Global health is much more than the two words that make up the term; it is the highly interdisciplinary intersection of epidemiology, policy and politics, law, environment, economics, demographics, climate change and sociology – to name but a few factors. Global health knows no national borders; it covers complex issues that are interdependent and often unfold far from their causes. Natural disaster, man-made conflict, climate change and unequal distribution all contribute negatively to global health.

Global health encompasses more than international health; it includes a wealth of new researchers and decision makers beyond the fields of health, who along with the traditional health sector workers and researchers aim at equity in health and fair distribution of knowledge and technologies; thus global health also has a highly political aspect.

A Globalised world

The UK government defines it thus: “Global health refers to health issues where the determinants circumvent, undermine or are oblivious to the territorial boundaries of states, and are thus beyond the capacity of individual countries to address through domestic institutions. Global health is focused on people across the whole planet rather than the concerns of particular nations. Global health recognises that health is determined by problems, issues and concerns that transcend national boundaries.”

In a globalised world disease travels almost at the speed of light; diseases travel with people, cargo, migratory animals as well as with human life styles. Historically, peoples and nations have been separated by e.g. distance, geography, climate and perhaps religion or ideology. Over recent decades increased travel, trade and communication have increasingly bridged these factors of separation.

Hence the health of everyone and every nation can be affected, some to a large, some to a lesser extent as some have more resources and resilience and some less.

Poverty and disease in one country can affect the health status of people in other countries. Chronic disease like obesity, diabetes, mental disorder, traffic injury, and abuse of alcohol and tobacco that used to affect mainly the industrialised world are now truly global. While some factors relate strictly to health, others stem from social behaviour and circumstances, e.g. poverty and/or lack of education.

Professor of Global Public Health at University of Copenhagen Maximilian de Courten puts it this way: ”As the industrialised world directly or indirectly exports some of the key global health risk factors, it would be their responsibility to be concerned about the consequences no matter where they occur.” In other words industrialised nations carry a larger responsibility for as well as a larger capacity to improve global health.

Health is a human right

Professor Ib Bygbjerg of Copenhagen School of Global Health at University of Copenhagen points out that in accordance with the Universal Declaration of Human Rights everyone has the right to life, liberty and security of person; and he builds on prominent American ”disease detective” Jeffrey P Koplan’s definition of global health in his summary of what it is:

• an area for study, research, and practice, that
• places a priority on improving health,
• advancing equity in health for all worldwide, while respecting everyone’s right to life, liberty and security of person;
• emphasizes transnational health issues, determinants, and solutions;
• involves many disciplines within and beyond health-sciences;
• promotes interdisciplinary and international collaboration;
• a synthesis of population-based prevention, with individual-level clinical care.

Thus caring for and preserving health in a global perspective is not solely a matter for specialised health workers; it involves e.g. politicians, lawyers, economists, sociologists, anthropologists, community workers, civil society, schools and teachers as well. And, strange as it may seem, these collective efforts can be fiercely opposed by other actors on religious, political or other grounds.

Unsexy and overlooked issues, the Nordic Agenda

“We want to point out areas where we lack knowledge, ‘unsexy’ problems that tend to be overlooked, future risks that we should focus on; one example is social determinants of health, which is totally overlooked and badly in need of attention,” says professor Morten Sodemann of Odense University Hospital and University of Southern Denmark.

He refers to the “Nordic Agenda”, which covers issues often shunned by the big national and international donors; e.g. the deeper cause of conflict and its impact on health as well as religious influence on health. Also, “HIV resistance towards medicine in developing and poor countries is one disaster that no one wants to know about, let alone do research on. Another example is the effect of urbanisation and the introduction of user fees in the health sector in Africa,” says Morten Sodemann.

Adds Birte Holm Sørensen, Independent Consultant: “While governments do make an effort to address issues of maternal mortality and family planning, the more contentious issues of access to safe abortion, access to information on sexual and reproductive health and services for young people, child marriage and other gender based violence issues and access to family planning for marginalized people are not addressed.“

All this most sensible and very hard to disagree on, one might think; but the Nordic Agenda has many critics and even enemies amongst donors and recipient countries that are driven by religious, political or other agendas that prioritise these above the health of their peoples.

