Textbook of Global Health (4th edn)

Anne-Emanuelle Birn et al.

[Link]
Published online: 23 March 2017 Published in print: 01 April 2017 Online ISBN: 9780199392315
Print ISBN: 9780199392285

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CHAPTER

14 Towards a Social Justice Approach to Global Health 

Anne-Emanuelle Birn, Yogan Pillay, Timothy H. Holtz

[Link] Pages 603–646

Published: March 2017

Abstract
This chapter lays out a committed activist—and critically hopeful—approach to global health. It begins
by recapping the textbook’s key themes, including the intransigence of mainstream approaches, ongoing
challenges in the eld, and points of inspiration. It invites the reader to think critically about personal
motivations and involvement, stressing the importance of humility, self-re ection, and long-term
solidarity, and reviewing the challenges, possibilities, and limits of global health work from an individual
and organization-level perspective, bearing in mind the larger constellation of forces and interests that
shape the contemporary world order. Showcasing an array of examples involving local advocacy, work
with NGOs, and social movements—both transnationally and “at home”—it demonstrates how a
solidarity-oriented, human and environmental rights perspective based on humility, struggle, and
commitment to political values of equitably shared power and resources can help contribute to
transformative change for health and social justice.

Keywords: mainstream approaches, social justice, social movements, transnational movements, social
justice oriented, activism, personal motivations, organizational missions, solidarity, world order
Subject: Epidemiology
Collection: Oxford Scholarship Online

We hope that reading this book will have stimulated you to think anew about the prospects and dilemmas of
global health. Ideally, the analyses and arguments presented will have sparked your desire to become involved
—or transform your involvement—in addressing the challenges of this arena. We also invite you to “decenter”
your own role. After all, the bulk of what is considered “global” health activity—though perhaps in dialogue
with transnational practices and agendas—is carried out by local health personnel, government policymakers,
community organizers, health promoters, laboratory technicians, mothers, traditional birth attendants,
parasitologists, and innumerable others, often with very limited resources and inadequate remuneration or
recognition for their work.
 De-centering your role means not privileging your personal interests and aspirations; rather, it entails guring
out where and how your participation can be useful based on your knowledge, abilities, and inclinations in the
context of pressing global health issues. Given your experience and potential to contribute, what is the
appropriate geographical or organizational setting for your engagement and activism? Pushing this further,
what alternatives to international experiences might powerfully contribute to improving global health justice,

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considering the constraints and possibilities of the political economy order? What should you know and learn
about the local, national, and global contexts of your potential activities and work and the related ethical and
ideological implications? What kinds of sources should you consult? These are all questions that anyone
contemplating paid or volunteer work in global health should re ect on, whether at home or transnationally
(Ventres and Fort 2014).
As we have seen, contradictions abound in the eld of global health. Much global health activity remains
premised on a one-way diffusionist model of funding, professionals, and agenda-setting from high-income
countries (HICs) to low- and middle-income countries (LMICs). Yet past and present, such a unidirectional
framing of ideas, resources, and expertise is both simplistic and erroneous (Ventres and Gusoff 2014). Without
LMICs there would be no HICs. The pro ts extracted from labor and natural resources in Europe’s African,
American, and Asian colonies (and via post-colonial Euro-American imperialism) enabled industrialization and
helped nance generous welfare states, contributing to better, if unequal, health in HICs. But LMICs, barring
elites, have bene ted far less. (In conducive contexts, a con uence of unions and social movements have
struggled for broad social protections. LMIC welfare states have invariably evolved on a shoestring, some
creatively and equitably so, others in more beleaguered fashion.) Similarly, far more health professionals from
LMICs go to work in HICs than vice versa, as part of the “brain drain” in which LMICs paradoxically (but
consistent with past experience) heavily subsidize HICs (see chapter 11).
p. 604 There are also countless, albeit little touted, public health policies and innovations from LMICs that have
shaped developments in HICs. This frames, for instance, how a child rights approach to health, pioneered by
Uruguay in the 1930s, moved onto the international agenda (Birn 2017); such a circulation of in uences also
helps explain the community health movement’s appearance in the United States in the 1960s, drawing from
prior efforts in South Africa (Geiger 2013) and the enduring African community health worker (CHW) model
for New York City’s efforts. Similarly, the United Kingdom has been inspired by Brazil’s family health strategy
to better integrate CHWs into its primary care system (Johnson et al. 2013). In addition, a signi cant portion of
global health activity takes place outside of HICs’ ambit altogether. Across non-metropolitan centers,
cooperation ranges from Latin American sanitary treaties and mutual public health policy sharing starting in
the late 19th century—renewed more recently under UNASUR—to the Group of 77’s challenging of neo-
imperialism (sparked by the 1955 Bandung conference) leading to mutual aid arrangements outside the Cold
War blocs, among other initiatives (see chapters 1 and 2).
Undoubtedly, there are various ways of thinking about work in global health. Some consider it a learning
adventure: well-meaning health professionals and students typically from HICs travel to low-income countries
(LICs) in hopes of alleviating health problems. Others regard global health as providing humanitarian and
technical assistance during times of civil con ict or ecological disaster. Still others see it in terms of mutual
cooperation aimed at improving health and social conditions, whether via international agencies and
nongovernmental organizations (NGOs), between LMICs, or among networks of health workers, organizations,
and professionals.
From a critical political economy viewpoint, global health work involves a lifelong commitment to
transformative social change. In implementing this perspective, students, health professionals, and
community actors may collaborate in solidarity (i.e., mutual support based on shared values) actions toward
improving health and social justice, whether at home or abroad (Hanson 2010). Integrating technical, personal,
social, institutional, and political approaches is feasible, if an ongoing and uphill challenge, as witnessed in a
variety of “healthy societies” (see chapter 13).
 In this chapter we lay out a committed and hopeful activist approach to global health—neither based upon
naïve optimism that fails to question structural inequities nor on cynical realism that views systemic injustices
as inevitable and intractable. Instead, we draw from the notion of “critical hope,” based on the ideas of Brazilian
educator-philosopher-activist Paulo Freire (1992), pushing us to think realistically and critically about the
possibilities for transformative change and how it can be achieved through long-term collective struggle. Using

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this premise as a guide, we explore how to move beyond mainstream approaches to foster a truly equitable
form of global health based on solidarity with oppressed peoples. We do not purport to have the answers—but
present an array of activities that heed the spirit of health and social justice.
We thus invite readers to navigate the complex world of global health from a critical perspective and consider
engaging in global health work that seeks bona de social justice. This chapter begins by recapping key
aspects of the dominant models, challenges, and points of inspiration in global health discussed throughout
this textbook. Next, we highlight solidarity-oriented approaches based on humility and commitment to
political values that contest oppression and aim to transform societies so that power and resources, and control
over them, are truly equitably shared. Throughout we showcase locales, organizations, and movements that
draw from critical hope to address global health problems “at home and abroad.” We wrap up by reviewing the
challenges, possibilities, and limits of global health work from individual and organizational perspectives,
bearing in mind the larger constellation of forces and interests examined in previous chapters.

Recapping the Global Health Arena: Dominant Approaches, Ongoing

Challenges, and Points of Inspiration

Key Questions:
• What are the limitations of dominant (mainstream) approaches to international health in the past and
global health today?
• What inspiring efforts have emerged that address global health’s ongoing challenges and serve as
alternatives to mainstream approaches?

p. 605 Dominant Approaches

Global health today remains deeply marked by international health’s historical trajectory. As discussed in
chapter 1, starting circa 1500 leading European powers ventured “overseas” to explore, settle, exploit, convert,
colonize, “civilize,” and pro t from peoples and lands of less powerful societies. Millions of people were forced
into slavery, indentured servitude, and other forms of involuntary migration/labor and worked under
oppressive and dangerous conditions on plantations, in extractive industries, and, later, in factories and
sweatshops. Colonial health and tropical medicine played a central part in the imperial enterprise, whether
protecting soldiers and settlers to enable colonial expansion, increasing worker productivity, staving off
epidemics to safeguard trade and investment, reinforcing political, economic, and social strati cation, “saving”
subjugated populations on religious and “civilizing” grounds, or attenuating social uprisings.
For example, in the 19th century Britain’s Army Medical Service prided itself on bringing “sanitary science to
India, stopping the ravages of cholera and improving the whole conditions there” (Harrison 1994, p. 227), even
as its primary mission was to protect the health of British soldiers and colonists; any bene t to the local
population was secondary. Moreover, many of India’s health problems—ascribed to local cultural and racial
de ciencies—were in fact created by the British through conquest and colonialism’s commercial ventures, such
as agricultural practices that “disrupted traditional systems of drainage exposing huge tracts of the country to
the ravages of malaria and waterborne disease” (ibid).
 In a related vein, the part played by Protestant and Catholic medical missionaries in disseminating Western
medicine to European colonies in Latin America, Asia, and Africa has been hailed by some: to this day, across
Africa many hospitals are run by missionaries, providing care that might not otherwise be available. Yet the
missionary project historically facilitated imperialist exploitation and extraction, as exempli ed in colonial
Belgian Congo (today the Democratic Republic of Congo [DRC]), which had one of the world’s most extensive

