Latin America at the margins? Implications of the geographic and epistemic narrowing of ‘global’ health

ABSTRACT

To explore the narrowing of the concept of ‘global’ in global health, this article traces how Latin America has held a place of both privilege and power as well as marginalisation in the field. We employ a modified extended case method to examine how Latin America has been ‘seen’ and ‘heard’ in understandings of global health, underscoring the region’s shifting role as a key site for research and practice in ‘tropical medicine’ from the mid-nineteenth century through World War II, to a major player and recipient of development assistance throughout the ‘international health’ era after World War II until the late twentieth century, to a region progressively marginalised within ‘global health’ since the mid-1980s/1990s. We argue that the progressive marginalisation of Latin America and Southern theory has not only hurt health equity and services, but also demonstrates the fundamental flaws in contemporary ‘global’ thinking. The narrowing of global health constitutes coloniality of power, with Northern institutions largely defining priority regions and epistemic approaches to health globally, thus impoverishing the field from the intellectual resources, political experience, and wisdom of Latin America’s long traditions of social medicine and collective health.

KEYWORDS:

• Critical global health
• Latin America
• epistemic justice
• extended case method
• health equity

Introduction

Global health ideology and practice have an ongoing influence in prioritising billions of dollars of funding annually for certain health outcomes in select global regions. Consequently, much is at stake in understanding conceptualisations of global health. While public health is enacted and practiced globally, the emphasis on evidence-based science has downplayed the political dimensions that influence its theory and practice. It is important to recognise the growing literature calling for the ‘decolonization of global health’ (M. Harvey et al., 2022, 2023; Krugman, 2023; Oti & Ncayiyana, 2021). Yet, scant attention has been paid to the extent to which public health ‘science,’ like ‘ideology,’ can be understood as a cultural system (Fassin, 2015; Geertz, 1983; Parker, 2023). Indeed, as Didier Fassin has argued, ‘Public health is therefore a domain of meanings in the way it constitutes both its objects and its subjects. And these meanings are deeply and specifically embedded in the society of their time’ (Fassin, 2015, p. 462). From this perspective, the field of global health generates what might be described as its own ‘social imaginary’ (Taylor, 2004): the meanings and values it produces to organise its own reality and the laws and institutions it creates over time to structure the practice of public health as both a discipline and a field. These developments impact issues of authority, credibility, and allyship and shape key aspects of doing and knowing in global health.

Yet what is often obscured is the epistemic injustice undergirding the long rationalities to both strategically invest in certain global regions and withhold investment in others. By epistemic, we refer to: what is known, the politics of knowledge production, and explicitly calling attention to what is valued enough to be known. Thus, the ways that conceptions of global health apply to certain places and spaces must be examined to better understand how they are linked to epistemic limitations that can systematically distort and/or ignore needed care and also discredit alternative epistemological and political approaches to health and wellbeing (Vasquez et al., 2019). Imaginings of global health cannot be divorced from the entangled social, political, and cultural histories, including colonialism, that preceded the relatively recent label ‘global health’ (Herrick & Reubi, 2017). Far from static, imaginings and enactments of global health have been assembled, built, and rebuilt across historical waves of international population health interventions (Bozorgmehr, 2010; Janes & Corbett, 2009; Parker, 2023).¹

The origins of the global health field can be traced back to ‘tropical medicine’: responses to diseases found in the colonies and perceived as threats to European colonial expansion (Horner, 2020). Towards the end of World War II, with the disintegration of colonial empires and the systems that had facilitated the development of tropical medicine, the creation of a new international order launched the next phase in the global approach to health, often described as ‘international health’ (Cueto & Palmer, 2014; Packard, 2016). Characterised by increasing international collaboration, institutionalisation, and bureaucratisation (Birn et al., 2017), the introduction of international health marked an important political advance by facilitating the greater participation of all nation-states, including newly independent nations that emerged from former colonial empires. Yet the field also faced major challenges due to ongoing geopolitical tensions, especially as the Cold War deepened from the 1950s through the 1980s (Packard, 2016; Packard & Brown, 1997).

Throughout a 20-year period in the 1980s and 1990s, the concept of ‘global health’ gradually replaced international health. Shaped by intensifying globalisation, global health was better suited to act transnationally, at least in principle, and within the neoliberal policy universe that had developed following the end of the Cold War (Birn et al., 2017; Cueto & Palmer, 2014; Packard, 2016). The definition and evolution of global health, distinct from previous concepts like international health, have become a subject of critical analysis due to its complex nature (Cabane, 2023). As the field of global health evolved, the power wielded by the WHO gradually gave way to that of other international organisations (such as the World Bank and the World Trade Organization [WTO]) as well as transnational and private actors (such as pharmaceutical corporations and private philanthropies like the Bill and Melinda Gates Foundation [BMGF]). Thanks to a massive upsurge in funding and investment, newly created Public-Private Partnerships (PPPs) (such as the Vaccine Alliance [GAVI] and the Global Fund to Fight AIDS, Tuberculosis, and Malaria [GFATM]) and large-scale Global Health Initiatives (GHIs) (such as the World Bank’s Africa Multi-Country AIDS Program y and the U.S. President’s Emergency Plan for AIDS Relief [PEPFAR]) increasingly came to dominate global health in the twenty-first century (Bartsch, 2011; Brown et al., 2006; Brugha, 2009; Packard, 2016; Parker, 2023; Ruckert & Labonté, 2014; Stevenson & Youde, 2021; World Health Organization Positive Synergies Collaborative Group, 2009).

