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Editorial (English version) Global Health: What are we talking about?

Celia ALMEIDA, Fred Eboko et Jean-Paul MOATTI
Traduction(s) :
Éditorial (version française) La santé globale : notre point de vue

Texte intégral

1By questioning the content of the term “Global Health” we wanted to echo a changing world that thinks about health issues differently at different times in history and for different purposes. Behind this polysemous expression lie the various logics that have structured global political thinking, institutional responses and health practices, particularly since the fall of the Berlin Wall, when the term began to appear with increasing persistence in the literature and international discourse on health. Differing perspectives frame the various meanings of “Global Health”, but two focuses can be identified in most definitions: health treated as disease, in the strict sense and centred on a certain few epidemic or endemic diseases; and the need to control health problems globally, which not uncommonly is bound up with geopolitical objectives.

2The literature contains differing definitions of Global Health. However, these definitions do not constitute concepts, understood here as words or terms that operate a theory, i.e., that have a theory “behind” them guiding the definition of the concept and in turn making it possible to explain certain realities and guide practice in specific circumstances. So what are we talking about then?

3For our interests in this issue of Face A Face, Global Health can be understood as the outcome of the permanent and reciprocal influence between international relations and health problems. On that basis the national and international determinants of the health of populations can be studied from a perspective involving knowledge from a range of different disciplines, with a view to proposing policies that point to solutions to those problems (Almeida, 2008, 2010). This means the field of knowledge dealing with national and international issues that impact on the health of populations at the global level. It constitutes a scientific and political field disputed by various different actors, disciplines and paradigms (Almeida, 2011, from Nunes, Marcondes & Cabral, 2010). Accordingly, here we are talking about the power relations that guide the world system and interlace with health-related issues, which involve enormous inequalities reflected in conditions of life, service provision, production and access to medications, international trade and so on.

4Currently, international debate over Global Health undervalues the perspective centred on the variables that determine improvement in the health of populations, groups and individuals, taking into account the political, economic, social and cultural dimensions in which societies are embedded. This outlook calls for multidisciplinary thinking and action by the health actors who provide the input for scientific endeavours and determine the quality of the knowledge needed for innovation and technological development in health care worldwide. This is the option chosen by, for example, Paul Farmer, Arthur Kleinman, Jim Yong Kim and Matthew Basilico when examining one dimension of the problem in their recent book Reimaging Global Health (2013). They explain:

"Global health delivery begins with the question, “how can a health system efficiently provide health services to all who need them?” More efficient and equitable delivery of existing health interventions could save tens of millions of lives each year. But even the best models of global health delivery cannot alone raise the standard of health care available to people worldwide. The health of individuals and populations is influenced by complex social and structural forces; addressing the roots of ill health – including poverty, inequality, environmental degradation – requires a broad-based agenda of social change." (Farmer et al., 2013: 10)

5Basically, what these authors describe is a way to address health problems that extend worldwide, across borders and bodies, by going beyond the biological and medical focus to address health concerns also as political issues and political options (Fassin, 2010; Lézé & Fassin, 2013). This means considering Global Health with an “attitude”. It also consists in looking at, questioning and acting with (and sometimes against) some of the unprecedented constellation of international and transnational actors involved in the political field of health. This is so permeated by inequalities and structural violence (Farmer, 2001; Fassin, 1996) that it now demands a collective struggle in both scientific research and political action on health. Accordingly, this struggle is no place for naivety; rather one should be mindful that it is also a locus of power relations and for building political force in order to achieve changes in health priorities. It is in this sense that the late 1990s marked a watershed in the uncritical acceptance of neoliberal dogma and the idiom of profitability (Moatti, 2011, Moatti et al., 2001; Moatti & Eboko, 2010) resting on legal norms incarnate embodied in legal violence (patents on drugs). This is the paradigm shift that should guide Global Health (Coriat, 2008), which derives its wealth from the porosity of its multidisciplinary boundaries.

6It is in this spirit of openness, vigilance and intellectual ambition that issue 12 of Face A Face, Perspectives on health is presented. The diversity of contributions gathered in this volume relinquishes nothing of the outlook that guides our “attitude” of considering health issues in their various different dimensions in socio-political and economic contexts that inform us about the territories of the battles to be fought.

