From International Health to Global Health
Michael Rueschman, MA
MPHP439, Dr. Neuhauser, Spring 2006
What is International Health? Is it a single, distinct definable field or merely a collection of health related ideas concerning the exotic underdeveloped world? Does it concern a particular set of beliefs, body of knowledge and practice that is shared by certain individuals who are claimed as professionals within the field? In “Textbook of International Health”, Paul Basch writes that indeed International Health includes a variety of perspectives from different fields of knowledge. It includes:
o An understanding of public health and epidemiological principles.
o Some appreciation for the root causes of ill health along with some level of technical comprehension
o A degree of sympathetic understanding of the emotional and psychological consequences which illness can cause individuals, their families and by extension their communities.
o An understanding of the economic significance of illness, the impact it can have upon an individual and his or her support system, as well as the economic aspects of seeking and accessing health care.
o Recognition of the social and environmental consequences of human population growth and development along with knowledge of non coercive family planning methods.
o Special consideration of the similarities and differences which exist within and among world’s populations.
o Familiarity with the structure and functioning of governments, especially ministries of health and other sectors related to health promotion and disease prevention.
o Understanding the relevance and importance of different systems of medicine and healing in various contexts.
o Sensitivity to ethical aspects of research and practice in marginalized groups and societies.
o Humanitarian response to disasters and emergencies, usually in situations when lives are suddenly disrupted by natural or civil calamities. (Basch, 1999, p. 5-6)
Certainly international health concerns all of these things and more. Our popular view of international health is constantly being shaped and reshaped by the images and stories produced by the media about HIV/AIDS, cholera and more recently SARS and avian influenza. But where does the professional discipline of International Health lie? This is an academic as well as practical endeavor pursued by many people with varying perspectives and skills, with underlying interests like those mentioned above.
In today’s world, International Health can be defined as health focusing “on the control of epidemics across boundaries between nations” (Brown, Cueto, & Fee, 2006, p. 62). Another definition considers it to be “knowledge and practice regarding health problems in less developed countries” (Coreil, 1990, p. 3). Thus, implicit in the foundations of international health is the role wealthier nations (countries of the North) play in affecting the health and well being of less wealthy nations or those nations of the South. However, within recent years, there has been a rise in the number of publications within the field of public health using the term “global health.” Brown et al. (2006) note that between 2000 and summer 2005 there were as many as 39,759 hits on PubMed for “global” (globalize and globalization) as compared to 52,169 for “international.” It is a rapidly growing area of interest to researcher. Furthermore, there have been ongoing dialogues concerning whether there is an apparent paradigm shift in motion or just a semantic shift among academicians. This chapter will focus on the paradigm shift from international to global health. We will review the origins of international health, the major players in the field as well as the economics of health as the implication for policy in this transition.
The origins of International Health
anthropologist George Foster wrote that international health can trace its
origins to the missionaries who visited indigenous populations with the hope of
curing both their bodies and minds rather than to employ preventative measures
(1982, p. 189). It wasn’t until the 19th
century, in what Basch (1999) refers to as the internationalization of health, and
began. Preventative measures were also becoming a more integral part of public health
measures at this point. In addition,
nation states began to co-operate more with each other in a variety of ways and
international health programs began to grow in breadth and complexity. One of the first government to government
forms of cooperation and recognition on a large scale of international health
occurred in 1874 with the International Sanitary Conference in
International Health in the 20th century: WHO inception
in the post World War II era really grew in importance. In addition, many
former colonies were newly independent and the rise of the Cold War continued
to influence how nation states related to each other. Some key organizations that have
traditionally played and have increased their roles in international health include:
The Bretton Woods Institutions, came out of a conference at
The United Nations group of organizations came out of a post-world War II declaration by 26 countries to continue fighting against Axis Powers (Basch, 1999). Under the General Assembly of the UN there are many activities and organizations which promote health and development such as the UN Children’s Fund (UNICEF), the UN Development Programme (UNDP), and The World Food Programme. Moreover, there are also several autonomous and specialized sub-organizations which set their own standards, set their own policies and provide technical assistance. The one most relevant to the current discussion is the World Health Organization (WHO), which has long been considered the leading premier of knowledge and expertise on the world health since the end of WWII (Perkett, 2003). But, in recent times many critics have begun to argue that the current structures of such organizations are ill equipped to handle global health issues in today’s world. This point will be discussed in later sections.
