In the rapid rise of the “decolonizing Global Health” movement, a crucial predicament has emerged. Despite the field becoming increasingly understood as white supremacist at its core and built upon historic and contemporary colonial political ordering, the kind of change being imagined and worked toward dominantly hinges on the continuation of the field—and this world’s—existence. This, I argue, is the result of over four decades of intertwining the seemingly universal, transcendently good ideal of ‘global health’ with the particularly constructed global apparatus that calls itself by that phrase, to the point where the idea and the field are now understood as inseparable. By tracing how the field that came to be known as Global Health monopolized the idea and imaginary of a healthier world, this commentary seeks to clarify what we mean when we say “global health”, and, through this, to rethink what pursuing global health and doing Global Health mean. The core of my argument rests upon establishing a simple fact, a heuristic tool, and new theoretical basis: Global Health—a social apparatus—is not global health—an ideal. By expanding what can be considered as Global Health action and foregrounding the existence and possibilities of global health pursuits beyond Global Health, I argue that what we are trying to change, how we conduct that change, and toward which horizons we move, begin to be reimagined when the myth that Global Health is global health is rejected.
Since the term “Global Health” arose as the new name of, and the concept backing the transnational apparatus dominantly called “International Health” in the 1980s, a paradox has defined this phrase and nomenclature. Simultaneously a title for a field and an idea of improving the world, for the past four decades this phrase has been defined by its seemingly inherent vagueness and its intrinsic moral connotation as an unequivocal good for the world. In itsrapid growth to become the largest organized effort to create a healthier world in history—which some see as directly predicated on simultaneous vagueness and righteousness at the core of the phrase (Fassin 2012)—this global apparatus that named itself Global Health and the very idea of creating a healthier world have become inexplicitly intertwined. Today, both in popular imaginations around the world and especially across academic spaces, the phrase “global health” evokes images of humanitarian interventions, randomized control trials, the World Health Organization (WHO), vaccination drives, global policy recommendations, humanitarian aid drops, epidemiological surveying, and other core activities of the field called Global Health. Inextricably intertwined, Global Health,the field, has largely come to be understood as the arbiter of, space for, and synonymous with. global health.
In the era of “decolonizing Global Health”, though, the entangled relationship between Global Health (the field) and global health (the idea) has produced a grave dilemma. Despite Global Health becoming increasingly understood as structurally white supremacist (Binagwaho et al. 2022) and inherently built upon colonial global political ordering (Richardson 2020), a world without the field is still largely unimaginable. This leads to imaginations and programming that seek to preserve the field, which itself is intrinsically entrenched in the systems that create the inequities we seek to solve (Chaudhuri et al. 2021). As Global Health is seen as global health and there are seemingly no obvious alternatives to the field in size, power, funding, prestige, globality, or reach, not only are reformist programs of change under the name “decolonization” vastly privileged and amplified (Krugman 2023), but scholars arguing for a new or broader field are punished (Kumar & Arya 2023). Dominantly across the field, visions of change committed to the end of Global Health and imagining worlds beyond are thus cast as “radical,” “impossible,” or “unrealistic”. Faced with the most widespread calls for change in the field’s history, actors across the field cling to the simultaneously vague yet transcendently righteous name/ideal of Global Health, skewing visions and programs of change toward reformism, thereby maintaining the field’s place inside the global racial capitalist it is supportive of and supported by.
What does global health actually mean? What are we referring to when we say we want to change it? What are the stakes and consequences of adhering to the idea that Global Health must continue to exist despite widespread calls for change? This commentary seeks to begin to answer these questions through establishing a simple fact, a heuristic tool, and new theoretical basis to be built from: Global Health is not global health. Though often described as the field committed creating “global health”, “Global Health” is a particular set of norms housed in a loosely constructed but massive global social apparatus of knowledge, industry, and practice that is fundamentally tied to the capitalist world system, developed in largely colonial contexts, and dominated by mostly white technocrats, academics, and scientists. It is one particularly constructed in pursuit of “global health”—the utopian idea that all the world should have equitable access to health services and opportunities to be healthy. I use the phrase “Global Health”, a proper noun, to reference the scope, conventions, and epistemologies of the scientific study and systematized practice of making the world healthier through the hegemonic global capitalist system. This is a subset of non-capitalized “global health”, the idea of creating a healthier world in the broadest possible sense, in which there are many social organizations, practices, and conceptualizations beyond the dominant but singular field of Global Health. The continued usage of “global health” to connote the ideal of a healthier world here is intentional. Departing from my positionality as a linguistic anthropologist, I see this as the first step toward a “linguistic reclamation”—a deliberate attempt to define global health in alternate ways so that it may be used and understood otherwise.
