On the genealogy of the global health justice movement

ABSTRACT

In the wake of the COVID-19 pandemic, it is clear that the struggle for global health justice must be our highest priority. To understand the challenges that such a priority faces, we must recognise that this struggle has a long history, and to analyse current challenges within this historical perspective. This commentary explores the gradual construction of the global health justice movement during different historical periods (tropical/colonial medicine, international health, and global health) in the history of approaches to health worldwide. It examines the changing relationship between the political economy of capitalism, colonialism, and racism. It analyses attempts to confront injustice through both human rights and social justice movements in seeking to address stigma and discrimination as well as poverty and social exclusion. It highlights emerging battlegrounds such as access to medical treatments and healthcare services as well as the ways in which private interests continue to undercut such efforts. But it also points to windows of opportunity for defending principles such as solidarity and social inclusion, for building advocacy/analysis alliances and toolkits to inform social movements, and possibilities to reconstruct global health ‘governance’ mechanisms and institutions in accord with the most basic principles of health justice.

KEYWORDS:

• Global health justice
• history
• public health imaginaries
• social movements
• political economy

If we seek to take stock of the field of global health in the wake of the COVID-19 pandemic, there is probably no area that deserves more urgent attention than the question of health justice. Whatever else the COVID-19 pandemic showed us – and it showed us many things (Parker & Ferraz, 2021) – it made it painfully evident just how far we are from achieving anything that might be described as global health justice. On the contrary, one of the most vivid memories that remains from the worst period of the pandemic is of the ‘vaccine apartheid’ that the global health governance apparatus was completely incapable of avoiding (Byanyima, 2021; Forman et al., 2023; Sparke & Levy, 2022; Torreele & Amon, 2021). The fact that this was the case in spite of the immense resources that have gone into the field of global health in recent decades should surely give us pause as we think about priorities for the future.

The rapid development of effective vaccines, together with the complete failure to provide equitable access to them on a global level, should make it clear that there is no greater priority for the future of global health than the goal for global health justice. Yet to be able to fully understand the current state of the global health justice movement, and the challenges that it faces, it is also important to recognise that the struggle for health justice has a very long history – and that this history in relation to what we might think of as health worldwide begins, above all else, with health injustice.

It is now widely accepted in the historical literature that the genealogy of health worldwide (what today we call ‘global’ health) has at least three phases: an initial phase that is typically described as tropical (or colonial) medicine, followed by a second stage that is described as international health, before finally a more recent phase, beginning only in the late-twentieth century, that is now described as global health (or, sometimes, global public health) (Bashford, 2006; Macfarlane et al., 2008; Packard, 2016). To be able to think more effectively about the future of health justice, it is therefore worth examining the history of the present – the history of how we got to where we are today (Bevir, 2008; Koch, 2021).

Tropical/colonial medicine

From this genealogical perspective, what we think of today as global health actually began to take shape in the mid-nineteenth century, during the age of empire, and was almost exclusively concerned with protecting white European colonialists from what were perceived as the health threats that they encountered in the tropics. The profoundly racialized nature of this capitalist system can be highlighted by remembering that slavery still existed legally in countries like the USA and Brazil at the time when tropical/colonial medicine emerged (Tomich, 2017), and that it showed little or no concern for the health conditions affecting (non-white) colonised populations – a situation that only changed gradually over time as colonised populations became the labour force of colonial/imperial capitalist enterprises in the tropics (Anderson, 1996; Chakrabarti, 2013; Greene et al., 2013).

Biomedicine is thus from the very beginning linked at the hip with global capitalism and capitalist/imperialist expansion, primarily focused on seeking to protect the human and financial resources of the capitalist system in the age of empire (Anderson, 2014; Baronov, 2008; Singer, 1992). And public health, as a field growing out of medicine to address the health of populations, was similarly linked to the growth of capitalism, with nearly all of the first schools of public health (described, at the time, as schools of hygiene and tropical medicine), such as the London School of Hygiene & Tropical Medicine, being founded through endowments from wealthy entrepreneurs whose fortunes resulted from their colonial enterprises (Bashford, 2003; Fisher, 1978; Hirsch & Martin, 2022).