Like tropical medicine and international health, global health is built on complex power structures and continually reshaped by changing political economies and geopolitical forces, especially those associated with the shape-shifting nature of neoliberalism in times of unfettered global capitalism. This has included the availability and distribution of development assistance for health for some regions alongside an increasingly limited analysis of the determinants of health and illness, a narrowing conceptualisation and implementation of health interventions, and significant boundaries in defining ‘global health governance.’ All of these developments have thus far received considerably less critical analysis than they merit (though Benatar et al., 2013; De Vogli, 2011; Haskaj, 2018; Kenny, 2015; and Sparke, 2020 provide some points of departure), and attention to the ways in which deepening health crises are related to underlying crises in neoliberalism, late capitalism, and liberal democracy is especially scarce (but see Birn et al., 2017; Breilh, 2023; Eckermann, 2017; Greer et al., 2020; Homedes & Ugalde, 2005; Kim et al., 2019; McInnes et al., 2019; Menéndez, 2003; Parker, 2023; Parker & Garcia, 2019).

Global health can thus be seen as a ‘new regime of representation and intervention’ (Adams et al., 2019, p. 1384), with limited research unpacking how power is wielded to privilege certain epistemologies while increasingly marginalising others (Cabane, 2023; Lee, 2015). Yet precisely because social imaginaries link power to culture and ultimately to action, recognising the geographic and epistemic fault lines that shape the field is crucial to understanding both its possibilities and shortcomings. Indeed, the re-biomedicalisation of the field has fostered great therapeutic progress and individual-driven solutions, which have triggered the rise of metrics and evidenced-based solutions while decreasing attention to larger social and political forces driving disease (i.e. poverty, exploitation, colonialism, racism and social exclusion). Accompanying the rising power of the World Bank, the BMGF, and the GFATM, this development supports the growing emphasis on evidence-based science and the search for biomedical and pharmaceutical ‘magic-bullet’ solutions (Adams et al., 2019).

While there have been important shifts within the various phases of global public health, a common thread across its history has been the hegemonic domination of biomedical approaches that privilege pharmacological, molecular, and genetic responses to illness, to the detriment of models focused on the social roots of health and illness (Adams et al., 2019). There is a great richness and variety of anthropological, historical and political science research that provide a critical analysis of global health (Erikson, 2019; Gaudillière et al., 2022; Kim et al., 2019; L. Fan & Uretsky, 2017), however, greater attention is needed to make these arguments more accessible to practitioners of global health.

To better understand the power and limits of the enactment of epistemic power, at times to the detriment of alternative epistemological approaches, this article focuses on Latin America to trace how the region has held a place of both privilege and power and marginalisation within evolving responses to health on a global scale. Latin America, and particularly the unique social medicine approaches emerging from key sites in Latin America (e.g. Argentina, Brazil, Chile, Costa Rica, and Cuba), offers important lessons in moving beyond neoliberal health policymaking and advancing equity, justice, and inclusion in the next iterations of health on a global scale. Our analysis of how Latin America is ‘seen’ and ‘heard’ in global health suggests that one significant factor in the region’s progressive marginalisation during the consolidation of global health over the past two decades is precisely the ways in which its approaches to social medicine and collective health have underscored how social, cultural, and political forces shape health and illness. By developing meaningful alternatives in relation to both epistemology and policy, Latin America has challenged the biomedicalisation that has dominated mainstream global health approaches.

Approach

This article is theoretically guided by a critical genealogical approach that explores multiple histories to better understand the relationship between power and knowledge (Bevir, 2008; Foucault, 1972; Garland, 2014). To do so, we utilise a modified extended case method (Burawoy, 2009; Murray et al., 2011, 2019; Schritt, 2022) to unite and leverage the authors’ ongoing work in examining and theorising Latin America’s role in global health. The extended case method is based upon a reflexive model of science rather than the more traditional positivist model (Burawoy, 1998) and thus our analyses presented here are indebted to the authors’ long-term engagement in critical global health in the Latin American region. The lead author has worked in Peru since 2009 primarily related to HIV prevention and arguments presented here are based on her extended ethnographic conducted between 2017–2019; approved by the institutional review boards of Columbia University, the Universidad Peruana Cayetano Heredia, and the University of Toronto. The second author is a PhD Candidate who has worked in academic global health institutions in the global North since 2015, collaborating on research projects across Central and South America, and whose ongoing ethnographic work explores workplace solidarity and solidarity economy movements in Costa Rica and has been approved by the ethics review board of the University of Toronto. The senior author has been working in Brazil since 1983 conducting ongoing ethnographic work on the politics of AIDS and global health more broadly in the Latin American region, with ongoing research review and approval from institutional review boards the University of California-Berkeley, the State University of Rio de Janeiro, Columbia University, and the Federal University of Rio de Janeiro.