Double burden of disease

Low- and middle-income countries are badly affected by infectious diseases; this unfinished agenda has a nasty contender in a growing epidemic of non-communicable diseases (NCDs), which are driven aggressively by development, industrialisation, urbanisation, investment, and aging. Malnutrition and infection in early life increase the risk of chronic NCDs in later life, and in adult life, combinations of major NCDs and infections, such as diabetes and tuberculosis, can interact adversely, with one fuelling the other.

“Because intervention against either health problem will affect the other, intervening jointly against non-communicable and infectious diseases, rather than competing for limited funds, is an important policy consideration requiring new thinking and approaches,” says Ib Bygbjerg.

The vicious circle of poverty

Morten Sodemann points out that most diseases are caused by poverty and cause poverty. Disease leads to reduction in farm production and increases school- and education dropout. HIV leads to a 50 per cent reduction in farm production in families where one adult is infected. Diseases like HIV and diabetes boost the effect of poverty. Every year, disease reduces 100 million people to live in extreme poverty due to the formal as well as the informal fees they have to pay for medical examination, treatment and medicine.

What to do?

Maximilian de Courten stresses the need for multidisciplinary cooperation with a particular focus on turning the effects of trans-national determinants of health into solutions; easier said than done …: ”Collaborations for this type of research are critical to address all health issues and especially global issues which have a multiplicity of determinants and involve a complex array of institutions dedicated to finding solutions,” says Maximilian de Courten.

Most can agree on solutions such as education, prevention, meaningful health budgets (economy permitting) and intervention.

Morten Sodemann suggests starting with ”school for all, gender equality in all fields, educate teachers, pay them a decent salary, strengthen the universities, strengthen the hospitals, go ahead with simple interventions like vaccine against measles, impregnated mosquito nets, malaria combination treatment for children and expecting women; also, donors should coordinate their efforts so as to make best use of resources, agree on who does what, do research on how the health sector contributes to inequality in order to secure equal benefit for all.”

Research, experience and knowledge must be coordinated in order to extract useful data to build on: “We need to rewind the process to where it all began and then set up a system that is immune to fashion, politics and religion. We have failed to setup a monitoring system so we could have learnt how and why we actually managed to reduce child mortality in the majority of the world’s countries,” says Morten Sodemann.

Maximilian de Courten points out that “healthy” policies need to be implemented; nationally and globally, by donors as well as recipients. Tobacco control is a case in point – as well as a prime example of how politics and health can be fiercely at odds.

New development goals; SDGs

The United Nations’ eight globally agreed Millennium Development Goals were set in 2000 to be achieved by 2015; they were poverty alleviation, education, gender equality and empowerment of women, child and maternal health, environmental sustainability, reducing HIV/AIDS and communicable diseases, and building a global partnership for development, all of which, if and when realised, contribute positively to the improvement of global health. Some have been achieved, to a varying degree in different parts; e.g. Brazil, China and Vietnam have done well. Sub-Saharan Africa has not.

In 2012 in Rio de Janeiro at the Rio+20 summit 192 UN member states decided to continue the process by designing a new set of Sustainable Development Goals, SDGs which are “action-oriented, concise and easy to communicate, limited in number, aspirational, global in nature and universally applicable to all countries while taking into account different national realities, capacities and levels of development and respecting national policies and priorities.”

One such simple goal from the point of view of global health: Improvement of life expectancy in terms of healthy years lived.

This requires in-depth analysis of successes and failures of the development goal process in order to continue along the lines of what went well – and change course where nothing or little was achieved. Experience, best practise and general knowledge needs to be pooled and made easily accessible for both experts and lay-people.

And further to all the above efforts, it takes courage and political will from governments and decision makers to seriously combat backwardness, ignorance and ill will.

So, this is one – distinctly lay – version of global health pieced together from many sources, and also with the help of wise answers from some of the founder-members of Global Health Minders. Hopefully, it will inspire further input and reflection from other stakeholders in the realm of social sciences, the law, politics, education and more … (and thus: to be continued)

Mette Holm is a free lance journalist; www.metteholm.com

Photo: IRIN (www.irinnews.org)