Global science and social movements: towards a rational politics of global health
Article Outline
Summary
Tropical medicine as a discipline was originally limited to those diseases that are the consequence of the ecology of disease in the tropics. Over the past 100 years we have come to realise that this limitation was the consequence of an historical snapshot. The commonality of human experience throughout the world speaks to our common biology and has led to the articulation of Global Health. We lack a coherent understanding of Global Health but its reach is beyond that of governments and entails concepts of justice and humanity as well as biomedicine and all the attendant semi-congruent disciplines. The development of Global Health will redefine the roles of all the stakeholders in the international health community be they individuals, institutions, agencies or medical journals. At present the gestation of Global Health involves the chaotic tumbling, rumbling and knocking together of ideas and aspirations. The hope must be that the outcome will be the highest attainable standard of health for all if not the perfectibility of humankind.
Keywords: Global science, Social movement, Global health, Health equity, Social justice
We do not live in a healthy world. About 100 years ago, Patrick Manson argued that tropical medicine was best seen as a branch of natural history.1 Both domains of inquiry shared many traits: ‘clearing the mind of tradition and cant’; ‘careful observation of facts’; deriving ‘hypotheses based on fact’; ‘testing such hypotheses by experiment’; and ‘the fearless application of the proved hypothesis in practice.’
He used the occasion of his Huxley Lecture in 1908 to look back on the fight to establish tropical medicine as a legitimate discipline. Tropical medicine was tropical, he argued, not because of where human beings with tropical diseases lived. Tropical medicine's uniqueness came from the effect of local climatic conditions on the disease ‘germ’ while it was outside the human body. For this specific group of organisms, high atmospheric temperatures were a precondition for successful passage from person-to-person. Cholera, leprosy and plague were not real tropical diseases, since they could flourish in any climate.
The strategic struggle and tactical manoeuvres that Manson and his colleagues engaged in to secure tropical medicine's birth, development and respectability are instructive today as we try to understand and advance the idea of global health. Unlike Manson's narrow definition of tropical medicine, global health seems to be all things to all people. It is any health problem that transcends national borders. Global health goes beyond governments and intergovernmental agencies. It embraces old and emerging diseases. It is biomedicine, epidemiology, demography, public health, anthropology, economics, political science, law, engineering, geography, informatics, even philosophy. Some advocates invest global health with such political and economic importance that it deserves, they say, the urgent attention of Presidents and Prime Ministers.
For Manson, the objective of tropical medicine was smaller, yet perhaps more achievable. The student's attention, Manson suggested, should be confined almost exclusively:
‘To protozoa and helminths, to the special vectors or media of these organisms, to their pathological effects, and to the prophylaxis and treatment of the diseases they give rise to.’
For those of us who might wish to be zealous participants in the new social movement that is global health, what is our objective? We have multiple, competing and sometimes contradictory frames of reference. Recently, The Lancet supported the idea of the right to the highest attainable standard of health.2, 3 We also put our weight behind health equity, through social justice.4, 5 One might equally see global health through the lens of human development, the Millennium Development Goals (MDGs), and poverty reduction; the global burden of disease (deaths and disability-adjusted life years); health risks; health systems; or foreign policy and health diplomacy.
In truth, there is no agreement about what we mean by global health. We are equally confused about how we should measure progress in global health. Is it survival (a powerful trope - e.g. child survival); age (a life extended); entitlements (a life defined by a minimum set of rights, opportunities or services); health (defined in so many different ways); freedom (after Amartya Sen6); relationships (a life among other lives); participation (as a fully equal citizen); pleasure (in a purely utilitarian sense); or productivity (as an economic unit in society)? Perhaps we mean all of these qualities. But that will not do. Confusion has consequences.
The lack of a coherent framework of understanding about global health is allowing, even encouraging, damaging competition between vertical health communities. AIDS versus everything, MDG-4 (child survival) versus MDG-5 (maternal health), MDGs versus non-MDGs (such as chronic diseases), and between global health initiatives (such as the Global Fund to fight AIDS, Tuberculosis and Malaria) and health systems. As we pass through a period of global economic instability, the fear of losing funding for global health is provoking potentially damaging behaviour. There is unwelcome and unseemly competition between sectors, as if global health was a zero-sum game. There has been rapid alignment behind vertical investments as instruments to strengthen health systems, largely in the absence of good evidence. There has been a hasty dash to the private sector to shore up the business case for global health.