Building on what Burawoy refers to as the ‘four moments’ of the extended case analysis (Burawoy, 2009), we jointly argue that one of the largely unexamined consequences of the shift from political to technocratic logic as a defining and governing principle in understanding and addressing health globally is the progressive marginalisation of most of Latin America from the definition of who and what ‘counts’ as ‘global’ within the current framework. The first moment describes the historical waves of responding to health on a global scale, examining Latin America’s shifting role in the changing logics and associated imaginaries within subdisciplines and specialised fields. The second moment considers the extension of these shifts over time and space to assess the paradox of global health, which looks broadly but acts narrowly. Indeed, in the transition to global health, a focus on quantitative health metrics (such as disease burden) funnelled funding away from Latin America and towards other regions that funders defined as priorities. Based on the unique expertise of the authors on the politics of HIV and AIDS, the third moment leverages the HIV and AIDS epidemic as a case study to show how, unlike prior iterations, the way that global health is currently configured progressively marginalises Latin America as both a beneficiary and contributor to knowledge production. We conclude with reflections on the implications of this processes of geopolitical exclusion to underscore the increasing narrowing of what counts as global health and the consequences of this narrowing.

Latin America: Historical waves of responding to health on a global scale

Early initiatives to develop the field of tropical medicine were deeply linked to Europe’s colonial expansion in the mid- to late nineteenth century. The term tropical medicine emerged alongside colonial endeavours as European travellers returned from the tropics with stories of unfamiliar diseases, perceived as threats to European settlers, labour productivity, and trade efforts (Horner, 2020). Health issues in this phase were therefore broadly defined by efforts to identify, prevent, diagnose, and treat diseases prevalent in the colonies (Macfarlane et al., 2008). Tropical medicine gained popularity as an area of specialisation and academic training as the Rockefeller Foundation supported the creation of schools of hygiene and public health across the global North (Canada, the United Kingdom, the United States) and key sites in the global South (Cuenca et al., 2019; Cueto, 1994; Farley, 2004; Hull, 2007; Obbadi, 2010; Ramasubban, 2007). Vertical, disease-specific approaches dominated, with the Rockefeller Foundation leading campaigns against hookworm, yellow fever, and malaria (Cueto, 2008).

In Latin America, where independence from colonial rule occurred earlier than in Asia or Africa, many countries also developed infrastructure to support their own forms of knowledge production. Amid the scientific race to identify new microbes and vectors in the early twentieth century, countries such as Brazil, Colombia, and Mexico played significant roles as not only research subjects but also knowledge producers in scientific research and practice related to tropical medicine (Cueto & Palmer, 2014; Kropf & Sá, 2009; Peard, 1999; Stepan, 1998). In this sense, Latin America was not merely an object of investigation and intervention in the world of tropical medicine, but rather an active participant in the construction of the field itself.

Although the field of social medicine emerged in Europe at roughly the same time as tropical medicine, nineteenth-century social medicine was primarily focused on social conditions in rapidly growing urban centres in the industrialised global North. There, it played a key role in critiquing the negative effects of social inequalities in relation to public health outcomes. Perhaps precisely because of its critical perspective, which was fundamentally linked to Marxist political-economic analysis, social medicine had minimal impact on tropical medicine, where its framework would have opposed tropical medicine’s colonial systems and imperial objectives. In the early twentieth century, especially between the first and second world wars, Latin America would become the major exception in this regard. This was thanks in large part to a number of pioneering Latin American thinkers and practitioners, whose academic training in Europe facilitated contact with leaders in the field of social medicine. They began to develop an important focus on social medicine upon their return to Latin America (Breilh, 2021; Carter, 2019; Krieger, 2003; Waitzkin et al., 2001).

Latin America was also a key player within the emerging multilateral health organisations established in the early twentieth century, starting with the Pan American Health Organization (PAHO) in 1902. Thus, with the creation of a number of international agencies focusing on health and social welfare issues – such as the Pan American (originally International) Sanitary Bureau (PASB), the League of Nations Health Organisation (LNHO), and the International Labour Organisation (ILO) – Latin American physicians, scientists, and intellectuals became increasingly involved in the collaborative networks that began taking shape. These agencies provided opportunities for multidirectional exchanges and collaborations that were far more horizontal, particularly compared to the vertical programmes supported by the Rockefeller Foundation (Birn & Muntaner, 2019; Carter, 2019). Through such exchanges and building on concerns about the role of structural inequalities across the region, distinctly Latin American traditions in social medicine and social epidemiology grew in countries such as Argentina, Brazil, Chile, Ecuador, and Uruguay, alongside more biomedically oriented approaches to tropical medicine and public health (Abel, 1996; Breilh, 2021; Carter, 2019; Lima, 2007; Susser & Myer, 2007; Waitzkin et al., 2001). Equally important, as Cueto and Palmer have argued, Latin Americans’ growing involvement in the international organisations established between the first and second world wars ‘would provide the principal blueprint for the fully ‘international’ health apparatus that emerged in the post-World War II era, when the nation-state became the global norm’ (Cueto & Palmer, 2014, p. 106).

With the gradual dissolution of remaining colonial empires and reconstruction of the international system following the end of World War II (Weiss & Daws, 2008), a second era known as international health began to dominate the field. In contrast with tropical medicine, international health focused more heavily on interactions between independent nation-states. New institutional spaces for cross-national cooperation were created. This also coincided with a growing emphasis on population health, rather than tropical medicine, as the primary framework for addressing international health issues (Parker, 2023). This emphasis on population health was linked to efforts to achieve greater international collaboration. International health interventions were developed within a broader institutional context articulating both national and international actions (Macfarlane et al., 2008; Parker, 2023). The 1948 formation of the World Health Organization (WHO) as the primary health agency within the new United Nations system accomplished this goal (Lee, 2009). Latin America continued to play an important role in international health through the UN system as well as through malaria eradication campaigns in the 1950s and 1960s (Cueto & Palmer, 2014; Tajer, 2003; Vasquez et al., 2019).

