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date: 24 May 2020

Global Health Politics: An Introduction

Abstract and Keywords

Global health politics has emerged over the last two decades as a distinct interdisciplinary field of study which, although its boundaries are not set, is beginning to demonstrate signs of maturity. It is concerned with the actions, practices, and policies that govern the sphere of global health. Its emergence then is intimately linked with the reconceptualisation of health as global. The field addresses not only the processes of decision-making, but also the structures of power that shape what is possible and the requirement for collective action to address global problems. Politics is unavoidable, necessary and integral to effectively addressing global health challenges. The study of global health politics therefore is not about how to minimise interference in rational decision-making, but rather about explaining and improving the quality of political institutions and processes that will in turn improve global health actions and ultimately outcomes. Fundamental to this is an understanding of the nature of politics and the workings of power. But the field also requires knowledge and techniques from a variety of disciplines, which intersect to produce a more complete understanding than any one discipline can provide. The result is inherently both multi- and interdisciplinary, characterised by methodological pluralism and varied theoretical perspectives.

Keywords: global health, global health security, global health governance, global health policy, right to health, international relations, infectious disease, non-communicable disease, disease control

Global health politics has emerged over the course of the last two decades as a distinct and interdisciplinary field of study. This has been underpinned by a shift in the nature of collective action concerned with health, not least as part of the broader zeitgeist of globalisation (McInnes and Lee 2012). Human health has been recognised as being affected by, but also contributing to, processes of globalisation both materially (through phenomena such as the globalised operations of the pharmaceutical industry, the increased speed and reach of disease outbreaks, and the initiation of global governance responses) and discursively (through how the world is described and understood in research and policy, such as UK government statements that ‘health is global’) (UK DoH 2008). This shift accelerated during the early 2000s such that, by the end of the decade, a consensus existed that a wide range of health issues—from antimicrobial resistance to zoonotic diseases—can no longer be viewed solely through a national lens or be addressed effectively only by international cooperation between states. Rather, broad ranges of health determinants and outcomes have become ‘global’, and thus the political actors and governance processes concerned with addressing them also require new thinking and practises.

Emerging from these developments over the past two decades, global health politics is now established as an important field of study, and we see evidence of its maturation in a variety of ways. The field attracts a growing number of students, new courses and degree programmes are appearing in universities around the world, leading journals frequently publish articles focused on global health politics, and panels on global health politics are appearing at major academic conferences (Davies et al. 2014, 826–827). We are also witnessing the emergence of a number of interrelated subfields that shape the field of global (p. 2) health politics. These include globalisation and health (Hanefeld 2015; Lee 2003); the relationships between global health and foreign policy, security, and development (Davies 2019 Price-Smith 2010; Youde and Rushton 2014; global health governance (Harman 2012; McInnes et al. 2014; McInnes and Lee 2015; Youde 2012; Kickbusch 2005); the global political economy of health (Schrecker and Bambra 2015); and policy debates focused on specific issues such as HIV and AIDS (Anderson and Patterson 2017 Dionne 2018), pandemic influenza (Kamradt-Scott and Lee 2011), tobacco control (Lee and Hawkins 2016), access to medicines (Roemer-Mahler 2014), health inequities (Ruckert and Labonte 2017; Benatar 2016), mental health (Howell 2011), Ebola (Gronke 2015), biosecurity (Enemark 2017; Osterholm and Olshaker 2017), legal and ethical frameworks (Poku and Sundewall 2018; Ruger 2012), and non-communicable diseases (Reubi et al. 2016). Even more tellingly, the field is now engaging in critical examinations of itself (Brown, Craddock, and Ingram 2012; McInnes and Lee 2012; Davies et al. 2014).