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networks of missionary hospitals (Lyons 2002) and among the richest mineral deposits—making the country
simultaneously vastly wealthy and indescribably poor.
As former colonies gained independence in the 19th and 20th centuries, asymmetrical power relations in the
realms of trade, global politics, and other arenas persisted, albeit under a new guise. At the end of World War II,
both continued imperialism and decolonization movements in uenced the new United Nations (UN) and
World Health Organization (WHO). The emerging post-war world (health) order was also shaped by Cold War
geopolitical relations among so-called First (capitalist bloc), Second (communist bloc), and Third (non-aligned)
World countries and accompanying ideologies of development (chapter 2). WHO initially built upon the legacies
of the Rockefeller Foundation, pursuing disease eradication programs (e.g., against yaws, malaria, and
smallpox), in the 1970s turning to a contrasting approach of primary health care (PHC) underpinned by the
non-aligned countries’ demands for a New International Economic Order.
The WHO’s role at the fulcrum of international health waned in the 1980s as dominant bilateral players,
particularly the United States (as part of its larger pullback from the UN), withheld signi cant nancial support
in disagreement with WHO’s advocacy of affordable essential medicines and of restraining the marketing of
breastmilk alternatives (both actions defying corporate interests). This took place in the context of an
ideological realigning of the world order under neoliberal globalization, forcing a circumscribed and pro-
corporate role for the public sector and a concomitant (re-)entry of private (and philanthropic) actors. At the
end of the Cold War, international health was rebaptized as global health to evoke the eld’s uni ed enterprise,
yet many of the dilemmas and arrangements of the past have persisted (chapter 2).
While those involved in global health today might (smugly) distance themselves from past prejudices and
practices, it is important to bear in mind that self-interested agendas still pervade, accompany, and motivate a
range of the eld’s current activities, such as controlling feared epidemics from crossing the globe (e.g., the US-
led, 50-member Global Health Security Agenda, which envisions a “world safe and secure from global health
p. 606 threats posed by infectious diseases” [GHSA 2016]) and pursuing strategic alliances (e.g., PEPFAR’s focus
countries). Indeed, the foreign policy agendas of many leading powers unabashedly frame health as vital
national security and economic concerns, employing this dual rationale to justify involvement in health-
related multilateral decisionmaking bodies and the use of activities and negotiations around health as a
diplomatic tool (see chapters 3 and 4).
Even as the “soft power” of health diplomacy is aunted by both traditional donors and emerging players as an
effective alternative to more aggressive foreign policy, there is inadequate transparency around spending and
its consequences. For instance, the largest donor, the United States, annually spends roughly US$10 billion on
global health, yet there is insuf cient coordination, accountability, and timely reporting around these efforts
(Post and Glassman 2016).
In the economic domain, global health is playing a renewed role in market expansion, advancing commercial
interests (Big Pharma, Big Food, etc.) over public health needs. Meanwhile, the palpable and cumulative effects
of global capitalism (especially in its neoliberal form; see chapter 9) on health inequity and social injustice are
problems sidestepped by dominant global health actors.
For these reasons, some wonder whether contemporary approaches to global health—including those that
express profound moral sentiments in favor of reducing poverty and improving health in LMICs—represent a
neocolonialist mode (Horton 2013), whereby “solutions” emanate from powerful interests and are imposed on
 subordinate countries and groups, all the while protecting pro table global arrangements. This “white man’s
burden,” as per the phrase popularized by British imperial poet Rudyard Kipling, supposes that aid stems from
generosity and responsibility on the part of imperial donors—who disregard the past and present exploitation
of subjugated economies and peoples.
Nowadays, global health actors have proliferated to encompass multilateral and bilateral aid agencies,

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international nancial institutions (IFIs), regional organizations, military actors, NGOs, humanitarian and
religious agencies, research initiatives, foundations, think tanks, advocacy groups, social and political
movements, public-private partnerships (PPPs), and business interests (see chapter 4). Particularly in uential
are a growing array of private and philanthropic actors active in global health, which embrace social
entrepreneurship (Lim and Chia 2016), venture investment, and pro t-oriented business models to addressing
development and global health problems, an ideology embodied in the term “philanthrocapitalism” (Wilson
2015).
Indeed, mainstream global health efforts increasingly draw from social enterprise strategies to “brand” their
programs (distinguish them from others; create a niche; show how they are “unique”) and “perfect the pitch”
(to launch and obtain funding for new ideas and promote existing programs) (Cruikshank, Clark, and Bartlett
2014). As well, market approaches to health favoring private sector health care delivery, in places as varied as
the United States, India, South Africa, and Mexico (see chapter 11), presume greater ef ciency despite evidence
otherwise. Market models also favor priority-setting driven by cost analyses that demonstrate a “bang for the
buck” for speci c interventions over the short term, while rejecting broad social investments that are
conducive to health and health equity over the long term and may ultimately be far more effective and ef cient
(see chapter 12).
Another dominant feature of contemporary global health is its relentless biomedical and behavioral bias,
notwithstanding ample evidence of the shortcomings of bio-behavioral understandings of health and well-
being. As explored in chapter 3, these models emphasize biology, genetics, and biomedical interventions (e.g.,
medications and insecticide-spraying) and lifestyle factors (e.g., diet, smoking, and physical activity). Both
models focus on the individual as the basis for health improvement, underplaying the role of societal politics,
power, and social relations, all central to a critical political economy of health approach.
As just one of countless illustrations of the entrenchment of bio-behavioral approaches, to mark World
Diabetes Day on November 15, 2015, then UN Secretary General Ban Ki-moon stated: “There is much all of us
can do to minimize our risk of getting the disease and, even if we do get it, to live long and healthy lives with it,”
suggesting, for example, that “anyone who can stand instead of sit, walks a little bit more each day and is
generally more active should do so.” He also urged that health facilities “expand care for diabetes” and that the
p. 607 private sector “improve the availability and affordability of healthier products and essential medicines” (UN
2015). Yet he disregarded the factors a critical political economy approach considers crucial: the role of trade
treaties enabling global penetration of transnational corporations (TNCs) that disrupt dietary patterns; fossil
fuel dominance that leads to unhealthy urban air quality; inadequate tax revenues (due to illicit nancial ows)
impeding investment in safe neighborhoods, daycare, clean water access, and public transport; and the
propagation of “ exible” work under neoliberal globalization, leading to unpredictable work schedules,
multiple jobs, and long commutes (as per chapters 7, 9, and 10); all interacting together with still other factors
to impede exercise.
Bio-behavioral and market approaches are also ubiquitous in vertical disease programs—global health’s
dominant modus operandi that entails attacking diseases one by one. Numerous analysts have critiqued such
initiatives for not addressing the underlying political, economic, and social determinants of health or the need
to strengthen infrastructure and PHC (Forman 2016; Gopinathan et al. 2015). In addition, excessive reliance on
technical tools, effective as they may be under controlled conditions, is highly problematic when the tool
becomes the end in itself, to be clocked rather than integrated into broad socio-political approaches (Adams
2013).
Disease initiatives can cause signi cant distortions in health systems. As health care workers are drawn away
from primary care to receive training for and staff disease-speci c programs, their former positions often
remain un lled (Keugoung et al. 2011; Pfeiffer et al. 2008). Furthermore, health professionals in LMICs may be

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overseen by outside “experts” or consultants who impose their own values and tools and negate, or even
denigrate, the importance and utility of local knowledge and the existing organization of social and medical
services.
Disease programs may be so narrowly focused that they overlook, or fail to treat, people who present with
problems not directly related to the campaign in question (Harper and Parker 2014). Moreover, the focus on a
few diseases comes at the expense of other primary care concerns, including routine immunization. India’s
eradication of polio, for instance, took place amid decreasing overall child immunization coverage and high
rates of other vaccine-preventable diseases such as pneumonia—the number one cause of child mortality in
the country (Laxminarayan and Ganguly 2011).
At its most extreme, the vertical approach can justify neglect in such obvious determinants of health as clean
water access, adequate nutrition, and decent housing (not to mention the underlying factors of uneven power
and resource control). For instance, elevating polio eradication above other approaches and health goals,
former President of Nigeria, Goodluck Jonathan went so far as to declare:
One thing I promise the Nigerian child, and also the Nigerian father and mother, is that if we cannot
solve all the health problems in this country now, one thing this present administration is committed
to is to eradicate polio by 2015 (Global Polio Eradication Initiative 2012).
It is both galling and unacceptable that in a country as oil-rich as Nigeria, polio eradication has served as an
excuse for inaction in other areas (perhaps harming the polio campaign itself, evidenced by resurgence of wild
poliovirus cases in 2016).
Because mainstream donor agencies typically follow corporate-style governance objectives that prioritize
short-term, ef cient activities to demonstrate success, they tend to favor narrowly targeted, cost-effective,
measurable interventions (and associated supportive research [Box 14-1]) that quickly show results according
to speci ed criteria. For example, donor-funded mass drug delivery for neglected tropical diseases—such as
lymphatic lariasis and schistosomiasis (see chapter 6)—is frequently portrayed as hugely successful by local
implementers and global advocates because shedding light on its shortcomings might affect future funding. In
reality, uptake is often suboptimal due to poor consideration of context and structural factors that affect
adherence to treatment (Parker and Allen 2014).
Box 14-1

This textbook draws from a gamut of global health research ndings; here we examine a few central
issues around the production, ethical quandaries, and political dimensions of global research in health.