One of the most important advances in this new system was the creation of a more democratic structure in which the independent nations that were replacing the former colonies of an older imperial system had the right to a ‘place at the table’ in discussions and negotiations about the issues and policies that directly affected them. Democracy as it is practiced in the UN, of course, is not absolute. The nations that are richer and more powerful created the structure of the system and continued to exercise more powers within it (Parker, 2023). But both richer and poorer countries – from both the South and the North – were nonetheless officially included in the decision-making arena (Parker, 2023). This marked a major shift from the earlier colonial world that had created tropical medicine. At some level, it can be understood as the defining criterion of the new international health system (Parker, 2023).

Alongside this framework of democratic policymaking, regional structures also provided a sense of greater equity and participation for countries from the global South. The Pan American Health Organization became the Regional Office for the Americas and served as a model for Regional Offices for Africa, the Eastern Mediterranean, Europe, Southeast Asia, and the Western Pacific (Cueto, 2006; Lee, 2009). Diversifying the WHO’s staff at every level, including the office of the Director General, further consolidated this sense of inclusivity. Over time, these appointments included Southern leaders from Brazil (for a full 20 years, from 1953 to 1973), South Korea, China, and Ethiopia as well as Northerners from Canada, Denmark, Japan, Norway, and Sweden.

Establishing a more inclusive and democratic structure was particularly important during the decades immediately following the creation of the WHO. This period launched a major wave of decolonisation, wars for independence, and the founding of new independent states that received significant technical assistance from the WHO in organising their health systems. Despite ongoing geopolitical tensions caused by the Cold War during the second half of the twentieth century, these new institutional structures provided an important space to recognise research traditions, public health expertise, and other practical expertise from different parts of the global South – knowledge rarely valued by dominant scientific and public health establishments in the global North. This was especially clear in Latin America, where the longer history of independence, institutional development, and epistemological and conceptual innovation in social medicine, social epidemiology, and collective health took on particular importance in the 1960s and 1970s. These traditions emerged as crucial sites of resistance to the military-authoritarian governments installed in many countries in the region, with tacit U.S. support as part of its ongoing war against communism (Cueto & Palmer, 2014; Miño & Eduardo, 2002; Vasquez et al., 2019; Waitzkin et al., 2001). Latin America's critical orientation highlighted its significant contributions to international health research and training. It emphasised the power imbalance, North–South differences, and tensions as crucial limitations in international health. These issues needed to be addressed in transitioning to a new approach to global health (Auer & Guerrero Espinel, 2011; Cabane, 2023; Pan American Sanitary Bureau & Pan American Health Organization, 1992).

The paradox of ‘global’ health: Looking broadly but acting narrowly

Beginning in the mid-1980s, international health transitioned to a global health framework. As health problems increasingly transcended national borders, this shift was characterised by heightened recognition of global interconnectedness (i.e. globalisation) as a key contributor to unequal disease burden. This vision included the global North as well as the global South. Indeed, the HIV epidemics in North America and Western Europe were as much a part of the global fight against AIDS as those in Asia, Latin America, and Sub-Saharan Africa. During this initial moment of change, the logic driving an inclusive emphasis on the ‘global’ was fundamentally political: the goal was to mobilise worldwide, and the perception was that the active involvement of the North and South would strengthen that political mobilisation. But alternative logics were also at play, perhaps most obviously articulated through the World Bank’s entry into the HIV response and, later, the field of global health. This early political emphasis would shift to a more technical focus, utilising concepts such as disability-adjusted life years (DALYs) and the global burden of disease as criteria for defining priorities within both HIV/AIDS responses and global health more broadly (World Bank, 1993, 1997).

Over time, the shift from a political understanding of global health to a depoliticised and technocratic understanding would lead to a very different approach in the field as well as a significant narrowing of how the ‘global’ was imagined. This approach would produce a sharply hierarchical conception of global health, with high-income donor countries as the source of necessary funding and main decision makers. Meanwhile, low- (and sometimes middle-) income countries in select parts of the global South became the recipients of aid and focus of global health interventions, in many ways reproducing the implicit colonial logic shaping the field since the phase of tropical medicine. Simultaneously, the World Bank and other supranational institutions – such as the WTO, which played a key role in regulating commercial disputes and intellectual property rights issues – increasingly began funding global health and engaging in policy making. As a result, the WHO’s role in global health declined and the infusion of free market ideas significantly opened the field to commercial and private interests (Brown et al., 2006; Kenworthy et al., 2016). In the early 2000s, public-private partnerships (PPPs) expanded and gained prominence, in part because of the BMGF’s financial backing and ideological commitment to promoting greater private sector involvement in global health (Levich, 2018; Ruckert & Labonté, 2014; Stevenson & Youde, 2021). The GFATM also rapidly became one of the most influential actors in global health, funding $10 billion USD in programming across 136 countries by late-2007 (Birn et al., 2017).

