Politics and Power in Global Health: The Constituting Role of Conflicts

Abstract

In a recent article, Gorik Ooms has drawn attention to the normative underpinnings of the politics of global health. We claim that Ooms is indirectly submitting to a liberal conception of politics by framing the politics of global health as a question of individual morality. Drawing on the theoretical works of Chantal Mouffe, we introduce a conflictual concept of the political as an alternative to Ooms’ conception. Using controversies surrounding medical treatment of AIDS patients in developing countries as a case we underline the opportunity for political changes, through political articulation of an issue, and collective mobilization based on such an articulation.

In a recent contribution to the ongoing debate about the role of power in global health, Gorik Ooms emphasizes the normative underpinnings of global health politics. He identifies three related problems: (1) a lack of agreement among global health scholars about their normative premises, (2) a lack of agreement between global health scholars and policy-makers regarding the normative premises underlying policy, and (3) a lack of willingness among scholars to clearly state their normative premises and assumptions. This confusion is for Ooms one of the explanations “why global health’s policy-makers are not implementing the knowledge generated by global health’s empirical scholars.” He calls for greater unity between scholars and between scholars and policy-makers, concerning the underlying normative premises and greater openness when it comes to advocacy.¹

We commend the effort to reinstate power and politics in global health and agree that “a purely empirical evidence-based approach is a fiction,” and that such a view risks covering up “the role of politics and power.” But by contrasting this fiction with global health research “driven by crises, hot issues, and the concerns of organized interest groups,” as a “path we are trying to move away from,” Ooms is submitting to a liberal conception of politics he implicitly criticizes the outcomes of.¹ A liberal view of politics evades the constituting role of conflicts and reduces it to either a rationalistic, economic calculation, or an individual question of moral norms. This is echoed in Ooms when he states that “it is not possible to discuss the politics of global health without discussing the normative premises behind the politics.”¹ But what if we take the political as the primary level and the normative as secondary, or derived from the political?

That is what we will try to do here, by introducing an alternative conceptualization of the political and hence free us from the “false dilemma” Ooms also wants to escape. “Although constructivists have emphasized how underlying normative structures constitute actors’ identities and interests, they have rarely treated these normative structures themselves as defined and infused by power, or emphasized how constitutive effects also are expressions of power.”² This is the starting point for the political theorist Chantal Mouffe, and her response is to develop an ontological conception of the political, where “the political belongs to our ontological condition.”³ According to Mouffe, society is instituted through conflict. “[B]y ‘the political’ I mean the dimension of antagonism which I take to be constitutive of human societies, while by ‘politics’ I mean the set of practices and institutions through which an order is created, organizing human coexistence in the context of conflictuality provided by the political.”³ An issue or a topic needs to be contested to become political, and such a contestation concerns public action and creates a ‘we’ and ‘they’ form of collective identification. But the fixation of social relations is partial and precarious, since antagonism is an ever present possibility. To politicize an issue and be able to mobilize support, one needs to represent the world in a conflictual manner “with opposed camps with which people can identify.”³

Ooms uses the case of “increasing international aid spending on AIDS treatment” to illustrate his point.¹ He frames the issue as a disagreement on the normative premises underlying the different policy-options, and he sketches three different positions: to feel compelled to act out of ‘compassion,’ acting to protect one’s own interests (‘enlightened self-interest’) and act out of an obligation to human rights (‘justice’). The first two positions could lead to an inclusion of AIDS treatment in their preferred policy, whereas the third would necessarily include such treatment in their policy.¹ This framing itself illustrates one of the limitations of the liberal framework. In the words of Carl Schmitt: “liberal concepts typically move between ethics and economics. From that polarity they try to annihilate the political as a domain of conquering power and repression.”⁴ Even if “international health aid were based on the right to health” as its normative foundation,¹ the basic constitution of power relations, political structures, and material interests in the world would still be the same. Thus the policy-outcome would not be given by the normative position, as Ooms implies, and neither would the actual implementation of the policy.

Refusing to provide antiretroviral (ARV)-treatment for patients in developing countries implicitly means to put a lower value on these patients than the value ascribed to HIV-patients at home. It is possible to provide different normative justifications of this difference, for example through the application of a version of the proximity-principle, stating that our moral obligation is stronger to those closer to us (geographically, nationally, culturally, etc.),⁵ or through some form of racism.⁶ With reference to psychological research one could also give an empirical explanation to this often actual difference in how we perceive human value.⁷ But both the normative justifications for such a difference and its empirical explanation are constituted on the basis of certain political structures, power relations and material interests. The fundamental point being simply that, the situation, in which HIV-patients in the developing world have to die due to lack of treatment, while HIV-patients in our neighborhood receive treatment, is not given by nature. Rather it is a result of economic structures, political conflicts, and relations of power. For Mouffe this also means that the situation can be challenged politically and thereby, changed.

