A New Approach to Global Health
The COVID-19 pandemic has demonstrated the need to revisit the holistic global health concept. This process should be inspired by a new conceptualization of global health, methodically combining strands that so far have been looked at in isolation.
The current COVID-19 pandemic shows in a drastic way the interconnectedness and the interdependencies that now exist on our planet, between and within populations, between health and wealth, social and economic determinants, development and foreign policy, preparedness and response, the human rights of an individual and the protection of entire populations. These interconnections have long been perceived as opportunities, while negative aspects have tended to be overlooked.
We have all learned a lot about viruses, at the microscopic or genetic levels, about the ways they spread and how they infect our bodies. This knowledge includes the dramatic consequences that pathogens can have at a global level, as well as the policies enacted in response to them—not only in terms of the burden of diseases and number of deaths they can cause but also the socio-economic consequences and even the impact on mental and social health conditions.
We have also seen the geopolitical power struggles and the consequences of populism that have influenced the spread of the virus and the responses to the pandemic. In addition, the delicate balance between scientific advice and policymaking and the importance of health literacy has become clearer. All these issues are obviously not new, and the concept of global health, which has evolved alongside the UN Millennium Development Agenda, has been addressing them for some time. The COVID-19 pandemic has now further underlined the need to strengthen global health as a methodology.
The Conceptual Framework
The term “global health” is used to describe transnational health problems, determinants, and solutions at the interfaces between politics, science, and society, and to promote interdisciplinary cooperation. This approach to global health complements and reinforces activities that are intended to implement the 2030 Agenda and the UN Sustainable Development Goals (SDGs). Global health is an open learning process, to enable health action and connect the relevant capacities. It is designed to address the interfaces of health activities in their technical, scientific, economic, cultural, and value dimensions. In particular, the concept of global health develops a comprehensive, human rights-based, multidisciplinary, and holistic approach. The focus is on health for all people worldwide and on global justice: how to align where we stand now and what must be done to achieve this goal.
These multi-dimensional topics, when unpacked and structured methodically, can be presented as integrated scientific-political-social practice fields with connecting options. The result is a holistic open system of elements and issues that can be dealt with under the innovative global health approach.
The global health architecture is constantly changing and is becoming increasingly complex, leading to the growing need for overarching and adaptive governance skills. There are regular proposals for the future division of tasks and prioritization, e.g. through a Framework Convention on Global Health. However, various political, historical, and economic factors make it more difficult to achieve progress. There is a disturbing lack of an adequate conceptual framework, one that would place the work of global health in a cross-cultural, value-driven, and comprehensively scientific-practical coherent perspective and present it as an ethical-pragmatic governance project.
Until the 1980s, medicine as a comprehensive interdisciplinary science for health to guide the art of healing, gradually became a science-based technology and economy to manage disease or health outcomes. This development affected different countries at various levels of speed and impact. With the technological revolutions and their immediate impact on industries, political and economic interest grew in the sciences, including health, to become competitive science/tech enterprises. For some, there had been only one feasible conceptual continuum―of liberal market models―to relate to when building or transforming their health systems, one that offered either state welfare or private business options.
Innovations in Science and Policy
The collapse of the Soviet Eastern Bloc in 1989 and the subsequent need for many countries to build a new health system during the period resulted in the ensuing entrepreneurial zeal and the export of this increasingly standardized health-economic monoculture, either in terms of participation according to the general rules (such as in the World Trade Organization, WTO) or in terms of learning from successful health business models.
This is just one aspect of the historical developments leading to the current innovations underway in both science and policy. They enable the comprehensive integration of physical knowledge and practical guidance, in order to develop global health as a trans-disciplinary, inter-cultural tool for advanced knowledge. To be better prepared to deal with pandemics in the future, information must not become an “infodemic.” Processes in health should enable resilience and cooperation, health maturity should be extended to all citizens and professionals, health economics should encourage the value of health knowledge, and health policies should become more sustainably reliable. Global health offers a powerful methodology for injecting ethics into the system and engendering trust so that proportional measures prevail.
Since the 1990s, there have been parallel advances in health research, technology development, and new global connectivity. Technologically and economically-driven globalization was instrumental in the development of the global policy field of health. This also applies to the Millennium Development Goals (MDGs) adopted by the United Nations, with their emphasis on improving health. They have led to major investments by public and private donors in global health projects and initiatives. In the field of development cooperation, health expenditure increased from approximately $7.7 billion in 1990 to approximately $40 billion by 2019. This has been made possible by philanthropic foundations such as the Bill and Melinda Gates Foundation and Rotary International, given the limited resources of transnational funds such as those of the WHO. While providing indispensable funds for immediate health and research needs, and emphasizing the crucial role of the health system and health economy development, this engagement made the need for sustainable health measures on “glocal” scales even more apparent.