It is important to emphasise that this process of change in the field of global health, defined by that label, was also profoundly grounded in an evolving set of changes in the dominant political economy of the capitalist world and principal donor countries. As international health underwent a gradual rebranding to global health, a new neoliberal ideology and system of economic organisation that advocated for free markets, deregulation, and reduced government intervention replaced the Fordist-Keynesian regime of capital accumulation, including social and political consensus between labour, capital, and the state, that had largely defined the industrialised political economy following World War II (Gledhill, 2007; D. Harvey, 2005). Indeed, by the 1980s, neoliberalism had become solidified as the ‘official ideology’ within the Thatcher and Reagan administrations in the United Kingdom and United States, respectively, while the end of the Cold War and dissolution of the Soviet Union from 1989 to 1991 had significant global ramifications. Within this new neoliberal context, international health, with its focus on the nation-state, would give way to a much greater emphasis on the private sector and private resources. In addition, potential contributions of civil society and non-governmental organisations (NGOs), including religious and faith-based organisations, would become key characteristics of global health.

The neoliberal project took on a new shape in the 1990s due to changes enacted by the Clinton administration and rise of the New Democrats in the United States, the Blair administration’s Third Way in the United Kingdom, and similar developments in other industrialised democracies, formulating what Nancy Fraser has described as ‘progressive neoliberalism’ (Fraser, 2019). These developments helped to build a new political economic order that forged alliances with identity-based movements (i.e. the civil rights, feminist, LGBTQI, and AIDS movements) while simultaneously joining forces with Wall Street, Hollywood, Silicon Valley, and comparable social and economic spaces beyond the United States to deregulate banking systems, financialise the economy, and accelerate deindustrialisation. This evolving configuration had a major impact on consolidating the field of global health in the 2000s, as well as in influencing an important shift towards increasingly technical (and some might say technocratic) interventions. In this context, metrics such as cost-effectiveness gained traction in the United States and other key donor nations as a means of determining funding priorities. Thus, the rapidly expanding and increasingly technocratic field of global health became a kind of ‘boom industry’ (Cohen, 2006; Leon, 2015; Packard, 2016; Parker, 2023). One of its key contradictions would be the extent to which ‘global’ would become a smoke screen for narrower understandings of health.

Transitioning into and out of global health: Lessons from the HIV epidemic in Latin America

In the 1990s and early 2000s, these shifts and tensions related to global health were especially visible within and in some ways driven by the global response to HIV and AIDS. Indeed, the conceptualisation of and social response to HIV and AIDS that emerged in the mid-1980s heavily influenced geographic interpretations of ‘global.’ As responses to the epidemic grew internationally in the 1990s, HIV and AIDS quickly became, as Allan Brandt has convincingly argued, the most important arena for ‘the invention of global health’ (Brandt, 2013).

While in the 1980s the WHO had a geopolitical vision that explicitly sought to involve all nations in international health governance, including those from the global South, by the 1990s and early 2000s this goal had become largely abstract. The successive creation of initiatives based in and/or led by global North actors and interests – such as the Joint United Nations Programme on HIV and AIDS (UNAIDS), the World Bank’s Methodology for Assessing Procurement Systems (MAP initiative), the GFATM, PEPFAR, and others – fostered exclusionary practices. Despite attempts to exhibit broader ‘representation,’ such as ‘hand-picked’ Civil Society Organisations (CSOs) based in the global South, the fact remained that these new spaces of governance were largely dominated by funding streams from the global North. In practice, that meant that governments across the global South were increasingly marginalised from contributing to guiding the vision and strategic aims of global health, particularly compared to the earlier phase of international health. This shift directly contributed to narrowing conceptualisations of what constituted global health throughout the 1990s, 2000s, and 2010s, and continues today.

By dominating funding paths and demarcating the boundaries of global health priorities, institutional actors from the global North have become critical in disseminating knowledge, practices, and discourse that define what ‘counts’ as global in the field. Within this context, the logics of global health – including concepts like disability-adjusted life years, ‘most-at-risk’ populations, and ‘low-and-middle’ income versus ‘high-income’ – reinforce centre-periphery dependency. As Aníbal Quijano’s framework of the ‘coloniality of power’ reminds us, these developments are not new, but rather a modern understanding of progress rooted in colonisation.

The response to HIV and AIDS in Latin America provides an illustrative case study of how a vision of ‘global’ came to represent just part of the globe, and how this conceptual narrowing privileged Northern knowledge and priorities. Specifically, the Latin American example demonstrates how agencies that ‘administer’ the AIDS epidemic (Parker, 2000), including the WHO but increasingly also supranational agencies like the World Bank, have contributed to constructing this narrow vision of global health.

During the first two decades of the HIV and AIDS epidemic, Latin America emerged as a success story in many ways, especially compared to regions such as Sub-Saharan Africa, Southeast Asia, and Eastern Europe. This relative success was not arbitrary or merely auspicious. On the contrary, it was precisely because of the Latin American traditions of social medicine, social epidemiology, and collective health that had evolved since the early twentieth century. These knowledge systems, along with the social and political mobilisation that had been significant in many nations’ redemocratisation processes, led to a response to HIV and AIDS that was markedly distinct. Latin American researchers were quick to focus on the social and political drivers of the epidemic (Aggleton et al., 2003; Bastos & Szwarcwald, 2000; Castro et al., 2003; Cáceres, 2009; Parker & Camargo, 2000), and civil society mobilisation began early, in the mid- to late 1980s, and expanded exponentially in the 1990s (Frasca, 2005; Galvão, 1997, 2000; Galvão et al., 2012; Garcia-Abreu et al., 2003; Smallman, 2007).

