Foundations of the modern understanding of global health diplomacy

2.2 Foundations of the modern understanding

tution was adopted in New York on 22 July 1946, the first statutory function of the new Organization being “to act as the directing and co-ordinating authority on international health work”. The Constitution came into force in 1948, when WHO was able to take up its work in Geneva.

However, it was during the latter decades of the 20th century that the present understanding of global health began to take shape. Heightened demand and expectations for global cooperation on health were triggered by several external factors, including globalization; transnational commercial interests; the cross-border nature of health determinants; global epidemics such as HIV/AIDS and tobacco use; the rising political profile of health; and the multiplication of international actors en- gaged in health issues.

The end of the 20th and the beginning of the 21st centuries saw a new two-way dynamic emerge in global health. On the one hand, the world witnessed a rapid rise in the number and intensity of transnational factors influencing health. Growing international trade, transnational companies, global tourism, transport and communications have significantly accelerated the cross-border movement of people, goods, services, information and lifestyles. New global threats, such as in- equality, climate change, food insecurity, resurging infectious diseases and mass migration, are having a significant impact on health and well-being. The benefits of globalization have not been equally distributed, and inequality has increased in the wake of the 2008 financial crisis and the austerity policies subsequently adopted by many countries.

On the other hand, it is now understood more clearly that health makes a considerable direct and indirect contribution to economic growth and sustainable development, and to international secu- rity, stability and peace. The wide-ranging economic impact of the COVID-19 crisis has highlighted this once again. Furthermore, the health sector has now become one of the largest industries.

Global annual health spending reached US$ 7.1 trillion in 2015 – a figure that was expected to balloon to US$ 8.7 trillion by 2020. Health is also a key sector in public finance and a major area of household spending (Deloitte, 2019a). Accordingly, health has acquired a prominent place on both the domestic and foreign policy agendas of most countries.

At the same time, two distinct approaches to global health have emerged. One is more focused on improving health in developing countries; it is based on the SDGs, financed by development aid and increasingly supported by large philanthropic organizations. The other – reinforced by the COVID-19 pandemic – is concerned with all countries, the health inequalities within and between these, and with health issues that transcend national boundaries and call for responses taking into account the global forces that determine the health of people. This dynamic interface between health and economic and societal factors cannot be tackled within national or regional boundaries alone: the challenges it poses require global solutions based on both multilateral and multi-stakeholder coor-

dination and action, especially during global health crises and outbreaks.

Today there is a lively ongoing debate on how global health should be understood. Governments and communities in the Global South, in particular, are no longer willing to accept approaches to global health in which they have not been involved from the start, or to adopt programmes developed “for”

them by others. Many global health professionals and organizations are still concentrated in the Global North: there have consequently been calls for a “decolonization” of global health (see Box 3).

Box 3: Decolonizing global health diplomacy

In recent years, there have been calls to “decolonize” global health, which some have described as an inherently “colonialist” field. University students have organized conferences to question the ahistorical and depoliticized teaching of global health. Journal articles have criticized the lack of inclusivity in the conduct and publication of research; for instance, African researchers were found to be grossly underrepresented in scientific papers about health issues in Africa. Some commentators have discerned “colonial” attitudes and practices in the global response to the COVID-19 pandemic – from early suggestions to use Africa as a “testing ground” for a potential vaccine to expert recommendations on handwashing and social distancing that do not take into account the local context in poor countries.

But what does it mean to decolonize? There are at least two major interpretations of the term

“decolonization”. The traditional view is that it refers to the end of one country’s territorial domi- nation of another. In this regard, most countries – especially in the “Global South”* – would al- ready count as “decolonized”. In an influential paper, however, the term was defined as “the re- versal of the process of European imperial expansion with all its political, economic, social, cultural and linguistic consequences” (Bismarck, 2012) – in short, a return to a people’s indige- nous roots. While many remnants of the colonial past, such as language and culture, are difficult, if not impossible, to purge, this does not mean that the legacy of colonialism as reflected in modern-day capitalism, sexism, racism and globalization cannot be explicitly acknowledged and constantly challenged.

When examining the field of global health, the related concept of “decoloniality” is also import- ant. Originating in Latin American scholarship, it refers to questioning the perceived universality and superiority of Western knowledge and culture. Much of centuries-old human medicine and contemporary global health has been shaped by Western thought, which largely ignored other systems of knowledge production. Therefore, decoloniality in global health is an invitation to a

more pluralistic vision of health that also considers non-Western and indigenous perspectives. It is hoped that such a dismantling of Eurocentric notions will give rise to health interventions, policies, practices and research arrangements that are inclusive and respectful of different peo- ples and their cultures. Some have argued, for example, that a lack of such respect led to a

“narrative of mistrust” in the international response to the Ebola outbreak in West Africa in 2014 (Richardson, McGinnis & Frankfurter, 2019).

How, then, is global health diplomacy to be “decolonized”? While the geopolitical colonization of the Global South by Western countries is largely over, colonial legacies still very much prevail in the form of neoliberal policies, gender discrimination, white supremacy and ecological destruc- tion, all of which to this day continue to drive health inequalities within and between countries.

If pressing global health issues, such as noncommunicable diseases, sexual and reproductive health, and the long-term health impacts of climate change, are to be seriously addressed, mul- tilateral and bilateral negotiations for health among countries must acknowledge and actively challenge these long-standing causes of power imbalances.

In addition, the platforms for health diplomacy must be made more inclusive and egalitarian.

Developing countries are still generally unable to transition from unequal relationships with their former colonizers (and now development aid donors), which dominate decision-making on global health (whether in United Nations agencies or public–private partnerships, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria). Much-needed reforms must therefore be institut- ed to give equal voice to all countries – rich and poor. The shift in 2017 to having the WHO Direc- tor-General elected by the World Health Assembly (that is, by all countries), rather than by the Executive Board, was an essential step in that direction. However, additional measures will need to be adopted to accelerate progress towards greater inclusivity and diversity in global health leadership, governance and diplomacy.

Finally, applying the decolonial lens to health diplomacy helps in uncovering voices that are either

“too loud” or “not heard at all” at the negotiating table. Beyond national governments, there are myriad actors who can be seen to be engaging in “neocolonial” behaviour and are exerting un- due and disproportionate influence in global health policy – from multilateral banks and transna- tional corporations to philanthropic foundations and elite think tanks. On the other hand, there are the “silenced voices” in global health – women, members of the LGBT community, ethnic minorities and indigenous communities, social movements from the Global South, among others.

In order to decolonize global health diplomacy, it has been argued that it is necessary to protect the negotiating space against “neocolonizers” and create more opportunities for the “colonized”

and oppressed to become involved in negotiations – an important first step towards making global health truly global.