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Supinda Bunyavanich, MPhil and Ruth B. Walkup, PhD

The authors are with the Office of International and Refugee Health, US Department of Health and Human Services, Rockville, Md.

Correspondence: Requests for reprints should be sent to Ruth B. Walkup, PhD, Office of International and Refugee Health, Room 18-105, 5600 Fishers La, Rockville, MD 20857 (e-mail: rwalkup{at}osophs.dhhs.gov).

	INTRODUCTION

TOP INTRODUCTION DEFINITION OF HEALTH NORMS HEALTH STATUS HEALTH CARE PROVISION HEALTH ETHICS CONTEXTS OF THE PARADIGM... CONCLUSION References

 
"Global health" has become a dominant phrase in international public health discourse. It frames World Health Assembly discussions¹ and presidential and vice presidential addresses,^{2, 3} stands as one of the US surgeon general's top priorities,⁴ commands attention at trade and development summits (e.g., the Annual Bank Conference on Development Economics, April 18–20, 2000, World Bank Headquarters, Washington, DC; the World Trade Organization's 3rd Ministerial Conference, November 30–December 3, 1999, Seattle, Wash), and underpins legislative bills for the advancement of global health.^{5, 6} But what do we actually mean by global health, and how does it differ from international health? Interpretations of this term affect strategies, support, and coordination for global health initiatives. Health policymakers and researchers can forge more strategic approaches to health promotion and disease prevention if they are empowered with a comprehensive understanding of "global health."

We held discussions with 29 international health leaders in government, nongovernmental, professional, multilateral, and academic organizations during July and August 1999. We asked 3 questions eliciting their theoretical and practical associations with the concept of global health in the context of their past experiences, current work, and future initiatives:

• What concepts do you see as fundamental to the globalization of health?

• In what tangible ways does the globalization of health affect your work and organization?

• Has globalization changed the meaning and direction of your initiatives and involvements?

The respondents fell into 2 groups. One group recognized worldwide commonalties in health approaches, but felt it unnecessary to coin a new phrase to describe business as usual. They believed that "global health" was mere jargon. "Nothing has changed," commented a Senate aide. "Saying global health instead of international health doesn't change anything." The other group emphasized profound differences between "international" and "global." "International" elicited conceptualizations of coordination constrained by nation-state boundaries, whereas "global" held a more positive connotation associated with improvement. Interestingly, "globalization" suggested many of the negative effects of increasing worldwide linkages in commerce, travel, and communication. "I associate ‘globalization’ with bad problems that involve the whole world," commented one professor. Overall, most people interviewed believed that "global health" was a loaded but meaningful term. We present our analysis of the respondents' interpretations here under 4 themes: definitions of health norms, health status, health care provision, and health ethics.

	DEFINITION OF HEALTH NORMS

TOP INTRODUCTION DEFINITION OF HEALTH NORMS HEALTH STATUS HEALTH CARE PROVISION HEALTH ETHICS CONTEXTS OF THE PARADIGM... CONCLUSION References

 
"Global health" signaled several definitional transitions among respondents. The adjective "global" instead of "international" highlights the irrelevance of geopolitics in addressing health. "There are now fewer boundaries," remarked a National Security Council advisor. "Countries must deal with health together, just as they do with defense and trade." Global health raises an expectation of health for all,⁷ for if good health is possible in one part of the world, the forces of globalization should allow it elsewhere. Respondents noted that global health does not refer narrowly to physical status but rather refers to broader needs for satisfying, productive lives. The World Health Organization (WHO) definition reflects this: "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."⁸ Interviewees from the National Academy of Sciences, the Food and Drug Administration, and WHO particularly emphasized these definitional aspects.

	HEALTH STATUS

TOP INTRODUCTION DEFINITION OF HEALTH NORMS HEALTH STATUS HEALTH CARE PROVISION HEALTH ETHICS CONTEXTS OF THE PARADIGM... CONCLUSION References

 
Interviewees stressed that the global interconnectedness of people, goods, habits, and pathogens has an impact on the health status of individuals and populations. Movements of people and goods across borders accelerate the spread of diseases⁹ and increase the potency of bioterrorism. "We increasingly need worldwide early surveillance to guard against disease mutation and to direct vaccine development and availability," stressed a US Department of Health and Human Services official. Trade and health are intimately linked, as exemplified by corresponding spreads of tobacco use and respiratory ailments. Communities once isolated from outside health threats now face food safety concerns from an increasingly global food supply and "the environmental challenges of global warming and pollution," as a World Bank advisor said. Finally, the adoption of poor lifestyle habits has made cardiovascular disease almost universal and threatens to do the same for other ailments. All interviewees who described "global health" as a meaningful term discussed the significance of these fundamental changes in health status.

