Ideologies of Global Health

In the days of the Soviet Union, the powerful Sanitation and Epidemiology Service sought out infectious diseases and stamped them out with compulsory vaccinations….the tactics were brutal—people were often taken from their families and hometowns for months to years—but they were effective. Now, instead, we have human rights. (1)–New York Times, December 5, 2000

This remark illuminates a recurring theme in the history of global health: every emerging global health framework comes with new ideologies that displace previous ones.  This article examines six ideologies founded upon differing principles and assumptions that have shaped the state of global health today: colonialism, international health, development, charity, social entrepreneurship, and social justice.  These ideologies are useful to understand because the ways in which global health problems are framed can inform the solutions proposed by organizations and policy-makers.

Colonialism

In examining colonial conceptions of global health and contemporary ones, we can see a clear distinction in how health problems are framed.  In global health discourse there has been a recent move toward a social justice and human rights framework.  In contrast, during the colonial era, subjugation of individuals for profit was the impetus for health interventions.  In other words, ‘public health’ served the interests of colonial powers, with improvements in local health a negligible and secondary side-effect.(2)  This is because colonialism was based, first and foremost, on the extraction of wealth to benefit the colonizing nation.  During the height of European colonialism in the nineteenth century, this wealth took a variety of forms including ivory, slaves, sugar and eventually cotton, rubber, gold, coffee, and tea.

The way in which colonialism informed global health can be witness in the construction of Panama Canal in the early 20th century.  The Panama Canal was primarily an effort to increase trade.  Unfortunately, this effort was at the expense of 21,000 laborers who died in the project before its failure. The failure of the French to build the Panama Canal was due to an epidemic of yellow fever and malaria among workers.  Two physicians and leaders in public health, Walter Reed and Carlos Finlay, tried to solve this problem by examining potential causes of the outbreak, such as increased mosquito populations and swamps. While this effort seemed to be a humanitarian endeavor, it was by no means motivated by charity or social justice ideals.  Instead, public health interventions were motivated by economic incentive as the poor health of workers was a detriment to commerce and colonial power.        

International Health

The legacy of colonialism left its mark, as public health conceived of and practiced in the United States and Western Europe during the past century has primarily been a state activity and has been closely connected to the protection of the state’s interests.  With concerns of an increasingly globalized world, many of the health issues that policy-makers face today remain “international” health issues.  One of the key principles of this international conception of global health has been to protect citizens against threats perceived as having an external origin, particularly infectious diseases carried across national borders.   “During the 1990s, American scientists, public health officials and defense experts argued that ‘emerging diseases’ presented a threat to American national security, international development and global health.  In doing so, they recapitulated the previous century’s dominant logics of international health policy”.(3)  Public health has thus been ‘international’, and closely allied with ideologies of national security and international commerce.  

Furthermore, Western medical research has addressed the needs of the developing world in beneficial ways—by developing quinine as a malarial prophylactic, prevention for yellow fever, etc.—but it has done so with a “West first” attitude consistent with the ethos of colonialism.  The advances made in vaccinations, preventions, and treatments were researched almost exclusively because Western nations had military or commercial interest in areas where tropical diseases were prevalent. Through prevention and treatment, the international spread of disease was curbed and the extraction of wealth was preserved.  

Philanthropy

Traditionally, global health has been tied to philanthropic ideals and religious notions of charity. In a humanitarian approach, people respond to human suffering by acting in a virtuous manner based on compassion, empathy, or altruism.

“Humanitarianism provides the primary ethical basis of voluntary action undertaken by non-governmental organizations (NGOs), and is also an important base of public support for official foreign aid. U.S. president George Bush in announcing US$15 billion in assistance for HIV/AIDS control described the pledge as a ‘work of mercy’”.(4)

It must be acknowledged that generous philanthropy from concerned individuals and many foundations, organizations, and new global initiatives can, and do, make valued contributions to improving the health of marginalized people in the world.  “Development aid from many countries should also be welcomed, and recent endeavors to increase aid from the current average of 0.23% gross domestic product to the recommended 0.7% are admirable.”(5)   However, development aid has been progressively reduced in recent years, and is increasingly being directed towards emergency humanitarian aid, rather than towards sustainable development. (6),(7)

This trend has occurred because philanthropy, while well-intentioned, can often be misguided. Many individuals from wealthier, industrial nations feel obligated to donate money or unused items to those less fortunate, yet oftentimes these donations are not useful and are given in ways that do not support the local economy.  Thus, the underlying societal rules and structures that generate the social ills are not addressed.  Furthermore, there are dangers that those who are helped can be placed in a dependent position, treated as victims not agents.  For example, if aid agencies were to purchase goods locally and hire local health workers instead of bringing in foreign staff, far more money would go into the local economy.  This would mean that more parents would have jobs and be empowered to take control of their health.  Instead, much of global health today comprises donated goods and unsustainable one-time initiatives.