7From this point of view, Global Health is a “matrix of public policy” (Eboko, 2013) that shows the differential dynamics of the relationships that ally or oppose the actors involved (governmental and international organizations, national and local institutions, NGOs, private companies, associations, researchers, public and private partnerships etc.), all driven by different agendas. The peculiarity of this matrix is that it is informed by the actors’ ability to form (or not to form) “epistemic communities” capable of leading or impelling political alliances to influence changes, as in the famous definition by Peter M. Hass: “An epistemic community is a network of professionals with recognized expertise and competence in a particular domain and an authoritative claim to policy-relevant knowledge within that domain or issue area” (Haas, 1992: 4). These are indeed channels through which new ideas circulate within societies and from one country to another (Bossy and Evrard, 2010). In this sense, to us Global Health rests on the idea that all and any effective action proposes an agenda of social change (Farmer et al., op. cit.).

8This volume comprises nine contributions. First, Juan Garay, Laura Harris and Julia Walsh offer their take on how the definition of “Global Health” has evolved, how it differs from “international health” and how the term is misused. Reasoning on the premise that Global Health should include “health for all, health by all and health in all policies” and be equity driven, they back their arguments with a data set. José Roberto Ferreira, Claudia Hoirisch and Paulo M. Buss take a critical approach to the issue of “global governance for health” as something yet to be constructed and whose architecture is still a subject for speculation. They highlight the effects of the various (financial, climate, food etc.) crises on its structure and functioning and discuss the WHO’s role in the process. From the national level, Julie Castro shows how the fight against AIDS in Mali has been influenced by international strategies reflected in a national history of global governance of public health. She discusses local mutations of the global “guidelines” against the backdrop of the Global Fund crisis, in order to illustrate national dependence on this foreign aid. Maud Lemoine, Pierre-Marie Girard, Mark and Gilles Thursz Raguin show how the exceptional mobilization and volume of funding against a single disease in Africa (HIV/AIDS) has produced another type of “neglected disease”, such as the non-communicable diseases, and put forward solid arguments based on data. Frédéric Le Marcis, Sylvain L. Faye and colleagues tackle the subject of malaria in the Casamance region of Senegal. In the light of accelerating knowledge production and the therapy renewal represented by ACTs (Artemisinin-based Combination Treatment), the authors show the progress and paradoxes of malaria control management. They highlight the importance of the national and local context, given the diversity of epidemiological features and behaviours in different regions of the country, which cannot be subject to the same timeframes. Clement Soriat shows that the global struggle against AIDS has created a kind of “AIDS governance” that privileges local NGOs and associations. He examines how these specific civil society actors in Benin, moving in transnational configurations that connect actors who accumulate cultural, political and relational capital that leverages their plans and their social mobility. Bouma Fernand Bationo explores the implementation of a so-called universal health insurance, formulated at the international level to provide access to a basic service package in one of the poorest countries in the world, Burkina Faso. The author analyses the economic and social difficulties facing this strategy, which fails to take account of either the profound national crises or the health needs of the population, the great majority of whom are extremely poor. Jean-Pierre Unger and colleagues at the Institute of Tropical Medicine Antwerp (IMTA) brings to light the importance of strengthening local health systems and their various different levels of care, as well as coordination among them in providing services. Drawing on their experience of organising such local systems in Latin America and Africa, they describe a unique application to the Belgian health system. They show how, within a health system in Europe, it is possible to reorganize coordination among system levels and health actors on the basis of small units of generalists and specialists working together.Finally, Vincent Duclos traces the genealogy of “Global eHealth”, which uses new information technologies for development (ICT4D) and are regarded as promoting digital inclusion, human development and participation in Global Health, making health/disease a form of stimulus to economic growth. That dynamic, it is argued, will close a “virtuous circle” to achieve, among others, the Millennium Development Goals (MDGs). The article discusses critically some of the assumptions underlying this endeavour, which makes the inner subject an object of political intervention.

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Celia ALMEIDA, Fred Eboko et Jean-Paul MOATTI, « Editorial (English version) Global Health: What are we talking about? », Face à face [En ligne], 12 | 2013, mis en ligne le 22 octobre 2013, consulté le 11 décembre 2017. URL : http://journals.openedition.org/faceaface/936

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Auteurs

Celia ALMEIDA

MD, MPH, PhD. Pesquisadora Titular ENSP/Foicruz (Professeur de santé publique), Rio

Fred Eboko

Sociologue et Politiste, chercheur à L'Institut de Recherche pour le Développement (IRD), HDR en science politique. UMR 912 SESSTIM (INSERM - IRD - AMU). Affectation Institut Africain de la Gouvernance (IAG) et IRD Dakar. Directeur de publication de Face A Face. Regards sur la santé.

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Jean-Paul MOATTI

Professeur d'Economie, Directeur de l'UMR 912 SESSTIM Aix Marseille Université (AMU). Directeur de l'institut de Santé Publique de l'INSERM.

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