The dynamism of global health politics as a field makes this an important time to publish a Handbook that brings together the current state of this scholarship. At the same time, this dynamism necessarily colours its current construction. This Handbook captures a particular moment in this field’s development when it is beginning to demonstrate signs of maturity and its boundaries and constituent elements are formative. We thus do not want to suggest that the field is fixed. Indeed, the range of issues constituting the field of global health is far from settled. When we began this venture, the 2014–2016 outbreak of Ebola virus in West Africa was waning, the Zika virus crisis was beginning, the Rockefeller-Lancet Commission on Planetary Health (see ‘Safeguarding Human Health’ 2015) had just commenced its work, and the UN General Assembly’s High Level Meeting on antimicrobial resistance had yet to take place. We have little doubt that the political agenda in global health will continually change and be reshaped by new challenges that emerge. At the same time, scholarly debates within subfields, including over the nature and extent of the field, remain far from settled. Major works were published whilst this Handbook was being prepared (e.g., Davies 2019; Dionne 2018; Patterson 2018) and will continue to appear after its publication. There are also important debates emerging about the need to decolonise global health as a field of study and practise: To what extent does existing scholarship too blithely sustain, replicate, and even exacerbate existing power differentials within the global system (Biehl 2016; Birn 2014; Waitzkin 2015)? An orthodoxy is emerging over the focus areas of the field and, like all orthodoxies, it is generating its discontents, who are pushing at the boundaries and critiquing the nature of the field (see, e.g., Birn, Pillay, and Hotz 2017). This dynamic and formative scholarship is what this Handbook attempts to capture and articulate in its present form. This volume is intended as both an assessment of the state of the field and, we hope, a distinct contribution to advancing that field. The latter ambition, in turn, comprises two elements, presenting an understanding of what the field is, together with its major subfields and critical perspectives, at a point of immanent maturity, and how individual essays further understanding of issues comprising the field and its subfields.

(p. 3) The Meanings of Global Health and Global Health Politics

Global health can be broadly defined as the health of human populations within a worldwide context. More specifically, it concerns those health determinants and outcomes that extend across and beyond defined geographical territories (especially the political boundaries of states) to address the world as a territorial whole and even as a deterritorialised space. It builds on a substantial and well-established literature on local and national health politics (Immergut 1992), but expands upon it by emphasising this de/reterritorialised nature of health determinants and outcomes, the broadening range of state and non-state actors involved in health policy and practise, and the reciprocal relationship with other policy spheres. In so doing, it draws heavily on thinking about globalisation and its broader societal effects across the world, which began to influence scholarly thinking in the 1990s (Kirton 2017; Lee 2003; McInnes and Lee 2012).

Beyond this broad understanding, however, consensus about the distinct nature of global health becomes more contested and problematic. The term has become ubiquitous in use, often poorly or inaccurately defined, akin to the over- and misuse of the term globalisation (Yach and Bettcher 1998a, 1998b; Kickbusch, Hartwig, and List 2005; Scholte 2008; Labonté 2018). Efforts to resolve this impasse have been valiant (Koplan 2009; Beaglehole and Bonita 2010; Rowson et al. 2012), but ultimately unsuccessful, in critically resolving tensions in past and present theory and practise. These efforts have highlighted the disciplinary differences that now silo global health thinking and practise, notably within and between the biological and clinical medical sciences and the social sciences. This is unfortunate given the wide recognition of how global health necessarily interacts with other policy sectors far beyond health, including foreign policy, security and law enforcement, trade and finance, environment, and development. These interactions in turn add further complexity to defining the boundaries of global health. For example, in development, global health becomes defined as a key element in providing basic needs and reducing poverty; for security, it becomes defined as a source and means of reducing existential threats to the state and the stability of the international order; and in trade and finance, global health becomes defined as a core element in generating macroeconomic growth.