The experience of a Gambian hospital provides a case in point.  In 2000, a referral hospital accepted a donation of oxygen concentrators to help maintain oxygen supplies.(8)  The concentrators broke down and were put into storage. A study was done to find the reasons for the problem.  Interviews confirmed technical problems with the equipment and revealed that the donation process was flawed, and that the hospital did not have the expertise to assess or maintain the equipment.  Subsequently a hospital donations committee was established to oversee the donations process. In 2002, World Health Organization produced guidelines for medical equipment donations to address problems that may be encountered when the majority of global health resources come from charitable donations.  When it comes to the intersection of charity and global health, similar guidelines should be publicized and used to inform well-intentioned donors.

Social Entrepreneurship

Social entrepreneurship should not be confused with charity. While charity reflects the benefactor’s compassion measured in terms of the generosity of donations to the less fortunate, social entrepreneurship reflects more than the good intentions of its practitioners, who are not merely driven by compassion, but are also compelled by a desire for social change. Oftentimes, charitable organizations survive at the mercy of their donors whose contributions vary with the economic climate. A nonprofit that practices social entrepreneurship, on the other hand, relies less heavily on donor funds because it creates social programs that are meant to be self-sustaining.  Social entrepreneurs manage donor contributions in an effective manner, investing in social ventures which can then generate their own revenues to sustain themselves.

In other words, while charity uses donor funds to buy food to ease the poor’s hunger, social entrepreneurship uses its funds to make a lasting social impact, creating instructional programs which teach the poor how to grow their own food so that they can take care of themselves in the long run.  According to J. Gregory Dees, social entrepreneurship “combines the passion of a social mission with an image of business-like discipline, innovation, and determination commonly associated with, for instance, the high-tech pioneers of Silicon Valley.”(9)  The social entrepreneur’s philanthropic energies are channeled into business ventures, creating value in business so that consumers are willing to pay for the goods and services, and by doing so, the social entrepreneur earns a profit which is invested in the social ventures.(10)  Dees elaborates on the ideology of social entrepreneurship:

“In society, I’d like to see more value placed on social impact and success than on good intentions or effective marketing or the severity of the need you’re claiming to serve. I’d like to see a fundamental change in ethics or culture around that. We still have the lingering effect of a culture of charity, which honors people for their sacrifice—how much they give and the purity of their motives. I’d love to see an ethics change, so that we honor people for the impact they’ve had directly, or indirectly in choosing to support programs and organizations and individuals that have had impact, not just for how much they give or how generous they are.”(11)

Development

There are two broad frameworks in the contemporary global health discourse: one motivated by social justice and the other by economic development principles.  Development ideology centers on the idea that increasing development is an economic incentive for the whole world— that “a rising tide lifts all boats” despite the inequalities that may result.  In other words, from the start of the development movement it was predicted that inequalities would worsen as a result of market-based policies, but ultimately the quality of life for all would improve. The goals of this economic dream were echoed in one of the most influential documents of this period, prepared by a group convened by the United Nations:

 “There is a sense in which rapid economic progress is impossible without painful adjustments.  Ancient philosophies have to be scrapped; old social institutions have to disintegrate; bonds of caste, creed and race have to burst; and large numbers of persons who cannot keep up with progress have to have their expectations of a comfortable life frustrated.  Very few communities are willing to pay the full price of economic progress.”(12)

The propagation of these early ideologies and the debt crisis of the 1980s ushered in a new set of programs around “development”.  These programs were supported by the major financial institutions, such as the World Bank and the International Monetary Fund, and promoted neoliberal policies.  Such policies, later termed “structural adjustment policies” emphasized the market allocation of resources, decreased public sector spending, deregulation, and privatization. Within this doctrine, individuals in a society were viewed as autonomous, rational producers and consumers whose decisions were motivated primarily by economic concerns.

Furthermore, the development discourse of the past revolved around conceptions of the “third world”.  In his book, Encountering Development, Arturo Escobar argues that this discourse created the construct of the third world in which the legitimating forces of the “first world” served the interests of the powerful rather than the powerless.  Today, the goals of the development movement remain ambitious—high levels of industrialization and urbanization, modernization of agriculture, rapid growth of material production and living standards, and the widespread adoption of modern education and cultural values.(13)  While the development agenda still continues, neoliberal structural adjustment policies have been curbed and the importance of cultural sensitivity and the pitfall of ethnocentrism have been recognized.

