:
10.1080/14747731.2022.2082130
To link to this article: https://doi.org/10.1080/14747731.2022.2082130
© 2022 The Author(s). Published by Informa
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Shaping the global: knowledge, experts, and U.S. universities in the
emergence of global health
Lydie Cabane
Institute of Security and Global Aairs, Leiden University, The Hague, The Netherlands
ABSTRACT
The term global healthhas become the dominant way to describe worldwide
interventions on health since the 2000s. Despite signicant 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 diusion of global healthas 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 diusion in universities. It shows
that the denition of global healthcame 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 scientic and
political elds in globalization.
KEYWORDS
Global health; globalization;
universities; knowledge;
United States
Introduction
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 reection of globalization
but instead reects specic contexts, visions, and paradigms, themselves embedded in power
relations. Knowledge is essential to the denition 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 diusing 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 dening 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 elds as an infrastructure of globalization. Yet,
as disciplines and universities are always embedded in national contexts, they also reect specic
countriesconcerns. In this article, I ask how the invention and the diusion of global healthcon-
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 redenition of US
supremacy.
© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
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work is properly cited, and is not altered, transformed, or built upon in any way.
CONTACT Lydie Cabane l.d.cabane@fgga.leidenuniv.nl
GLOBALIZATIONS
https://doi.org/10.1080/14747731.2022.2082130
Global healthhas 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 healthonly really emerged in the 1980s1990s. During the
2000s, it replaced international healthas a conceptual and political paradigm for intervening
on the health of populations worldwide, supposedly in reection 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 oers 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
globalas a self-evident issue the world has gone global, and so has health, and so should health
governance the global oers here a point of departure for an inquiry about the politics of becom-
ing globalat the turn of the twenty-rst century.
By focusing on the origins of global health’–as a concept and a paradigm I suggest that the
global talkabout health (Hodges, 2012) is not intrinsically global but the result of a specic and
localized entanglement between knowledge and politics.More specically, the article focuses on
how US experts and universities actively engaged in the practice of dening and shaping global
health.
1
It argues that the framing of global healthreected the specic concerns, interests and
values of those who developed and promoted the notion. Global healthconsists of a specic 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 armation of U.S.
power and the structuring of neoliberal and economic globalization (Sparke, 2003).The denition
and adoption of the term resulted from specic 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 scientically.
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 (Jasano,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-
turesof 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 insuciently discussed the role of knowledge and expertise in the emergence of global health.
Below, I examine how global healthwas rst coined as a concept, how it circulated and became
dominant as an academic eld and a way to think about health worldwide.The article combines
archival research, an analysis of institutional reports and the scientic literature, as well as a few
interviews with global health experts from Harvard University. As a whole book would be necessary
to give a denitive account of this history, I focus on selected meaningful moments, places, and
actors. A systematic literature review of the origins of global healthhelped me identify the key
institutions and actors I then focused on.
First, I review the dierent 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
2L. CABANE
U.S. to dene Americas vital interests in global health. The third part delves into the institutio-
nalization of global healthin 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 healthby 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 healthreplaced international health.
The rst and most common is globalisation. This view considers global healthseen as a response
to structural transformations generally coined under globalization, reecting 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-rst 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 healthprimarily reects 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 suciently explain why
the term global healthwas used, where it originated from, and how it circulated.
An alternative explanation examines how global healthepitomized a redenition of security
and statesinterests 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 diseasessuch as AIDS and Ebola. In their view, these pandemics, potential or real,
compromised Americas security and ability to trade and prosper alongside economic globalization.
Notably, the 1997 report of the Institute of Medicine, Americas Vital Interest in Global Health, best
captured this worldview(King, 2002) and formalized a denition of global health. This focus on
the role of experts, knowledge and parochial concerns in Washington points to signicant connec-
tions between expertise and US hegemony in the invention of the notion. Yet, it provides fewer
clues on its diusion, particularly beyond biosecurity issues and broader global governance circles.
Global health entailed not only a discursive change but also signicant 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 healthin response to growing competition from other
players in the eld of international health an argument echoed by others (Birn, 2009; Chorev,
2012; Cueto et al., 2019). The World Bank challenged the WHOs leadership in 1993 when it
GLOBALIZATIONS 3
dedicated its annual report, the World Development Report,toInvesting on Health. The report
promoted new economic measurements of health, and dened health as a prerequisite for econ-
omic development, rather than the contrary development for health which was the WHOs 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 redenition of
its mandate (Antezana, 1997; Godlee, 1997; Lee et al., 1996; Stenson & Sterky, 1994). Global health
oered 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 reected 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 healthbut 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 healthsignalled a shift in health interventions from
social development to economic growth, from equity to cost-eectiveness, 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 reection 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 diusion of global health.