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The scope of research in the global health arena ranges from tracking longstanding and emerging
patterns of mortality and morbidity to discovering and distributing effective, accessible, and affordable
preventives and treatments for the leading causes of illness, disability, and death; and identifying and
addressing the societal determinants of health (SDOH) and disease patterns and their (in)equitable
distribution (see chapters 6–7). These areas of course interact. As discussed, understanding and
remedying the underlying causes of health inequities perforce rests on relevant data collection, which in
turn re ects larger political struggles around how populations are counted and how information is
shared and used (see chapter 5).
Scienti c research plays a vital role in global health, especially when it involves ethical, non-exploitative
collaborations and when both research agendas and discoveries are integrated with policies aimed at
enhancing equity and addressing SDOH. Alas, this goal is rarely met: the private sector funds half of all
global health research and development (R&D) (Chakma et al. 2014)—a trend that will likely continue.
Expectations of favorable returns on investments in this more than quarter trillion dollar industry means
that research disproportionately attends to the places/people generating the greatest pro ts, thereby
excluding most LMIC inhabitants and many in HICs.
In the 1990s, the Commission on Health Research for Development adopted the term “10/90 gap” to signal
that the health needs of 90% of the global population were being addressed by only 10% of the world’s
health research monies. This gap entails (Pang 2011):
1. “Imbalances,” re ecting who wields power and whose interests are privileged in setting and
realizing research agendas, leading to:

• Barriers to setting priorities and accessing the bene ts of health research, particularly for LMIC
populations (e.g., between 1975 and 2004 only 1.3% of new drugs developed were for “tropical”
diseases, and today 75% of LMIC-targeted health research funding goes to just three diseases:
HIV, TB, and malaria)
• Limited research spending on chronic diseases, violence, and road traf c injuries in LMICs
• More research on developing new technologies (e.g., new vaccines) than on better access to
existing interventions (e.g., antibiotics or clean water) or on SDOH (e.g., how living and working
conditions interact with disease processes)
• Almost no research on the political economy (and world order) factors underlying multiple
diseases (most research assumes a bio-behavioral model of disease control)
2. Improved LMIC research capacity (e.g., around HIV), but continued lags (in contexts with limited
resources, research infrastructure, and posts for scientists)
3. Inadequate research accountability and problematic ethics:

• Growing clinical research taking place in India, South Africa, and China, among other LMIC
settings (motivated by lower costs and large numbers of potential participants), often under the
auspices of private companies or PPPs
• Unethical research practices (e.g., illegal and/or unsafe testing of unproven therapies)
 4. Weak knowledge translation (connecting research/evidence to health policy/practice)
5. Inadequate governance of global health research, especially with many new players pursuing their
own agendas, mainly disease-speci c interests
This is not to say that LMICs lack research capacity—to the contrary, given constraints, there has been

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remarkable research production in various MICs and some LICs (see chapter 11). To name just two
examples, past and present: Brazilian physician-bacteriologist Carlos Chagas’s identi cation of American
trypanosomiasis, its etiology, and carrier insect in 1909—an unprecedented discovery of all links in the
epidemiological chain by a single person; and Chinese chemist Youyou Tu’s isolation of artemisinin,
extracted from a traditional herbal medicine plant, for the treatment of malaria, earning her a 2015 Nobel
prize in medicine.
Nonetheless, the imbalance of research funding, capacity, and infrastructure between HICs and LMICs
persists. A growing number of North–South (and some South–South) research and training partnerships
have emerged to address this issue. Reciprocal North–South research efforts are typically fragmented and
underfunded compared with university backing and donor support for biomedical research (Pinto et al.
2014). In some places, such as Rwanda, research partnerships and exchanges must have government
approval and assurances of non-extractive research (Chu et al. 2014). Other arrangements, although
promising on paper, perpetuate uneven power relations (Moyi Okwaro and Geissler 2015; Smith, Hunt,
and Master 2014). Many institutions in LMICs are unable to effectively partake in joint research, and HIC
participants and priorities often dominate partnerships and publications. Each year thousands of HIC
health researchers receive grants to carry out studies in LMICs, but it is virtually unheard of for a
scienti c team from, for instance, India or Senegal to be funded to investigate health problems in, say,
Canada or France. Of course, resident researchers in some LMICs may be as well-trained as many
foreigners (and frequently poached by HICs), and are almost universally more knowledgeable about the
local situation.
But “research imperialism” is only one side of the coin. The US’s 1980 Bayh-Dole Act granted permission
to federally funded researchers to patent and license inventions, generating rising con icts of interest
between the pharmaceutical industry and university-based researchers (Liang and Mackey 2010). This
has also fostered “academic capitalism,” whereby universities articulate missions of global health equity
and innovation while pro t-seeking from global health (Merson 2015)—patenting research, attracting
resources (often with directives) and contracts from the private sector—making them bound to donors
and potentially exploiting LMIC partners (Cantwell and Kauppinen 2014).
The Ethics and Politics of Global Health Research

Another key concern connected to global health research is ethical conduct, an issue only systematically
addressed as of the mid-20th century. Following revelation of the atrocities of Nazi human medical
experiments before and during World War II, the Nuremberg Code of 1947 established the requirement for
voluntary consent by all human medical research subjects. Subsequently, codes of research ethics have
been promoted by various professional groups, based on the principle of informed consent and individual
decisionmaking autonomy.
Yet even as these codes were developed, harmful research continued. Among the most infamous cases
was the Tuskegee Syphilis Study, conducted by the US Public Health Service (USPHS) between 1932 and
1972 on over 400 poor African-American men in the US state of Alabama who had been diagnosed with
syphilis. The recruited men believed they were receiving treatment but in fact were never appropriately
treated, even once penicillin became the standard syphilis cure following World War II. The study resulted
in at least 40 deaths and a gross health and ethical violation (Gamble 1997; Reverby 2009). After the study
was uncovered, the US government enacted more stringent regulations and control over research
involving human subjects, beginning with the 1974 establishment of a National Commission for the
Protection of Human Subjects.
More recently, historian Susan Reverby uncovered an international arm of the syphilis study, supported
by the Pan American Sanitary Bureau and the Guatemalan government. From 1946 to 1948, USPHS
researchers intentionally infected more than 1,300 Guatemalan prison inmates, psychiatric patients, sex