This commentary begins by tracing the specifics of how Global Health monopolized the idea of global health and showing how the field exists in a plurality of other social organizations that pursue alternate constructions of global health in order to definitively divorce Global Health from global health. Through then outlining the utility of this separation, I establish how this heuristic distinction creates clarity about changing the field and alternate possibilities. Having shown how this deeply held idea, that Global Health is the only, best, superior superstructure in pursuit of a healthier world, is a powerful, charting myth, I argue that the future of changing Global Health lies in aligning with those already working toward global health on anti-colonial, anti-imperialist, and anti-capitalist fronts—which, in the end, would necessarily lead to the dissipation of Global Health. In destabilizing the foundational, false, and perhaps arrogant belief that Global Health is the transcendentally “good” social apparatus in pursuit of a healthier world, I not only seek to open new grammars of creating a healthier world, but also broaden the horizon for what it means to do Global Health work and action.
Much like the term “decolonization,” the very idea of global health was a cooptation from movements from beyond the Global North. As a number of scholars make clear (Cabane 2023; Perez-Brumer et al. 2024), the idea of global health as theorized in academia emerged in 1980s Latin American critiques of International Health, when scholars in nations traditionally targeted by Global North health interventions and unilateral aid began arguing against Global North dependence, eurocentrism, and opposition between “developed” and “developing” nations. These scholars from the South not only theorized a new understanding of disease as a global phenomenon, unrestricted by nation-state borders, but also framed the new understanding within the material inequalities of International Health and how to change them. By the early 1990s these ideas had led to growing debates and conversations in powerful Northern spaces. Prominent US scholars began using the term not only in ways that connoted the reform of International Health, but also in ways that assumed that the ideal of global health was explicitly connected to and would be led by the social organization that would become “Global Health” (see Berlinguer 1999, Fidler 1997,; Jain 1991).
These processes unfolded during and in conjunction with larger transformations of the global social, political, and economic order. As Cabane (2023) makes clear, Discourses of global health were institutionalized “within the US academia through the constitution of an academic field dominated by the U.S., its anchoring in economic and political dimensions of the U.S.’ insertion in the globalization, and the shaping of policy through networks and lobbying” (2023, p507). This occurred precisely during the establishment of American hegemony after victory in the Cold War and the rise of neoliberal structural adjustment. Through “extracting” the idea of global health from its “original production context” and consequential “successful diffusion” into International Health structures, “the politics of inequalities it initially intended to tackle were obfuscated, reproducing asymmetries of power” (Cabane 2023, p. 512). Repackaged for the new era of capitalist global hegemony and neoliberal structuring (Birn, 2009), US Global Health departments, funding bodies, private organizations, and people who participate in this machine of procuring money to conduct different projects proliferated throughout the early 21st century (Macfarlane et al. 2008). As anthropologists made clear, not only did behavioral interventions, randomized controlled trials, and policy initiatives under the label of Global Health dramatically proliferate, but these programs also became vessels for the implementation of privatized health system organization, individualistic ideas of health, and broader tenets of neoliberal ideology into formerly communist nations and longstanding Global South targets (Foley,2008, Janes 200,; Keshavjee 2014, Rivkin-Fish 2005). Built outward from the US and replicated across Europe and the Global South, over the past four decades Global Health has “defined health problems as global threats or opportunities from the U.S. point of view, thus embedding those partnerships in an inevitable unequal power relations” dictated by the global system (Cabane 2023, p. 510), while disseminating particular practices, logics, and ideas about health inherently attached to these programs around the world (Brada 2023, Dubal 2018;, Richardson 2020).
