From International Health to Global Health
How Africa’s HIV/AIDS crisis influenced the rise of global health
Von Chris Simms
Over the last dozen years ‘global health’ has been replacing ‘international health’ in public health discourse and the transition from one to the other is seen to represent an important paradigm shift. Among different factors the HIV/AIDS crisis played a key role, explains Chris Simms*.
Among the factors explaining paradigm shift from international to global health are globalization itself, terrorism, and the fear of newly emerging infectious diseases. Several pieces of evidence suggest however, that the donor community’s abject failure to respond to HIV/AIDS crisis in the 1990s, particularly in Sub-Saharan Africa (SSA) was central to the decline of international health and the shaping of global health. The following paragraphs briefly explore this evidence using a simple matrix developed by the Consortium of Universities for Global Health Executive Board that describes global and international health according to five basic categories (see Table 1).
Table 1 Comparison of global and international health Source adopted from Lancet 2009 (JP Koplan and TC Bond, 2009)
1. Geographical Reach
Focuses on issues that directly or indirectly affect health but that can transcend national boundaries
Focuses on health issues of countries other than one’s own, especially those of low-income and middle-income
2. Level of Cooperation
Development and implementation of solutions often requires global cooperation
Development and implementation of solutions often requires bi-national cooperation
3. Individuals or Population
Embraces both prevention in populations and clinical care of individuals
Embraces both prevention in populations and clinical care of individuals
4. Range of Disciplines
Highly interdisciplinary and multidisciplinary within and beyond health sciences
Embraces a few disciplines but has not emphasized multidisciplinarity
5. Access to Health
Health equity among nations and for all people is a major objective
Seeks to help people in other countries
First, the most obvious feature of global health distinguishing it from international health is its ‘geographic reach’; this represents a shift in focus from poor countries to encompass all countries and all populations. AIDS, the first disease to become global in our time, was unlike other diseases that typically beset Africa; it first came to light in the United States of America (USA) in 1980. This was important in the long-run since influential western aids activist, advocacy groups (such as Act Up) and the World Health Organization’s (WHO) Global Program on AIDS (GPA) took the view that tackling AIDS was a burden to be shared. They helped cast this first post-modern epidemic as truly global.
Formation of global partnerships
Second, the AIDS crisis prompted a new way of funding and delivering development aid that led to the formation of global partnerships and cooperative action. Before 2000, most donor aid was delivered mainly through bilateral relationships. The GPA began to change this by reaching out for the first time in the WHO’s history to nongovernmental organizations (NGOs). (UNAIDS, 2008) When UNAIDS replaced GPA in 1996, one of the main rationales for its creation was to establish more cooperation and partnership among the UN agencies. The novel UNAIDS structure, originally made up of six, later 10 UN agencies represented a radical restructuring of global architecture towards cooperation and partnership, now a hallmark of global health action.
Third, HIV/AIDS elicited levels of multidisciplinary action not previously seen. Although international health was nominally multidisciplinary, donors placed little emphasis on the determinants of health that lie outside the medical care system. The nature of the HIV/AIDS changed this in several well-known ways: its enormity soon made it clear this was not only a health crisis but an economic and development crisis as well; it seemed to reveal the essence of many cross-cutting issues such as poverty, gender inequalities and human rights; it changed traditional disciplines such as demography and epidemiology forever while at the same time introduced many to newer ideas such as complexity science and social networks and; without an AIDS cure, intersectoral behavioral change strategies drew upon many new disciplines. A key driver of the creation of UNAIDS was to develop truly multisectoral responses that included support for public-health interventions as well as structural determinants. (Merson / O’Malley et al., 2008)
The new goal of equity
Fourth, while international health embraced both prevention in populations and clinical care of individuals, the HIV crisis led to an increased emphasis on curative, rehabilitative, and other aspects of clinical medicine and basic sciences. Part of this stems from the heavy burden placed on African health systems by HIV and other related illnesses and, the need for ongoing home care and social support. Ultimately though, it was the introduction of antiretroviral drugs (ARVs) in the late 1990s that eventually led to enormous investments in curative care. Total per capital spending on health in SSA in the 1990s that tended to average about US$10-15 per person annually, is in sharp contrast to today’s spending on ARVs that range about US$900 per infected person. (Rosen / Long, 2010)
Fifth, Africa’s HIV/AIDS crisis made international health’s access goal “seeks to help people in other countries” irrelevant and it was replaced by the goal of equity. The world community, long-accustomed to the extreme inequalities between North and South, was unprepared for the inequalities associated with the pandemic: the 30 million Africans dead or dying from HIV; the fizzling out of donor aid to US3 per infected individual by 1998; and, the exclusion of all but a few thousand Africans from access to ARVs while the North contemplated universal access. The results left the world community appalled and the donor community certain of its own failure.
The reasons for the rise of global health are not necessarily the same as those that explain the decline in international health, yet the features of each seem explain the trajectory of both. Until this first post-modern epidemic hit SSA, the effectiveness of donor community had never been fully and publically tested. The vacuum created by donors’ failure to respond effectively and appropriately with a robust, equitable, multidisciplinary, team effort led to a reconfiguration of the aid architecture, pouring in of fresh resources, new ideas, new standards and an insistence on better accountability.
*Dr. Chris Simms is assistant professor at the School of Health Administration, Dalhousie University, in Halifax. He has spent most of the last 20 years living and working in Africa and Asia. His areas of interest include the influence of reform and globalization on access to effective health care particularly by the poorest quintile, aid effectiveness, the policy process, and the HIV pandemic. Chris is on the Board of Directors of the Canadian Society for International Health, and editorial board member of the International Journal of Clinical Practice. Contact: ch638828@DAL.CA
S. Bunyavanich and R. Walkup, 2001, American Journal of Public Health, Volume 91, No. 10 October 2001.
- T. Brown, M. Cueto, E Fee, “The World Health Organization and the Transition from ‘International’ to ‘Global’ Health”, American Journal of Public Health, 2006, Volume 96, p. 62-72
- JP Koplan and TC Bond (2009) “Towards a definition of global health”, Lancet Volume 373, Issue 9679 June 6 2009, pages 1993-95
- UNAIDS (2008) “The first 10 years”,http://data.unaids.org/pub/Report/2008/JC1579_First_10_years_en.pdf
- M Merson, J. O’Malley et al (2008) “The history and challenge f HIV”, Lancet, 372, 475-88
- S. Rosen and L. Long, (2010) “How much does it cost to provide antiretroviral therapy to HIV/AIDS patients in Africa?”, Boston University Health and Development Discussion Paper.no.9, October 2006. http://dcommon.bu.edu/xmlui/bitstream/handle/2144/1303/hddp_9-cost_of_art_in_africa.pdf?sequence=1