Global health politics is concerned with the actions, practises, and policies that govern the sphere of global health. It addresses not only the processes of decision-making by relevant institutional actors, but also the structures of power that shape what is possible. We understand structural factors as ‘social and political mechanisms (governance, macroeconomic policy, social policy, public policy as well as social and cultural values) that generate, configure and maintain socioeconomic position (social class, gender or (p. 4) ethnicity)’ (Krumeich and Meershoek 2014). Global health actors include the state, but also encompass

  • international (state-to-state or intergovernmental) organisations (such as the World Health Organization [WHO] and the World Bank),

  • private for-profit entities (such as corporations),

  • public-private partnerships (such as the GAVI Alliance),

  • civil society organisations (such as the International AIDS Society and Médicins sans Frontières),

  • charitable organisations and foundations (such as the Rockefeller Foundation, Rotary International, and the Wellcome Trust), and

  • individuals wielding normative or material power (such as Bill and Melinda Gates, Michael Bloomberg, and Mark Zuckerberg).

Importantly, global health politics is intimately concerned with power in at least two dimensions. First, power is distributed amongst and exercised by global health actors (or agents), but is also embedded within global health structures. The ways in which global health actors (i.e., actors with recognised roles and/or interests in global health) interact within a so-called global health architecture is shaped by their relative power. At the same time, these interactions take place within structures that enable or disable the exercise of that power. Second, power is both material (the distribution of and capacity to access and use resources such as financial and human capital and technology)—and ideational (the distribution of and capacity to access and use ideas in ways that persuade others of the cognitive validity of their worldview) (Carstensen and Schmidt 2016). Ideas shape what are deemed priority needs, agreed policy solutions, or legitimate norms to be pursued in global health. Ideas structure global health by delineating not simply what is desirable but what is possible. For example, the idea of globalisation enables initiatives for the global surveillance of communicable diseases, the idea of health as a human right legitimates the involvement of civil society actors in global heath discussions, and the idea of humanitarianism underpins development aid. But ideas also provide competing understandings about global health within which agents operate. Thus, from the perspective of a right to health, access to medicines is highly desirable, but from a position of international trade, incentivising research and development via patent protection is vital even if it limits affordability by keeping prices higher. In this sense, both material and ideational power interact together to shape the politics of ‘who gets what’ in global health.

The Development of Global Health Politics

Global health politics as a field of scholarly inquiry has emerged as a result of not only the discursive shift to ‘global health’, but also the changed political landscape. During the (p. 5) twentieth century the dominant discourse presented health primarily as an issue of domestic social policy, with some technical aspects requiring international cooperation, and it focused on the state as provider. By the end of the twentieth and beginning of the twenty-first centuries, however, this perspective was challenged by a series of political developments that provided the permissive atmosphere for the reconceptualisation of health as a global concern. Not least, the post–Cold War world appeared to open the doors for a ‘new humanitarianism’, exemplified by Tony Blair’s ‘Chicago Speech’ (Blair 1999) and by the UN’s Responsibility to Protect agenda. From this understanding, a belief in the obligation of the rich to help those in need flowed, reaching its high-water mark in the Group of Eight’s Declaration following its 2005 Gleneagles Summit. Fundamental to the Gleneagles Declaration was promoting health, partly as a poverty reduction strategy but also because of concerns over the alarming spread of HIV and AIDS, especially in Africa.

Furthermore, the accelerating processes of globalisation appeared to create a situation in which the most pressing challenges were not soluble by states working on their own; rather, global problems required global solutions. The 2002–2003 SARS epidemic and the response to it exemplified how successfully addressing global health requires a collective response and gave a touch of reality to concerns over the potentially rapid and damaging spread of diseases in the twenty-first century. Not only were new diseases appearing more frequently, but responding with appropriate pharmaceutical interventions was becoming more challenging. The high cost of research and development, the consolidation of the pharmaceutical sector into a small number of transnationals, and the networked nature of modern science combined to create a global pharmaceutical sector—even if access to the most modern drugs and health technologies was far from universal. This reinforced the move to global health, but despite advances in drugs and medical technologies, new diseases, drug-resistant strains of existing diseases, and antimicrobial resistance all suggested that pharmaceutical interventions were insufficient on their own to guarantee global health security. Rather, collective action was required to prevent and limit the effects of global health emergencies, requiring a degree of political cooperation.