Thus, by the 1990s, researchers, policymakers, and governmental programmes across the region had begun to adopt rights-based approaches to the epidemic, focusing on structural factors such as inequality, poverty, and racism as key barriers to prevention (ABIA, 2000; Badilla, 2006; Paiva et al., 2013). The value of epistemic diversity – learning from a variety of actors – generated health programmes intended to address such structural inequalities. With these emphases, countries in Latin America were the first in the world to adopt universal treatment access as official government policy, years before any international agency involved in the global AIDS response had taken a position on treatment access (Chequer et al., 2002; Nunn, 2009; Rich, 2019). These early efforts to prevent and treat HIV and AIDS are among the factors that contributed to successes in Latin America (Smallman, 2007).

A key example is Brazil, which led the way in enacting universal access to antiretrovirals (ARVs) on a global scale, prompting some analysts to highlight the importance of what has been described as an ‘activist state’ (Biehl, 2004). However, the state’s unusually active involvement should not obscure the critical role of civil society in campaigns for treatment access. Indeed, cooperative and often combative collaborations between the state bureaucracy and civil actors – including AIDS activists, the sanitary reform movement, academics, and social medicine and collective health professionals – proved crucial. While the complexity of Brazil’s accomplishments was impossible to fully emulate, by the late 1990s and beginning of the 2000s, the United Nations as well as mainstream media hailed Brazil’s National AIDS Program and broader social mobilisation efforts as both a success story and ‘best practice’ model in responding to the epidemic (Coordenação Nacional de DST/Aids, 1999; Rosenberg, 2001; see also Berkman et al., 2005; Okie, 2006; Wogart & Calcagnotto, 2006). Brazil’s rapid action in manufacturing and distributing generic antiretrovirals also enabled support for other HIV treatment initiatives. Working with HORIZINTECH – the Horizontal Technical Cooperation Group, a regional network of governmental programmes created in 1995 to stimulate South-South cooperation on HIV and AIDS (PAHO, 2005; Parker, 2008, 2020) – Brazil assisted in exporting antiretrovirals to other resource-scarce countries in Latin America (Berkman et al., 2005; Oliveira-Cruz & Kowalski, 2004; Pimenta et al., 2006).

In addition, Latin America’s crucial advocacy role within the WTO allowed these lessons to spread beyond the region in valuable ways. In the late 1990s, for example, this advocacy helped other global South nations like India and South Africa resist U.S. efforts to limit HIV treatment access on behalf of the transnational pharmaceutical industry for intellectual property infringement. This work proved to have long-term effects through the development of the 2001 Doha Declaration on the TRIPS (Trade-Related Aspects of Intellectual Property Rights) Agreement and Public Health (Abbott, 2002; Amorim, 2017; World Health Organization, 2002; World Trade Organization, 2001). Brazil further extended this work in the 2000s through a foreign policy emphasis on HIV and AIDS (Almeida et al., 2023; Parker, 2020), South-South development assistance to strengthen the industrial capacity for antiretroviral pharmaceutical production in Lusophone African countries (De Moraes Achcar, 2022; Follér, 2013), and together with Chile, aiding in the 2006 founding of UNITAID to support new drug development and distribution for low- and middle-income nations (Douste-Blazy & Altman, 2010).

Yet while innovative Latin American responses to HIV and AIDS drew significant scholarly interest, they garnered limited attention from bilateral and multilateral donors, who continued to focus on Northern assistance to Southern clients (Abdenur & Da Fonseca, 2013; Buss & Tobar, 2017; de Renzio & Seifert, 2014). Rather than supporting global South production capacity, they preferred to invest in the global North pharmaceutical industry to channel medicines to the South in ways that would ensure continued dependency. Moreover, throughout the 2000s and 2010s, countries across Latin America and the Caribbean were increasingly classified as ‘upper middle income’ and ‘high income,’ rather than ‘low income’ and ‘lower middle income’ (World Bank, 2022). These classifications had important implications for funding eligibility. The World Bank’s power in this arena yielded a shift in the meaning of ‘global’ in global health, limiting the designation to the world’s poorest countries – mostly in Africa but also in Asia – while gradually withdrawing high-income regions along with middle-income Latin America. Despite the creation of new funding schemes, Latin American countries were often ineligible for this support, which began to focus primarily on Sub-Saharan Africa and some countries in Southeast Asia. Consequently, by the mid- to late 2010s, Latin America’s ability to respond to the epidemic waned, yet the ongoing perception of its success prevented the region from receiving the degree of financial support needed to sustain the AIDS response from bilateral donors like the World Bank, U.S. Agency for International Development (USAID), PEPFAR, and the GFATM.

