Resurrecting “International” and “Public” in Global Health: Has the Pendulum Swung Too Far?

The fashionable term “global health” seeks to convey that health issues are universal and transcend national boundaries. The term’s focus on problem identification within the problem–solution framework undermines critical thinking about solutions at the national and community levels. Public health is ultimately about responding: promoting, protecting, and enhancing the health of populations, especially that of the poorest and most vulnerable populations. The global health system plays an important role in setting standards and noble goals, but action is ultimately taken at national and community levels. Political boundaries confer authority (and responsibility) to uphold the well-being of a population. While recognizing a world of increased interaction and exposures, it is essential to remain grounded in the practicalities of the “international” aspect of public health.

Over the past decade or so, we have observed a trend away from the term “international public health” and a movement toward the term “global health.” In a Lancet commentary, Koplan et al. distinguished between “international health,” “public health,” and “global health.”¹ Multiple authors responded,^2–4 but, to our knowledge, none focused on how this semantic shift concentrates on only half of the problem-solution framework (i.e., problem identification and assessment) and neglects the solution aspect of the framework and the central role that nation states play in responding with solutions. While the term “global health” seeks to convey that health issues are universal, that health issues transcend national boundaries, and that diseases can and often do spread quickly (and often without respect for political boundaries), the term implies more of a focus on the problem than on what must be done about the problem. The term “global health” may be appropriate when referring to health issues, which are increasingly global in nature, but semantics must not cause us to lose our focus on how to address these problems.

The word “public” by definition means “of or concerning the people as a whole.”⁵ While communities or nations comprise individuals, individuals do not exist in isolation; they are part of a larger, interconnected whole. This larger whole (or population) is the focus of public health. There is tremendous heterogeneity across populations in terms of contextual risk factors driving health outcomes, and the nation state may be a useful unit of comparison with political, economic, and cultural commonalities relative to other countries, even though there are often disparities within nations. “Global health” as a term on its own, however, does not allow for population-level analyses, whether at the national or community levels. “Public” also means “being in service of a community or a nation.”⁵ This definition implies a governmental role, and the responsibility of a government is to serve and protect its people, including the health of its people. While public health is certainly not the exclusive domain of government, the importance of the governmental role and the responsibility of governments to protect and enhance their public’s health cannot be ignored.

Public health is also ultimately about the approach of responding to health problems. It is about promoting, protecting, and enhancing the health of groups and populations with an emphasis on preventing illness and injury in the first place (i.e., primary prevention). And, public health is about being responsible to all within the population, especially to its poorest and most vulnerable members. The Institute of Medicine’s frequently cited definition of “public health” refers to “what we, as a society, do collectively to ensure the conditions in which people can be healthy.”⁶ Often, in order for this response to health problems to truly affect the population as a whole, government must be involved to set policies and standards; regulate and enforce those policies and standards; monitor health status and risk factors; and even provide services to the population. The core functions of public health—assessment, policy development, and assurance⁶—are ultimately the responsibility of government, thus a public responsibility. In fact, the Institute of Medicine’s report stresses the importance of a strong governmental public health infrastructure to ensure and protect the health and well-being of the population.⁷

While the United Nations (UN) and other multilateral organizations such as the World Bank represent an important role for coordinated, global action, the implementation of any global action relies on the willingness and cooperation of member states. The UN was established in 1945 (original membership of 51 nations) with one of its primary purposes being “to help nations work together to improve the lives of poor people, to conquer hunger, disease and illiteracy, and to encourage respect for each other’s rights and freedoms.”⁸ The UN holds an important leadership role setting a global vision, facilitating collaborations, and providing the support to move toward that global vision. Ultimately, however, the enactment of any global vision depends on national governments. It is national governments who decide whether to become signatories to conventions, whether to implement and enforce conventions to which they are signatories, and whether to follow proposed norms and standards. It is national governments who enact policies and decide whether to participate in or cooperate with health monitoring and surveillance.

The World Health Organization, established in 1948 as the primary health agency of the UN, is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends.⁹ However, to act on these trends, national governments must decide to buy into such agendas and be willing to invest resources in such implementation. International political borders matter tremendously in public health because those borders determine authority over policies, interventions, and implementation.