Concern with what we think of today as ‘health justice’ only begins, very timidly to emerge in the late-nineteenth century with the work of people like Rudolf Virchow and others, who began to focus on how social inequalities impact health and illness, in what would come to be known as ‘social medicine’ (Pridan, 1964; Rosen, 1948). Although social medicine initially had only a minimal impact on tropical or colonial medicine in much of the world, it is also important to emphasise that the Latin American region was something of an exception in this regard and was a true leader in terms of highlighting the importance of social medicine (Waitzkin et al., 2001). Concern with the role of social inequalities in shaping health and illness – with the importance of the social and political determinants of ill health – has been a key part of the Latin American tradition since the early-twentieth century, shaping uniquely politically-conscious approaches to social epidemiology and a broader vision of what in many parts of the region is described not just as public health but as ‘collective’ health (Breilh, 2006; Cueto & Palmer, 2014; Tajer, 2003; Vasquez et al., 2019).

International health

Perhaps because of this early emphasis on the social and political dimension of health, Latin American actors made important contributions to developing new approaches to health worldwide as the European colonial empires began to disintegrate, and especially as a new international order emerged at the end of the Second World War, in the mid- to late-1940s (Carter, 2018; Cueto, 2004, 2008, 2019; Packard, 1997). With the creation of the United Nations, and especially with the founding of the World Health Organization (WHO) – and, not coincidentally, the passage of the Universal Declaration of Human Rights – both in 1948, a new phase in the genealogy of health worldwide was initiated, typically described as the period of ‘international health’ (Brown et al., 2006; Cueto, 2019; Lee, 2008; Morsink, 1999; see, also, Gostin et al., 2018).

In contrast with tropical medicine, international health focused more heavily on the interactions of independent nation states. New mechanisms for cross-national cooperation coincided with a growing emphasis on public health (rather than tropical/colonial medicine), which became the primary conceptual framework guiding the response to health challenges in international contexts. This emphasis was linked to the goals of achieving greater international regulatory cooperation and developing health interventions within a broader context of health systems and health policy capable of articulating actions both nationally and internationally (Cueto, 2019; Macfarlane et al., 2008; Packard, 2016).

Perhaps the most important advance in this new system was the creation of a more democratic structure in which the old sites of empire could be reconceived as independent countries in their own right – and were given at least a ‘place at the table’ in discussions and negotiations about health issues and policies that directly affected them (Abi-Saab, 1962; Cohen, 1960; Emerson, 1971; Finger, 1972; Hovet, 1960). Although ‘democracy’ as it is practiced in the UN is very far from absolute, and the richest and most powerful (i.e. Northern) nations structure the system and exercise unequal powers within it, the fact that countries from both North and South, both rich and poor nations, were at least in principle included in the decision-making arena represented a major change from the colonial world that had generated tropical/colonial medicine, and at some level can be understood as the one of the defining characteristics of the new international health system (Kaufmann, 1980; Reinalda & Verbeek, 2004).

Geopolitical power conflicts continued to mark the world of international health (albeit in very different form from that of colonial/tropical medicine), with the impact of the Cold War and the tensions between US and Soviet spheres of influence playing the greatest role over the period running from the 1950s to the 1980s (Cueto, 2019; Packard, 2016). But it was at least possible, within this phase of international health, to articulate greater inclusivity as an ethical/political principle linked to a notion of justice, and this was perhaps most concretely symbolised in a number of developments. For example, the WHO- (and UNICEF-) sponsored Alma Ata Conference on Primary Health Care (and its Declaration of Health for All by the Year 2000) was held in 1978, and became a landmark event in promoting a notion of the right to health for all as a fundamental part of human rights more broadly (World Health Organization, 1978; see, also, Cueto, 2019; Pannenborg, 1979; Roemer, 1994; Sparke, 2020a; Taylor, 1978).

In specific countries, this concern with the rights and the politics of health for all was also expressed in response to specific local circumstances. In Brazil, and other key Latin American countries, for example, the ‘sanitary reform’ and ‘collective health’ movements played key roles in resistance to military-authoritarian dictatorships, providing support for re-democratization processes in the late 1970s and across the 1980s (Cohn, 1989; Escorel, 2008; Lima et al., 2005, 2015); Paim, 2008; Vasquez et al., 2019). Across the Latin American region, social epidemiology was linked to the politics of emancipation (Ayres, 1995; Breilh, 2006, 2021, 2023), and social medicine and collective health professionals have been deeply involved in movements for progressive politics and policies (Birn & López, 2020).