	HEALTH CARE PROVISION

TOP INTRODUCTION DEFINITION OF HEALTH NORMS HEALTH STATUS HEALTH CARE PROVISION HEALTH ETHICS CONTEXTS OF THE PARADIGM... CONCLUSION References

 
Many respondents indicated that the term "global health" suggests commonalities in health care knowledge, provision, funding, and politics. Advanced information systems allow research to cross borders easily. "Public health fieldwork is so much easier now," commented a Centers for Disease Control and Prevention officer. "Even when you're in poor countries you can communicate by e-mail and ask anyone in the world what intervention might be appropriate." Remote regions can increasingly access professional and laboratory services clustered in hi-tech loci.

Although pharmaceutical companies have made drugs more globally accessible, they have also fostered dilemmas concerning exclusive manufacturing rights and antibiotic resistance. "We need to protect drug developers in the global market," remarked a WHO health attaché, "but we also need to ensure access to drugs." Questions of health care funding have risen in importance as corporate providers expand their geographic scope. One professor noted, "We're seeing increasing commonalities in the components of health care systems because basic health needs are similar worldwide." Respondents noted that these concerns evoke questions concerning the politics of global health care provision—who decides and who pays?

	HEALTH ETHICS

TOP INTRODUCTION DEFINITION OF HEALTH NORMS HEALTH STATUS HEALTH CARE PROVISION HEALTH ETHICS CONTEXTS OF THE PARADIGM... CONCLUSION References

 
The shift to a global health framework elicited ethical concerns about health disparities and national sovereignty from academics, the World Bank advisor, the Institute of Medicine administrator, and health association representatives. Approximately 90% of global health resources are concentrated on 10% of the world's health problems.¹⁰ The status quo is unsustainable, but will "global" strategies improve equity? If resources are a zero-sum game, a global strategy could divert resources once exclusively marked for underserved populations.¹¹ "Although it might be good to think globally about health, we must still focus on decreasing disparities to ensure that benefits reach everybody," said a World Bank advisor.

Global health agenda-setters, most of whom come from regions with adequate resources, may remain unresponsive to the health priorities of resourcelimited communities, as depth must often be sacrificed for breadth in the search for global scope. Globalizing health does not necessarily confer equal voice and power. "We must use the new momentum of globalization to grapple with the old problem of inequalities and health disparities," insisted a professor. "We need to listen to poor people of the world and their priorities." Inequities will continue if the right to health care is not taken seriously.

	CONTEXTS OF THE PARADIGM SHIFT

TOP INTRODUCTION DEFINITION OF HEALTH NORMS HEALTH STATUS HEALTH CARE PROVISION HEALTH ETHICS CONTEXTS OF THE PARADIGM... CONCLUSION References

 
Our research indicates that the US international public health community is shifting toward a paradigm of global health. Although this transition is relatively recent, its underlying ideas are embedded in broader contexts of history, theory, politics, technology, and identity. Appreciating these contexts can help us understand where these current ideas on global health will take us.

Concepts of general global connectedness were first clearly articulated in 1974 by sociologist Immanuel Wallerstein.¹² Wallerstein argued that global economic and political relationships are characterized by relations between strong, wealthy "core" states and less influential "peripheral" states. Although world-systems theory was criticized for its simplistic dichotomous structure, some of its mechanisms are evident today. Markets and trade are indeed controlled by the developed world, whose influence is expanding across the globe with greater speed and reach than ever before. Wealthier nations still wield greater political influence in a world where individual countries strive to retain nominal autonomy. However, the complete global homogenization of cultures that many people feared has not occurred.

These theoretical underpinnings of globalization are woven into global health discourse today, as evidenced by our data, by academic commentary, and by politics. The worldwide dynamics of growing markets, modernization, and struggles for national and ethnic identities have become inextricably linked to health care politics. Some scholars, for example, argue that WHO is losing health policy leadership to the World Bank, an economic institution influenced by wealthy countries.¹³ Health policy theorist Vicente Navarro charges that multilateral organizations involved in health, including WHO, UNICEF, the United Nations Development Program, the International Monetary Fund, and the World Bank, have not been deliberate in their political roles toward equitable globalization of health.¹⁴

The Institute of Medicine's document America's Vital Interest in Global Health argues that the United States' involvement and leadership in global health can be justified on grounds of national security, good economic sense, and as a mechanism for continued global authority.¹⁵ WHO officials Derek Yach and Douglas Bettcher posit that legal and media communities have a new role in influencing global health politics, enforcement, and advocacy.^{16, 17} In practical terms, Howson et al. stress that, for a healthier world, there must be a reevaluation of traditional national borders and demographic divisions.¹⁸

One of the most far-reaching changes is a broadening sense of place in the greater world. Health planners, activists, academics, and consumers have an expanding mental vision of the world, and this expanded vision greatly influences their discussions about global health and how they envision their role in it.¹⁹ Our research suggests that US public health leaders are indeed appreciating their changed roles in a world of increased global linkages.

