Lately, the field of global health–led by journals like the BMJ Global Health that often set the discourse–has opened itself up for introspection. Researchers and writers from around the world have been critiquing the field, its theory and praxis. As encouraging as this attempt at introspection and critique is, it runs the risk of not asking the right questions: what is global health anyway? Who sets the agenda? And what does global health hope to achieve?
In light of these fundamental questions, we begin to see a dissonance between the hopes and vision laid out for global health and its reality. Randall Packard has tapped into this zeitgeist well with the subtext of his book “A History of Global Health”. The book is subtitled “Interventions Into the Lives of Other People”. Viewed from the trenches of health care delivery in the developing world, Packard’s pithy subtitle resonates well.
The current global health paradigm might matter to some people, but to the elderly woman with a chronic disease who is let down by her barely functioning health post in the mountains of Nepal, it does not. Nor does it matter to the health worker who has to make do with what little she has and what little she can do for the woman. Or even to the managers at the Ministry of Health in Kathmandu, who have seen up close the divergence between the policy challenges they face and the normative discourse shaped in the journals and global health conferences they attend abroad.
But Packard’s critique of global health is even more accurate when viewed from his vantage point at a western academic medical center. There, global health is mostly a fringe exercise, the preoccupation of a few individuals who have taken it upon themselves to rescue unfortunate “other people” in some “wretched” corner of the world. At Packard’s university health system, whose annual revenues exceed the national health budgets of most developing countries, it would be ludicrous to suggest that an overarching global health paradigm should inform their own local health agenda, policies or programs. Against that reality, the vision of global health as an endeavor in transnational solidarity in recognition of our shared hopes for a healthier world crumbles. What remains is the shadow of that vision. That is what global health essentially is today.
There are many reasons for this sorry situation. The current global health paradigm came onto the stage in the wake of the global AIDS crisis. HIV and AIDS related grant money that became available around the turn of the century catalyzed the global health paradigm, with funding mechanisms like the Global Fund and the US President’s Emergency Plan for AIDS Relief (PEPFAR) taking access to HIV care to unprecedented heights. The nascent field of global health became synonymous with HIV and AIDS, and later a few more infectious diseases. To a bystander, it would have appeared as if people only suffered from AIDS, TB, malaria with a smattering of maternal and child health issues.
With AIDS money, western academic centers found a new source of funding. Global health departments were hurriedly latched on to divisions and sections of infectious diseases. And like all bureaucracies, academic units once created begin to find their own raison d’être. Thus came the papers, conferences and journals, in the image of the academic departments that created them. And this is how the discourse and agenda for global health was set.
From the vantage point of a developing country, influencing global health’s agenda or normative discourse always felt out of reach. This is why the current global health paradigm feels inauthentic and even irrelevant for people there. Trying to influence the global health agenda feels like trying to blend into the popular culture when the purveyors of that culture are on the other side of the world. No wonder there is a dissonance between the vision of global health and what it has come to mean to the very people it purports to help.
The ongoing introspection in global health journals is a good idea—any attempt at self-reflection and humility is worthwhile. However, true progress—to make global health relevant for everybody— requires the Global South to elevate and shape its own normative discourse and agenda, to generate local knowledge for a global world, and to lead in solving its own problems. That’s how to create an authentic and relevant global health agenda. Until this is the case, any egalitarian vision of global health that is relevant to the entire world will remain out of reach. And global health will continue on with its identity crisis.
About the authors: Kiran Raj Pandey is a physician and a health services researcher. He is the author of the book “Up Is The Curve–A genealogy of healthcare in the developing world”.
Brian Citro is a human rights lawyer and independent researcher. Before this, he taught at the University of Chicago and Northwestern Pritzker schools of law and lived and worked in India for the UN Special Rapporteur on the Right to Health.
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and we have no conflicts of interest to declare.
Handling Editor: Neha Faruqui