In addition, the 2010s saw a major shift regarding private funding, as many of the foundations and philanthropic donors that had supported AIDS-related work (such as the Ford, MacArthur, and Rockefeller Foundations) followed suit and ceased to prioritise Latin America. Likewise, newer private donors that emerged post-2000s exhibited limited interest in the region. Indeed, the BMGF, where the majority of private philanthropy for HIV and AIDS is concentrated, still does not have a programmatic priority for Latin America. Interestingly, the Gates’s ongoing inattention to the region may have roots in the negotiations regarding the TRIPS agreement in the late 1990s, as Bill Gates was actively involved in these intellectual property debates, and is reported to have worked consistently since that time to resist changes that might weaken pharmaceutical industry protections (Zaitchik, 2021). Foundations established by pharmaceutical corporations also do not fund organisations involved in contesting intellectual property rights.

Consequently, according to a 2020 report from Funders Concerned About AIDS (FCAA), which tracks private funding sources for the global HIV/AIDS response, 67% of private funding was issued by Gilead Sciences, Inc. and the BMGF. Of the total private funding available, only 1% went to Latin America, even though the region was estimated to house approximately 6% of people living with HIV (PLWH). In comparison, 30% of private funding went to Sub-Saharan Africa, where 67% of PLWH are located, and 49% to Western and Central Europe and North America, where 6% of PLWH are located (Funders Concerned About AIDS, 2022).

As funding sources pivoted to include U.S.-based private entities like the BMGF and HIV and AIDS-related global public health research funders, such as National Institutes of Health (NIH) funding and Centers for Disease Control and Prevention (CDC), as key agents in overseeing the administration of global health, the field began to emphasise ‘targeted health prioritising’; that is, financially investing in areas where the burden of disease is calculated as the highest (Mahajan, 2019; Perez-Brumer, 2019). As a result of this shift from political to technocratic logic as a governing principle in understanding and addressing health, limited attention has been paid to Latin America in definitions of who and what ‘counts’ in global health, disqualifying the region from several valuable sources of funding, research, and practice. Since 2006, for example, more than 95% of the Latin American HIV response has been funded by domestic resources, compared to 64% of Sub-Saharan Africa’s response financed by international development assistance (UNAIDS, 2018).

This narrowing has had significant and quantifiable consequences. Due to global health investments in Eastern and Southern Africa, HIV incidence declined among the general population between 2010 and 2020. For example in general population studies, average annual incidence declines since 2010 were 0.25/100 person-years among men and 0.42/100 person-years among women in southern Africa (Joshi et al., 2021). Latin America, on the other hand, has been backsliding, as new yearly infections rose by 21% between 2010 and 2020 (PAHO, 2020). Indeed, over the past 20 years HIV has increased in most countries in Latin American and the Caribbean (Institute for Health Metrics and Evaluation, 2013). These isolated funding patterns are continuing and as of 2021, 74% of GFATM investments are funnelled to Sub-Saharan Africa while just 3% are allocated to Latin America and the Caribbean. This is a significant drop when compared with 2002–2003, when 11% of investments were going to Latin America and the Caribbean (The Global Fund, 2003).

Thus, during the present era of global health, multilateral organisations and private donors replaced the WHO as key decision makers in defining geographic health priorities and distributing HIV and AIDS-related funds. Accompanying this shift was a greater emphasis on quantitative evidence (i.e. metrics) as a driver in allocating funding based on disability adjusted life years and burden of disease (Adams, 2016; Kavanagh et al., 2021). Due in part to Latin America’s early successes in responding to HIV and AIDS – which should be understood as a form of solidarity and resistance to the growing neoliberal health agenda – the region ceased to meet the evolving criteria for major funding mechanisms based on HIV incidence, prevalence, morbidity, and mortality, and since the 2010s has been largely excluded from ‘global’ responses to the epidemic. As a result, today Latin America is progressively pushed to margins of global health.

Health is political, globally

Our case study of Latin America’s place in global health as it developed over the past three to four decades demonstrates that the field’s conceptualisation of the ‘global’ is much more limited than the word indicates. It suggests that the definition of what ‘counts’ as the domain of global health – what is included and prioritised, and what is not – has changed over time in largely unexamined ways. We argue that the political dimensions and consequences of these changes exhibit the need for more sustained critical analysis of how the field of global health has developed over time.

As the research that does address this topic reveals, the transition from what was previously described as ‘international health’ to what today is known as ‘global health’ began to take shape in the 1980s, deepened significantly during the 1990s, and became more clearly consolidated in the 2000s and 2010s (Macfarlane et al., 2008; Packard, 2016). Latin America’s approach to public health research and practice made significant contributions to the emergence of global health during the 1980s and 1990s, especially in emphasising the importance of social epidemiology, social medicine, and what came to be known as ‘collective health’ (Abel, 1996; Breilh, 2021, 2023; Carter, 2019; Lima, 2007; Susser & Myer, 2007; Waitzkin et al., 2001). These traditions were central in shaping what were viewed as highly successful responses to HIV and AIDS across the region, as well as in promoting access to health as a fundamental human right (ABIA, 2000; Badilla, 2006; Paiva et al., 2013). Latin American policymakers and ambassadors were also recognised for key strategic contributions to emerging structures and processes of global health governance as they developed during the 1990s, with active involvement in the changing institutional architecture of the field through intergovernmental agencies such as the WHO, the World Bank, UNAIDS, and the WTO (Buss & Tobar, 2017).