Similar complex histories related to the politics of health can be found in other regions as well, where sanitary policies were sometimes used by colonial regimes to enforce colonial domination, but health professions and professionals often became directly involved in struggles for independence, and health justice was part of broader movements for political liberation as well as in movements for justice specifically in relation to health. From the 1970s through the early 1990s, for example, at exactly the same time when the sanitary reform movement was active in the fight for redemocratization in many parts of Latin America, public health professionals and community health workers (both in exile and on the ground in South Africa) became deeply involved in the battle to end apartheid, and public health institutions suffered reprisals from the South Africa government during the closing years of the apartheid regime (Coovadia et al., 2009; Frank & Muriithi, 2015; Van Ginneken et al., 2010; Mbali, 2013, 2021). After 1994, during the post-apartheid democratic reconstruction, struggles around the right to health for all became an integral part of the ongoing social and political movement for the reconstruction of South Africa life (Coovadia et al., 2009; Hassim et al., 2007; Mbali, 2013, 2021).

The northern-dominated field of global public health has typically tried to present itself as an evidenced-based science that is essentially acultural and uniform (Fassin, 2004, 2015). Precisely because of this it is important to stress that during the post-war period, the field of international health was in fact characterised by increasing diversity, with the emergence of both national and regional traditions and what we might describe as public health ‘imaginaries’ (Anderson, 1983; Jasanoff & Kim, 2015; Marcus, 1995; Taylor, 2004) that were diverse. Especially in the global South, ethical and political principles focusing on both health justice and global justice played an increasingly significant role (Benatar et al., 2003).

This period in international health also witnessed a gradual paradigm shift from ‘population control’ to ‘reproductive health and rights’ (championed by the international women’s movement and its allies) (Corrêa & Reichmann, 1994; Dixon-Mueller, 1993; Eager, 2004) from the mid-1980s to the early- to mid-1990s, and the global mobilisation against HIV and AIDS (led first and foremost by affected communities and populations in the face of unabashed stigma and discrimination, and gradually albeit belatedly, taken up by the WHO) also from the mid-1980s to the early to mid-1990s (Cueto, 2019; Maluwa et al., 2002; Mann et al., 1992; Parker, 2011; Parker & Aggleton, 2003). In Brazil, the sanitary reform movement and AIDS activists also joined forces in the late-1980s to mobilise against the commercialisation of blood and blood products, and in articulating to include this provision, together with a firm commitment to ‘the right to health’ in the new ‘democratic constitution’ of 1988 – a process that was also linked to a re-assessment of the politics of blood and blood donation internationally, foreshadowing a much broader concern with commercialisation and profiteering of biological and health related products and materials that was soon to come (Parker, 2020; Prentice et al., 1990; Santos et al., 1992, 1993).

Together, such developments fed into an increasingly articulate understanding of ‘health and human rights’ as the defining ethical/political framework of the international health era, and a key area of debate as the field of international health was in the process of being redefined as global health (Cueto, 2019; Gostin et al., 2018; Gruskin et al., 1998.; Mann et al., 1994). While all these developments faced resistance (often in the name of ‘cost-effectiveness’) in some instances from powerful countries (like the USA) (Harrison & Bryant, 1996) and supranational institutions (like the World Bank) (World Bank, 1993), over the course of the early- to mid-1990s gradual advances took shape in the direction of greater inclusion and justice. This consolidation was closely tied to transnational social movements – linking human rights to social justice on the part of what some would describe as a kind of rainbow coalition (movements focusing feminism and women’s rights, LGBTQI+ rights, civil rights/anti-racist movements, ecological and environmental justice movements, movements of poor and marginalised populations, and so on) (Pichardo, 1997).