Efforts to create an integrated global community concerned with health have too often led to self-serving factionalism, a disregard for evidence, quasi-Stalinist political manoeuvring, and a view that global health is merely another vehicle to strengthen personal and institutional goals. We might ask, for example, who decided that the H8-WHO, UNICEF, UNAIDS, UNFPA, GAVI, the Global Fund, World Bank and the Bill & Melinda Gates Foundation–should become the umbrella coordinating body for global health? Why is there no open, transparent, accountable and meritocratic system for senior health appointments across the UN? And why do we in the health community stay silent while our governments implement policies that contravene principles of human rights, promote violence, deepen inequalities and foster further aid dependence?
There have been several positive signals of reform. The Paris Declaration, endorsed in 2005, was designed to improve the quality of aid and its impact on development.7 2010 is the target year for delivering progress on country ownership of aid plans, alignment to national policies, harmonisation of programmes, managing for results by performance measurement and mutual accountability. Independent attempts have also taken place to monitor and evaluate progress in global health. The Global Health Watch, an alternative world health report, is one example.8 Another is a preliminary attempt to draw up a scorecard on global health.9 But these types of assessment make one huge and unsupported assumption: that progress is possible. This assumption may be wholly or, at least, partly incorrect.
In 2005, the political philosopher, Thomas Nagel, published an article in Philosophy and Public Affairs entitled ‘The problems of global justice.’10 His arguments have received no serious discussion in the health community. Yet the implications of Nagel's ideas are dramatic.
He begins with an obvious truism: ‘We do not live in a just world.’ He points out that our notions of justice depend upon political institutions that have the authority to deliver justice. In our world today, those institutions are strongest in nation-states. Nagel argues that any meaning of justice that we would understand cannot be brought about except by a nation-state. Justice, and here Nagel means socio-economic justice, requires a government to have the power to ensure that justice is delivered. The concept of global justice is meaningless without some form of world government, backed up by law and force.
No international institution yet exists to deliver justice at a world level. Nagel goes on to defend a view of justice which says that justice is only something we owe to those with whom we stand in strong political relation. That is, those to whom we are related in a nation-state. As Nagel puts it: ‘the full standards of justice…apply only within the boundaries of a sovereign state’. And since there is no such thing as a global sovereign government, there can, by definition, be no such thing as global justice.
If we accept this argument, the predicament it creates for global health is acute and potentially destructive. We speak of global heath as if somehow we have the means to gain traction on global health challenges. But health faces the same difficulty as justice. A health system exists only within the jurisdiction of the nation-state. Only a national government has the authority to strengthen that system. There is no meaning for health outside the context of the nation-state. Only the stateless are truly global citizens, and they remain a group with the least political power of all. With no global governance of health–and WHO certainly does not and cannot provide this kind of governance, except in extreme epidemic situations–there can be no global programme to meet international health objectives. Following Nagel's logic, the concept of global health is meaningless. The best we can say is that the objective of health is something we owe only to those with whom we stand in strong political relation–that is, as fellow citizens within a nation-state. To paraphrase Nagel: the full standards of health apply only within the boundaries of a sovereign state.
Before we blame Thomas Nagel for taking such an unambitious and conservative view of what might be achieved at a global level, it is only fair to point out that his argument has a long and respectable history. The earliest expression of a hierarchy of human obligations that I can find comes from Cicero in 44 BC, in his book On Obligations.11 Cicero asked: how should we treat one another? He acknowledges that human beings share many attributes. But he concludes that it is in the best interests of our community if ‘our bounty is bestowed most of all on those most closely connected with us.’ Cicero investigated the meaning of ‘human fellowship’ with great care. He point out that:
‘First comes that which we see existing in the fellowship of the whole human race…this more than anything separates us from the nature of the beasts.’
He argues that we have an obligation to give firstly to strangers what costs us nothing–running water, fire and ‘honest advice.’ But, like Nagel two millennia later, Cicero wishes to qualify ‘our generosity’. What should take first place in our obligations is ‘our country and our parents’. Next come our children and household. And after that, our relatives and friends. But it is our allegiance, commitment and obligation to the sovereign state that demands our first and absolute loyalty. Why? Because of ‘the debts we owe to the benefits which they bestow.’