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workers, and soldiers with syphilis—without participant consent—to test the ef cacy of penicillin
(Reverby 2011). Following a US government apology, and the Guatemalan government’s declaration of the
experiments as “crimes against humanity,” the Presidential Commission for the Study of Bioethical
Issues (2011) concluded that the scientists involved in this research violated the ethical standards of the
time, going to great lengths to keep their experiments secret while still obtaining funding from high level
authorities who should have halted the research. Almost 800 of the former research subjects and their
families are pursuing legal action and demanding compensation in both the United States and
Guatemala, with no resolution to date (Reverby 2016). The United States was hardly the only powerful
entity sponsoring ethically fraught research; for example, in the 1950s, a dangerous and largely
ineffectual trypanosomiasis vaccine made by a French pharmaceutical company was the basis of a
coercive campaign in multiple African colonies (see chapter 1).
Seeking to prevent such violations, ethical guidelines have been produced by the World Medical
Association (Helsinki Declaration, revised in 2013), the Council for International Organizations of Medical
Sciences (most recent biomedical revision 2016, epidemiology revision in 2009), UNESCO’s World
Commission on the Ethics of Scienti c Knowledge and Technology (1997), and the African Union (2003
Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa), as well
as by many national health ministries.
Yet ethical concerns abound. The proportion of clinical trials conducted in LMICs rose from 10% in 1991 to
62% in 2010, in part because in 2008 the US Food and Drug Administration withdrew its compliance with
the Helsinki Declaration and its restrictions around placebo use, post-study treatment access, public
disclosures, and compensation for study-related harms (Burgess and Pretorius 2012). Moreover, rising
costs and restrictions on R&D in HICs have made it increasingly attractive for pharmaceutical companies
to conduct drug trials in locales where expenses are low, the length of the trial may be reduced, and
administrative oversight is relatively lax (though regulatory and ethical restrictions have begun to tighten
in many LMICs). Rates of certain diseases (e.g., HIV) are higher in LMICs than HICs, making it easier to
reach required study sample sizes and lowering costs (Okonta 2014), important considerations to be sure,
also for publicly-funded research. But “offshoring” has turned LMIC-based research into an attractive
“cheap bargain” for a pro t-maximizing industry that spends US$80–90 billion annually on clinical
trials (Durisch and Gex 2013). As such, issues of adequate ethical oversight and study monitoring,
including ensuring informed consent, are critical (PHM et al. 2014): arguably there should be stringent
justi cation for conducting pharmaceutical trials in LMICs, especially when only a fraction of the local
population might bene t from the results, and study sponsors leave little or nothing behind in terms of
health system infrastructure or access to medications.
In the mid-1990s, a series of US government and UNAIDS-funded experiments focused in sub-Saharan
Africa sought to determine whether there were less expensive ways than established HIC standards of in
utero AZT administration to reduce vertical transmission of HIV. Half of the 12,000 pregnant women
participants received AZT in varying dosages and for varying lengths of time, and half received an inert
placebo. When the study came to light, critics demanded that it be halted on ethical grounds, given
existing evidence of AZT’s ef cacy (albeit with a different regimen) and arguing that hundreds of babies
would needlessly contract HIV (Lurie and Wolfe 1997). Although considered a question of equipoise by the
US National Institutes of Health and Centers for Disease Control and Prevention, which sponsored the
research—they argued employing placebos was the only way to obtain quick, inexpensive, reliable results
and most of the women would not have had AZT access outside of the trial (Varmus and Satcher 1997)—
subsequent studies were compelled to discontinue use of placebos.
Private pharmaceutical companies continue to operate similarly unethical overseas clinical trials, subject
to less public oversight. For example, a mid-1990s study carried out by P zer on a meningitis drug in
Nigeria—amid a government-MSF treatment campaign—failed to obtain ethical clearance or informed

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consent, taking advantage of the desperation of the local population and abandoning the community
after the trial was over despite the ongoing epidemic (Okonta 2014). As recently as 2010, a schizophrenia
drug trial conducted by Merck in several LMICs withdrew all current treatments—replacing them with
either the study drug or a placebo—jeopardizing the health and well-being of both research subjects and
their communities (Durisch and Gex 2013).
The main mechanisms for applying ethical guidelines are ethical research committees (ECs) or
institutional review boards (IRBs), which decide if the proposed research violates the rights of subjects.
Problems abound: ECs may be composed of fellow researchers who are more sympathetic to researchers
than the rights of subjects; in small institutions, committee members may be collaborators with proposal
authors; EC members may not be adequately trained; ECs may lack representatives of the subjects’
background; or they may be thousands of miles away from the context of the research (Durisch and Gex
2013). Whether in HICs or LMICs, ECs often neither consider Indigenous ethics around community
governance nor re ect Indigenous conceptions of health or promote self-determination. Moreover, many
communities never bene t from the research (Minaya and Roque 2015).
Furthermore, IRBs in various LMICs are overwhelmed by the number of applications they are asked to
review, a reality that some foreign companies abuse to conduct research without appropriate oversight
(PHM et al. 2014). EC approval, though important in terms of patient protection, may become just another
way for HIC private market actors to penetrate LMICs.
The practice of compensating study participants may also compromise informed consent in poor
communities (in HICs and LMICs alike), serving as an inducement to participate (Snyder 2012). Trials
may constitute the only way patients can access treatment for their conditions and thus can exploit their
vulnerability (Wemos Foundation 2010). Additionally, some trials offer only limited and unsustainable
access to interventions after clinical trials end: either drugs and devices become exorbitantly expensive or
the country regulatory authority does not approve them. The importance of protecting the rights of the
“researched” extends to taking into account the power differential between researchers and those
researched, language differences, literacy levels, the impact of patriarchy on women participants’ ability
to provide truly informed consent, and other matters (PHM et al. 2014).
Important as are issues of locally grounded, equitably directed, ethical research, they remain insuf cient
to address the principal global health problems. As attention to global health research mounts, it is high
time that critical political economy of health questions become priorities (Kickbusch 2016). Ongoing
research—and application of ndings—around the impact of skewed political, social, and economic
power across the world (Hanefeld 2016), as well as how some countries have struggled to challenge these
lopsided power relations, is crucial. One approach might entail research on the building of healthy
societies, especially regarding how some LMICs have fruitfully integrated public health with equitable
investments in housing, education, neighborhoods, and secure employment, undergirded by overall
efforts at fair societal distribution of power and resources.
This is not merely a question of adding a few more variables and continuing prior lines of research. To
begin there must be “political articulation of an issue, and collective mobilization based on such an
articulation” (Askheim, Heggen, and Engebretsen 2016, p. 117), deriving from the reality that global health
is a contested eld, with contrasting ideologies shaping distinct research questions and resultant policies
and practical approaches.
 In sum, “the longer we isolate public health’s technical aspects from its political and social aspects, the longer
technical interventions will squeeze out one side of the mortality balloon only to nd it in ated elsewhere”
p. 608 (Birn 2005, p. 519). Yet global health initiatives sponsored by the likes of the Global Fund,

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p. 609

p. 610

p. 611
PEPFAR, and the Gates Foundation (chapters 4, 11, and 13) continue to operate on this premise.

Ongoing Challenges
Amplifying the constraints of dominant approaches to global health are a set of ongoing challenges raised
throughout the text. One issue has to do with global governance for health, an arena that offers the potential to
improve the coordination, representativeness, and fairness of current global health and development
institutional and decisionmaking arrangements. However, the proliferation and penetration into the global
p. 612 health arena of powerful non-state actors, especially corporations and large philanthropies, poses a threat to
democratic governance of WHO and global health writ large, perpetuating donor-driven agendas that have
been repeatedly critiqued by the G-77, the Paris Declaration, public interest NGOs, social movements, and many
others (see chapters 2–4). Rather than uncritically celebrating the infusion of funds into global health over
recent years, it is essential to ask why these monies are being invested and how they are shaping global health
activities.
A political economy approach also helps to identify, at a theoretical level, variables that in uence health and
health inequities and to translate them into data that are collected and monitored in support of efforts to
modify and transform global, national, and local policies to enhance health equity. Many countries lack
adequate civil registration systems to collect vital statistics (foremost, births and deaths), there is uneven
quality of population health data collected through censuses and surveys, and major de ciencies in cause of
death (especially in LICs) and morbidity data (globally). To be sure, data collection is more than a technical
exercise or challenge. It is permeated by political and ideological agendas around generation of and access to
data: identifying and addressing health inequities is circumscribed by what (and who) is counted and not
counted, who controls information, and how it is disseminated (see chapter 5).
Likewise, mapping the distribution of morbidity and mortality is both a technical and political activity. One
challenge is tracking patterns by setting and over the lifecourse, as we do in chapter 6, and health concerns that
are speci c to or pronounced in particular groups, including women, men, LGBTQIA, people living with
disabilities, and Indigenous populations.
Another challenge is transcending the traditional dichotomy of communicable versus noncommunicable
(chronic) diseases, which explains little about the conditions that produce disease or even the very nature of
communicability or chronicity. Instead, we employ a political economy of disease typology: diseases of
marginalization and deprivation (e.g., diarrhea, malaria, and respiratory infections); diseases of modernization
and work (e.g., cardiovascular disease, cancer, and road traf c deaths and injury); diseases of both
marginalization and modernization (e.g., diabetes, tuberculosis, and HIV); and diseases of emerging (global)
social and economic patterns (e.g., Zika and in uenza). Rather than distinguishing between chronic and
infectious diseases—a misleading divisory line since some chronic diseases are infectious (e.g., cervical cancer
due to human papillomavirus [HPV]) and vice versa (e.g., HIV and tuberculosis [TB]) and because there is much
shared underlying etiology across these categories—our typology relates patterns of disease, disability, and
 death to the larger political economy order that spans countries of different income levels and development
trajectories.
Related to this is how the global health arena addresses the SDOH and health inequities, beyond a rhetorical or
super cial level. We grapple with this issue in chapter 7, using SDOH to operationalize chapter 3’s critical
political economy of global health framework. We examine how health and disease are produced (determined)