Disease and health as bounded by national borders to the birth of the Global Village
In light of the rapid pace and magnitude of globalization, there is a need for a radical reconceptualization of how we think about health and prioritize global health issues. However, we must first define globalization. Wikipedia, an online encyclopedia that is itself a product of global collaboration defines globalization as:
The worldwide phenomenon of technological, economic, political and cultural exchanges, brought about by modern communication, transportation and legal infrastructure as well as the political choice to consciously open cross-border links in international trade and finance. It is a term used to describe how human beings are becoming more intertwined with each other around the world economically, politically, and culturally. Although these links are not new, they are more pervasive than ever before. (“Globalization”, 2006, para. 1)
This Wikipedia entry lacks any mention of “health,” but one can recognize that the globalization of these forces can affect different aspects of the local population including health, which everyone has. The globalization of health has many implications and the connections aren’t always clear. In addition, globalization of health (international health) is no longer about the health or the fear of infectious diseases from the South but also about the spread of industries such as tobacco and fast food to poorer nations where legislation for control has not yet come into being. The transfer and exchange of values and ideals is an important aspect to the global health discussion. There have been arguments which have promoted the concept of “global mindedness” and hold macrocosmic views of the world in which they are fundamentally connected to other people around the world (Scholte, 2005). The idea of the “global village” proposed by Banta promotes a sense of an all encompassing, broad approach to dealing with the world’s health problems that requires much more than the help of specific nations but a partnership of sort with different players (2001). This is essential to the global health concept and represents a key shift in thinking about the health of the world’s population.
Who is Responsible for the health of the Global Public?
The WHO has traditionally been the main player in “directing and coordinating international health work” (Walt, 1998). But in today’s world it has become one of many stakeholders in the health of the global public. The WHO has been increasingly criticized in recent times for being ill equipped to handle the health concerns of the world in this age of rapid globalization. On the other hand, the increasing participation of the World Bank has shown that there is a shift in focus on how health and its determinant are constructed and perceived on the international level even under the UN umbrella of organizations. Furthermore, the ever rising roles of other private organizations, non governmental entities such as Oxfam or foundations such as Rockefeller and Gates, and profit-making pharmaceutical (such as the donation programs run by Merck and Glaxo, Smith and Kline) and insurance companies have definitely widened the playing field. Yet, many authors will argue that there is still a role for the WHO and other specialized agencies in this ever increasing interdependent world. Walt argues that since politically neutral organizations such as the WHO cannot be replaced by bilateral organizations, the rising roles of non-governmental entities involved in health will continue to use the WHO and UN as their primary vehicles of representation and change in the global health world.
So, with the growing range of players in the global health arena, all stakeholders must ask consider certain key points such as: Can organizations like the WHO and UN operate effectively in their current structural states?; What roles do international organizations have the monitoring and promotion of international cooperation in this changed world?; and What role(s) should national governments have in this globalized world of public health? (Walt, 1998) These are crucial concerns and are important to the discussion in examining the health of the global public. Furthermore, the challenges are great and will continue to grow as globalization continues to intensify all levels of relationships among different players. So, there is a need to rethink the role of international health organizations, there is a need for each player; but at the same time, there is a recognition that it may be often easier to retreat into one’s domestic sphere and detach from the global responsibility in the growing global village.
The Economics of Global Health
As the number of actors in the global health arena has increased in recent years, issues surrounding the economics of the field and resources required to tackle some of the world’s most pressing problems have come to light. In this sense, economics is used here to mean not only finances but all of the resources and services intertwined with global health matters. Inequalities are readily apparent between the developed and developing worlds, although as diseases become more salient between the haves and have-nots there arises a problem about what health issues take precedence in this burgeoning arena. There are divergent streams of thought about where money and other resources should be aimed to best improve global health; for example, North vs. South, infectious vs. chronic diseases, technological vs. social solutions. The complexity within all facets of the global health arena makes this issue of economic distribution and dissemination even more important, because in order to effectively address the world’s health there must be a cohesive and comprehensive body of actors working together toward a common, altruistic goal.