Thus, not only was the rise of the particular apparatus of Global Health parallel with, informed by, and connected to, the rise of 21st century neoliberal capitalist global ordering, but its rise was an active part of establishing this system as the hegemonic global order. By taking conceptualizations of global health theorized in the Global South, depoliticizing it by using the term to define International Health reform, and then spreading that coopted conceptualization around the world, “the definition of ‘global health’ thus became an attempt to shape global governance in ways that conveniently served (North) America’s interests.” (Cabane 2023, p. 506). Here we can see the establishment of a global social structure that became known as “Global Health”, and that pursues a particularly constructed idea of global health structured in reflection of and in accordance with the dominant global system. While called Global Health, this “academic-economic enterprise” (Adams 2016) “came to legitimize U.S. supremacy, merging postcolonial concerns” of recognizing Global South scientists and perspectives “with neoliberal market forces” (Cabane 2023, p. 512).
Because the phrase and originating ideas of global health were transplanted from the South during and in connection with a particular moment of capitalist expansion in the form of neoliberalism, and because the phrase and originating ideas became the name and vague guiding concept for a particular global apparatus of interventions, aid, practice, and surveillance intimately intertwined with the states, financial organizations, and people advancing American political and economic dominance, the field of Global Health cannot possibly be seen as the same or sole owner of the idea of global health. Rather, the myth that Global Health equals global health has been purposefully created. Placing the field into the wider system in which it exists, Global Health can be defined as a hegemonizing force both in and of itself and as a servant of that broader global racial capitalism. As “spatial expansion and moral normalization” of Western capitalist influence and the ideas of health, healing, globality, and life associated with it occurs, (Fassin 2012, p. 108), Global Health is any organization that seeks to be a part of this superstructure and pursues bettering the health of the world’s population through working in conjunction with and willfully following the rules of the global capitalist system. This global social apparatus thus pursues particularly constructed ideas of “global health.” While there is no homogenous conceptualization of the central ideal/name that animates the field (Salm et al. 2021), ideas of global health in Global Health necessarily have to be configured to be palatable and functional for the broader system within which Global Health lives. Often predicated on the assumptions that capitalism is final and eternal, that nation-states are the primary unit from which to understand social organization, and that the ideas of individualism, self-interest, nationalism, and human rights are universal and inherent, the conceptualizations of global health found in Global Health are inherently designed to imagine a healthier world within the confines of the existing political and economic structuring.
These definitions of Global Health and the visions of global heath within the confines of the field are further illuminated by Global Health’s “others”: alternate movements, organizations, and global social apparatuses that explicitly pursue a healthier world, that do not affiliate with Global Health and, more importantly, that seek to create global health through resisting the systems and structures Global Health works with and for. In response to late 20th and early 21st century “globalization”—or, hegemonization of the US-led neoliberal capitalist order—social movements, Indigenous resistance, socialist nation-states, anarchist and communist institutions, and other groups with similar visions who had been long resisting racial capitalist expansion, colonialism, and imperialism adapted to new forms of oppression and utilized new technologies to create “globalization” that was directly in juxtaposition to and resistive of neoliberal capitalist “globalization” (Arrighi et al. 2012,Graeber2002, 2009). Thus, as Global Health arose in conjunction with and for the benefit of the hegemonic system, counter-hegemonic understandings of global health and movements toward it on global scales were formulated at the same time.
Examples of these counterhegemonic global health movements and organizations based on their legacies are plentiful. The ACT UP and Love and Rage anarchist collectives, which fought for and developed their own networks of HIV/AIDS care across North America (Gould 2006), pursued ideas of what “global health” is and how it could be facilitated through protesters keeping each other alive in the face of militarized police attacks (Kennelly 2002). The Zapatistas—the collective name of Indigenous people living in autonomous communes across Chiapas, Mexico created in 1994 to directly resist and subvert neoliberal globalization and state enforcement of it—developed a similar vision of “global health” as communal care and anti-capitalist struggles enacted through their reclaiming of land and development of transnational aid networks (Aloisio 2009). Perhaps most familiarly to Global Health actors, the saúde colectiva movement in Brazil and more broadly across South America (Breilh 2021; Harvey et al. 2022, Vieira-da-Silva & Pinell 2014) exemplifies a public health system that functions unlike, and is unsupported by, Global Health. Growing “South-South” exchanges that similarily do not rely on normative global North infrastructures are creating and exchanging “otherwise” conceptualizations of global health based on activism, resisting Northern global governance and anti-capitalist public health organization (Birn et al. 2019). “Global” in the way that they fight to create a world where localities around the world have the autonomy to pursue health on their own terms, these efforts demonstrate how other social bodies that work toward alternate conceptualizations of global health exist on a variety of scales beyond Global Health.