As the field was shifting from a framework of international to global health at the start of the new millennium, Latin America seemed poised to take on a new leadership role. The region was at the forefront of developing an emphasis on South-South collaborations, and its focus on confronting social and economic inequalities offered exciting alternatives to the more limited frameworks that had dominated approaches to worldwide health science and practice during the phases of tropical medicine and international health (Birn & Muntaner, 2019; Carrillo Roa & Santana, 2012). But despite these potentially transformative contributions, as the global health ‘boom’ began taking off in the 2000s, Latin America’s prominence in global health interventions, knowledge production, and public health practice declined. Moreover, changing understandings of ‘global’ worked to steadily diminish the region’s eligibility within the category, with significant consequences for public health.

During the late 2000s and 2010s, Latin America was relegated to the margins of the field, as large-scale Global Health Initiatives, dominant funders such as the BMGF, and an emphasis on metrics as the primary source of evidence (as promoted by the Institute for Health Metrics and Evaluation, among others) became hallmarks of the global health era. Funders and donors from the global North, such as the BMGF and PEPFAR, shifted their priorities to other regions, where the burden of disease was determined to be greater. Consequently, Latin American actors’ involvement in the global health assemblage waned, and the approaches to health on a global scale that had favoured ‘collective health’ in the region also shifted in important ways, especially as the ‘pink tide’, a shift towards progressive policies, social reforms, and a focus on addressing inequality and poverty, began to pass (Ellner & Santos, 2020; P. H. Smith & Sells, 2017).

In addition, over the course of the 2010s, political changes at the regional level intersected with those taking place globally, such as the rupture of liberal democracies in many parts of the world (Castells, 2018), a growing crisis in what has been characterised as ‘progressive neoliberalism’ in the global North (Fraser, 2019), and the rise of nationalist populism in many countries, both North and South (Cox, 2017; Roth, 2017). Although some important work did consider the health impacts of growing populist politics, especially after the emergence of COVID-19 (Falkenbach & Greer, 2021; Garrett, 2017; Williams et al., 2020), the vast majority of the global health field – and the institutions that coordinate it – seem to have paid relatively little attention to this changing political climate. Carrying on with business as usual, they have – largely uncritically – adopted a growing emphasis on biomedical and pharmaceutical solutions in an attempt to circumvent the need for more complex or far-reaching forms of social change. This was perhaps most obvious in the global response to HIV and AIDS in the 2010s, as the dynamic of ‘global scale-up’ came to focus almost exclusively on expanding access to antiretroviral treatment (and reliance on treatment as prevention), with indicators of success focusing solely on biomedical markers (Kenworthy et al., 2018; Sandset, 2021).

Within this context, any previous receptiveness to Latin American contributions to health inequality has given way to a narrowing epistemological focus on the Northern-dominated world of global health. As Latin America’s significance and participation in the field declined as a result of these changes, so too did its successes in responding nationally and locally to key global health challenges. This derailment is evident in mounting setbacks within Latin America’s previously successful responses to HIV and AIDS (Berkman et al., 2005; Oliveira-Cruz & Kowalski, 2004; UNAIDS, 2011) and, more recently, in its significant early challenges in addressing COVID-19 (Burki, 2020; The Lancet, 2021). Based on our analysis, it is only possible to fully account for these changes if we analyse the ways in which politics and political processes, within and across local/national and global/transnational actors, have shaped the field of global health over time. It is important to note that a primary limitation of this paper is its focus on HIV and AIDS as the main case study. Given the limitations of space, we have chosen to draw on our ongoing engagement with the politics of HIV and AIDS in the region where we have had the greatest experience. We hope that this case study will serve as an invitation for other scholars to explore how processes of marginalisation have manifested across various health outcomes, in this as well as in other regions, within the broader field of global health.

Finally, the narrowing of global health considered here should be analysed as a manifestation of what Latin American scholars have described as the coloniality of power (Quijano, 2000) – a form of domination that impacts how resources are distributed and how knowledge is produced and valued. By distancing itself from the preceding structure of international health, especially during the 2000s and 2010s, the field of global health has contributed to the growing epistemicide of Southern theory and thinking. We must listen to and learn from Latin American scholars and health professionals who continue to advance understandings of health as shaped by sociopolitical factors (Alianza Latinoamericana de Salud Global, 2016; Nunes & Pimenta, 2016), and offer valuable critiques of unequal distributions of power and resources in reproducing health inequities globally (Franco-Giraldo, 2016).

Authors’ contributions

APB and RGP led conceptualisation, and APB, DH, and RGP jointly drafted manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article.

Additional information

Funding

This work was supported by the Canadian Institutes of Health Research under Grant [CRC-2021-00132; Canada Research Chair, Tier 2 PI: Perez-Brumer]. 

Notes

1 It is also important to emphasise that the various assemblages and imaginaries in global health do not exist solely in the realm of ideas or as idealist constructs. Although they involve cultural meanings, discourses, narratives, and representations, they also constitute complex social systems that seek to organise approaches to health worldwide or across borders via systems that are simultaneously processual but also ‘structure-like’ (Amelina, 2021, p. 353; Marcus & Saka, 2006). By integrating the idea of assemblages, we seek to highlight the significance of process (or ‘processuality’) as well as constant, ongoing change. This framework suggests a strong focus on cross-border processes (which is one of the qualities that makes it especially useful for thinking about ‘global’ health) and the relative openness and flexibility that can strategically adapt to shifting circumstances (Nail, 2017).