Global HealthFootnote 1 has emerged as a flourishing field of study that advances key ideas and debates in International Relations. Twenty-five years since Caroline Thomas's article ‘On the Health of International Relations and the International Relations of Health’ first appeared in the Review,Footnote 2 this Special Issue presents a richly diverse collection of articles that are deeply informed by, and offer new insights into, International Relations. The specific focus of this Special Issue is thus decidedly on the rapidly growing field of Global Health research emerging within the discipline of International Relations (IR). It showcases how the study of Global Health is increasingly generating new perspectives on some of the core assumptions and debates in the discipline. Indeed, as the articles in this Special Issue show, the field of Global Health in International Relations is rapidly maturing by drawing upon and challenging a broad range of influences from within IR. At the same time, the articles included herein also contribute to the strong interdisciplinary character that has become such a defining hallmark of Global Health research, which has engaged with scholarship emanating from disciplines like History, Geography, Anthropology, and Sociology,Footnote 3 as well as Public Health.Footnote 4
The thriving state of Global Health in International Relations is seen perhaps most clearly in the number and range of books published in the last five years, from security,Footnote 5 to global governance,Footnote 6 international organisations,Footnote 7 international political economy,Footnote 8 and international relations more generally.Footnote 9 In the last decade, a small but growing number of journal Special Issues have been published on global healthFootnote 10 and particular aspects of health in IR, including HIV/AIDS,Footnote 11 issue framing,Footnote 12 and international political sociology.Footnote 13 Additionally, new groups and associations have formed around their shared research interests in global health, such as the BISA Working Group on Global Health established in 2011, and the Global Health Section inaugurated by the International Studies Association in 2013. New research centres on Global Health have also sprung up in International Relations departments in the UK and internationally,Footnote 14 while research centres addressing adjacent issues have also turned to Global Health, drawing in IR experts in the process.Footnote 15 Increasing numbers of new courses in the politics of global health are being offered to IR students across the United Kingdom, Europe, United States and internationally, while the growing number of IR doctoral researchers working in the area of Global Health suggests that this will continue to be an important research area in the discipline.
In part, this thriving growth in the study of health in IR responds to the heightened density of global health activity. There is a growing awareness that – like many international environmental issues – pressing global health challenges transcend national borders and, because of their centrality to human and societal wellbeing, they generate sustained political demands for more concerted international responses. In particular, three changes can be identified. The first was a renewed sense of crisis. For the first time in generations, Western states saw their populations and economies at risk from novel infectious diseases.Footnote 16 Multi-drug-resistant Tuberculosis, periodic outbreaks of Ebola and Plague in the 1990s, followed by the emergence and rapid spread of SARS in 2003, heightened concerns on the potential impact of a novel infectious disease to national security and state stability. In a number of states in sub-Saharan Africa, not only did the risk of state failure from the high prevalence of HIV appear real,Footnote 17 but risks to peacekeepers prompted a UN Security Council Resolution – the first ever Resolution on a health issue.Footnote 18 The second was a sense of failure: that despite decades of health assistance, the poor in the world remained disproportionately at risk from disease and early death. Nor was this simply a problem for the poorer states. While some analyses suggested that HIV appeared to affect middle- to high-income states as well as poor ones, WHO's influential Commission on Macroeconomics and Health, chaired by Jeffrey Sachs, identified how poor health in low-income states was a global economic issue (that is, affecting high-income states too).Footnote 19 The third change concerned an acceptance that globalisation had a profound impact on health risks and services. If, as the 2008 UK White Paper claimed, ‘health is global’,Footnote 20 then this appeared to many to require new forms of political as well as technical relationships, and global governance not of but for health.