The view of health as a domestic social concern was also accommodated in the popular distinction—especially prevalent in the discipline of international relations—between ‘high’ and ‘low’ politics. Whilst high politics dealt with issues of power between states, low politics concerned ways of living and social conditions. Some even called health ‘really low politics’ because it was considered technical, humanitarian, and non-political (Fidler 2005). This perspective has now been usurped, partly through work in other fields that have critiqued the high/low distinction. Arguing that the ‘personal is political’ and that how people live their lives is conditioned by global forces and power inequalities, scholars successfully demonstrated how individual lives are inextricably linked to global forces (e.g., Enloe 2014). But the perspective has also been usurped by linking global health to traditional concerns of high politics such as security, global governance, and foreign policy (McInnes and Lee 2006; Youde 2016; Youde and Rushton 2014). As a result, if health was global, then it was also political, a priority area requiring policy action worldwide.

(p. 6) For the policy community, global health has therefore become a subject of heightened concern within the context of post–Cold War geopolitics, intensified globalisation, and growing disparities between the ‘haves’ and ‘have-nots’. Impetus has stemmed from perceptions of new transboundary risks from infectious disease outbreaks and new patterns of health and disease (epidemiological transition) caused by the effects of globalisation on health determinants such as climate change, corporate marketing, illicit activities, and trade liberalisation. In addition to threatening to reverse advances in basic health indicators achieved over the twentieth century, wider concerns about potential impacts on poverty reduction strategies, macroeconomic growth, and security put global health higher on policy agendas worldwide. Consequently, global health was introduced into national policy statements on development, foreign policy, and security; featured centrally in the Millennium Development Goals and the subsequent Sustainable Development Goals; has risen in prominence on agendas of major international organisations (such as the UN, World Economic Forum, and Group of 8/Group of 7); has led to the creation of a multitude of new global initiatives (e.g., UNAIDS, GAVI Alliance, and Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria); has prompted UN Security Council resolutions; and has defined the activities of new and existing civil society organisations, charitable foundations, and private sector actors.1

This remarkable growth in policy attention originated in part from studies conducted by academics and in policy think tanks that focused on the growing ‘threat’ posed by infectious diseases (see, e.g., Brower and Chalk 2003; Elbe 2003; Garrett 1994, 1996; National Intelligence Council 2000, 2002; Osterholm 2005; and Price-Smith 2001). These studies tended to concentrate on the threat of infectious diseases to high-income countries, which had for several decades been largely protected from these concerns due to improved standards of public health and increased access to medicines such as antibiotics and antivirals. In addition, events such as the 2002–2003 SARS outbreak, the apparent inability to halt the HIV and AIDS pandemic in sub-Saharan Africa, the fears about the emergence of pandemic influenza, the linkage drawn between improvements in health and macroeconomic growth (WHO, 2001), and fears over bioterrorism (especially after the September 11, 2001, attacks and the anthrax letters in the United States) provided sustained impetus for world leaders to address global health issues in the years surrounding the turn of the new millennium. This in turn prompted academic inquiry into global health in general and the politics surrounding it more specifically.

