David Reubi

Framing global health: The governance challenge

Abstract With the emergence of global health comes governance challenges which are equally global in nature. This article identifies some of the initial limitations in analyses of global health governance (GHG) before discussing the focus of this special supplement: the framing of global health issues and the manner in which this impacts upon GHG. Whilst not denying the importance of material factors (such as resources and institutional competencies), the article identifies how issues can be framed in different ways, thereby creating particular pathways of response which in turn affect the potential for and nature of GHG. It also identifies and discusses the key frames operating in global health: evidence-based medicine, human rights, security, economics and development.

The politics of non-communicable diseases in the global South

In this paper, we explore the emergence of non-communicable diseases (NCDs) as an object of political concern in and for countries of the global South. While epidemiologists and public health practitioners and scholars have long expressed concern with the changing global distribution of the burden of NCDs, it is only in more recent years that the aetiology, politics and consequences of these shifts have become an object of critical social scientific enquiry. These shifts mark the starting point for this special issue on ‘The Politics of NCDs in the Global South’ and act as the basis for new, critical interventions in how we understand NCDs. In this paper, we aim not only to introduce and contextualise the six contributions that form this special issue, but also to identify and explore three themes – problematisation, care and culture – that index the main areas of analytical and empirical concern that have motivated analyses of NCDs in the global South and are central to critical engagement with their political contours.

The Human Capacity to Reflect and Decide: Bioethics and the Reconfiguration of the Research Subject in the British Biomedical Sciences

This article examines how a fundamental element of the British bioethical assemblage – the literature on informed consent published between 1980 and 2000, a period when bioethics became a powerful force in the UK – has influenced contemporary understandings of the research subject. Drawing on Foucault, the article argues that this corpus of texts has created a sphere of possibilities in which research subjects can imagine themselves as human beings who reflect and decide whether they want to participate in medical experimentation. In particular, it shows how the narratives found in these texts portray relationships between researchers and their human subjects as ‘paternalistic’, and calls for their replacement by new, more ethical relationships characterized by both ‘dialogue’ and ‘respect’ and articulated around subjects who can ‘think and take decisions’. It also discusses the different strategies – using patient information sheets, a list of possible questions and invitations to take time to reflect – which the bioethical literature has developed in order to realise these new, ethical relationships. As the article suggests, these narratives and strategies provide researchers and research subjects with models and examples of how to interact with each other that are very different from the ones that prevailed before the emergence of bioethics.

The promise of human rights for global health: A programmed deception? A commentary on Schrecker, Chapman, Labonté and De Vogli (2010) "Advancing health equity in the global market place: How human rights can help"

There have been an increasing number of initiatives and efforts to use the language, institutions and procedures of human rights in the field of global health over the last 20 years (Gable, 2007). HIV/ AIDS was one of the first global health issues where human rights were deployed, generally to protect those with HIV/AIDS from stigma and discrimination. The creation of a Human Rights Office by Jonathan Mann within the WHO’s Global Program on AIDS is a typical illustration of such efforts (Fee & Parry, 2008). Global health activists have also used human rights in relation to access to medicines. Indeed, from the celebrated South African HIV/AIDS medicines access campaign led by large, international NGOs like Oxfam and Médecins Sans Frontières, to efforts by Brazilian patient groups to obtain free drug treatment for rare genetic diseases, all have explicitly appealed to human rights norms found in international treaties and national constitutions (Olesen, 2006; Petryna, 2009). More recently, public health advocates have sought to use human rights in the field of tobacco control. They have tried to exploit the monitoring and complaint mechanisms offered by UN human rights conventions to force the adoption of more stringent anti-smoking policies (Reubi, in press). Schrecker, Chapman, Labonté, and de Vogli’s (2010) Social Science & Medicine article ‘Advancing Equity on the Global Market

The Internationalisation of Tobacco Control, 1950-2010.

This article explores the internationalisation of tobacco control as a case study in the history of international health regulation. Contrary to the existing literature on the topic, it argues that the history of international anti-smoking efforts is longer and richer than the making of the World Health Organisation’s Framework Convention on Tobacco Control in the early twenty-first century. It thereby echoes the point made by other scholars about the importance of history when making sense of contemporary global health. Specifically, the article shows how the internationalisation of tobacco control started in the 1950s through informal contacts between scientists working on cancer research and how these initial interactions were followed by a growing number of more formal initiatives, from the World Conferences on Tobacco or Health to the Bloomberg Initiative to Reduce Tobacco Use. Rather than arranging these efforts in a linear narrative of progress culminating with the Framework Convention on Tobacco Control, we take anthropological claims about global health’s uneven terrain seriously and portray a history of international tobacco control marked by ruptures and discontinuities. Specifically, we identify three successive periods, with each of them characterised by specific understandings of international action, tobacco control expertise, advocacy networks and funding strategies.

Modernisation, smoking and chronic disease: Of temporality and spatiality in global health.