So, are we paralysed? There is no supranational authority to force states to deliver any or all of what we mean by global health. Maybe this alarming situation is not so completely hopeless. First, Nagel points out that our ideas–‘our concepts and theories’–about global justice are only in the early stages of formation. The same can be said for global health. 1851 marked the first attempt to reach agreement on a matter of international health: the world's first International Sanitary Conference was held in Paris, attended by 12 European states. Before 1851, the idea that governments would have taken responsibility for the health of their and other peoples would have seemed ludicrous. Fear (of epidemics) drove unprecedented collaboration. After Paris in 1851, governments met in 1859 (Paris), 1866 (Constantinople), 1874 (Vienna), 1881 (Washington), 1885 (Rome), 1892 (Venice), 1893 (Dresden), 1894 (Paris) and 1897 (Vienna). The crucial catalyst for this political cooperation was scientific discovery: the tubercle bacillus (discovered in 1881), cholera vibrio (in 1884), and diphtheria, typhoid and plague (all shortly thereafter). Understanding the biology of infection accelerated the politics of infection. These same scientific forces are operating today. They have the potential to bring about step changes in global health policy.
The idea of a permanent institution to govern global health is only just over a century old. It was first raised in 1874 in Vienna. The Pan-American Sanitary Bureau opened in 1902. By 1923, a Paris and Geneva office had opened, the latter as part of the League of Nations, with a remit to ‘endeavour to take steps in matters of international concern for the prevention and control of disease.’ After World War II, it is Brazil we have to thank for adding the word ‘health’ to the UN Charter, signed in San Francisco in 1945. Brazil and China then combined efforts to investigate the possibility of establishing an international health organisation. The Constitution of WHO was ratified on 7 April 1948. Its advantages were a huge step forward: independence, breadth of remit, an ambition to defend health as a universal right, a social as well as an individual definition of health and regionalisation.
But WHO's power were heavily circumscribed. The agency could only assist, promote, provide, foster, study and report–not instruct, require, enforce or implement. Early supporters of WHO identified three crucial weaknesses that still disable it to this day. First, that WHO was inter-governmental, not supra-governmental. Second, that its budget and facilities were limited. And third, that its impact totally depended on the will of countries. As one observer put it, the creation of WHO was little more than ‘a remarkable gesture of good will’.12
We are left with the question: what can be done to reduce the toll of human disease and to increase the sum of human health? Politically, there is no obligation on any country to assist those not within its sovereignty. Most of us make an invisible contract with our society. We expect our governments to deliver a certain level of democracy, justice, health, education and so on (government has a set of obligations towards us) in return for our acceptance of state authority and power (e.g. to raise taxes). No such contract exists at a global level. Surely we have to conclude that the quest for global health may be an admirable ambition, but it is a commitment that is politically and scientifically empty.
At the end of his essay, Nagel lets himself loose from his rather nihilistic–but I suspect realistic–argument. He speculates about one possible positive future. He anticipates that power will continue to be concentrated in the hands of a few and that increasingly unjust supranational institutions are inevitable. We can even name some of those institutions: the G8, International Monetary Fund, World Bank and the World Trade Organization. The only way out of this situation will be a slow strengthening of the call to make those institutions more just:
‘Unjust and illegitimate regimes are the necessary precursors of the progress toward legitimacy and democracy…the path from anarchy to justice must go through injustice…An example, perhaps, of the cunning of history.’
In other words, the world will have to get worse before it gets better. If we apply this argument to health, we might rapidly reach a point of despair. But if I read Nagel correctly, perhaps we can actually discover a cause for optimism. For the greater the injustice, the greater the traction we have to resolve or reduce injustice. The greater the health predicament, the greater the demand for change. The more serious the economic instability, the greater the opportunity for reform. We can be more specific still. Nagel argues that:
‘There is no obligation to enter into [a] relation with those to whom we do not yet have it.’
So our objective should surely be to protect, create, and strengthen these relationships to build truly transnational communities. This approach might work across multiple dimensions of medical life. In some areas, it is working.
At medical schools in the western hemisphere, there has been a huge increase in interest around global health. Students are energised and radicalised by issues such as trade and health, access to medicines and health worker migration. This astonishing generational commitment to the diseases of poverty is often let down by a sluggish, inward-looking, and regressive educational bureaucracy that squeezes out the kind of passion and engagement that should be nurtured and rewarded.