In short, Global Health cannot be seen as equivalent to global health. While Global Health has become the most powerful, largest, and richest regime in pursuit of a healthier world, due to its intrinsic connections to and role inside of the capitalist world system, there has always been a variety of other social organizations who are also working toward a healthier world that is fundamentally set against that system, and conceptualize “global health” as liberation from it. Global Health is not in any way morally superior to these other efforts, nor is it less political or idealistic than ACT UP or the Zapatistas. Rather, Global Health is a particularly constructed political force that pursues a particularly constructed milieu of ideas concerning what global health is. Undoubtedly, for the past three decades Global Health has created metrical progress towards constructed health indicators, and it has alleviated innumerable cases of suffering from diseases such as polio, smallpox, HIV/AIDS, malaria, and other ailments. This, though, comes at the expense of monopolizing the idea of global health and aiding the expansion of a global capitalism and North Atlantic political and economic dominance.
Thus, we can now see when Global Health and global health are used interchangeably, as they so commonly are today, it naturalizes and reproduces the myth that Global Health is global health while obfuscating, delegitimizing, and marginalizing the other social organizations and movements that are legitimately working to create global health on their own terms. The question becomes, what happens to our imaginations of what Global Health could be and how it could change when we apply this distinction? Table 1 begins to demonstrate what happens semantically when Global Health and global health are used differently. As seen, specificity and clarity emerge. When the proper noun “Global Health” is used, it connotes that the health issue, aspect of work, or framework for change concerns the global apparatus of Global Health only. When the common noun global health is employed, it communicates the ideal of a healthier world that can include the same issues, strategies, and goals of Global Health, but it can also include the other movements and social organizations that are beyond or set against Global Health on account of subservice to global capitalism.
|
Example of “Global Health” usage |
Meaning |
Example of “global health” usage |
Meaning |
|
“HIV/AIDS is a Global Health issue.” |
“HIV/AIDS is an issue that is and should be addressed by the global social apparatus currently called “Global Health.” |
“HIV/AIDS is a global health issue.” |
HIV/AIDS is a disease that affects people across arbitrary borders around the world that can be addressed through a variety of social organizations, methods, and programs. |
|
“Activism is a key strategy of Global Health.” |
Activism that is sanctioned by the powers that rule the field is an important aspect of what actors inside Global Health do. |
“Activism is a key strategy to create global health.” |
Activism, whether it be in the form of advocating governments or taking direct action against capitalist and imperial facilitators, is an important way to create better health around the world. |
|
“We have to change Global Health.” |
The social organization currently called “Global Health” must be reformed or reconfigured to create a healthier world. |
“We have to change global health.” |
The health of the world is currently inequitable due to the structure and systems in which we live. We have to create a healthier world by any means necessary. |
Table 1. Comparative examples of the usage of Global Health and global health
In the context of the “decolonizing Global Health” movement, divorcing global health and Global Health creates further lucidity while also vastly expanding the possibilities of change. Because Global Health is a particularly constructed social apparatus that is, in the end, structurally antithetical to the notion of global health, given its connections to the system that produces health inequities and not the righteous manifestation of the global health ideal, the need to preserve Global Health, in projects of change that have so defined efforts of change thus far, dissipates. As Abimbola and Pai (2020) and Affun-Adegbulu and Adegbulu (2020) begin to theorize, a world without Global Health is not a collapse of health in formerly colonized regions. In sharp contrast, it is the building of autonomous public health systems, decentralized knowledge creation, and dignity in a decentralized, relational global system (Abimbola 2023). Through separating Global Health and global health, we can see that reforming the field in this way is undertaking the same transition that Birn outlines as having occurred from International Health to Global Health (2009). It is the cooptation of a radical idea to reform a field committed to global capitalist hegemony and colonial relations of power so it can preserve itself and reproduce the myth that the world needs the field and, thus, “global health” can be created within the bounds of global racial capitalism.