At the same time, there has been a substantial increase in international diplomatic coordination around health, not least in response to global pandemics (such as HIV/AIDS, SARS, and ‘swine flu’). This can be seen in the way that key international institutions – from the United Nations Security Council, United Nations General Assembly, the World Bank, and the Group of Eight (G8) through to the World Health Organization (WHO) – have converged on seeking to tackle many more global health issues. These have been flanked by an array of more recently established institutions that have been set up explicitly to further that goal, such as UNAIDS, the Global Fund [to Fight HIV/AIDS, Tuberculosis and Malaria], and the GAVI Alliance (which increases access to immunisation for low-income countries). Global health has also become a priority for many new (and existing) NGOs active in international development, and is drawing in powerful new philanthropic organisations operating internationally, notably the Bill and Melinda Gates Foundation. Several global health goals (such as child mortality, maternal health, malaria, and tuberculosis) were also explicitly included in the UN Millennium Development Goals (MDGs) and will likely continue to feature prominently in the ‘Beyond 2015’ development agenda.Footnote 21 The United Nations General Assembly, led by the Global Health and Foreign Policy group (France, Thailand, Senegal, Norway, Indonesia, Brazil, and South Africa), passed the first General Assembly resolution on universal health coverage in 2012.Footnote 22 This shared interest is reflected in the fact that governments in both high- and low-income countries are displaying heightened interest in expanding global health beyond infectious diseases to include ‘lifestyle diseases’, while the WHO has recently launched a major new initiative on Global Mental Health.Footnote 23 Moreover, ‘health’ is also increasingly being deployed as a tool for achieving other ends in global politics, whether in foreign policy, in foreign aid, or in warfare. As such, the field of Global Health in IR has grown in part in response to the need to better understand these major new initiatives, which have been pursued both as diplomatic initiatives and through the framework of global health governance.
As the articles in this Special Issue demonstrate, Global Health research does much more than apply existing IR concepts to the study of these new developments. Increasingly, the field is showing how attention to global health presents some fundamental challenges to how we think about IR as a discipline, and how we think about global political processes. Indeed, as the field of Global Health matures, it is becoming clear that, rather than being thought of as merely one more ‘topic’ for IR to address, global health research also has the potential to alter how we think about global politics. When we place health at the centre of analysis, some of the fundamental assumptions and concepts upon which various strands of IR scholarship rest begin to be seen in a new light and are even called into question. What sense does it make to view global governance and security as separate areas of study, when global health is treated as a matter of security that must be addressed through global governance? What referents should we highlight when we speak of ‘survival’ in IR, when we acknowledge that human mortality rates go hand-in-hand with global inequality? How might we rethink what it means to talk about life and death in IR via a focus on health or the global politics of medicine? These are the kinds of questions that come into sharp relief when we conduct research on global health in IR. This is not to assert that there is any agreement on these questions in Global Health in IR. Rather, the articles presented here will give the reader a sense of the depth and breadth of the field, which is diverse in its empirical concerns, its methodologies (including positivist and postpositivist, quantitative, qualitative, and mixed methods), and its perspectives.
This diversity in Global Health has been built not only by engagements with various strands of IR, but also through interdisciplinary research drawing from and challenging the fields of health research in sociology, anthropology history, science, and technology studies, as well as the discipline of public health. One of the most productive engagements for IR scholars of Global Health to date has been with the field of global public health studies situated in the discipline of Public Health. Yet one theme that emerges in this issue is that the study of Global Health can no longer necessarily be equated with ‘Global Public Health’. For instance, the articles collected here explore a broad array of global health issues – ranging from pandemic influenza, polio, HIV/AIDS, tuberculosis, and malaria, through to so-called ‘neglected tropical diseases’. Thus they illustrate how the field is no longer being guided by disease-centric modes of thinking about global health (an approach that makes more sense in public health). This shift represents confidence that studies of Global Health need not justify themselves by being disease-specific, but rather that the field can engage more robustly with the politics of global health and medicine. As such, the articles presented here also analyse the politics of global health in a multiplicity of disparate international political and geographic locales – ranging from the Middle East, North America, Africa, Europe, Southeast Asia, and the emerging market economies in BRICS (Brazil, Russia, India, China, and South Africa). Other articles included here expand this engagement further still by focusing our attention thematically (though no less empirically) on cases such as the pharmaceutical industry, practices of warfare, international development, and health security.
The articles offer a collective analysis that moves, simultaneously, in two complementary directions. First, they explore how IR scholarship can expand our understanding of the politics that shape global health policies and practices, and secondly, they examine how the study of Global Health can help to shape how we think about International Relations. The remaining portion of this Introduction illustrates these two simultaneous moves in order to draw out how the articles included in the Special Issue work towards reshaping our understanding of the practices of both global health and international relations.