Many health issues are in fact global in nature and do not respect national borders, but the response may be either considerably constrained or enabled by these political boundaries. Take for example the recent poor air quality in Singapore caused by Indonesian pollution. Because of weather patterns, forest fires in Indonesia resulted in Singapore recording its poorest air quality since 1997, which then prompted the country to issue health alerts.¹⁰ Outdoor air pollution is clearly a global health issue. The governments of Singapore and Malaysia (another country also affected by Indonesian air pollution annually) can do little to reduce air pollution as a risk for respiratory illnesses within their populations without cooperation from the Indonesian government, which is ultimately responsible for regulating air quality and pollution originating from within its own borders. Thus, the approach to addressing the global health issue of poor outdoor air quality requires an international public health response. Our ability to protect the respiratory health of those living in Singapore, Malaysia, and surrounding countries is very much constrained by geopolitical boundaries.

Another example of a global health issue hampered by the public health response of national governments is the issue of young women and girls who are the victims of sex-trafficking and who are thus at increased risk of HIV/AIDS and interpersonal violence. Sex-trafficking is a particularly important issue in the South Asian region (although certainly not exclusively there), and it is an important risk factor in the spread of HIV/AIDS. One study estimated the HIV prevalence among sex-trafficked Nepalese women and girls repatriated from India to be approximately 38%,¹¹ markedly higher than Nepal’s overall estimated prevalence of 161 per 100 000.¹² Thousands of Nepali women and girls are trafficked every year to work in the brothels of large Indian cities. While international and local nongovernmental organizations often provide much of the support and care services for women and girls rescued from trafficking,¹³ national governments are responsible for enacting and enforcing legislation against such as trafficking. It is also the national governments who have the authority to negotiate and enter into regional agreements, such as the South Asia Association for Regional Cooperation, in which the member states of Nepal, India, Pakistan, Bangladesh, Bhutan, Sri Lanka, and Maldives signed the Convention on Prevention and Combating the Trafficking in Women and Children for Prostitution in 2002.¹³ We cannot hope to succeed in tackling sex-trafficking as a human rights issue and as a risk factor for interpersonal violence and HIV/AIDS without recognizing the important role of political boundaries and the authority (and responsibility) they confer.

The global health framework also aims to minimize the dichotomy between higher- and lower-income countries and to recognize the commonality of health issues. Public health as a discipline places particular emphasis on improving the health of the poorest and most vulnerable segments of the population. From this perspective, it makes sense that international public health would focus more heavily—but certainly not exclusively—on improving the health conditions in lower-income countries, and, in particular, for women, children, and marginalized populations within lower-income countries, as they constitute some of the poorest and most vulnerable populations worldwide. It is also true that many lower-income countries still face significant burden from health conditions nearly eliminated from higher-income countries, such as certain life-threatening micronutrient deficiencies, maternal mortality and childbirth injuries, and infectious diseases like leishmania. These countries are also experiencing an increase in health conditions such as cardiovascular disease and cancer historically associated more with higher-income countries.

Finally, the term “international public health” technically refers to what other societies outside one’s home country are doing to prevent disease and protect health among their populations. To learn effectively from others and conduct cross-cultural comparisons, all public health students should develop a solid reference point around which to process their knowledge and experience with health systems elsewhere. Ideally, students will gain an in-depth fundamental understanding and familiarity with one high-quality health system, as defined by health indicators and equitable access to services, to serve as their reference point. Students also need to become well versed in the general, theoretical structures of multiple types of health systems, so that they can conduct comparative analyses across systems. This familiarity with a reference-point health system is essential for comparison when studying about or working in other countries. Such knowledge also promotes the exchange of ideas related to policies and interventions as one works with populations, programs, and policies in countries other than one’s home country. With a firm grounding in one reference setting, the potential for idea flow, both from the country of study to other countries and vice versa, increases. More and more, public health experts in the United States and other high-income countries are looking outside their borders for ideas on how to solve the challenges facing their populations.

With the tide of criticism surrounding the term “international public health” comes a somewhat blind following in the use of “global health.” Even within our universities, we apply the name widely to departments, centers, and institutes with little regard for its nuances. In our view, the term “global health” does not adequately convey the real need for public health prevention and solution-oriented international work. While there is a distinct and vital role for the global health perspective within the UN system and for the characterization of trans-border health issues, ultimately solutions will be found and enacted at the national and community levels. We cannot and should not lose sight of international public health.