Turning now to one of the most ambitious and publicized efforts toward improving global health, the Bill and Melinda Gates Foundation (BMGF) is now funding the Grand Challenges in Global Health initiative (Varmus et al., 2003). The Gates family have pledged to donate $6.2 billion to research related to global health. The directors of the initiative outlined 14 Grand Challenges that deal with some of the most pressing health problems of the world, and over recent years the BMGF has provided hundreds of millions of dollars to spur research and development on these global health issues. The 14 Grand Challenges are:
Improve childhood vaccines:
Create new vaccines:
Control insects that transmit agents of disease:
Improve nutrition to promote health:
Improve drug treatment of infectious diseases:
Cure latent and chronic infections:
Measure disease and health status accurately and economically in developing countries:
This brief presentation of the 14 Grand Challenges is quite general, although in considering these proposals as a whole one can see that they definitely seek to tackle some of the most pressing problems in global health today. Issues related to infectious diseases are present in many of the Grand Challenges, which makes sense because of the extreme disease burden impressed upon the world by tuberculosis, malaria, HIV/AIDS, and others. There is reason to distinguish between grand challenges and grand problems such as the HIV/AIDS pandemic. As Richard Klausner, Executive Director of the Global Health Program of the Gates Foundation, explains:
Grand challenges are not the same as grand problems. We need to distinguish between the two. AIDS is a problem but it is not a grand challenges. Finding an AIDS vaccine is not even a grand challenge. But solving the bottleneck that prevents the creation of an AIDS vaccination is a grand challenge. It’s about finding critical pathways through the problems. Many proposed problems did not make it onto the Grand Challenges list because they could not be turned into critical pathways. (in Walgate, 2003, p. 915)
Comprehensive appraisals of these critical pathways will lead to successes in addressing the Grand Challenges of Global Health. The BMGF consistently acknowledges the complexity of issues cast in a global light, and in taking such a mindset the foundation disperse its financial resources to a wide array of researchers working on various facets of these challenges.
Though the BMGF is a fitting example of an organization currently offering vast resources for research on global health initiatives, questions still persist about whether current economic outpourings are reaching the right people and actually making a difference in the global health landscape. Criticisms aimed directly at the Gates’ Grand Challenges of Global Health include its shying away from the issue of chronic disease (Walgate, 2003) and its focus on basic research instead of delivering drugs and preventives today (Cohen, 2006). Certainly, though, the BMGF can not be faulted for engaging in extensive philanthropy and creating a unique agenda that highlights global health as a top priority. Other organizations that have joined the fight to address global health challenges include:
These are only a few programs, each with different areas of focus but all with a common goal of dedicating resources toward solving these daunting health problems.
Finally, in the arena of economics of global health, there has been a recent proliferation of so-called public-private partnerships (PPPs) (Buse & Walt, 2000; Widdus, 2001). The public side often includes mainstays in international health such as the WHO and UNICEF, but often the financial resources necessary to get intervention programs off the ground must come from private sources. Janes (2004) notes the diminishing of the state’s role in health care provision and the decrease in funds dedicated to public health, a trend which is likely in part responsible for the collaboration between the public and private sectors. Other possible reasons for the development of PPPs include the private sector’s desire to be more closely involved in global governance in a world immersed in globalizing forces (Buse & Walt). Pharmaceutical companies have been some of the most important players in the PPP environment because they often possess the drugs that global health organizations need to effect change on the ground. Later in this chapter one of these public-private partnerships will be showcased in the case of the global fight to eliminate lymphatic filariasis.
Global Health Policy and Management
Tied intimately to the economic landscape in global health is global health policy-making and management, the results of which ultimately impact health outcomes on the ground. Therefore, knowledge of the processes underlying these policy and management decisions is absolutely essential in order to conceptualize global health and to trace the various pathways that lead to either successes or failures in application. As discussed earlier, there are a variety of players in the global health arena who have stakes in the world’s health, and this section will further elaborate on the manner in which such organizations have operated and interacted in a global gaze over time.