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at multiple, coexisting levels: historical, social, economic, and political contexts (including colonialism, the
trade and production regime, the distribution of wealth, and class, race, and gender-based power arrangements
and social structures); societal governance and social policies (democratic processes, welfare state regimes,
conditions related to migration, poverty, education, work, environment, and public health); and living
conditions (neighborhood, housing, and nutrition). For example, we show the interaction between particular
agents of disease and death—be they chemical exposures, microbes, weapons, narcotics, or unhealthy foods
and beverages—and the societal circumstances that shape differential exposure to them and their varied
consequences based on class and occupation, gender, race/ethnicity, work and neighborhood factors, and
governance and policy contexts. Drawing from ecosocial theory, we explore how these synchronous levels and
the intersectionality of SDOH over the lifecourse lead to the embodiment of health and illness in individuals
and manifest in patterns of health inequities.
Here we stress both between-country and within-country inequities—for example, the enormous and
enduring health inequities between dominant and Indigenous populations in country after country, linked to
p. 613 historical and ongoing internal colonization—and how societal factors shape health at every level, from
discriminatory power structures to social policies, resource access, daily living conditions, and ultimately
evidenced in shorter, sicker lives for Indigenous groups worldwide.
Public health and health care systems are important SDOH and their absence can contribute to global health
problems. Certainly the global community’s neglect of health care system investment in the face of high-
pro le disease campaigns is reprehensible. Moreover, though health care systems are largely a national concern
governed by domestic politics, they remain heavily in uenced by the larger world order, whether due to loan
conditionalities requiring reduced public spending, trade and investment treaties favoring privatization of
social services, or illicit nancial out ows depleting national treasuries (see chapters 3, 9, and 11).
Global health activities may also be directly responsible for health care system de ciencies. A notable
illustration: global health initiatives are typically siloed from health care systems, facilitating donor
monitoring and evaluation while fragmenting policies and diverting resources, infrastructure, and personnel.
In most HICs, by contrast, disease control campaigns are integrated into primary care and overall health care
systems, averting these problems. Global health donors whose activities weaken health systems arguably
should be held accountable for this problem.
Another challenge has to do with generations of global health policy prescriptions for health care reform (see
chapter 12), which have often had the effect of decreasing accessibility, quality, affordability, equity, coherence,
and comprehensiveness. The latest reform avor advocated by the World Bank, WHO, and the Rockefeller
Foundation, among others, is universal health coverage (UHC). UHC sounds promising but addresses only the
question of coverage, not the other principles listed here, and indeed may exacerbate them, for example, by
only offering a reduced package of services, lowering quality by introducing competing private providers, and
further fragmenting and stratifying coverage.
This points to an overarching concern around the dominant global health arena’s cooptation of social justice-
oriented concepts (invoking social justice principles without practicing them or infusing them into research
and work), such as gender empowerment, community participation, sustainability, equity, and so on (and even
solidarity and political economy). In this context, the long struggle for universal health systems—that is,
uni ed, accessible, equitable, and high quality publicly nanced, national health systems—has been coopted
 and distilled into a market-oriented approach that expands population coverage (and insurance revenues)
without the elements integral to the full meaning of universal health care (Birn, Nervi, and Siqueira 2016). In
sum, a social justice approach to global health also rests on vigilance around “mainstreaming” of progressive
ideas—and being alert to their appropriation, with prior intent changed.
Among the most widely shared, if at times contentious, rationales for global health relates to the humanitarian

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impulse to address health under crisis situations. Many people are drawn into this eld through desire to
provide rst-hand assistance (clinical, logistical, advocacy, organizing) to deal with the health consequences of
ecologic disasters, food insecurity and famine, violence and war, and complex humanitarian emergencies in
con ict and/or politically unstable settings, such as the plight of soaring refugee and displaced populations.
Although to some it is unthinkable to critique humanitarianism, others argue that humanitarian assistance
(e.g. food aid and war relief) ought to be subject to a political economy analysis to examine the extent to which
aid agencies (inadvertently) contribute to the proliferation of humanitarian emergencies by enabling
governments and corporate interests to continue “business as usual” (including promoting and pro ting from
militarism) and by not suf ciently advocating for transforming the conditions that lead to war and other crises
in the rst place.
As novelist Teju Cole (2012) remarks on this controversial point: there is much more to doing good
work than ‘making a difference.’ There is the principle of rst do no harm. There is the idea that those
who are being helped ought to be consulted over the matters that concern them … [and that beyond
the immediate urgency of] hungry mouths, child soldiers, or raped civilians, there are more complex
and more widespread problems. There are serious problems of governance, of infrastructure, of
p. 614 democracy, and of law and order. These problems are neither simple in themselves nor are they
reducible to slogans. Such problems are both intricate and intensely local.
This is certainly a tall order for humanitarian workers who are already sacri cing much, but perhaps a tting
quid pro quo for witnessing and mitigating the suffering of others.
Moving to the environmental domain, while the issue of climate change has belatedly captured mounting
global attention, there has not been concomitant concern with the even larger problems of environmental
degradation: resource depletion and the contamination of the air we breathe, the water we drink, the food we
eat, and the places where we live. These, in turn, lead to direct and indirect health effects: cardiovascular
disease, respiratory infections, cancers, waterborne diseases, loss of food sovereignty, and even forced
population displacement (Birn et al. 2015). A challenge going forward is how the global health community will
analyze and address the link between the environment and health issues and the associated underlying forces
including: global capitalism and market-based, consumption-driven economies; industrial production; and
polluting industries such as energy, mining, and agribusiness.
The greatest underlying global health challenge of our era is, of course, the role of the current political economy
order: the neoliberal phase of global capitalism (see chapter 9). The pathways that tie neoliberal globalization
to patterns of ill health and death are complex and at times seem so unfathomable that they cannot be tackled.
But the centrality and impact on health of the features of the contemporary world order, from structural
adjustment programs in LMICs following the 1980s debt crisis to the post-2008 nancial crisis austerity
agendas in HICs—and from trade and investment agreements to corporate power and tax abuse—is
undeniable (Schrecker 2016). In particular, global health actors are insuf ciently attentive to documenting,
decrying, and redressing the extraordinarily deleterious impact of TNC-controlled extractive, food, and
manufacturing sectors. Bolstered by neoliberal globalization, TNCs, national elites, and their government allies
have ratcheted down environmental regulations, consumer protections, labor standards, and occupational
safety and health, aggravating precarious and dangerous work conditions across the world, social and
economic inequality, and civil strife.
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Health and human rights approaches offer some prospects for addressing these issues (Box 14-2 ), but the
challenges remain gargantuan.
Box 14-2

The health and human rights movement arose in the early 1990s in response to the AIDS epidemic.
Calling for broad structural issues—such as poverty, discrimination, and accessible health care systems—

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to be addressed in order to curb the spread of HIV, health and human rights advocates sought to transcend
dominant biomedical and behavioral approaches to the epidemic. Health and human rights, according to
its progenitors, are linked via three pathways (Mann et al. 1999): (1) Health affects human rights—health
policies and programs can respect or violate people’s rights in their design and implementation; (2)
Human rights affect health—violations to human rights can have devastating, even fatal, effects with
both short- and long-term consequences; conversely, upholding human rights can improve health; and
(3) There is a synergistic relationship between health and human rights: the protection and promotion of
one is not only related to the protection and promotion of the other, but dependent upon it.
In recent years, there has been increasing incorporation of a human rights-based approach “into the
implementation of policies, programs, projects, and other health-related interventions with a view to
enhancing effectiveness” (Hunt, Yamin, and Bustreo 2015, p. 1). This operationalization of the principles
outlined in human rights treaties and declarations (and the WHO Constitution) as applied to health and its
determinants—bolstered by advocacy for and monitoring of governmental responsibility for assuring
these rights (Gruskin and Tarantola 2013)—offers a useful framing of health and social justice values.
However, these treaties are not universally rati ed, and enforceability rests largely at the national level,
with few repercussions when they are not enforced. Where international human rights treaties are
rati ed and/or included in domestic constitutions and there are effective and willing judiciaries, social
justice movements—together with political parties representative of worker and peasant interests, and
political systems that do not privilege moneyed interests over others—play a key role in the realization of
rights (Schuftan, Turiano, and Shukla 2009).
The main international reference document on the right to health is Article 12 of the International
Covenant on Economic, Social, and Cultural Rights. The UN’s General Comment 14 (2000) interprets
Article 12’s articulation of the “right of everyone to the enjoyment of the highest attainable standard of
physical and mental health” as encompassing both the right to health care and rights to underlying
determinants of health including water, basic sanitation, food, housing, and safe and fair working
environments. States have the duty to respect, protect, and ful ll these rights, allowing for a progressive
realization (i.e., incremental steps) of some of these rights if limited resources affect the ability and speed
at which rights can be realized. An important caveat is that resource constraints do not justify taking
regressive measures in the realization of rights.
Table 14-1 summarizes certain government and international obligations on the right to health outlined
in General Comment 14. Minimum core obligations of the right to health should be guaranteed by states
irrespective of resource constraints (i.e., progressive realization is not enough) (Forman et al. 2013).
General Comment 14 also outlines which state actions (or inactions) can be considered violations of the
right to health. Violating the obligation to respect may occur through discriminatory denial of access to
health services. Violation of the obligation to protect may transpire through failure to adequately regulate
corporations, such as mining and energy TNCs, so as to prevent them from harming health via
environmental degradation. Violation of the obligation to ful ll could stem from failing to implement a
national health policy that ensures the right to health for all or from misallocating public resources in a
way that jeopardizes socially excluded groups.
While General Comment 14 interprets the right to health as comprising a range of SDOH, many other
health-related rights have signi cant health and health equity consequences without falling within the
purview of the right to health. These include: the right to education, an adequate standard of living, social
security, civil participation, the bene ts of scienti c progress, and protection from all forms of violence
and discrimination (see chapter 7).
Emerging social rights jurisprudence in South Africa and various Latin American countries is showing
that on one hand health rights are increasingly enforceable, and on the other, the use of litigation as a
means for realizing rights necessitates careful evaluation to ensure that unequal access to justice does not