Global health

If the geopolitical shift announced by the end of the Second World War was central in ushering in the new era of international health, the end of the Cold War at the end of the 1980s (with the fall of the Berlin Wall and the opening up of a new era of post-Cold War possibilities), combined with increasingly intense processes of globalisation and transformations in the global capitalist system over the course of the 1990s, was a key part of the transition as international health gradually began to be reconceived as ‘global health’ (Macfarlane et al., 2008; Packard, 2016). This transition to global health was marked from the very beginning by fundamental conflicts and tensions that have yet to be resolved: on the one hand, the financial and political interests of the rapidly expanding globalised neoliberal capitalist system, and on the other, the struggle for access to health for all, based on ethical and political principles of human rights and social justice. These conflicts and tensions would be reproduced as well in the fundamental tension between North and South, understood not just geographically but also socially and economically, in terms of poverty and social and economic exclusions of the South within the North, in pockets of poverty and the black holes of informational capitalism that have grown significantly both North and South over the course of recent decades (Castells, 1998).

The movement for access to medicines was at the heart of these conflicts, and it exploded at precisely the moment of the transition to global health, in 1996, when for the first time, news of effective antiretroviral treatments for HIV infection was announced at the 11th International AIDS Conference in Vancouver, Canada (Cohen, 1996). After 15 years of fighting a deadly global pandemic with no effective treatment, this news was overwhelming – but it was also almost immediately obvious to all of us at that conference that because of the high cost of these new medications almost no one living in poor countries, or in poor communities even in rich countries, would have access to them (Vella et al., 2012).

In a matter of just days, before the end of the conference, the reasonably well-organised Brazilian coalition of activists, scientists, and programme staff attending in Vancouver had staged demonstrations in the pharmaceutical industry display booth area to protest the cost of the new medications and the politics of exclusion, and in less than six months following the conference had successfully organised a campaign and built a bipartisan alliance to pass legislation guaranteeing legal access to antiretroviral therapy (ART) for all who need them in Brazil through SUS, Brazil’s Unified Health System (Galvão, 2002, 2005; Nunn, 2009; Parker, 2020). Successful implementation of this universal access policy depended on key conditions not available in many other locations – such as the existence of Brazilian businesses capable of producing generic medications, including the existence of state-owned pharmaceutical R&D and manufacturing capacity through Fiocruz (the Oswaldo Cruz Foundation), as well as the existence of SUS to distribute these locally-produced medications (Flynn, 2014; Mello e Souza, 2007; Nunn, 2009; Rosenberg, 2001). Its continued success over nearly three decades also depended on ongoing watchdog and advocacy initiatives that civil society groups like GTPI, the Working Group on Intellectual Property, based at the Brazilian Interdisciplinary AIDS Association (ABIA), have carried out over more than 20 years now (da Fonseca & Bastos, 2014; Villela, 2019).

But while it would be an ongoing process, Brazil’s universal access policy for ART was a spark helping to light a movement that would spread across Latin America, as well as to parts of Africa and Asia and around the world, linking activists and allies both North and South, and stimulating a global debate about health justice and treatment access that would dominate the next five years leading up to the 2001 United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in NYC (Olesen, 2006; Parker, 2011; United Nations General Assembly, 2001). Over this period, the single largest shift ever seen in worldwide health policy would take place, with activists and their allies overturning the almost complete consensus that treatment was too expensive to be possible for all but a privileged few, and reconceiving access as a moral and ethical obligation, a fundamental issue of justice, for all (d’Chan, 2015; d'Adesky, 2006; Smith & Siplon, 2006). Led by key countries from the global South, it would also result in successful negotiations within the World Trade Organization (WTO) in the ‘Doha Declaration on the TRIPS Agreement and Public Health’, adopted in the WTO Ministerial Conference in November of 2001, permitting countries to declare public health emergencies and to make use of the Agreement on Trade-Related Aspects of Intellectual Property (TRIPS) flexibilities (such as compulsory licensing) to address such emergencies (Abbott, 2002; Forman, 2013; ‘t Hoen, 2002; World Health Organization, 2002; World Trade Organization, 2001). Taken together, important diplomatic victories such as the UNGASS on HIV/AIDS and the Doha Declaration would unleash the HIV ‘scale-up’ era, but also the ‘boom’ in the growth of the neoliberal global health industry over the course of the 2000s and the 2010s (Kenworthy & Parker, 2014).