Janes (2004) traces the initial efforts to establish a global health policy to the World Assembly held in Alma Ata in 1978. From this conference a vision was shaped that put an emphasis on immunization, reproductive health care, contraception, sanitation, and the promotion of safe motherhood (Janes, 2004, p. 458). Brown et al. (2006), in describing the results from Alma Ata, state that “the Declaration of Primary Health Care and the goal of ‘Health for All in the Year 2000’ advocated an ‘inter-sectoral’ and multidimensional approach to health and socioeconomic development, emphasized the use of ‘appropriate technology,’ and urged active community participation in health care and health education at every level” (2006, p. 67). This conference resulted in basic guidelines that were supposed to help guide effective public health programs throughout the world, though clearly its lofty goal to have a healthy world at the turn of the century did not succeed. The importance of Alma Ata is not lost, though, because it certainly did mark one of the first worldwide collaborations aimed at solving some of the world’s most devastating health problems.
The world’s health problems were exacerbated in the 1980s with an increase in chronic diseases, the HIV epidemic, and the resurgence of infectious killers like malaria and tuberculosis. This trend led to a shying away from Alma Ata’s primary health care ideals to an approach more focused on selective interventions rather than genuine social change (Janes, 2004). Global health managers and policy makers in recent decades operated in a mindset that “focused on downsizing and streamlining the state and on ensuring that its commitments to guaranteeing an acceptable level of care was achieved at the least possible cost” (Zwi & Yach, 2002, p. 1620). Interestingly, in the 1990s the WHO was losing some of its prominence in the global health arena as a multitude of other organizations entered the scene, though the most crucial policy formed during this period may have been the World Bank’s 1993 World Development Report, which conceptualized the health of the world in terms of efficacy and economics (Brown, Cueto, & Fee, 2006). Janes (2004) explains that the World Bank report “advances an argument for health reform based principally on an assessment of the cost-effectiveness of health interventions in a global context of shrinking public investment in health care and public health” (2004, p. 459). The World Bank’s greatest strength was its ability to mobilize large financial resources; by 1996 its loans for health surpassed the total budget of the WHO (Brown et al., 2006). Dominant global health policy following the recommendations of the World Development Report called for a reduction of state commitments to health and instead encourages privatization of the health sector. Unfortunately, in a frame of mind dominated by cost-effectiveness and efficiency, the countries with the least amount of resources could not mount campaigns powerful enough to quell growing health issues. Thus, diseases of the world became the target of global health interventions, not the people who contract and suffer the diseases (Janes, 2004).
One response to economic and development based global health reform has been a focus on health care equity (Zwi & Yach, 2002). Equity is a topic relevant at many levels, not only between developed and developing countries, and that is likely why it has become very prevalent in global health discussions in recent years. An equity based approach to health care departs from more macroeconomic frameworks of health and acknowledges the social determinants of health. Equity can be thought of as “striving to reduce systematic disparities in health between more and less advantaged groups within and between countries” (Zwi & Yach, p. 1616). Global health management and policy that takes equity as a prime directive must consider three socioeconomic processes: 1) fair mobilization of resources to pay for everyone’s health care (often termed vertical equity); 2) needs-based distribution of health services – in terms of access, quality, and type of care (horizontal equity); and 3) fair protection afforded to individuals and families from the consequences of catastrophic illness (Janes, 2004, p. 461).
Health care for all, economics-driven health care, and equity based health care represent only broad strokes in the history of global health. Policy and management decisions ultimately rest with those who have power of the resources linked to health, although clearly this playing field has shifted as the role of the state in health has diminished while international and nongovernmental organizations have seen their roles increase. Global health policy does not stem from one, overseeing organization, but rather emerges through worldwide collaboration involving countless actors.