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exclude people who most need their social and economic rights claims addressed (Yamin 2011).
Litigation is not the only channel for promoting human rights at the domestic policy level.
Notwithstanding political instability, since 2000 Nepal has implemented explicit rights-based maternal
and child policies around safe abortion, neonatal health, paid maternal leave, and gender equality
(Bustreo et al. 2013). In 2015 Nepal adopted its rst democratic Constitution, which recognizes the right
to free basic health services, and equal access to health care, clean drinking water and sanitation, safe
motherhood, and reproductive health, as well as health, social, economic, and other rights of socially
excluded groups including Dalits (the most excluded and discriminated group based on Nepal’s centuries-
old caste system), Indigenous persons, people with disabilities, and sexual and gender minorities
(Simkhada et al. 2015). Though ongoing challenges remain, infusion of human rights principles into
Nepalese social policy, in uenced by international declarations (e.g., 1978 Declaration of Alma Ata) and
social movements, has contributed to improvements in women’s and children’s health, with infant
mortality halved from 59.6 to 29.4 per 1,000 live births between 2000 and 2015 (WHO 2016).
Human rights approaches, when anchored by broad social and political movements, can be well aligned
to the political economy perspective portrayed in this book. Humanitarian organizations such as Oxfam
International and CARE also integrate rights-based approaches into their work through concepts of
“dignity,” “injustice,” “sustainable livelihoods,” and “non-discrimination” (Gruskin, Bogecho, and
Ferguson 2010).
Yet global health actors also risk distilling the “right to health” into a “right to health care” because
improvements in the broad determinants of health may be harder to realize than the right to health care
(Health and Human Rights Journal 2015). In some domains, the right to health care has been further
interpreted to signify access to a particular package of biomedical technologies. Important as are access to
diagnostic tools, surgery, medicines, and other treatments (Weigel et al. 2013), they constitute just one
component of the right to health and ought not push out health-related economic and social rights.
Some critique health and human rights approaches for drawing heavily from Western concepts based on
individual rights rather than collective needs. Others express concerns around the cooptation of human
rights by mainstream development actors, including corporate interests (e.g., via the UN’s Global Compact
—see chapter 3). In the end, there is a certain dilemma to invoking health as a right without attention to
the politics of the distribution of power and resources, returning us to the origins of health and human
rights approaches.
 Points of Inspiration
As we send this edition of the textbook to press—amid a global refugee crisis, repression and seemingly
intractable wars in the Middle East and Central Africa, political volatility across Latin America, spikes in
xenophobia and racism in Europe and North America, repressive economic policies and militarism in which

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corporate elites and powerful countries have a heavy hand, and yawning inequities within South and East Asia
and across the world—there appear to be countless reasons for dismay. But the tendency to despair might be
kept at bay by notable examples of health and social justice activism under equally or even more challenging
historical moments. Presuming that many readers are relatively young and undoubtedly energetic, we hope
you will take inspiration from examples highlighted here (and drawing especially from chapters 9, 10, and 13)
pointing to the importance of persistence in the ght for health justice.
Throughout the text we have incorporated experiences of movements and organizations struggling for global
health and social justice. For instance, in chapter 7 we explore various Health in All Policies approaches to
achieving health equity (ensuring that health and health inequity are tackled through every dimension of
societal decisionmaking). Examples include Scotland’s radical critique of neoliberal macroeconomic policy
buttressed by government protagonism around redistributive measures, and an informal Mombasa (Kenya)
settlement’s intersectoral commitment to reducing child malnutrition and inequity by engaging with health
care, education, agriculture, gender, child and social development, and water constituencies, creating a national
model for Kenya.
In chapter 9 we pro le various ongoing social movements, organizational, and governmental struggles against
neoliberal globalization. These efforts include: resistance to water privatization in Bolivia and Indonesia;
p. 615 public-interest NGOs in Canada ghting to ban asbestos, and global-level efforts against unethical
p. 616

p. 617
TNC marketing of infant formula; plus experiences of Brazilian and Indian governments challenging
monopolistic patent regimes. We also cover political movements contesting austerity, the alternative of
worker-run cooperatives, and worker activism against corporate impunity.
 Table 14-1 Summary of State Obligations with Respect to the Right to Health

Obligations State Measures

Minimum

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• Ensure at a minimum, provision and realization of these core obligations:
national core
obligations - Non-discriminatory access to health care facilities, goods, and services, including for socially
excluded groups
- Access to nutritional and safe food and freedom from hunger
- Safe drinking water and basic sanitation
- Basic shelter and housing
- Access to essential medicines as defined in the WHO Action Programme on Essential Drugs
- Equitable distribution of health care resources
- National public health strategy with right to health indicators and benchmarks

Selected
• Respect the right to health in other countries and prevent third party violations via legal or political
international
measures.
obligations
• Ensure that international agreements do not negatively a ect the right to health.
• Ensure that lending policies and agreements, and structural adjustment programs of IFIs (IMF, World
Bank, regional development banks) are in accordance with protecting the right to health.

Source: General Comment 14 (2000)

Not all such efforts reach a felicitous outcome and advances may be tenuous. Brazil’s 1988 Constitutional
guarantee of the right to health care (see chapter 11) grew out of decades of struggle against dictatorship: in
recent decades Brazil has built a national health care system widely admired in LMICs, combatted poverty
through cash transfers (see chapter 13), and enhanced rights based on gender and race. However, this has taken
place in the context of a capitalist, highly unequal society with entrenched elite interests unwilling to cede
nancial and social power. As resources for social programs began to dry up, particularly after the collapse of
oil prices in 2014, the unmet expectations of the population led to mounting protests, fueled by soaring costs of
living and accusations of political corruption. Capitalizing on the unrest, elites eager to dismantle the public
health care system and other social entitlements orchestrated a dubious impeachment of the President. As
soon as it could, the new government began attacking the health care system, claiming that the Constitutional
right to health was too expensive to ful ll. That a health care system that took years to build could begin to be
dismantled in a matter of days points to the centrality not just of public policies but of the overall political and
economic order: Brazil’s long struggles fell short of achieving a profound political transformation. The crisis
may yet serve as an opportunity, but it is too early to know what shape this might take.
Some more sanguine experiences are emerging around protecting health from global environmental
degradation and contamination (see chapter 10). These occur at multiple levels of change: global and regional
responses such as agreements banning harmful chemicals and treaties controlling export and disposal of
hazardous waste; national environmental regulations (e.g., limiting deforestation) and standards (e.g., air
quality); and local energy conservation efforts. Perhaps portending the greatest transformation are a wide
range of environmental justice actors and movements: mobilization to conserve natural resources (e.g.,
p. 618 Pakistan’s Indus Consortium), preserve food sovereignty (e.g., La Via Campesina), confront mining and oil
TNCs contaminating local environments and committing human rights violations (e.g., in Indonesia, Ecuador,
and Nigeria and via MiningWatch Canada), protest weak government environmental protections, and pressure
large academic, government, and private entities to divest from fossil fuels (e.g., [Link] movement).
 Most importantly, chapter 13 showcases the making of healthy societies across diverse settings. Prime
illustrations are the integrated political, social, and public health approaches of high-income welfare states,
such as Sweden, and the even more remarkable LMIC exemplars of Costa Rica, Cuba, Uruguay, Sri Lanka, and
Kerala state, India. In these places, decades-long political and social struggles have led to widely-embraced
public, universal, and inclusive policies around education, health, work, and well-being. Some of these settings