However, they do not oer specic grounds for the terms invention and have diverging accounts
of its rst uses at the WHO, the US Institute of Medicine, or in specicelds of knowledge. To
tackle these limitations, I turn the focus to how science shapes understandings and the politics of
globalization through the invention and diusion 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 dene problems, policies and solutions in inter-
national policy coordination (1992). More recent approaches have either focused on discourse
and power (while neglecting the specic 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
4L. CABANE
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
denition of concepts by actors are essential in shaping the global objects and, consequently, global
politics.
This last theory rejoins a urry 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 denes global objects and, thus, shapes
political interventions. Jasanoand others have demonstrated how science is a political agentin
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 Allans 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 healthboth as a
scientic 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 dening 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 denition structures glo-
bal politics in ways that reect the visions, values and interests of those who invent them. This argu-
ment builds on recurrent claims about how power in the eld of health is co-constructed by
knowledge (Fillol et al., 2021; Gaudillière et al., 2022; Moon, 2019; Shiman, 2014). Put dierently,
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 eld of global health, which also reects 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. Dening the globalrequired 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-armation 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 diseasesworldview essential in dening the security politics of global health(King,
2002)however, neglecting the humanitarian component of global health(Lako,2010). Sparke
(2003) also makes a similar point by asserting that global healthis associated with a transform-
ation of the US Empire. I shift the attention to the specic role of US experts and universities in
dening 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 signicantly contributed to
shaping knowledge production about the globalthrough 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:rst, the invention of the concept at the interface of
GLOBALIZATIONS 5
science and politics in North America in the early 1990s; second, its stabilization as an academic
eld connected to the market and politics of globalization in the U.S. in the 2000s.
Inventing global health: critiques and reconguration of international health at
the turn of the 1990s
The emergence of global healthas 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 eld of health. New ideas coming from the Americas reected concerns and inter-
ests about development, economic globalization and security.Experts circulating across networks
and political institutions dened and spread the notion of global healthin the early/mid-1990s at
the interface of U.S. interests and shifting geopolitics.
Redening 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 dicul-
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
countriessupremacy and power to shape health interventions in the developing world. Economic
development, demographic transitions, and globalization were redening 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 redene 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 scientic and economic developments arouse American political interests in inter-
national health. The 1980s were times of considerable scientic 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 scientic 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 nations decline in the 1970s, these developments appeared as an oppor-
tunity to revive the U.S.inuence through investments in biotechnologies and international
health.
2
In 1985, a report from the Oce of Technology Assessment of the U.S. Congress rec-
ommended increasing research funding and international collaborations in those elds.
3
Whereas
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 redening international health
as a security and economic interest, that oered 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.
6L. CABANE
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 healthwas a humanitarian
endeavour to extend the benets 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 reected those of Western countries, global healthappeared 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
this zeitgeist:
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 healthis 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 globalstemmed 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 populationshealth 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 ourished and best articulated those cri-
ticisms about the oldinternational 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 dene 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 transitionto a newinternational health aimed at
reversing previous hegemonies, considering that health problems as issues that are the responsi-
bility of all countries(Frenk & Chacon, 1992, pp. 205221). At the same time, they advocated
for the emergence of a [new] paradigm of international healthas an interdisciplinary eld. This
conceptual redenition sought to promote their own work at a time when old paradigms were
breaking down and when there were opportunities for redening globalpolitics.
GLOBALIZATIONS 7
These discussions were vital in bringing forward the notion of global healthas they signi-
cantly inuenced 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.
Americas interests in global health.
These debates converged in an inuential report by the U.S. Institute of Medicine, AmericasVital
Interest in Global Health, published in 1997. The report formalized the rst denition of global
healthas 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 dened. The
insistence on interdependence and cooperation reected 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 rst
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.
4
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-
icasinterestsin a post-Cold War, postcolonial, globalizing, neoliberal world.
Three aspects of that denition 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-
lationshealth but served to dene American interests. The globalappeared as a justication 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 Americas 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 basisfor intervening globally on health, and an engineof economic and political power.