Social Justice and Human Rights

In the past decade, global health activities have been increasingly framed within the context of social justice and human rights.  Several key principles of this framework include: (1) health as a global public good, (2) health as a key factor of sound business practice and social responsibility, and (3) the ethical principle of health as global citizenship.(14)

“It was one of the characteristics of modernity to take health out of the confines of religion and charity and make it a key element of action of the state and the rights of citizenship.  The process, initially within the context of the constitution of the nation state, today needs to go global as a key dimension of global justice.  Global health needs to move out of the charity mode of bilateral aid and philanthropy into the realm of rights, citizenship, and a global contract.”(15)

An example of this move toward a social justice framework is the Alma-Ata declaration. The Declaration of Alma-Ata was adopted at the International Conference on Primary Health Care and expressed the need for urgent action by all governments to protect the health of all the people.  The declaration contained ten main points, the most important of which is the principle of health as a fundamental human right.  Furthermore, Articles 25 and 27 of the 1948 Universal Declaration of Human Rights were particularly revolutionary because they revealed a new focus on social and economic rights.  Specifically,Article 25 states that everyone has the right to a standard of living adequate for the health and well-being of him or herself and of his or her family.  These rights include food, clothing, housing, medical care, necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or in circumstances beyond control.  Dr. Paul Farmer is one individual champion for the use of a human rights discourse in global health.  He advocates for a life in which one has the opportunity to pursue one’s aspirations, and that this idea should be used as the basis of a social justice movement in global health:

Whether or not we see these horrible deaths [from disease and poverty], whether or not we avert our gaze, they are happening….there are historical precedents for enshrining social and economic rights in official human rights declarations. One need only read the Universal Declaration of Human Rights:  articles 25 and 27 seem to speak directly to the issue and are infused with the human values advanced in this lecture… And these articles are actionable, at least on a small scale and almost surely on a much larger one, if we find the rhetorical tools necessary to bring the privileged on board as we build a movement to promote the rights of the poor.…”(16)

Conclusion

The ideologies of global health presented here are a simplistic outline of the more complex and dynamic frameworks around which global activities have been justified.  Today, these ideologies exist in various forms and continue to validate interventions and motivate funding.  Colonial sentiments, concerns of national security, charitable notions, development frameworks, business models, and human rights discourses form the hodgepodge of motivations for global health work.

These frameworks are not mutually exclusive and each possesses unique strengths and weaknesses.  For example, while a human rights framework may be better suited to scale-up interventions through the public sector, an entrepreneurial framework may allow for greater innovation.  In order to tackle the challenges of global health today, the strengths of these ideologies must be utilized in order to gather attention and resources.   

Lastly, it is important to understand the limitations of each ideology as the assumptions upon which global health work is founded have implications for the solutions proposed.  While the field of global health may never be devoid of prejudice and new mistakes to be made, the key to progressive movement lies in unraveling the faults of the past with the hope of a better future.

Footnotes

(1) Chidi, Anselm Odinkalu. “Why more Africans don’t use human rights language,” Human Rights Dialogue: Human Rihts for All? The Problem of the Human Rights Box, Carnegie Council on Ethics and International Affairs, Winter 2000: 2(I).

(2) Arnold (1988a)David Arnold, ‘Introduction: Disease, Medicine, and Empire’, in Arnold (1988b): 1–26.

(3) King NB. 2002. Security, disease, commerce: ideologies of postcolonial global health. Social Studies of Science 32:763–89.

(4) Alkire S, Chen L. Global health and moral values. Lancet 2004;364;1069-1074.  

(5) Birdsall N. How to help poor countries. Foreign Aff. 2005;84:136–152.

(6) Lancaster C. Transforming foreign aid: United States assistance in the 21st century. Washington (D.C.): Institute for International Economics; 2000. 108 pp.

(7) Woods N. The shifting politics of foreign aid. Int Aff. 2005;81:393–409.

(8) Howie S, Hill SE, Peel D, Sammeh M, Njie M, Hill PC, et al. Beyond good intentions: lessons on equipment donation from an African hospital. Bull World Health Organ. 2008;86(1):52–6.

(9) Dees, J.Gregory. "The Meaning of "Social Entrepreneurship".” http://www.caseatduke.org/documents/dees_sedef.pdf (8 June 2009),1.

(10) Martin, Roger L., and Sally Osberg. "Social Entrepreneurship: The Case for Definition." Stanford Social Innovation Review (2007): 28-39. http://www.skollfoundation.org/media/skoll_docs/2007SP_feature_martinosberg.pdf (8 June 2009), 34-35.

(11) Dees, J. Gregory. Personal interview. . 8 June 2009 <http://www.caseatduke.org/documents/deesinterview.pdf>.

(12) United Nations, Department of Social and Economic Affairs, Measures for the Economic Development of Underdeveloped Countries, 1951.

(13) Escobar, Arturo. Encountering Development. Princeton: Princeton University Press, 1995.

(14) Kickbusch, Ilona. From charity to rights: proposal for five action areas of global health. J Epidemiol Community Health 2004;58:630–631.

(15) Ibid.

(16) Paul Farmer. “Never Again?: Reflections on Human Values and Human Rights.”  The Tanner Lectures on Human Values. Delivered at University of Utah, March 30, 2005.