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have sought to upend social and political power structures, others have been engaged in more gradual
transformations, and various are pursuing post-industrial, more environmentally sound economic policies.
The envy of some far wealthier societies, LMIC welfare states remain fragile, subject to both domestic
constraints and global political and economic pressures.
Another point of departure for progressive health efforts is health promotion (articulated in the 1986 Ottawa
Charter) espousing a social justice and participatory approach to addressing the factors underlying health.
These ideas have inspired Health in All Policies and Healthy Cities efforts, characterized by green space, urban
agriculture, improved water and sanitation, and accessible public transport—in locales as varied as Bogotá and
Tehran. We also cover the viability of alternative paradigms of Buen Vivir and degrowth for generating healthy
and environmentally harmonious societies.
In addition, we cover social medicine-inspired efforts that demonstrate how progressive taxation, universal
social programs, and entitlements prioritizing the most oppressed groups (Mexico City), and run by
community-level social policy committees ( Misión Barrio Adentro in Venezuela) can improve the health and
well-being of socially excluded groups. The latter draws from social justice forms of South–South collaboration
—that is, when LMICs with shared political and social values cooperate symmetrically with one another—as an
p. 619 alternative to dominant patterns of aid (Box 14-3).
p. 620
Box 14-3

Although most global health efforts have long re ected and entrenched dominant political and economic
interests, contrasting health and social justice-oriented approaches also have a considerable historical

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trajectory. A notable past example was the medical solidarity provided by health worker brigades from
around the world to democratic forces ghting fascism during the 1930s Spanish Civil War (Lear 2013). In
the 1950s and 1960s Third World countries took on this mantle through the non-aligned movement
challenging neocolonialism in aid, demanding “respect for national sovereignty,” and calling for a New
International Economic Order, an idea embedded in the 1978 Alma-Ata declaration (see chapter 2).
More recent attention to South–South cooperation (SSC) as a form of “soft power” health diplomacy does
not always evoke the social justice dimensions of these earlier examples. Indeed, focus on the role of so-
called BRICS countries (Brazil, Russia, India, China, South Africa), highlights the geographic (and income
level) provenance of these “emerging” donors (Bliss 2013) more than the nature of their engagement. A
frequent assumption, often advanced by BRICS countries themselves, is that SSC differs in form and
orientation from North–South cooperation (NSC) by its very “Southern-ness” (Harmer and Buse 2014),
that is, entailing the interactions of formerly colonized, dominated, or “underdeveloped” countries that
operate on a non-imperial, non-hierarchical, ethical basis (Cabral, Russo, and Weinstock 2014).
Though societies with common histories of oppression may be better able to identify and address their
own population health problems, without having to enter into the unequal power relationships inherent
to North–South cooperation, this contention should not be taken at face value (Bond and Garcia 2015).
There are also self-interested motives with SSC apparent in, for instance, Chinese and Brazilian oil,
mining, and construction interests in Africa, South and Southeast Asia, and Latin America: these need to
be scrutinized when assessing the true nature of SSC health projects.
Both countries have pursued mainstream and solidarity-oriented SSC. China sent medical teams to
decolonized Algeria and in support of Nyerere’s African socialist efforts in Tanzania as far back as the
1960s (see chapter 2), even as its current cooperation goes hand in hand with primary resource
extraction. Brazil’s structural cooperation approach has involved capacity-building, health systems
support, and “horizontal” dialogue and decisionmaking with national and international counterparts,
particularly within Latin America and in Portuguese-speaking countries in sub-Saharan Africa (Ferreira
et al. 2016). Dozens of projects in Africa—many led by Fiocruz, Brazil’s famed national health research
and training institute—range from training programs for physicians and other health care personnel
(e.g., lab technicians) to technical support for HIV, TB, and malaria programs, donation of HIV drugs, and
establishment of an ARV factory in Mozambique (Santana 2011; Roa and Silva 2015). While Brazil has
sought to challenge the dominant political order framing aid—prioritizing the interests and needs of
LMICs and refraining from incorporating conditionalities into its own aid—its aggressive economic
interests in African mining, construction, and other industries operate parallel to health diplomacy
(Garcia and Kato 2015; Ventura 2013), just as is the case with NSC. Nonetheless within Latin America,
Brazil’s leadership in UNASUR around disease surveillance, health human resources policy, universal
health systems development, access to medications, and policy cooperation around SDOH and health
promotion (e.g., uni ed regional deliberations with WHO) has been carried out on more equal footing
(Buss and Ferreira 2011).
To distinguish South–South cooperation that is truly social justice-oriented, guided by shared political
values around social rights, shared power, redistribution, and solidarity with social and political
movements toward health equity, the notion of social justice-oriented SSC (SJSSC, [Birn, Muntaner, and
Afzal 2016]) implies a departure from prevailing models of international cooperation. These more
solidarity-inspired forms of global health diplomacy, which contest the dominant, self-interested, and
“realist” geopolitical-economic forces propelling the eld, emerged particularly in Latin America
(Riggirozzi 2015). A con uence of factors enabled this development: the (re-)election over the past
decades of progressive and social democratic parties on welfare regime-building and social rights
platforms (Fleury 2010; Mahmood and Muntaner 2013), coupled with economic growth based on rising
oil prices in certain MICs, such as Brazil and Venezuela (growth that has now stalled, and in conjunction

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with political turmoil, is putting the future of these efforts in jeopardy). In sub-Saharan Africa, too,
growing interest in health diplomacy stresses regional unity, an ethic of liberation, and equitable forms of
development, though new possibilities of SSC suggest the need for vigilance around a “disguised role of
private actors” (Loewenson, Modisenyane, and Pearcey 2014, p. 1).
Cuba is one of the most longstanding and active proponents of bilateral and triangular SJSSC (and
arguably the most consistently solidarity-oriented): since the 1960s over 135,000 Cuban medical
professionals have served abroad in South Africa, Haiti, Pakistan (after the disastrous 2005 earthquake),
Angola, Guatemala, Bolivia, Sierra Leone (2014–2015 Ebola response), and many other countries.
Remarkably, all of this has been carried out with minimal nancial resources given Cuba’s small
economy. Like any such program, Cuba’s health cooperation offers political advantages (Feinsilver 2010).
Yet most countries it has helped, including Haiti, provide no payment or quid pro quo for services
(Beldarraín Chaple 2006), even as more recent examples of thousands of Cuban medical personnel
working in Venezuela and Brazil have been in exchange for oil and currency (in the context of recent
decades of economic dif culties in Cuba). Cuba’s placement of doctors “where no doctor has gone before”
has made a signi cant impact in communities around the world (Huish 2013). This is complemented by
Cuba’s health care workforce training effort at Havana’s Latin American School of Medicine, which has
granted full scholarships to students of low-income backgrounds from over 80 LMICs and the United
States (see chapters 11 and 13).
Despite often purveying similar forms of cooperation as NSC and SSC in terms of health personnel
training, human resources, health care equipment and infrastructure, distribution of medication, and
surgical interventions, SJSSC also places greater emphasis on PHC and international policy activism (such
as against monopolistic patent protections).
Moreover, SJSSC differs from mainstream development assistance for health on at least three counts:
rst, it decreases dependence on aid channels from HICs and multilateral agencies, which constrain
sovereignty by attaching conditions to receipt of aid. SJSSC does not dictate unilaterally the terms of
health and development cooperation, instead responding to national and local demands for equity and
drawing from a strong emphasis on social rights, involving legal obligations and constitutional
protections for health-related human rights and local participatory democracy in areas including public
provision of PHC (Medicus Mundi 2010). Aid is a priori invited on equal terms: with power and resource
differentials between donor and recipient much reduced, aid is turned into genuine horizontal
cooperation or exchange. Second, much SJSSC aid seeks to be transformative, for example in building
social infrastructure, training PHC practitioners, and working hand in hand with government agencies to
create lasting and equitable means of addressing essential needs. Third, even while sometimes convening
international partners through “triangular” cooperation, many of these efforts are community based: not
only are priorities de ned through local agenda-setting, but local populations are integral to shaping
cooperative activities through their ideas, labor, and decisionmaking.
There are also examples of social-justice oriented NSC, including organizations working in transnational
solidarity (e.g., the Hesperian Foundation, which produces multilingual PHC-oriented guides for
community health workers and activists around the world) and Scandinavian countries that historically
supported PHC efforts. A prime illustration derives from Nicaragua in the 1980s. After the 1979 Sandinista
revolution ousted the longtime dictatorial Somoza dynasty, USAID, the IMF, the World Bank, and the
Inter-American Development Bank pulled out to protest the country’s new leftist administration (which
 subsequently won [and later lost] democratic elections). Even as US-backed rebels were waging a
destructive civil war against the Sandinista government, cooperation from Sweden, among other
countries, supported the hallmark expansion of PHC units across the country (White and Dijkstra 2003).