However, a simple binary between the worlds of academia and policy/practise fails to reflect the close relationship between the two. Although not a ‘revolving door’, academics have held senior posts in the policy world, policymakers have entered or returned to the academic world, some straddle both simultaneously, and yet others operate in the ‘grey area’ of think tanks. For example, Peter Piot, a Belgian scientist, led UNAIDS from 1995 to 2008 before returning to academia as director and Handa Professor of Global Health at the London School of Hygiene and Tropical Medicine (LSHTM). Laurie Garrett started her career as a science and medicine reporter for Newsday before directing the Global Health Program at the Council on Foreign Relations from 2004 to 2016. David Heymann initially worked as a medical epidemiologist with WHO’s smallpox (p. 7) eradication campaign in India before working for the Centers for Disease Control and Prevention (CDC) and the WHO Communicable Disease Cluster. Since leaving WHO, he has directed the Centre on Global Health Security at Chatham House, served as the chair of Public Health England, and held an appointment as professor of infectious disease epidemiology at LSHTM. David Fidler, as a law professor at Indiana University, has also advised top policymakers with the CDC, WHO, and UN Secretary-General. He is also an adjunct fellow with the Council on Foreign Relations. Ilona Kickbusch held senior roles with WHO during the 1980s and 1990s before leaving to start the Global Health Program at the Yale School of Public Health in 1998 and then taking her current position as the director of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva. Building upon their connections in both the policy and academic realms, Kickbusch and Heymann worked together to develop a crisis simulation during the G20 Health Ministers meeting in 2017. These connections have allowed for a degree of cross-fertilisation between the academic and policy spheres.

The Structure of the Handbook

The study of global health is located at the intersection of several academic subjects and disciplines. At its heart are the biomedical sciences and public health, given their efforts to understand, develop, and implement effective measures to protect and promote population health amid globalisation. The field of global health politics involves a similarly multi- and interdisciplinary breadth, including

  • political science and especially international relations (given its interest in power, security, rights, and governance at the international and global levels),

  • development studies (given the marked rise of health development aid since the 1990s),

  • economics (given the importance attributed to healthy populations for economic growth and prosperity),

  • anthropology (given the variety of understandings of health and disease around the world and the challenges of external actors providing health services in communities), and

  • public administration (given efforts to strengthen and reform the performance of global health institutions).

At the heart of this, however, are the disciplines of politics and, especially, international relations. The study of both politics and international relations dates back over centuries, and the disciplines have developed sophisticated methods and ideas, controversies, and insights into the workings of power; how decisions are made; questions of rights and responsibilities; and understanding who gets what, how, and why at multiple (p. 8) levels of analysis (i.e., to employ a perhaps overused phrase, ‘from the local to the global’). These are precisely the concerns of global health politics, and it is therefore entirely appropriate that these disciplines, politics and international relations, and their ideas should provide a core of knowledge and understanding to the field. Works on global health politics do not always demonstrate this underpinning awareness of the disciplinary expertise in political science and international relations (Paxton and Youde 2018). Nevertheless, an understanding of the nature of politics and the workings of power appears to us to be fundamental to the study of global health politics. But equally the field cannot be limited to this; to use Kenneth Waltz’s well-known aphorism, it is necessary but not sufficient. Rather, the field requires knowledge and techniques from a variety of disciplines, which intersect to produce a more complete understanding of global health politics than any one discipline can provide. The result of this intersection is a field that is inherently both multi- and interdisciplinary. It is also characterised by methodological pluralism and varied theoretical perspectives: from positivism and empirical studies, to critical theory and social constructivism.

This Handbook seeks to capture both the benefits of and complications arising from this intellectual diversity. We have organised the Handbook into five sections. The first (this chapter) outlines our understanding of the field and reflects on its development at a particular moment. The second section charts the shift from international to global health and introduces two themes that are central to the study of global health politics as a whole. The first is that of power. The determinants and outcomes of global health are not equal, nor is the manner in which issues are constructed and solutions articulated. The nature of global health is intrinsically political, reflecting power relations which play a significant role in whether various groups can set the political agenda and/or claim resources. Second, we introduce ideas of critical thought, which are then pursued in more detailed chapters elsewhere in the volume. This is important both to the Handbook and to the field in problematising what are seen as ‘givens’, in asking questions about the perceived nature of the material world, and in opening up a space for different ways of seeing the world of global health. For us, this is a part of global health politics not in the Kantian sense of critique—that global health politics is about the application of reason and the use of rationality to solve problems—but, as Alan Ingram states ‘to approach global health critically is to appreciate that any analysis of global health takes place in the midst of power relations, power struggles and political events’ (see Ingram, this volume). Not least, thinking critically challenges the manner in which power structures establish what is considered acceptable. It suggests that ‘common sense’ is not an objective assessment of an independent material world, but rather a construction ‘for someone and for some purpose’, to use Robert Cox’s famous trope (Cox 1981, 128).