Universities are global institutions. Their students are drawn from an increasingly porous international community. These new generations will likely have international career paths. Some universities have fully embraced this global identity, creating new alliances, new institutions, and new teaching and research programmes to meet an urgent need. Global health is becoming a critical part of the educational, research and moral mission of the university.
Clinical specialist societies and professional bodies are recalibrating their work to take account of these globalising forces. Institutions are reaching out to other nations through their human diaspora. They are trying to fashion responses to big questions about the implications of climate change or new pandemic diseases. They are adding global health to their strategic objectives.
The leaders of health systems are recognising that they are stewards of global organisations. A health system has a global dimension through its multinational patient population and workforce, together with its professional and academic interests in global health. And the research community–the most globalised community of all–is now turning its attention to great questions in global health–malaria elimination, new vaccines, new diagnostics and new medicines for neglected diseases.
The political repercussions of these waves of global transformation are substantial. A US report from the Institute of Medicine, entitled The US Commitment to Global Health, recently called for global health to be highlighted as a pillar of US foreign policy, in addition to the appointment of senior political advisers in global health, new strategic capacity, more funding, stronger partnerships, and expanded research.
Even our scientific journals are slowly embracing research, news and policy reports from low- and middle-income settings. My personal hope is that more journals will move faster to reflect the changing world they are part of. Hundreds, if not thousands, of journals avoid global dimensions of health. Their readers see a deeply distorted perspective on the world. There are reasons for this aversion behaviour: money, impact factor and reader resistance. Much of medical publishing is still narrowly parochial and geographically exclusive. This bias puts a sharp break on new ideas for strengthening the global culture of medicine and science.
Finally, I want to come back to the role of the scientist and physician. What are the ideal kinds of behaviour for scientists and physicians today?
Most health scientists would probably sign up to the idea that science's great strength is its method: efficient, transparent and usefully impersonal. Science delivers a large part of its authority from the fact that it does not depend on who does it. If there had been no Patrick Manson, someone else would have led us to the mosquito in malaria. This success for science has had two consequences. The benefit is that science is now seen as the best means for providing reliable knowledge. The cost is that science has transformed itself from a 17th century amateur and vocational calling, revealing the mysteries of nature, into a 20th century professional occupation devoted to the industrial production of technical knowledge, often with an economic purpose. This secularisation of science has delivered huge improvements in productivity and delivery. But it has also demoralised and depoliticised both science and scientists.
Scientists have increasingly become instruments, often of the state or industry. It is harder and harder for scientists to work as independent individuals, concerned only with the intellectual and moral dimensions of their work. Science established itself in the 17th century out of a concern for the moral and spiritual progress of humankind. Medical scientists, and especially those working in global health, are rediscovering this complementary–even sometimes antagonistic–moral and political purpose to science. Science should not be seen as impersonal. The views of medical scientists do matter–for the making, meaning and management of knowledge.13
To sum up. Science delivers reliable knowledge. Medicine applies that knowledge globally in the service of human health. Progress in health will depend on the will of countries. We must regret the weaknesses of global health institutions. Individuals–health workers and health scientists–can help by remoralising science and medicine. Scientific discovery will accelerate political change. Meanwhile, we can strengthen relations with peoples beyond our borders. These stronger relationships will increase our collective urgency for tackling our unhealthy world–by extending the neighbourhood of our concern beyond national borders, to redraw those borders to include peoples who remain excluded and disadvantaged. These stronger relationships will also give us better reasons to reverse the deepening injustices we see in global health.
I began by recalling Patrick Manson's use of natural history to define the scope, boundaries and legitimacy of tropical medicine. We need some of that Manson-like insight today as the extraordinary complexity of global health–its huge tasks and vast possibilities–face us. Manson drew his example from Huxley. As we reflect on the 200th birthday of the supreme naturalist, Charles Darwin, we might remember Darwin's statement that:
‘Man in the distant future will be a far more perfect creature than he is now.’
Perfection might take some time. But the broad, sprawling, undisciplined, irritable, fractious, chaotic, divided, competitive and sometimes maddening community that is global health is one of the few fields of science and medicine that offers a manifesto to fulfil Darwin's, and maybe Manson's, great hope.
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Conflicts of interest
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PII: S1876-3413(09)00011-4
doi:10.1016/j.inhe.2009.06.003
© 2009 Published by Elsevier Inc.