This is also what actually happened, during the first years of the new millennium, as a result of research, advocacy, activism and collective political mobilization.^8,9 The level of contestation was political and concerned public action and the debate was political as it required a decision to be made between conflicting alternatives. By articulating politically the equal right for all to health, and thereby to ARV-treatment, AIDS-activists all over the world constituted a ‘we’, and their opponents became ‘them.’ The activists successfully represented the situation in a conflictual manner and people had to choose sides, “allowing for passions to be mobilized politically.”³ If we consider AIDS to be a ‘crisis,’ which became a ‘hot issue’ as the world community started to realize the severity of the crises, and which then became a ‘concern of organized interest groups,’ we see that Mouffe’s conception of the political is the same as the one Ooms “are trying to move away from.”

The process of expanding access to ARV-treatment was not a result of static economic realities relating to patents and the cost of the treatment. As Ooms points out, the economic realities changed,¹ partly because of softening of the patent-rules and the production of generics, and partly because of “sustained pressure to substantially increase funding.”¹⁰ Thus we see that by politically articulating an issue, the situation itself can change through a reconstituting of the social field, re-drawing “the boundaries of what was possible.”¹⁰ Nor was the expanded access to ARV’s a result of a rational consensus, where different affected actors deliberated and agreed on what was to be done. Some of the drug companies were practically forced to approve of the production of generics, and millions of AIDS-patients died before they got the chance to receive treatment.⁹ When consensual agreement is reached in political matters, it is usually because something or someone is excluded.³ This is the ideological face of universalism. The reframing of political questions as administrative, technical or rational, makes them seem neutral, and thus simply a matter of finding the best solution.¹¹ But every such solution tends to distribute costs and benefits unevenly amongst those subject to it. “If the trade-offs in advantages and disadvantages were identical for everyone, judgments involved in making collective decisions would be roughly equivalent to those involved in making individual decisions.”¹² In this case, there’s an obvious difference between a drug-company losing some of its profits, and a HIV-patient losing his/her life.

The great weakness of the liberal understanding of the political is that it neglects the constitutive function played by power and conflicts. In Mouffe’s view, this happens largely through the “conflation of political discourse with moral discourse,”¹³ through the reduction of political questions to “mere technical issues to be solved by experts,”³ and through the belief in the attainability of a rational consensus.¹⁴ When politics is thought of in normative terms, it turns into an individual matter where each of us must choose how to act. But only political discourse concerns public action.¹³

Conclusion

We agree with Ooms that there is a need to uncover the role of politics and power in order to be able to challenge “the role of the powerhouses of global health.” But without a more conflictual concept of the political, he remains trapped within the situation he criticizes. By framing the implementation issue as either a normative issue or an issue about empirical evidence, he effectively removes the opportunity for political articulation of the issue, and collective mobilization on the background of such an articulation. Instead, it becomes a question of researchers’ “personal opinions” or scientific truth,¹ and then also something one can rationally reach an agreement or a form of consensus about. The reason why global health’s policy-makers are not implementing the knowledge generated by global health’s empirical scholars, is not because they use different normative premises. It is because the policy-makers are politically constrained by interests and power structures. The conflict is not a difference in normative opinion, but a political conflict. Political here understood in Mouffe’s terms as “collective participation in a public sphere where interests are confronted, conflicts sorted out, divisions exposed, confrontations staged and in that way […] liberty secured.”¹³ This perspective is crucial if global health researchers want to understand their own situation in relation to other actors within the field of global health. Rather than looking at the lack of consensus as a weakness for global health, we should see it as a possibility for political changes and a sign of the field’s vitality. “The theorists who want to eliminate passions from politics and argue that democratic politics should be understood only in terms of reason, moderation and consensus are showing their lack of understanding of the dynamics of the political.”³

Ethical issues

Not applicable.

Competing interests

Authors declare that they have no competing interests.

Authors’ contributions

CA conceptualised and drafted the paper; KH and EE revised and edited the paper; KH, EE, and CA agreed on final draft.

Citation: Askheim C, Heggen K, Engebretsen E. Politics and power in global health: the constituting role of conflicts: Comment on "Navigating between stealth advocacy and unconscious dogmatism: the challenge of researching the norms, politics and power of global health." Int J Health Policy Manag. 2016;5(2):117–119. doi:10.15171/ijhpm.2015.188