The third section examines the politics of how global health has influenced, been affected by, and sometimes become part of other policy arenas. Indeed, one of the tensions in global health politics is whether linkage to these other policy arenas—such as international development and security—provides additional leverage for global health, allowing it to become more prominent on political agendas, or means that health is (p. 9) subsumed under other priorities. The fourth section addresses global health governance: the institutional actors and structures that govern global health, their ability to establish rules and norms of behaviour that transcend the state, and what this reveals about power relations in global health. The final section discusses key issues that have occupied global health politics and have thus featured in the existing literature and policy debates. This section is not intended to be comprehensive, but rather indicative of both the types of complex issues that occupy the heart of this field of study and practise and the different ways in which they have been studied.

Pondering the Future(s) of Global Health Politics

Identifying where the future of the field might lie risks a form of intellectual path dependency—that we extrapolate from current trends and assume that these will determine the future. Although genuinely disruptive events can, of course, only be predicted in hindsight, even existing trends may move in unpredictable directions. Nevertheless, a number of questions do suggest themselves as being significant for the future of the field.

First, as previously noted, global health politics as a field is dominated by the voices of a privileged few, which is inherently problematic. Crudely put, many of the scholarly voices in global health politics are white and male (including two of the authors of this chapter). Notwithstanding the sincere commitment of many of these people to improving global health, the power to shape the scholarly and policy agenda worldwide remains highly skewed in favour of a relative few. How might greater diversity of scholarship be supported, addressing intersectional categories of marginalisation by geography, race, gender, and socioeconomic status? There are growing efforts to broaden the diversity of voices heard by gender, for example through the creation of several lists recognising female leadership in global health, including academia. Most of these lists, however, have so far had limited success in addressing intersectionality. Therefore, although encouraging trends are apparent, the degree to which decolonising the scholarly agenda will be realised is still uncertain.

Second, existing global health governance institutions, many of which have been created since the late twentieth century, have faced closer scrutiny regarding their internal governance. First, WHO has been the subject of long-standing scrutiny focused on its mandate and performance, and amid the proliferation of other, sometimes competing global health actors. Searing criticism of its response to the Ebola virus outbreak in West Africa has prompted yet further calls for reform to strengthen the organisation’s capacity (Busby et al. 2016; Moon et al. 2015). WHO is not alone, however, in facing greater scrutiny. A 2017 report on fraud and corruption in the use of funds disbursed by the Global Fund prompted an internal Governance Review and (p. 10) Action Plan (Global Fund to Fight AIDS, Tuberculosis, and Malaria, Office of the Inspector General 2017). A blunt independent investigation in 2018 of harassment and bullying by UNAIDS senior officials has raised broader questions about the appropriateness of a disease-specific initiative (UNAIDS Programme Coordinating Board 2018). Which institutions will emerge as the key players in global health governance in the coming years?

