In recent years the spread of diseases such as AIDS, SARS and avian flu has pushed health issues towards the top of the international agenda. Such outbreaks have serious political, economic, and social consequences and remind the world of the necessity of global cooperation in order to deal effectively with the challenges they pose. Global Health Governance offers a comprehensive introduction to the changing international legal environment, the governmental and non-governmental actors involved with health issues, and the current regime’s ability to adapt to new crises. Reviewed by Edward Larkin.
Global Health Governance. Jeremy Youde. Polity Press. April 2012.
Jeremy Youde’s book Global Health Governance attempts to explain both the trajectory of global health institutions over the past century and their current operations and influence. As such, it is not a book for the casual reader (or even, frankly, the casual health policy wonk). It is instead a book for grizzled veterans looking to pry open the case on the workings of global health organizations and have a look at the motherboard. Those weaned on the teat of Mountains Beyond Mountains will almost certainly be disappointed, but Youde’s book is an accessible and clearly written introduction to the subject.
Youde, a political scientist at the University of Minnesota-Duluth, narrates the rise and, in many cases, fall, of various global health institutions, most prominently the WHO, the World Bank, UNAIDS, the Global Fund, and the Gates Foundation, wading through the detailed leadership structures of each. It soon becomes clear that Youde’s quest – to delineate the governance structure of the global health ecology – is an admirable one indeed. It is an incredibly messy, non-intuitive, infighting, acronym-laden landscape.
This last point is perhaps the most salient from the beginning. Acronyms abound in global health, and one can be forgiven for thinking that every permutation of the letters W, I, O, D, U, G, and, of course, H, has at one point existed as an organization dedicated to improving health. To give one particlulaly stark example, the co-sponsors of UNAIDS are UNDP, UNESCO, UNFPA, UNICEF, WHO, the World Bank, UNODC, ILO, WFP, and UNHCR. To add to the problem of the acronyms, language in global health governance often tends to be sucked into opaque bureaucratese about “engaging diverse stakeholders”, and “broad-based social and political mobilization”.
This being the case, the philosophy of global health governance is actually fascinating in that it exposes our noblest rhetoric to the sharp light of reality. Do we believe that all people are created equal, that everyone is deserving of life and a true attempt at happiness? If so, how responsible should we consider ourselves for people in other parts of the world? How responsible should our governments consider themselves to people in other parts of the world? Should we export ideas and values, or just health resources? Can they be separated? The structure of global health governance is critical in answering these questions, as it determines how resources are allocated to countries in need. Should they be financed predominantly by tax dollars or private donations? In tracing the history of the WHO, the World Bank, UNAIDS, the Global Fund, and the Gates Foundation, Youde narrates an uneasy balancing act between moral obligation and economic self-interest.
Some criticize global health institutions for a failure of focus. They claim that it is economic growth that eventually bears the real health fruits, and that such economic growth is in turn dependent on competitive economies and capable political institutions. This view is sometimes presented as antagonistic to global health efforts, as if the situation were a binary choice.
The focus on economic growth may be correct, in the long run. But how long is too long? How many people will we allow to die because of failed political institutions before said institutions finally right themselves? Global health organizations understand the fact that, as Keynes said, “in the long run, we’re all dead.” That things will eventually work out, or that health will eventually get better given economic growth, doesn’t change the urgency of the fact that people are currently dying from avoidable and preventable diseases, and that there is something unacceptable in that; something so unacceptable that simply focusing on long-run growth isn’t enough.
Walter Isaacson’s recent biography on the late Steve Jobs received much attention for what Jobs said about Bill Gates and his efforts in global health: “Bill is fundamentally unimaginative and has never invented anything, which is why I think he’s more comfortable now in philanthropy than technology.”
That Jobs pitted philanthropy as the natural opposite to technology – a place one slinks off to after proving unfit for the major leagues – is unfortunate. As Youde shows, the funding for global health has shifted over the past century from national governments and towards private actors. Antipathy from the leaders of Mountain View and Palo Alto, where billion is the new million, would certainly prevent the movement from blossoming to its full potential. Moreover, modern technology has never been better positioned to tackle health problems in the developing world. The application of the information technology, ubiquitous communication, and ever-cheaper sensors and diagnostics to global health is incredibly compelling.
As Malcolm Gladwell pointed out, just because global health isn’t “fun” in the way that technology is fun doesn’t mean that it’s unimportant or ineffectual. One underestimates public health at their own peril: over the past century, life expectancy in the developed world has shot up from 50 to 80, and public health (sanitation, vaccination, etc.) has undoubtedly played a role. That’s a rate of increase that even technologists, used to riding the curve of Moore’s law straight into the heavens, should respect.
As Youde makes clear in the closing chapters of the book, despite the incredible gains in health in the past century, there are still many challenges to be faced in the near future. While it might be easy for various groups to lambast the entire effort as a neoliberal colonialist exercise in political influence or a hopelessly byzantine collection of institutions fighting the wrong battle, we should remember that these are areas that the market has forsaken, at least in the short term. Given the simultaneous potential resurgence of infectious diseases due to globalization and the rise of chronic disease in low-income countries, the global health world will have a lot on its hands in the near future. Rising to the challenge might perhaps even take some imagination.
Edward Larkin is a medical student at the University of Pennsylvania. He studied for an MSc in International Health Policy at the LSE in 2011-12, where his dissertation investigated the relationship between uncertainty and technological change in health care. He graduated from the University of Notre Dame as valedictorian in 2011, studying biology and classics. Interested in the intersection of science, technology, and society, Edward has worked in wireless health care and at the UK Department of Health, as well as in basic science laboratories. Read more reviews by Edward.