A fundamental tension that is still with us today would emerge over this period of scale-up and consolidation of the global health industry. On the one hand, the field of global health would be marked by an ongoing movement on the part of health justice advocates (and, occasionally, some progressive governments) to defend and expand understandings of health and human rights through policies and programmes aimed at inclusion and access. It is this struggle that has motivated many of the most important activist and advocacy organisations and actors in the field of global health – groups like the People’s Health Movement (PHM) (https://phmovement.org/), founded in the year 2000 to mark the date that was identified in the original Declaration as the year when Health for All would ideally have been achieved, which has become a key contributor through its Global Health Watch Reports, monitoring the WHO and a range of global health governance policies (Baum et al., 2020; Narayan & Schuftan, 2004; San Sebastián et al., 2005; see, also, People’s Health Movement, 2006). Between 2005 and 2023, six editions of the Global Health Watch report, which described itself as an alternative to the World Health Report (which is published annually by the WHO), were published and can be found free for download on the PHM website (https://phmovement.org/global-health-watch). But it is also this movement that motivates work on global health carried out by many other organisations: the Third World Network (https://www.twn.my/), the South Centre (https://www.southcentre.int/), Development Alternatives for Women of a New Era (DAWN) (https://dawnnet.org/), Health Action International (HAI) (https://haiweb.org/), Health GAP (the Global Access Project) (https://healthgap.org/), the Health Justice Initiative (HJI) (https://healthjusticeinitiative.org.za/), the International Treatment Preparedness Coalition (ITPC) (https://itpcglobal.org/), Oxfam (https://www.oxfam.org/en), Médecins San Frontières (MSF) (https://www.msf.org/), and too many others to be able to list here, but who together constitute a broad front of allies working for health justice globally.

But as the field of global health has evolved over the 2000s and the 2010s (Sparke, 2020b), on the other hand, another cast of characters has evolved – what I tend to think of as the global health industry, or when I’m feeling more optimistic, the global health assemblage, and when I’m feeling angry, the global health establishment – that is far more powerful and influential. This larger global health industry includes the technical ‘experts’ and management consultants, the global health governance agencies, the administrators who call the shots and run the show, and the industries that make their profits through the commodification of health and illness. I’m primarily thinking here not just of the representatives of the private sector, but also of the philanthropic institutions (and especially the philanthrocapitalists), and the majority of Northern-country governments who maintain control over programmes and policies (through large-scale, Northern-dominated Global Health Initiatives [GHIs], Public-Private Partnerships [PPPs], and similar mechanisms) in ways that make the global health assemblage work without jeopardising Northern control (and without attenuating industry profits) (Biesma et al., 2009; Birn, 2014; Buse & Walt, 2000; Clark & McGoey, 2016; Flynn, 2021; King, 2013; Ruckert & Labonté, 2014; Sell & Williams, 2020; Stuckler et al., 2011; Youde, 2019).

Some of these actors, like the majority of the Big Pharma companies, were created in earlier phases of health worldwide. But many other actors have evolved specifically since the period of global health began. Both GlaxoSmithKlein (https://www.gsk.com/en-gb/) and the Bill & Melinda Gates Foundation (https://www.gatesfoundation.org/), for example, were founded in 2000 – perhaps not coincidentally, the same year as the PHM was founded. And they have been joined by other similar actors, like GAVI, The Vaccine Alliance (https://www.gavi.org/), the Global Fund to Fight AIDS, Tuberculosis and Malaria (https://www.theglobalfund.org/), the U. S. President’s Emergency Fund for AIDS Relief (PEPFAR) (https://www.pepfar.gov/), the Institute for Health Metrics and Evaluation (IHME) (https://www.healthdata.org/), the Merck Global Health Institute (https://www.merckgroup.com/en/research/global-health-institute.html), the Coalition for Epidemic Preparedness Innovations (CEPI) (https://cepi.net/) and countless others who make up the global health assemblage. While such a diverse collection of organisations may strike some as strange bedfellows, a careful examination of the recent history of global health and the workings of both global health science and global health governance makes their collaboration and interdependence very clear, and unfortunately highlights how extensively private interests have penetrated and compromised the workings of many of the most important intergovernmental agencies. While this global health industry has been very effective at selling positive images of itself and its accomplishments, it has been considerably less effective at truly contributing to health for all – even though it claims to be doing exactly this.