At the beginning of the 21st century, many new organizations, programs, initiatives, and partnerships were initiated to achieve the MDGs. During the same period, WHO member states agreed on two globally legally-binding health agreements: the Framework Convention on Tobacco Control (FCTC) was adopted in 2003.
In the wake of the Severe Acute Respiratory Syndrome (SARS) epidemic, the International Health Regulations (IHR) were revised by WHO member states in 2005. The latter now forms the international legal basis for the global fight against infectious diseases and are regarded as a milestone among international agreements for the benefit of public health.
“The Most Important Task”
In order to embrace the rapid growth in the field, some countries, including Switzerland, the United Kingdom, and Germany, published special national strategies on global health. The growing importance of health for global policy was also demonstrated by the 2007 Oslo Ministerial Declaration, in which the foreign ministers of seven countries (Brazil, France, Indonesia, Norway, Thailand, Senegal, and South Africa) described health as “the most important, largely neglected long-term task of foreign policy of our time.”
Global health was also increasingly addressed at the G7/G8 and G20 meetings. In May 2017 the German government hosted a first meeting of G20 health ministers in Berlin, focusing on combating global health hazards. This included a health emergency simulation exercise. Looking back on this meeting from today’s perspective, the description of this exercise and the questions that were raised and discussed sound predictive in some way.
Interestingly, the present COVID-19 pandemic has not much affected low-income countries so far, as most people would have expected then, but mainly the G20 countries themselves, who were all part of this exercise.
This fact was also reflected in an earlier warning by Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases, in a speech he made in January 2017 shortly before the inauguration of President Donald Trump. Fauci highlighted a list of items needed to prepare for the next outbreak, such as strengthening global health surveillance, increasing investments in research, and setting aside emergency funds. Clearly, preparedness was not a task for “notional low-income countries” but a deliverable from global leaders.
The German government adopted a new strategy for global health in October 2020, following a two-year deliberative process that involved a wide range of stakeholders from politics, academia, think tanks, non-governmental and youth organizations, as well as the private and philanthropy sectors. The aim of the new strategy was to harness Germany’s political engagement and expertise across a number of areas―including health promotion and disease prevention, the environment, climate change, and health―holistically, strengthening health systems, tackling cross-border health hazards, and promoting research and innovation. The strategy is closely linked to the UN 2030 Agenda for Sustainable Development and, therefore, covers the period from 2020 to 2030. One major objective is to reform and strengthen the WHO as the leading and coordinating authority in the area of health on the global level.
Even before COVID-19 hit the world, the importance of creating credible moral foundations for global health was obvious. However, beyond historical lessons, what are the implications of ethical reflections on the advanced global health model? Global health connects the abstract virtue of credibility with the effectivity and efficiency of the relevant economic and political measures. It stimulates practical learning from what we know must be done concretely, in order to share responsibilities along the entire network of values, measures, and practices.
A New Global Health Diplomacy
Global health provides a powerful narrative for global collaboration. It has begun to define the range of realistic future scenarios for individual and concerted action. These scenarios simultaneously account for both universalizing and particularizing factors that shape a global health perspective for social, scientific, and economic systems. Such a “glocalizing” approach cannot limit itself to a theoretical analysis and objective description of health situations. It depends on the successful real collaboration of cultural diversity, especially within health diplomacy.
There is an intimate connection between human rights and global health that also requires a reform of global governance structures to better reflect global realities. Beyond the scope of realpolitik, it is important to identify the systemic blind spots that have allowed global health injustices to flourish, or even facilitated poor developments, and to connect the dots that have been left out of the current governance frameworks. This includes the rules of implementation of health standards. It commands attention to dynamics of meaning in different languages and translation across borders and boundaries. In this context, it is important to note that many of the desired cultural encounters in the area of global health diplomacy and politics are either often still loaded with bias or they lack shared experiences to generate trust.
In the face of the COVID-19 crisis, the need for advanced health diplomacy may point us toward ways to refine and transform not only the means to organize health beyond nations and strata, but inspire deliberation about health requirements in terms of global interconnectivity. This includes sustainable collaboration on logistics, infrastructures, translational standards, governance, research funding, education, and health science in the media, on top of the desirable outcomes in the context of public health. This is the call for an innovative turn to responsible citizenship within a specific global health portfolio. Again, the concept highlights the health responsibility of all actors, to inspire individuals and nations to reflect upon the health impact of their actions, so that the related deliberations on balanced and appropriate health-enabling practice can be interlinked with their supporting socio-economic conditions.
A major challenge for health diplomacy that depends on the currency of trust is to avoid the politicization of global health while preserving the respect for the international diversity of political cultures under the UN framework and looking for options to advance successful collaboration. Global health acknowledges the indispensable need to strengthen connecting nodes and can thereby contribute to chartering and negotiating the margins of health diplomacy. Thus, it can inspire pragmatic collaborations toward shared goals. How broadly diversity can stretch and to what extent health policy differences that challenge the common value base can be tolerated should be made the subject of continued joint inquiry, not prognostic judgements or biased assertions.