How can International Relations scholarship deepen our understanding of the politics of global health?
Given the complex nature of many global health challenges as both biomedical and social problems, what particular contribution can IR scholarship make to better understanding the global dimensions of health? In different ways, all the contributions to this Issue show that global health is anything but simply a technical pursuit: health policies, practices, and outcomes occupy politically contested spaces. The articles illustrate and unearth the myriad ways in which global health governance is continuously influenced by political considerations. Such influences can include the underlying patterns of violent conflict (Sara E. Davies), international economic and business developments (Anne Roemer-Mahler), changing conceptions of security (Stefan Elbe, João Nunes), the inherently political nature of modern medicine and medical practices (Alison Howell), the pursuit of military objectives (Colin McInnes and Simon Rushton), and implementation of global policy agendas at the level of national government (Garrett Wallace Brown). It is impossible, in that sense, to isolate a ‘pure’ space of global health, or to simply reduce global health to a technical pursuit. Practicing global health necessitates navigating all of these complex and competing political pressures. Here, International Relations scholarship is helping us to understanding the politics around global health and why attempts to improve global health are always a bit messier and even ‘dirtier’ than they appear on paper.
The contributions in this Special Issue also deepen our understanding of both the role and agency of power in global health diplomacy. The influential editor of The Lancet, Richard Horton, argued that ‘matters of armed conflict, internal displacement, and fragile situations are never seriously discussed in global health fora. No UN head of agency has made the security dimensions of health a headline issue of their leadership.’Footnote 24 For all the progress in health diplomacy, there has been limited conversation about making the case for a health-centred understanding of international peace and security. The research being pursued in this Special Issue, as well as others in IR scholarship, attempt to start building the framework and evidence for such a role. Health as a matter of international peace and security is a key theme in Nunes' rearticulation of power as domination, in the role of ‘soft power’ in military interventions (McInnes and Rushton) and in the investment in population health as a conflict prevention measure (Davies). The presiding concern is who frames such investments and interventions – as is highlighted and emphasised by the contributions in the Special Issue in analysing the political structure of contemporary global health governance. Roemer-Mahler, for example, identifies the role of structural power in terms of the ongoing exclusion of emerging market producers in global health governance. Brown, meanwhile, reveals the robustness of the state system, particularly its leadership, in relation to the South African politics of HIV/AIDS. Other contributions in this Issue highlight the productive effects of power in global health politics. This is emphasised not just by Nunes in terms of the corporality of global health, but also by Elbe in his account of the pharmaceuticalisation of security, and in Howell's account of the productive effects of medicine and war in imagining security. Here the sensitivity of International Relations' scholarship to the role of power also brings the discipline's more critical orientation to bear on the politics of global health.
IR scholarship can also deepen our understanding of Global Health by exposing the contrasting logics and rationalities that underpin the fields of international politics and health, making for both fascinating tensions, and – as Howell shows – even symbioses. Those tensions can surface in very stark ways, as illustrated by McInnes and Rushton in the context of counterinsurgency operations where difficult dilemmas emerge between humanitarian commitments and military imperatives. They are also explored by Howell in the context of social security and her study of medicine, by Nunes in revealing how security of some depends to a great extent on the insecurity of others, as well as by Elbe in the context of the productive interplay between security and pharmaceutical logics in pandemic preparedness planning and antiviral stockpiling. The Special Issue thus refocuses our attention on several of the central concerns and concepts of the discipline – such as politics and power – in order to rethink approaches to global health more generally. Yet the Issue makes a further contribution by showing that a focus on Global Health can also help to reform, reconsider, and rethink existing approaches to International Relations.
What can the study of global health tell scholars of International Relations about contemporary world politics?
The sheer volume of global health issues, and their intersection with International Relations theory, also enables the study of Global Health to generate new perspectives on the theories and methods that have informed the discipline. The emergence of feminist IR, critical security studies, constructivism, and poststructuralist IR has been critical for the area of Global Health to be explored and, even, accepted in the discipline. Here Global Health scholarship serves as a salient reminder that – as corporal human beings – biological processes form a continuous substratum to ongoing international political deliberations. The study of Global Health, in this sense, demands a fundamental rethinking of what it means to talk about survival in global politics. By focusing on Global Health, survival can be rethought in the discipline as a matter intimately tied to the existence of stark global inequalities. Such inequalities have a profound impact not only on people's health and life prospects, but also their very survival.