If Global Health is fundamental to and fundamentally a part of the violent world system in which we live, visions and programs of change that seek to end the field of Global Health as we know it become not only conceptually viable, but also necessary. Far from “radical,” “impossible,” or “unrealistic,” the alternate path toward structural change includes frameworks that seek connection to alternative movements, or efforts to create a field that is not dictated by colonial political ordering or global capitalism. Ways to pursue this path are becoming increasingly clear. Showing how the decolonial dreams of Accredited Social Health Activist (ASHA) women health workers in India refute academic “decolonizing Global Health” discourses, Pandhi develops the idea of global health in/as praxis in which “the decolonial possibilities of public health” are “instantiated on the ground in resource-poor settings” by the community health workers who serve as the backbone of public health systems across the South (Pandhi 2024, p. 23). As Birn and Brown (2013) elucidate, for decades, public health practitioners and scientists have traveled around the world as comrades to assist anti-hegemonic social movements that are disconnected from philanthropic, academic, or nation-state-based International Health and Global Health. Outlining a history of Global Health interventions complementary to this commentary, Yates-Doerr and colleagues call for “interventions otherwise”—“alternative modalities and relations through which global health is practiced” that “will not only help to amplify grassroots, non-Western, anti-imperial, and anticapitalist work happening in global health, but potentially also bring attention to changing techniques and technologies of power” (Yates-Doerr et al. 2023, p. 197). In short, not only can we see how what constitutes Global Health work and action expands, but we can also see also how these actions more definitively move toward the dismantlement of Global Health through simultaneous “non-reformist reform”, transferring control, power, and wealth to Global South actors while in solidarity with anti-capitalist and anti-colonial social movements. Seeking to create pluriversality (Affun-Adegbulu & Adegbulu 2020) and autonomy (Abimbola 2023), as Rochelle Burgess generatively summarizes, these are “slow steps to build real structures that eventually mean an end to the need for a ‘Global Health’ at all” (2022, p. 5).
By way of conclusion, I declare for a final time that Global Health is not global health. As I have shown, separating Global Health from global health provides a vital heuristic tool for imagining the future of the social organization that calls itself Global Health and the idea of creating a healthy world. Without the constraints of the myth that Global Health is global health, we are free to imagine change that is not constrained by the need to preserve Global Health. When we recognize that Global Health is not definite, and that the possibilities of what public health and interventions to make the world healthier can be are much more than this field, it is clear that we have only just begun to explore what global health is and what it could possibly be.
Thus, more work is needed. Here, I have sought to construct a basis to be built from, and more questions than answers emerge from its limitations and contradictions. If, as anthropologists warn us, the “global” is inherently a problematic frame stemming from Western epistemology that is limiting of what can be imagined and enacted (Cohen2012, Yates-Doerr 2019), is “global health” really a coherent idea worthy of pursuit and use by different social movements (or, label of their work as a project of “global health” as I have done here)? Further, if Global Health is not global health, how are we to make sense of liminal people and social organizations committed to health justice but who use a plethora of methods and frameworks that sometimes align with hegemonic Global Health, but sometimes align with anti-globalization movements (Musolino et al.2020,Parker 2023)? As Pandhi points towards, it is precisely in “the social and cultural contours and contradictions that exist in between” hegemonic and anti-hegemonic structures, practices, and people that we may begin to find “otherwise” visions for organizing communal health (2024, p. 23). What I offer here is a grammar for recognizing those liminal places more, and a language for those seeking to change Global Health and move us toward alternate horizons of change and praxis.
The author would like to thank Seye Abimbola, Michael Harvey, Marina Schor and Beauty Dhlamini for their generative and generous suggestions and comments on drafts of this paper.
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