Third, the broader context within which global health politics occurs is changing in several potentially significant ways. China’s continued political and economic rise may challenge long-standing distributions of power in global health. The creation of the Asian Infrastructure Investment Bank in 2016 represents a new multilateral development financial institution that could compete with the World Bank and International Monetary Fund (Dahir 2018). As China has assumed a more prominent global role, it has also shown an interest in global health governance, though it has tended to prioritise its own bilateral initiatives over existing institutions (Chan 2011). Furthermore, the success of populist movements around the world—from Donald Trump’s successful presidential campaign in the United States, to Brexit in the UK, to the election of far-right politician Jair Bolsonaro to the presidency of Brazil, to the significant increase in support for far-right Eurosceptic parties across Europe—suggests the emergence of a strong constituency disillusioned with the effects of globalisation. The very countries that have played such important roles in creating and sustaining global health governance institutions and laying the foundations for the successes achieved so far are now openly questioning the usefulness of these organisations, and of multilateralism and globalisation in general. This is not to say that we are witnessing the end of globalisation, but that it has reached a new phase that includes potential changes to the structures, norms, and funding systems that have supported global health governance thus far. When global health politics started to come into its own as a field, globalisation was the dominant geopolitical narrative. Recent political changes now hint that this agenda is more contested.

Fourth, if the narrative of globalisation is being questioned from a resurgent nationalism, then equally it is being taken in new directions with the emergence of a ‘planetary’ agenda. If globalisation focused on the increased speed and intensity of human interactions on a global scale, ‘planetary politics’ firmly places animal and environmental factors in the mix. For some, such as the Rockefeller Foundation-Lancet Commission on Planetary Health, this is largely about how global environmental developments (particularly related to climate change and the food chain) will affect human development and health (Horton et al. 2014; ‘Safeguarding Human Health’ 2015). For others, it is a much more radical reimagining of the political (e.g., Burke et al. 2016). For health, this is seen in the ‘One Health’ agenda, in which the politics surrounding animal welfare and the environment are integral elements to understanding global health.

Fifth, the field of global health politics is presently largely characterised by a mix of multi- and interdisciplinary work. As is evident in this volume, some chapters can be readily accommodated within single disciplinary perspectives. Others, despite drawing on elements from several disciplines, are clearly ‘majoring’ in one; some—probably the minority—are fundamentally interdisciplinary. That the field is so inherently open (p. 11) to interdisciplinary research begs the question of whether the move from multi- to interdisciplinarity will accelerate, or the structure of research will compromise these moves. Can (or should) a genuinely transdisciplinary field of global health politics ultimately emerge? Although major interdisciplinary funding initiatives are increasing, structural factors and disciplinary gatekeeping still limit the development of genuine interdisciplinarity.

Finally, the one thing that we can confidently predict is that new health issues will continue to emerge for global health politics to negotiate. This includes new patterns of health and disease, emerging and re-emerging disease threats, existing issues breaking through the glass ceiling of political awareness (such as antimicrobial resistance), and the emergence of unimagined problems (where, for example, will artificial intelligence lead? or genetic manipulation?). Perhaps equally unpredictable yet expected will be changes within the broader political context. What will be the dominant changes in the political zeitgeist at both the national and global levels? How will the growing effects of climate change influence international and domestic politics? These are some of the ‘known unknowns’ of global health. But there are also ‘unknown unknowns’, which might have dramatic and far-reaching effects. As a result, we need to consider how we understand the need for political systems that are flexible enough to adapt to the new challenges that will emerge.

Conclusion: Politics and Global Health

Politics is often perceived as a negative force by global health policymakers and practitioners, an interference with achieving effective ‘evidence-based’ action. Commentators and practitioners talk about the need to ‘get politics out of global health’ and instead enable scientific rationality to guide action. We argue—and this Handbook hopefully demonstrates—that politics is not only unavoidable, but necessary and integral to effectively addressing global health challenges. The study of global health politics is not about how to minimise interference in rational decision-making, but rather how to improve the quality of political institutions and processes that will in turn improve global health actions and ultimately outcomes. This is why more rigorous and thorough scholarship is needed. Global health politics is a new field embodying a wide range of questions—and does not (yet) have answers for many of them. Our hope is that this Handbook will help scholars, policymakers, and practitioners understand how the field has emerged, appreciate where it is now, and inspire vitally needed research in future.


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(1.) On these developments, see, for example, McInnes and Lee (2012); Davies (2010); and Youde (2012).