Global Health also contributes to contesting the distinction between high and low politics. In this way, studies of Global Health share natural affinities with a number of other IR fields. These include: environmental studies, which has drawn attention to the indivisibility of the local and the global in a context where problems such as climate change, like infectious disease, transcend borders; feminist IR, which has challenged the private and public distinction through its insistence that the personal is political and sustained inequality exacerbates collective insecurity, is an ally for health-focused research in IR; and with critical IR, which has challenged the inside/outside divide in IR in order to crack open the black box of the sovereign state, and to take seriously the human impacts of global politics, such as inequities in health. The field of Global Health highlights the ways in which any separation between high and low politics is, itself, highly political and a matter more of power than of any lived reality. By examining how political inequalities generate the conditions in which certain issues take centre stage on the international political agenda, the field of Global Health seeks to contest the ‘common sense’ division between ‘high politics’ and ‘low politics’.
From such vantage points, scholars of Global Health including the authors of the articles in this Special Issue, draw from, but also challenge, a number of core concepts in IR. For example, through the examination of the complex interplay of differing logics of international politics and global health, the limits of the concept of securitisation are exposed (Nunes, Elbe, and Howell). Davies critically explores the presumed positive relationship between democratic peace thesis and health gains in postconflict reconstruction. Brown offers a rethinking of the concept of the norm life cycle, as well as norm failure and success, while McInnes and Rushton forge a rethinking of the concept of ‘smart power’. As the field of Global Health and International Relations matures, it is thus emerging as much more than just another ‘topic’ for IR to address; it is also beginning to suggest rich possibilities for challenging how we think about global political processes and IR as a discipline.
The overriding picture that emerges from the contributions to this Special Issue, then, is that global health bears upon most, if not all, of the areas and subfields of the discipline. In their focus on health, these pieces invite us to rethink some of the central modes of studying IR, such as political economy (Roemer-Mahler), security (Nunes, Howell, and Elbe), global governance (Brown), war and conflict (Davies, McInnes and Rushton), foreign policy (Davies, McInnes and Rushton), and also some of the core concepts of IR. What these articles illustrate by drawing on the broader field of global health studies is that conventional divisions between IR's subfields are not only limiting, but in many ways arbitrary. Here the study of global health works alongside other scholarship in IR to break down the fallacy of division between, for example, security studies and global governance studies, international political economy and foreign policy analysis, peace and conflict studies and diplomacy studies, to name a few.
What does the discipline of IR contribute to the improvement of global health outcomes?
While it is of course true that there are debates and disagreements in Global Health scholarship, the field is also marked by a feeling of cooperative endeavour, of pioneering what it means to study global health precisely as a field marked by robust debate. That common spirit is fostered by the acute awareness of the centrality of health to people's wellbeing, and the immense health inequalities that remain in the world. Yet many of the articles in this Special Issue also implicitly highlight a core dilemma that emerges when seeking to improve global health outcomes: how can the field at once take seriously the challenge of global health and the inequalities and injustices that underpin this challenge, whilst simultaneously not approaching prevalent normative claims about global health uncritically. While it has long since been argued that all IR theory has normative commitmentsFootnote 25 (whether they are expressed explicitly or not), the field of Global Health in International Relations must certainly grapple with normative questions in its engagements with practical efforts to improve global health outcomes. The articles included in this Issue develop a posture of holding normative commitments to the improvement of global health in productive tension with the need to empirically evaluate the effects – whether intended or not – of global health practices.
Here the contributions to the volume have deployed a wide array of methods and theoretical approaches to also expose some of the limits of ongoing policy responses – drawing on extensive desk research, archival research, interviews, field work, site visits, and quantitative approaches. Between them the scholars in this Issue have also marshalled an array of critical theoretical perspectives, ranging from predominantly empirical, to theories of power, to poststructuralist and neo-Gramscian approaches, as well as making interdisciplinary contributions drawn from pharmaceuticalisation theory, management and business studies, the sociology of power, and the history of medicine. In a further reflection of the growing scope of the field, the contributions are able to consider a long list of interventions from medicines and pharmaceuticals, to reconstruction and spending on health systems, and the building of hospitals and pharmaceutical companies to meet international criteria.
