Power and priorities: the growing pains of global health

Abstract

Shiffman has argued that some actors have a great deal of power in global health, and that more reflection is needed on whether such forms of power are legitimate. Global health is a new and evolving field that builds upon the historical fields of public and international health, but is more multi-disciplinary and inter-disciplinary in nature. This article argues that the distribution of power in some global health institutions may be limiting the contributions of all researchers in the field.

A new community of researchers and practitioners has emerged during the past 20 years to create the new field of global health, which draws upon two fields with longer histories – public health and international health (1). Although there is some debate about what global health is and what it does (2), there is general agreement that the field is united by the common goal of reducing health inequalities globally. Although it has roots in the natural sciences and medicine, global health is usually more inclusive of social sciences than public health or international health; it is more multi-disciplinary and inter-disciplinary in nature, and more strongly recognizes the need for international cooperation to coordinate policy and allocate resources.

In a recent commentary, Jeremy Shiffman argued that the exercise of power is pervasive in global health but on the whole, we have spent far too little energy analyzing the distribution and legitimacy of power in this field (3). In particular, he asserts that what he calls “epistemic and normative” powers, which are derived from expertise and claims of moral authority, are rarely recognized or questioned in global health. Shiffman highlights three interesting examples: the emergence of the Institute for Health Metrics and Evaluation (IHME) as a leader in the field of global health metrics, the rise of the Lancet as a global health actor, and the formulation of the post-2015 health-related sustainable development goals. He argues that there needs to be more questioning of whether, and under what conditions, these actors represent legitimate power brokers in our field. I agree. As Shiffman argues, such unchecked power has the potential to distort global health priorities. There is little reflection on these forms of power in part because global health has no common epistemology or normative framework, which leads to tension in the field (4). If we are to stay united in our goal to help improve health for the disadvantaged, we need more opportunities to allow more inclusive dialogue across (and within) disciplines.

As Shiffman argues, not all power in global health is illegitimate, nor is it unwelcome. Indeed, the opposite is perhaps closer to the truth. There is growing agreement within the field that the real challenges in global health are due to the types of power imbalances that can sustain a world in which life expectancy at birth in some countries is less than half what it is in others, or where 99% of maternal deaths occur in the developing world. Without shifts in power, there will be no changes to the status quo and the rise of the IHME, the Lancet, and the goals-based development agendas have all contributed to marked health improvements in recent decades. There is less agreement on how to address these imbalances in power. Haas has argued that the defining features of an epistemic community include its shared values and its beliefs regarding theory (5). Global health has not yet achieved this transition away from its historical origins in international health and public health into a unified epistemic community with shared values and common causal beliefs. There is not even a consensus that this should occur. But the concentration of power noted by Shiffman may be preventing the types of dialogue that may ease the growing pains that global health faces as it enters its adolescent years.

Unquestionably, the IHME’s greatest contribution to global health has been advancing the global burden of disease framework, which has helped introduce rationality into priority setting discussions and represents a vast improvement of the previous construct in which estimates of illness were not internally consistent and morbidity was irrelevant (6). However, IHME’s strong reputation has given it, and its framework, a lot of clout in global health. Burden of disease is sometimes advocated as the primary (or only) criterion to be used when setting priorities, and imprecisions and imperfections in generating estimates are now largely ignored. But if burden of disease metrics are the only criterion that should be used to set resource allocation priorities, then, according to this logic, it was perfectly acceptable that the world invested so little in epidemic preparedness, such as against Ebola. This logic seems less valid than it did just one year ago, which is a reason to further discuss the importance of  burden of disease metrics, including their imperfections, in future resource allocation decisions.

There is no question that the Lancet is the most influential academic journal in the field of global health. It has published over 100 special issues exploring important global health topics from newborn survival to ageing. However, it is a medical journal, the publishing formats and structures of which are at times inconsistent with social science publishing needs. The lack of inclusion of non-medical methodologies and perspectives also limits opportunities for productive debate and discussion of the best approaches to improve health outcomes. A further disconnect between the Lancet and the field is that the journal’s editor has questioned the entire contribution of the discipline of economics to the field of global health (7). The journal recently sparked controversy by publishing what may be deemed a political paper, which led some to wonder if a medical journal should ever publish politically oriented papers (8). Social scientists have a great deal to add to the debate about which approaches should be prioritized in order to improve global health, which makes it important for these views to be better reflected in the pages of this journal.

Political science is the study of the distribution of power and resources in society. Shiffman’s article is a timely reminder that we also need to better understand the origins, distribution, and validity of power in global health. But doing so will require us to confront our varied disciplinary roots and beliefs about evidence. Such exercises are likely to be challenging, but are arguably important in the pursuit of global health improvements, which will likely require more cohesion and cooperation around advocating for resource allocation and priority setting exercises.

To move forward with this agenda, at least three changes could help rebalance power in the field. First, there need to be new fora for true inter-disciplinary and multi-disciplinary research. Twitter and social media may have a role to play in this process, but so could new multi-disciplinary global health journals. This new journal may represent such an outlet. Second, to encourage exchanges in such fora, the incentive structures must also shift to give researchers more credit for sharing their views. Judging the contribution of social scientists by the number of publications in medical journals is a weak indication of their true output. Finally, there also needs to be more investment in multi-disciplinary and inter-disciplinary training opportunities for global health researchers and practitioners. Such exchanges may help reduce tensions in the field and increase appreciation of other perspectives.

The good news is that global health has become a powerful field, one that has more ideas and actors than ever before committed to the pursuit of reducing health inequality globally. People seem to be living longer, healthier lives in most parts of the world. The challenge in the coming decade will be finding ways to use this power in the most constructive and cohesive way to ensure that the right priorities in global health are pursued to further these health improvements. Redistributing power to more diverse actors in global health will be key to this process.

Ethical issues

Not applicable.

Competing interests

Author declares that she has no competing interests.

Author’s contribution

KAG is the single author of the manuscript.

Citation: Grépin KA. Power and priorities: the growing pains of global health: Comment on "Knowledge, moral claims and the exercise of power in global health". Int J Health Policy Manag 2015; 4: 321–322. doi: 10.15171/ijhpm.2015.48