While the battle lines that separate the health justice movement from the global health industry seem relatively clear, it is far less evident precisely how both sides of this struggle have been impacted by the extensive political and economic crises that have emerged over the past decade – the crisis in capitalism, in neoliberalism, the ruptures in liberal democracy, the effects of remilitarisation, the global climate crisis, and, of course, the crisis in global health itself resulting from the emergence of the COVID-19 pandemic in 2020. Indeed, nowhere were the tensions and conflicts that characterise the contemporary field of global health more evident than in the years since the beginning of COVID-19, in the denial and negation that marked initial policy responses to the pandemic, the ‘irrational rationales’ and ‘strategic ignorance’ that it produced, the stigma and discrimination that it generated, the stockpiling and hoarding of vaccines on the part of countries from the global North, and the ‘vaccine apartheid’ that the current global health system quickly produced (Eaton, 2021; Fassin & Fourcade, 2021; Forman et al., 2023; Fortaleza, 2020; Greer et al., 2020, 2021; Ortega, 2021; Parker, 2021; Yamey et al., 2022). And if tensions and conflicts marked the COVID-19 era, they came to a head in the failures surrounding the negotiation of the TRIPS ‘waiver’ for COVID-19 vaccines, in which the private interests that drive the global health industry more generally became painfully visible and contributed to gutting and undercutting the waiver’s potential (Correa & Syam, 2022; Fischer et al., 2023; Furlong et al., 2022; Sparke & Levy, 2022; Yu, 2022; Zaitchik, 2021).

Just as the global health establishment began to declare HIV and AIDS effectively over (or on the ‘fast track’ to an end) even though millions of people living with HIV still have no access to treatment (Kenworthy et al., 2018), today the claim that the COVID pandemic is now over also covers up and denies the collective failure that vaccine apartheid made so clearly visible. Such unfounded claims and denials should remind us that the struggle against health injustice has been long and hard. We have achieved important victories along the way, but the road ahead in seeking to defend health justice – like the road that one day might lead to climate justice, racial justice, gender justice, or social justice more broadly – suggests that it will be an exceptionally difficult journey.

This conclusion should not be understood to suggest that there are no ‘windows of opportunity’ that we might be able to open. On the contrary, there are important possibilities on many different fronts that we must urgently seek to explore. Just to name a few, in relation to what might be described as the public or collective health imaginary, we should work to truly value the importance of principles such as solidarity and social inclusion, and to build our collective memory about the history of social movements that have organised to fight for health justice and their contributions in different countries and regions of the world. Conceptually, we must work together (and across both disciplines and social movements), to emphasise the integral connection of causes such as health to other key issues such as the climate crisis and the defence of democracy, the importance of coordination of actions aimed at advancing these causes, and the importance of building advocacy/analysis alliances and toolkits to help inform and sustain these struggles. And strategically, to demand accountability from governments and philanthropy to act in a coordinated and effective manner together with organised civil society, to rethink and redirect global health ‘governance’ mechanisms and institutions in accord with the most basic principles of health justice, and to reform and revise the key treaties and agreements that could potentially help to make this governance more just – both existing, such as TRIPS, and possible or proposed, such as the Framework Convention on Global Health (FCGH) (Gostin, 2012) and, more recently, the Pandemic Accord (da Silva Nunes et al., 2023).

Precisely because the challenges in seeking to build a global health justice movement are great, the road ahead, like that already travelled, will be long and difficult, and we must commit ourselves to the collective project of reimagining the future for the kind of world in which we wish to live.

Acknowledgements

An initial version of this commentary was originally developed for presentation at an international conference, Why Health Justice Matters: The COVID Pandemic – Global South Lessons, Reflections and Intersection with Climate Justice, held in Rio de Janeiro, Brazil, from 25 to 27 April 2023, and organised by the Health Justice Initiative in partnership with the Associação Brasileira Interdisciplinar de AIDS (ABIA), Vacunas Para La Gente Latinoamérica, the People’s Vaccine Alliance (PVA), Public Services International (PSI), The Access Campaign of Médecins Sans Frontières (MSF), Rethink Trade, the Third World Network (TWN), Oxfam, and FASE (Federação de Órgãos para Assistência Social e Educacional). For an overview of the meeting, see the conference website (https://rio2023.org.za/). Thanks to Fatima Hassan, Jane Galvão, Susana van der Ploeg, and Veriano Terto Júnior for comments on earlier drafts.

Disclosure statement

No potential conflict of interest was reported by the author(s).