This article explores the spatio-temporal logics at work in global health. Influenced by ideas of time–space compression, the global health literature argues that the world is characterised by a convergence of disease patterns and biomedical knowledge. While not denying the influence of these temporalities and spatialities of globalisation within the global health and chronic disease field, the article argues that they sit alongside other, often-conflicting notions of time and space. To do so, it explores the spatio-temporal logics that underpin a highly influential epidemiological model of the smoking epidemic. Unlike the temporalities and spatialities of sameness described in much of the global health literature, the article shows that this model is articulated around temporalities and spatialities of difference. This is not the difference celebrated by postmoderns, but the difference of modernisation theorists built around nations, sequential stages and progress. Indeed, the model, in stark contrast to the ‘one world, one time, one health’ globalisation mantra, divides the world into nation–states and orders them along epidemiological, geographical and development lines.

Blood donors, development and modernisation: configurations of biological sociality and citizenship in post-colonial Singapore

This article examines the governmental apparatus organised around Singapores Blood Transfusion Service (SBTS) and the knowledge, experts and techniques associated with transfusion medicine. I term this apparatus, which was in place in the Singapore from its first steps towards political independence in 1959 until 1990, ‘Singapores haemato-logic assemblage’. Drawing on the work of Foucault, the article explores how this assemblage overflowed into and reconfigured understandings of biological sociality and citizenship in post-colonial Singapore. More specifically, it argues that, in the 30 years following independence, this assemblage brought into being a new figure of the biological citizen by creating a sphere of possibilities for Singaporeans to think and act accordingly. This new figure of the citizen is ‘the blood donor’. Articulated around the SBTS and the knowledge and techniques of transfusion medicine, this donor is a Singaporean who gives blood to save the lives of fellow citizens and participates, thereby, in the development and modernisation of the newly independent nation. To substantiate this argument, the article shows how the haemato-logic assemblage helped to realise this new figure of the citizen by creating – through narratives, statistics, spaces and rewarding schemes – a sphere of possibilities in which Singaporeans could think and act as blood donors.

Of neoliberalism and global health: human capital, market failure and sin/social taxes.

Abstract This article tells a different but equally important story about neoliberalism and global health than the narrative on structural adjustment policies usually found in the literature. Rather than focus on macroeconomic structural adjustment policies, this story draws our attention to microeconomic taxation policies on tobacco, alcohol and sugar now widely recognised as the best strategy to control the global non-communicable disease epidemic. Structural adjustment policies are the product of the shift from statist to market-based development models, which was brought about by neoliberal thinkers like Peter Blau and Deepak Lal. In contrast, taxation policies are the result of a different epistemological rupture in international development: the move from economies and physical capital to people and human capital, advocated by Gary Becker and others. This move was part of wider change, which saw Chicago School economists, under the influence of rational choice theory, redefine the object of their discipline, from the study of markets to individual choices. It was this concern with people and their choices that made it possible for Becker and others to identify the importance of price for the demand for tobacco, alcohol and sugar. The same concern also made it easier for them to recognise that there were inefficiencies in the tobacco, alcohol and sugar markets that required government intervention. This story, I suggest, shows that structural adjustment policies and pro-market ideology do not exhaust the relationship between neoliberalism and global health and should not monopolise how we, as political and social scientists, conceive it.

Epidemiological accountability: philanthropists, global health and the audit of saving lives

Abstract There have been concerns about the recent private turn and re-emergence of philanthropies in world health, with many worrying about philanthropies’ perceived lack of transparency and accountability. In contrast, I argue that while the private turn might have led to a decline in democratic or public accountability, it did not bring an end to all forms of accountability. Specifically, I suggest that philanthropists’ involvement in global health has led to the spread of another, new form of accountability: epidemiological accountability. The latter is a combination of two regimes of expertise and practices hitherto kept separate: audit and epidemiology. To substantiate this argument, I draw on my research on the Bloomberg Initiative – a global effort to reduce tobacco use spearheaded by the Bloomberg and Gates foundations.

A Genealogy of Epidemiological Reason: Saving Lives, Social Surveys and Global Population

Metrics have become all pervasive in global health today. Instead of highlighting their advantages or shortcomings, this article builds on Hacking’s notion of historical ontology and explores their political, conceptual and material conditions of possibility. Drawing on research on the Bloomberg Initiative to Reduce Tobacco Use in Developing Countries, one of the largest international efforts to address the non-communicable disease epidemic in the global South, the article starts by introducing the notion of epidemiological reason – a thought style associated with modern epidemiology that undergirds the metrics permeating the global health field and which is made of a multiplicity of elements, from the ethical imperative to save lives to the social-scientific technique of the survey and the concept of global population. The article then goes on to explore the genealogy of this thought style, arguing that three epistemological ruptures have been critical to its development: the reconfiguration of power articulated around a biopolitics of population in the eighteenth and nineteenth centuries; the twentieth-century shift in medical thought marked by the emergence of surveillance medicine and the idea of lifestyle; and the re-organisation of world health informed by globalisation theories at the start of the twenty-first century.