Here is an example from the early COVID-19 experiences. WHO on-site inspections were permitted by Chinese authorities to investigate outbreak areas in early 2020 only after delays and political quarrels. Health science researchers at the University of Bielefeld, Oliver Razum and Kayvan Bozorgmehr, pointed out in an article that “drastic quarantine measures at the population level were implemented without much societal debate in Wuhan/China. They were broadly accepted by the population and successful in reducing local transmission to a few instances. When these measures were strongly recommended by the WHO-China Joint Mission, it quickly became clear that they were not acceptable to all societies in the same way.” The most imminent problem was: how and what should other countries learn from the Chinese case? How could trust be built under conditions of uncertain information, suspicion, and the urgent need for cooperation?
China deserves credit for assuming responsibility and signaling openness to pragmatic cooperation across political and cultural borders. Then again, the Chinese government should be able to perceive opening to international interactions as something other than as a threat. This requires a proactive engagement on the part of the “old” governance actors, a willingness to learn mutually, and a readiness to invest trust as a preparatory step to fair criticism.
The emergence of new global health actors that are culturally different, such as China, must be seen as an opportunity for global health, conceptually. Cultural health knowledge and social experience with health organization models can benefit learning for better systems. This is an opportunity to redefine global health as an integrated trans-disciplinary methodology, and to reconfirm the semantic and ethical purpose of global health. Limiting ourselves to traditional frameworks, such as aid, capacity building, and diplomacy is redundant. It can even be self-defeating. The prevailing portfolio of organized approaches to global issues of health evidently has not been successful in delivering a robust universal best practice framework.
Seen as a programmatic methodology for glocal strategies, global health carries a substantial advantage: we do not depend on vested corporate interests, state pragmatism, or time restrictions for the agenda. We remain free to exercise responsibility in consideration of the blind spots and structural weaknesses that inhibit the full development of social economic value for sustainable global health. This implies adding what is missing where it makes sense and aligning everything under a clearly defined priority scheme. It guides us to do what is needed and to be honest about it.
The Way Forward
Today, the COVID-19 crisis is providing a lesson about the global connectivity of holistic health issues. It demonstrates how a new global health conceptual approach should be designed that can help align all social resources for health beyond medicine. This approach will mobilize the existing health knowledge and connect it conceptually so that processes of inquiry, research, and socio-political interaction can support global collaboration in terms of a coordinated division of labor for sustainable and resilient health measures. It will embed the building of timely health delivery infrastructures within a culture of health in all policies.
A values-based and trans-disciplinary global health approach focuses on learning from the crisis. It connects general health objectives shared by all humankind and the ecosphere with the means and the hard and soft skills to achieve them. The concept of global health is an attempt to integrate global health diversity within a comprehensive, trans-disciplinary framework that can facilitate the holistic aspirations of the WHO definition of health and the intrinsic purpose of the SDGs.
The German government is now increasingly shaping the field of global health and has initiated two interesting iniatives in recent years. The Federal Ministry of Health initiated the Global Health Hub Germany (GHHG) in 2019 as a platform to integrate actors from all relevant sectors in global health, one that choses a semi-open format for the inclusion of informal actors. The GHHG provides the grassroots connection for effectivity and legitimacy gains in society. Its counterpart, the German Alliance for Global Health Research, sponsored by the Federal Ministry of Education and Research, organizes the established institutional players in health research with international perspectives.
In summary, the pursuit of global health includes three inter-connected goals:
First, cross-disciplinary cooperation should make all relevant knowledge accessible and practical in order to enable comprehensive and effective trans-disciplinary science collaboration for health. In particular, the value of the humanities should be developed accordingly, starting with the curricula. Thereby, health-related sciences can evolve as health-enabling sciences.
Second, the coherence of comprehensive and sustainable trans-sectoral policies should be achieved, for efficient and adaptable health policy making. Knowledge from research on healthy system collaboration should be used to overcome compartmental barriers.
Third, effectivity and efficiency should be combined through a conceptually advanced methodology. The values proclaimed for global health can be aligned with general acceptance and support adherence on all levels. Global health can be used to mobilize health interface networks, such as health systems and social health infrastructures, accordingly.
The COVID-19 crisis makes it abundantly clear that these actions are not only desirable, but urgently needed, both on the national and the global level.
Mathias Bonk is founder and director of the Institute for Global Health Berlin (Institut für Globale Gesundheit Berlin, IGGB).
Ole Döring is co-founder of the IGGB. He is a sinologist and cultural philosopher and, inter alia, professor at the Department for Global Health at Beijing University.