The U.S. global health policy needed medicine and public health to ght 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 healthresulted from the convergence of pol-
itical, economic and academic interests and the American governments strong interest in science
and biotechnologies in the 1980s. Earlier formulations of global healthas a criticism of Western
8L. CABANE
domination were eventually overturned to provide a new legitimacy to the U.S. as a conductor of
global governance in the twenty-rst century. The praiseworthy attempts to redene 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 ghting 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
dening international organizationspriorities, 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 healthtook obecause
it could articulate dierent visions, from powerful countries and international institutions to the
criticisms of the previous colonial and development period.
The denition of global healthwas thus an attempt to shape global governance in ways that
conveniently served (North) Americas interests. The notion originated from various debates but
was formalized and dened 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.
Diusing global health: the role of U.S. science and universities in shaping global
health
How did global healthbecome 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 healthin the US academia
was essential to its broader diusion. Empirically, US universities have become actors of global
healthpolitics through their education and scientic programmes or by supporting global organiz-
ations with their research. Theoretically, such a focus can be justied by the coproductionargument
(Jasano,2004), according to which the stabilization of knowledge within a eld 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 globalopportunities and discourses. This part examines
how the institutionalization of global healthwithin the US academia through the constitution of an
academic eld 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 healthresearch
The rise of global healthin 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
GLOBALIZATIONS 9
(Byass, 2013). In 2008, almost nine out of ten articles published on global healthin scientic
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
healthwere 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 healthis highly localized in
the US.
The development of global healthprogrammes, institutes, initiatives, and partnerships
throughout the 2000s largely supported this supremacy. Whereas 24 global healthprogrammes
existed in 2002 in the U.S., this number reached 52 in 2009 (Merson & Chapman, 2009). In
2015, 88 North American universities were aliated with the Consortium of Universities for Global
Health, the organization that federates global healthacademic programmes in the U.S.
5
The devel-
opment of an academic infrastructure supporting global healthknowledge thus reects the same
ambiguities as the concept. The globalin global healthindicates rst 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 healthas an academic engine
In 1999, the University of California San Francisco created an Institute of Global Health, one of the
rst in the United States to use global healthto designate its activities (Macfarlane, Agabian et al.,
Figure 1. Number of global healthpublications in PubMed.
Note: For Figures 13, searches were carried in English, which may bias the results. However, combining various languages would be
dicult given that the databases enabling such comparison include more English publications, reecting wider structural inequalities.
Besides, English is the predominant publication language, especially in medical elds, even outside English speaking countries. Besides,
globalization has also generated a diusion of the term, incentivising other countries to adopt the term global healthto position
themselves in this eld. 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.
GLOBALIZATIONS 11
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.
6
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 Forumsto foster health leaders networks, and headquartered a working
group of the WHO Commission of Macroeconomics and Health. Global healthpositioned 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-rst 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 armation expresses best the complexities and ambiguities of global health. On the one
hand, the new label sought to arm 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 healthappeared as a protable academic endeavour
anchored in the U.S. economy. It dened 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 healthwas 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 healthin California: for the year 2007, it estimated that business activity related to
global healthgenerated 49,8 billion dollars, including 4 billion by the Universities of California.
7
Academics and universities considered global healthas a protable academic enterprise
8
notably
through international clinical experiments, research partnerships (Petryna, 2009), or international
educational programmes.
9
Global interventions in the eld of health became a strategic economic asset. As an academic
enterprise(Adams, 2010), global healthmade markets and academic research the prime source
of power for the U.S. under the global healthparadigm. This reversal of values is part of a broader
movement that saw American universities become over the past 30 years economic enginesinte-
grated into the market, massively beneting 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 diusion and institutionaliza-
tion of global healthwent hand in hand with the armation 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 healthin the U.S. academia contributed to its diusion by creating cog-
nitive tools and research infrastructure to support Americas 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 universitiesadvocacy, which co-constructed political
understandings of global health.
The development of global healthrst responded to the U.S. governmentsnancial 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.
10
In 2015, the federal
budget dedicated $8 billion to global health against $1 billion in 2000 (Ravishankar et al.,
2009).
11
U.S. presidents initiated and drove this rise in global healthfunding, particularly with
the Presidents 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 healthstill represented the rst component of U.S. foreign assistance (24%).
