A global health?

Reevaluating the biases that shape how we think about, and engage with, the world.

I am writing from within the country where I live, the United States. Being non-native to this country, I find myself often reflecting on place—what it means to be thinking and writing from within a particular place, and what influence the geographic region with which we identify has on how one thinks.

The more one reflects, the more one realizes that place influences more or less everything. That is not to say that one embraces a nationalist perspective that excludes any consideration of other countries and the people who live in them. But it is to say we should not overlook the degree to which most of us see the world through the lens of where we live. This perspective implies an acknowledgment of the difference between places, that however much we may embrace a universalist outlook—and we should embrace such an outlook—places are different, and this is reflected in the values and attitudes of the people who live in them. For all we share in common, we should remember that not everyone in the world lives the way we live, thinks the way we think, or has the same aspirations we have. Where we live is central to shaping our thinking about all of this, and this has direct applicability to how we think of the role of health within a global lens.

What do I mean? Well, let us consider how living in the US shapes our perspective of the rest of the world. The US has near ubiquitous availability of clean water and breathable air, essentially all children go to school through high school, and we do not see anything like the violence and displacement suffered by many in much of the world. This shapes how we think about the foundational drivers of health. If we see the world from the perspective of advantage, it can be difficult for us to imagine contexts where most people live without basic necessities. I have written before about how the poorest half of the world’s population makes a mere 8.5 percent of global income, with the richest 10 percent making 52 percent. Only two percent of the world’s wealth is controlled by the poorest 50 percent of the world’s population, while 76 percent of the world’s wealth is controlled by the richest 10 percent.

One of the challenges with this is that one often thinks of the world outside high-income contexts as “over there,” but, of course, just 16 percent of the world’s population lives in high-income countries, with the rest living in low- and middle-income countries. So, I am working in a national context where the foundational drivers of health are better than they are for roughly 85 percent of the world’s population. This makes it easy to feel, even when we intellectually know better, that the way we experience life is the norm for everyone, when in fact it is not—far from it.

What, then, does it mean to write and think about the foundational drivers of health from a high-income country perch? What does it mean for the notion of thinking of health as a global aspiration? Does that aspiration change when one applies different national lenses to it? In the past decade, such questions have come to the fore in the rethinking of global health as an academic discipline. We have turned our focus inward to ask whether what we have been calling global health is truly global in its perspective and approaches. And what we have seen has pushed us to commit to doing better in our engagement with global health. For example, observations that over 90 percent of publishing in science and engineering comes from upper middle- and high-income countries have helped the field realize the importance of partnerships that elevate authors from the all parts of the world our work aims to represent. That is all to the good. We should indeed be reevaluating the structures that support the elevation of some voices over others, keeping ourselves open to the possibility of reform and change, even as we resist the occasional impulse to tear down structures just for the sake of doing so. As always, reason and prudence should guide our efforts.

But, in some ways, this refashioning of global health into a partnership to study health globally, even if critical, falls quite a bit short, does it not? If most academic papers continue to be published by publishers based in high-income countries and English remains the language of science even as it is spoken by just about 15 percent of the world’s population, then we clearly have a long way to go before we have shaped a global health that is truly global in scope, and fully inclusive of the worldwide population. It is true that this is a challenge not easily addressed, and the first step to doing so is by speaking honestly about the bias that shapes our perspective.  

So, what does this bias mean for our frame of reference? It means, I fear, that, as with many other biases, it is a bias based in ubiquity, making it very hard to see beyond. Looking past this bias means carefully and intentionally pushing ourselves to see the world through different lenses. The bias of wealth and advantage is “the water in which we swim” in high income countries. Recognizing this is the first step to broadening our perspectives to see how the rest of the world lives, which can allow us to more effectively pursue a truly global vision of health. Our job is to think of health achievement within a global context, and everything we do to this end, no matter how seemingly small, represents incremental steps towards the larger goals of thinking globally about health.

What are some steps we can take in this direction? We can begin by recognizing our biases. There is little question that having the global health agenda shaped by those of us who happen to be living in high income countries is, on some level, simply an abdication of a broader responsibility towards improving the health of all populations. I realize there is some irony to my writing about this. After all, if my bias indelibly shapes my engagement with global health, how then can I separate even my analysis of this from my biases? The first step to solving this challenge is to acknowledge that it is indeed a challenge, one that it is on all of us to address, even with no clear solution in view. One of the reasons I write these essays is that I have found the act of articulation can itself be clarifying. Solving the problem of high-income bias in global health will likely take a range of approaches, but fundamentally it will take a commitment to creating pathways for intellectual engagement at a global level by people from all countries. This will take work and investment in scholarship and pathways for such by a new generation of thinkers and doers who come from all over the world. Getting to these solutions means first recognizing the need for them, then committing to doing what it takes to shape a more equitable intellectual foundation for global health.

Second, our thinking will require shaping a new wave of science that encompasses the world, with all perspectives not simply included but on equal footing. A global population health science that supports the theory and practice of public health should include comparative studies and the elevation of ideas that surface what might matter to populations living in many regions and contexts. It also requires scholarship that discusses and elevates values that animate health across borders, that sees the world through different philosophical lenses and different traditions over thousands of years. We are quite far from this right now, but surely centering such an approach is critical to anything that we do to truly get us to a global health going forward.

Third, we will need to encourage the type of exchange that truly crosses borders. This is the kind of exchange that science—based as it is on universal principles of free and rational inquiry— can do, and that those concerned with the health of populations must do. Our work is at its best when we are learning in each other’s countries, seeing the world through the eyes of others. This means ensuring that those engaged in health continue to engage with one another, work that is particularly necessary in an increasingly divided world. Because setting an agenda for a global health will need global thinking, and that can only be achieved through conversation and engagement.

Fundamentally, our mission is to achieve health for everyone globally. In much the same way that achieving our aspirations for health requires that we talk about health in a particular way, that we change the conversation on health, to achieve a global focus we will need to think globally, with a global lens, and global engagement. This means shifting how we think, perhaps the hardest of all tasks. But we owe it to our field to make the effort, to shape a philosophy of health that can support a vision of a healthier world for all.

__ __ __

Also this week

A new piece in the Boston Globe, “Is it OK to stop worrying about COVID?”

Thoughts with Michael Stein on misinformation and its significant (and growing) threat to the efficacy and utility of science in the latest Observing Science.