Yet all the contributions come to the same conclusion: attempts to improve global health as technical endeavours themselves frequently attract political controversy because they are inherently political actions with political consequences. There is no ‘technical’ solution or diplomatic cooperation that may be pursued in the area of health based purely on the logic of consequences; the logic of appropriateness deeply influences actors and agency.Footnote 26 The use of medicine in war, whether conceived as a misuse (McInnes and Rushton) or as part of a long historical trajectory of the uses of medicine in war (Howell), the stockpiling of pharmaceuticals like antivirals (Elbe), the extent to which global health interventions can serve as a bridge for peace (Davies), the growing role of public-private partnerships in global health governance (Roemer-Mahler), or the top-down nature of global health governance (Brown, Nunes), reveal how political motivation shapes both local and global health outcomes. It is not only the obstacle of the global health challenges themselves, but the type of interventions chosen which raise difficult questions about equal representation in the international political economy, the role of pharmaceutical companies and private foundations in global health governance, and around issues of international distributive justice and legitimacy. As such, the current global governance architecture is crucial for the success or failure of confronting profound health inequalities, possibly, regardless of health innovations.
The articles presented in the Special Issue proceed via engagements with some of the major thematic areas and concerns of IR, while also demonstrating, in their relation to each other, how arbitrary these divisions may be when global health is at stake. In one sense, the articles proceed through three sets of concerns that will be familiar to scholars in IR: war and peace, global governance, and security. Yet, what the articles make evident is that there is significant overlap in terms of the concepts, approaches, and critical questions posed about the role of health in global politics across these thematic concerns. The issue as a whole gives a sense of how a focus on health can challenge the treatment of questions of conflict, governance, or security as discrete phenomena. In each case, the articles show how a focus on health can generate new perspectives and help us re-examine fundamental concepts in the discipline.
The Issue opens with a focus on the delivery of health assistance in war, McInnes and Rushton ask us to rethink central concepts in contemporary foreign policy, including ‘smart power’ and diplomacy. Davies in turn focuses on the relationship between health and postconflict stability, highlighting how we must reconsider the explanatory power of the Democratic Peace Thesis. Next, the Special Issue turns to Brown's empirical study on the role of global health partnerships in participatory governance mechanisms in South Africa, inviting readers to reconsider processes of norm diffusion in international relations by showing how such processes are frequently ‘glocalised’ by national actors. Roemer-Mahler examines the involvement of pharmaceutical companies in global health governance, illustrating how a focus on health can also help to better understand the role of business in IR, especially the role of corporations from emerging markets – including BRICS countries. The focus on pharmaceuticals is also at the heart of Elbe's article, which transitions into the final section of the Issue focusing on how we may rethink security in IR through a greater attention to international health issues. Via a case study on state stockpiling of ‘medical countermeasures’ meant to defend populations again pandemics or bioterrorism, Elbe's piece maps the ‘pharmaceuticalisation’ of security, showing how security must be rethought in light of the increasing molecularisation of politics. Next, Nunes' article focuses on health security, and attends to the meaning of insecurity so as to challenge any narrow understanding of security or deterministic approaches to its effects. Finally, with Howell's article, the Issue comes full circle in connecting questions of security with the critical study of war and conflict, but marks a point of departure in arguing that contrary to a focus on health, more can be gained by an IR focus on the ‘global politics of medicine’.
In conclusion, we hope that the scope, diversity, and extensive coverage of this Special Issue will continue the process of engagement by the discipline with global health. The contributions collectively point out that global health issues are not just a new empirical area of analysis, but in some ways are also becoming constitutive of the international itself. Far from merely being matters of ‘low’ politics, the need and desire to respond to global health challenges are in fact shaping the core practices of international politics. If that is true, then the study of health in IR can help us grapple with and make sense of the complexity of contemporary world politics.