A Success Story: The Global Programme to Eliminate Lymphatic Filariasis (Ottesen, 2000)
One prime example of success in the global health arena
is the Global Programme to Eliminate Lymphatic Filariasis (GPELF). Though not as well-known as diseases such as
tuberculosis or HIV/AIDS, lymphatic filariasis (LF) affects nearly 50 million
persons worldwide and is endemic in tropical regions of Asia, Africa, Central
The two factors that brought this global health initiative to fruition were the increase in the political commitment to address the health impact of LF and the technological refinement of treatment regimens by pharmaceutical companies. In 1997 the WHO “called for countries to strengthen activities toward eliminating lymphatic filariasis as a public health problem and requested the Director General of WHO to mobilize support for global and national elimination activities” (Ottesen, 2000, p. 592). Pharmaceutical breakthroughs included the enhancement of the drug into an annual, single-dose, which when given to an entire community over an approximately five-year period would effectively kill off the disease vector. Additionally, a crucial step in establishing the GPELF came when SmithKline Beecham (now known as Glaxo Smith and Kline) agreed to work with the WHO and provide all the required drugs for free to see the elimination program through to its conclusion. These technical and political halves merged to form the GPELF and worked together to develop a set of guidelines by which countries in the endemic region for LF could follow in order to address this widespread health problem. In conjunction with the global partners in this initiative individual countries start out with a plan of action, which is ultimately agreed upon by all parties so that work on the ground can begin and the necessary drugs can enter the country in need.
As of 2000, 29 of the 80 endemic countries in the world have entered into this elimination process, and at the end of 2000 over 25 million at-risk individuals have been treated for the disease. The benefits of the GPELF extend beyond simply reducing disease burden from LF. First, the widespread use of the elimination drugs also holds ancillary benefits for other endemic diseases such as hookworm and other intestinal parasite infections. All of these health problems affect not only person well-being but also productivity of the population in general. The nations who undertake this objective stand to benefit greatly and demonstrate in a cost-effective manner the value of this particular global health program. As Ottesen (2000) summarizes:
The third, and perhaps most broadly important, consequence of the GPELF is its reinforcement of a new approach to the health problems of the developing world. Good health is directly beneficial to all sectors of society. While responsibility for health problems has generally fallen to the public sector, resources and skills to address these problems are increasingly found in the private sector. Hence shared responsibility by the public and private sectors for the health problems of the world is extraordinarily important, and the network of partners that form the Global Alliance for the Elimination of Lymphatic Filariasis can become a model for approaching the health concerns of under-served populations worldwide. (2000, p. 594).
This chapter has provided a brief introduction into some of the major concepts and actors in the emerging field of global health. The world is indeed a Global Village, with globalization and the emergence of new threats to the world population’s health requiring a paradigm shift from international health to global health. Inherent in this global health paradigm is perspective writ large, necessitating an approach that addresses and accounts for global and local phenomena when considering health matters. Globalizing forces are not new but have rather intensified in recent decades, and these global processes have indelibly changed the face of the world’s health. The landscape of global health managers and policy makers has also shifted over time, bringing numerous new players into this arena. This added complexity makes assessments of global health’s underlying mechanisms more difficult, but still necessary in order to make worthwhile gains in the struggle to improve the world’s health.
Global health reporting site -
News site providing links to articles, conference proceedings, and conference annoucements concerning HIV/AIDS, tuberculosis, and malaria
Global Health Council - http://www.globalhealth.org/
The Council works to ensure that all who strive for improvement and equity in global health have the information and resources they need to succeed.
Global health facts site -
Site provides current epidemiological data, both globally and by country, concerning HIV/AIDS, tuberculosis, malaria, and selected other infectious diseases.
Carter Center health programs - http://www.cartercenter.org/healthprograms/healthpgm.htm
information about the
GlobalHealth.gov - http://www.globalhealth.gov/
Site of the Office
of Global Health Affairs, a section of the U.S. Department of Health and
Human Services. Contains employment and funding opportunities as well as
reports of the activities of the
HHS Office of Global Health Affairs -
Presents the mission and scope of activities of the Office of Global Health Affairs. Not the same as GlobalHealth.gov, though the two are linked.
CDC Office of Global Health -
Describes the efforts of the CDC and the ATSDR to recognize and respond to international influences on US health and to engage in global public health research and practice.
Globalization and Health
journal - http://www.globalizationandhealth.com/
Peer-reviewed, open-access journal devoted to consideration of the effects of globalization on health.
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