	CONCLUSION

TOP INTRODUCTION DEFINITION OF HEALTH NORMS HEALTH STATUS HEALTH CARE PROVISION HEALTH ETHICS CONTEXTS OF THE PARADIGM... CONCLUSION References

 
The paradigm shift toward "global health" among US public health leaders suggests new coordination, resources, and solutions for health problems and should motivate departures from traditional health care provision. To translate "global health" into action, leaders should capitalize on the unprecedented advantages stemming from globalization's cross-boundary effects. They should think across disciplines in communicating health strategies, gathering knowledge, identifying approaches, formulating teams of players, and requesting and allocating funds. Communication linkages should be used to coordinate the solving of international health problems. The key to achieving global health will lie in formulating comprehensive and sensitive plans that draw from improved understandings of what the term now means and what it should encompass, especially for those who lead our global public health efforts.

	References

TOP INTRODUCTION DEFINITION OF HEALTH NORMS HEALTH STATUS HEALTH CARE PROVISION HEALTH ETHICS CONTEXTS OF THE PARADIGM... CONCLUSION References

 
1. Report of 52nd Annual World Health Assembly; May1999; Geneva, Switzerland. Available (in PDF format) at: http://www.who.org/wha-1998/WHA99/listang.htm. Accessed July 27, 2001.

2. Remarks by the president to the 54th session of the United Nations General Assembly, September 21, 1999. Available at: http://clinton3.nara.gov/WH/New/html/19990921_1.html. Accessed July 27, 2001

3. Remarks as prepared for delivery by Vice President Al Gore, UN Security Council Session on AIDS in Africa, January 10, 2000 [press release]. Available at: http://www.un.int/usa/00_002.htm. Accessed July 27, 2001.

4. Satcher D. My priorities. Available at: http://www.surgeongeneral.gov/myjob/priorities.htm. Accessed July 27, 2001.

5. The Advancement of Global Health Act, HR 2399, 106th Cong, 1st Sess (1999).

6. Global Health Act of 2000, HR 3862/S.2387, 106th Cong, 2nd Sess (2000).

7. United Nations General Assembly. Global strategy for health for all by the year 2000. Available at: http://www.un.org/documents/ga/res/36/a36r043.htm. Accessed July 27, 2001.

8. World Health Organization. Definition of health. Available at: http://www.who.org/aboutwho/en/definition.html. Accessed July 27, 2001.

9. Zacher MW. Global epidemiological surveillance: international cooperation to monitor infectious diseases. In: Kaul I, Grunberg I, Stern MA, eds. Global Public Goods: International Cooperation in the 21st Century. New York, NY: Oxford University Press; 1999:266–283.

10. Brundtland GH. Speech to the 51st World Health Assembly, Geneva, 13 May 1998. Available at: http://www.malaria.org/SPEECH.HTM. Accessed July 27, 2001.

11. Cohen HW, Gould RM, Sidel VW. Bioterrorism initiatives: public health in reverse? Am J Public Health.1999;89:1629–1630.[Free Full Text]

12. Wallerstein IM. The Modern World-System. New York, NY: Academic Press; 1974.

13. Berlinguer G. Globalization and global health. Int J Health Serv.1999;29:579–595.[Medline]

14. Navarro V. Health and equity in the world in the era of "globalization." Int J Health Serv.1999;29:215–226.[Medline]

15. Institute of Medicine. America's Vital Interest in Global Health: Protecting Our People, Enhancing Our Economy, and Advancing Our International Interests. Washington, DC: National Academy Press; 1997.

16. Yach D, Bettcher D. The globalization of public health, I: threats and opportunities. Am J Public Health.1998;88:735–738.[Abstract/Free Full Text]

17. Yach D, Bettcher D. The globalization of public health, II: the convergence of self-interest and altruism. Am J Public Health.1998;88:738–741.[Abstract/Free Full Text]

18. Howson CP, Fineburg HV, Bloom BR. The pursuit of global health: the relevance of engagement for developed countries. Lancet.1998;351:586–90.[Medline]

19. Keane C. Globality and constructions of world health. Med Anthropol Q.1998;12:226–240.[Medline]

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