What is the value of the “global” in “global health”?
“Global health is an attitude. It is a way of looking at the world. It is about the universal nature of our human predicament. It is a statement about our commitment to health as a fundamental quality of liberty and equity”
Richard Horton
When I did my MPH at UNC Chapel Hill I was frustrated by the lack of global content in the curriculum, along with other classmates with global ambitions. Every model, framework or theory we were taught was explained through examples from motivating rural African American women in North Carolina to get mammograms.
While I was proud of the commitment UNC SPH had to local health and development, I felt like the lack of global content was bad for all students - whether they wanted to work in urban Boston, rural North Carolina or Malawi. I wanted to know how to adapt models to different contexts, to understand how the social, economic and cultural setting might shape health status, and shape how we approach our work.**
I thought this was fundamental to a good education in public health.
Professors were bewildered by our complaints. How do we do this? What does this mean? What is the value add? Why is the health of people in Malawi our business?
Good questions.
I initially thought I was a global health professional. But now, most of my work is in India and my colleagues are mostly Indian. I am all-consumed by the complexity and heterogeneity of the domestic context. Indeed, solving public health challenges in India –as elsewhere - requires a hard look at preventable suffering and death, inequalities, and other social, economic and state failures – all local and immediate – with specific histories. This seems to require our whole attention. We do not have time to look at evidence of what works in Ghana.
As in the US, there is some resistance to a global perspective in India. If you want to change policy or guidelines, the evidence must come from India. We hear: We can’t compare ourselves to Bangladesh, (who does much better than India on health indicators) we have many more complexities…The perception is that India is unique, knowledge from elsewhere does not apply.
So it seems like a good time to revisit my self-perception as a global health professional. Is this all a conceit? Why aren’t I just a public health professional?
I have an answer to that....
The point of an education is to give you a perspective beyond your immediate and local circumstances. That’s what differentiates you (as a person with an education) from a paddy farmer (no disrespect to the paddy farmer – he dodged student debt).
The source of much ill-health lies comfortably within local and global disparities.
Working in global health typically involves some kind of commitment to equity, and overcoming such disparities.
Overcoming health disparities requires some ushering of financial – and sometimes human - resources from rich countries to poor countries. That is fundamental and obvious. In my career, I have mostly worked on projects funded by donors from elsewhere (the UN, BMGF, USAID).
Seeing as my formal global health education was a bit patchy (see above) I thought I would flick through Reimagining Global Health: An Introduction by Paul Farmer (et al) to see what he advises. The book is thoughtful, inspiring and a great resource, I really wish I had this book when I did my MPH. It covers service delivery, scale up, global health’s colonial legacy, human rights frameworks, values and faith in global health.
Did I learn anything new from the book? While the principles of accompaniment are familiar to me, the concept is new. Accompaniment outlines a way to make foreign aid work, by accompanying local partners and building capacity in order to eventually withdraw. The principles are:
favour institutions that the poor identify as representing their interests
fund public institutions to do their job
make job creation a benchmark of success
buy and hire locally
co-invest with governments to build strong civil services
work with governments to provide cash to the poorest
support regulation of international non-state service providers
support regulation of international nonstate service providers
apply evidence based standards of care that offer the best outcomes.
The book closes with a call to a movement for global health advocacy, basically outlining an activist toolkit for people to mobilise resources and political will towards health equity. An excellent resource to improve public health pedagogy and practice.
** It should be noted that UNC SPH – due to the concerted efforts of many - has made great strides in globalizing their curricula since I was there.