12
This funding
largely irrigated universities thanks to the National Institute of Health research or educational
grants, USAID partnerships, or global healthpartnerships eligible for development assistance aid.
Moreover, the rise of public-private partnerships and foundations in global health boosted univer-
sitiesactivities (Rushton & Williams, 2011). The most prominent actor is the Gates Foundation, cre-
ated in 1994. It dedicates a signicant part of its budget to research organizations and universities in
rich countries, which turned it into a major sponsor of global healthon American campuses (Sridhar
&Batniji,2008). For example, when Harvard University started its global healthactivities in 2000,
the Gates Foundation donated 44 million dollars to its Global Health and Social Medicine department
to build its international programmes.
13
It also funded one of the agship 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 healthas a worldwide activity, and an element of U.S. global activities.
These nancial ows do not simply indicate a mechanical response to nancial incentives and pri-
orities dened by political powers. Inuential global healthU.S. academics shaped these political
intereststhrough their research and advocacy as in other globalacademic elds (Kamola, 2019).
The most notable case is that of Harvard global healthscientists 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 healthand a professor of
social medicine at Harvard. Farmersinvolvementinglobal healthincarnatedthosesameambiguities
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.
Conclusion
By enlightening the debates and conditions in which the notion of global healthemerged, this
article has shown how, far from simply reecting global conditions and modes of governance, it
GLOBALIZATIONS 13
was part of a re-ordering of world politics. At a time when global governance and globalization
were emerging, the denition of a category to describe worldwide interventions in the eld of
health served to redene and legitimise the U.S. position and power in global aairs. The article
demonstrated how the co-institution of political interventions and academic research in the US
was essential in dening 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 countriesagency. 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 benecial to U.S. universities, which
institutionalized global healthand diused 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 diusion 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 healthand 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 diusion. This perspective opens new
scope for global health research in IR: for example, how U.S. academicsconnections with private
philanthropies and policy actors shape U.S. and international policies; how scientic 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 elds of
knowledge in parallel to politics.
Second, this articles other contribution lies in showing how the denition of the global
(in health) stemmed from U.S. parochial concerns and ideas. The history of how international
health became globalprovides a relevant example to question how we think of processes as global.
This episode is an important reminder that the notion of the globalis not xed. Instead, it reects
power relations; the ability to dene 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 globalto uncover knowledge and power
dynamics.
Notes
1. To make clear that I focus on the invention of global healthas a concept, I keep the expression in
brackets.
2. Quality and Relevance of Research and Related Activities at the Gorges Memorial Laboratory (Washing-
ton, DC: Oce of Technology Assessment, Congress of the United States, 1983), 93. [Source: the OTA
legacy website: https://www.princeton.edu/~ota/].
3. Status of Biomedical Research and Related Technology for Tropical Diseases (1985, p. 294); Washington,
DC: Oce of Technology Assessment, Congress of the United States.
4. Global Health Population at 50: 50 years of capacity-building and partnerships. Harvard Global Health
Institute, http://web.archive.org/web/20141214003825/http://globalhealth.harvard.edu/news/ghp50-
fty-years-capacity-building-partnerships.
5. http://www.cugh.org/membership/members.
6. http://web.archive.org/web/20020615010350/http://igh.ucsf.edu/about/index.html.
7. The Importance of the Global Health Sector in California: An Evaluation of the Economic Impact
(San Francisco: UC Global Health Institute, 2009).
14 L. CABANE
8. Meeting Report. University Consortium for Global Health Inaugural Meeting 79 September 2008
San Francisco, California(University Consortium for Global Health, 2008).
9. Interview, September 2013, Harvard University, Centre for Global Health, MGH.
10. Committee on the U.S. Commitment to Global Health; Institute of Medicine, The U.S. Commitment to
Global Health: Recommendations for the Public and Private Sectors (2009).
11. http://k.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of-the-scal-year-
2015-budget-request/.
12. http://k.org/global-health-policy/issue-brief/a-ce=heck-up-on-u-s-global-health-policy-after-one-year-
of-the-trump-administration.
13. Interview, professor, Department of GHSM, Harvard University, September 2013.
Acknowledgement
The author thanks the reviewers and the various colleagues who gave valuable input this paper.
Disclosure statement
No potential conict of interest was reported by the author(s).
Funding
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 Aairs, with an interdisciplin-
ary background in sociology and political science.
ORCID
Lydie Cabane http://orcid.org/0000-0002-0696-6725
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