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A Social Justice Approach to Practicing Global Health: Individuals,
Organizations, and the Logic of the World Order

Key Questions:
• How can global health efforts contribute to social justice and address the roots of health inequities?
• What are the connections among personal motivations, institutional goals, and the geopolitical context of
global health?
• What alternatives to mainstream global health help foster bona de cooperation in terms of shared social
justice values?
The secret to change is to focus all your energy not on ghting the old, but on building the new.
—Socrates

First they ignore you, then they laugh at you, then they ght you, then you win.
—Mahatma Gandhi

p. 621 A society’s model of justice determines how resources and burdens are allocated and, hence, whether the
population’s health is protected via individual responsibility (market justice) or—fundamentally countering
this approach—through collective action (social justice) (Beauchamp 1976). Transposed to the world order,
(neoliberal) capitalist ideology holds that the market pursuit of pro ts under capitalism, locally and globally, is
the engine of human well-being. Counterposing this stance is equitably allocating resources according to need
(Reid-Henry 2016). But “just giv[ing] money to the poor” (Hanlon, Barrientos, and Hulme 2010) to tackle
extreme povery and attenuate economic inequality does not go far enough.
Indeed, social justice moves well beyond distribution of resources according to moral fairness or even ensuring
rights and opportunities. As political philosopher Iris Marion Young (2011, p. 16) has argued, “The concepts of
domination and oppression, rather than the concept of distribution, should be the starting point for a
conception of social justice” because of the centrality of processes (not only certain end results, such as income
distribution) and the rules, relations, and institutional contexts in which distribution occurs. This means that it
is not enough to guarantee rights or access to material goods as per a distributive paradigm, but that
transforming the relations of power among social groups and the institutional arrangements in which power is
wielded are central to pursuing and achieving social justice.
Health and social justice-oriented beliefs, movements, and activities have been explored throughout this
textbook. Here we consolidate discussion of these efforts based on individual aspirations, organizational aims,
and the possibilities of the world order. It is important to note that most global health training programs focus
on mainstream, largely technical approaches, often paying only minor attention to the political economy and
social justice perspectives presented here. We invite students to encourage their current or prospective
institutions to cover (or require!) critical political economy of global health framings and approaches in courses
(or better yet make critical political economy central to global health training), so that they do not nish their
 academic careers thinking that health aid provided via donor organizations is THE solution to global and local
health problems and health inequity.
Social justice approaches do not exclude dominant global health research, interventions, institutional roles, or
humanitarian impulses, but they imply that each of these be carried out in an entirely different way, one that
places the struggle against oppression at the heart of solidarity efforts, putting the needs of the majority of

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people, and those most vulnerable, rst (Biehl and Petryna 2013).
As emphasized in various chapters, the struggle for health and social justice rests on collective action by
citizens, governments, civil society organizations, social movements, and international agencies representing
and responding to the needs of workers, peasants, Indigenous and racially-discriminated groups, children,
youth, LGBTQIA, the elderly, people with disabilities, women in the home, community, and workplace, and
people lacking homes and adequate income—against the concentrated power of social and economic elites,
corporate and nancial interests, and their political associates. Striving politically—at local, national, and
transnational levels—for equitable distribution of power and resources and fair rules governing these
arrangements are thus central to human progress everywhere.
As we have discussed, in mainstream global health approaches “experts” go to look, see, learn, provide some
technical assistance, and then leave. By contrast, a transformative approach to global health, drawing from the
principles of introspection, humility, solidarity, and commitment to health and social justice, incorporates the
following elements:
1. As full an understanding as possible of the socioeconomic, cultural, and political contexts and the
implications for health, SDOH, and health care services
2. A willingness to learn from local communities and local experts
3. A nonjudgmental attitude to local problems
4. A commitment to share and learn from expertise in ways that empower local people and contribute to
lasting change
5. Solidarity work, which, without necessarily involving travel or “assistance” per se, may be extremely
useful
6. Incorporating social justice movement building into one’s work
As well, those involved in global health endeavors are encouraged to remain conscious of historical patterns
p. 622 and legacies, not so much because people link their ongoing oppression to the distant past but because the
present conditions and realities of making a living endured by the majority of the global population (and the
actions of most health and development actors) are molded by historical trajectories, from the colonial period
to the Cold War and decolonization, to the more recent experience of neoliberal reforms. Indeed, those
currently working in global health need to continuously bear in mind the troubling possibility that even the
most well-meaning and well-informed global health efforts may perpetuate inequalities in power (and thus
unintentionally contribute to health inequities) (Hanson, Harms, and Plamondon 2011). People who seek to
participate in solidarity-oriented work need to be able to recognize these patterns in order to begin to break
with them (Ventres and Gusoff 2014).
It is also important to be cognizant of the potentially high personal costs of speaking out, that is, articulating
social justice-oriented transformative positions or being involved in organizations that challenge mainstream
global health. These costs may include institutional isolation, missed funding and work opportunities, public
humiliation, or in extreme cases under authoritarian and repressive regimes, incarceration or worse (Birn and
Brown 2013). Paying such a high price is not common, even as it is possible: working with supportive
 movements and organizations (e.g., the Asociación Latinoamericana de Medicina Social [ALAMES]; see chapter
13) can help shield individuals from the gravest dangers.
In sum, how can people concerned with global health and social justice reconcile the larger world order with
the reality of practicing global health day-to-day in an organization? Approaches include:

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• Working with/for an organization in whose long-term vision and modus operandi you believe
Many progressive-minded agencies are listed in chapter 4. For example, Doctors for Global Health goes
only where it is invited, and uses the concepts of “health as reconciliation” and “anti-colonization” as its
guiding principles when setting up cooperative projects in marginalized communities (Smith, Kasper, and
Holtz 2013) (Box 14-4).
• Working from within a mainstream well-established organization, pushing it toward more socially just
global health approaches and practices
Those who work for mainline agencies can play an important role in advocating that their employers:
practice symmetrical and pro-equity agenda-setting; abide by their articulated missions; and vocally
decry the deleterious health effects of larger political economy forces, such as militarism and harmful
investment agreements. Crucially, civil society alone cannot be responsible for ensuring that public and
humanitarian institutions ful ll their missions and eschew con icts of interest. Those working in UN and
other multilateral or bilateral agencies or at universities (especially well-funded HIC institutions) arguably
have a special obligation to serve the public given their privileged positions. For instance, the struggle
against unaccountable private sector actors at WHO has been spearheaded by current and former WHO
employees, together with public-interest civil society activists and researchers (Velásquez and Alas 2016).
• Acting in solidarity with a social-justice movement to transform ideologies and practices related to global
health, locally and in the larger political economy order
For decades, grassroots movements worldwide have been tackling the negative consequences of
neoliberal globalization with the support of committed transnational allies. La Via Campesina,
representing 200 million peasants, agricultural workers, and smallholders from over 160 organizations in
almost 75 countries, explicitly challenges corporate ownership and control of land, water, seeds, livestock,
and biodiversity. As a vigorous voice for food sovereignty, it has been one of the most effective movements
in favor of social justice for producers and against the incursion of agribusiness across the world.
In another vein, street medic groups have a long history of supporting movements that seek to transform
power dynamics locally and globally, from civil rights movements to the Arab Spring (Nakad 2016).
p. 623 Doctors for the 99% and National Nurses United are coalitions whose members have provided care and
worked in solidarity with the Occupy movement, among other mobilizations. Similarly, Greece’s citizen-
run social health clinics sprang up following mass austerity measures in 2011 that cut access to health care
services; the clinics bene t from volunteer medics and international solidarity.
 Box 14-4

The small Central American country of El Salvador suffered a brutal civil con ict from 1980 to 1992, a war
largely fueled by the US’s support of an oppressive government. The “scorched earth” policy of the

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Salvadoran military resulted in 80,000 deaths, and produced one million refugees and innumerable
tortured and “disappeared” persons in a country of only 6 million people. Massive aerial bombardment
and use of napalm caused severe deforestation. The Salvadoran government was responsible for grievous
violations of human rights, including murderous attacks on cleric advocates of liberation theology calling
for social justice for the oppressed (among those assassinated was Catholic Archbishop Arnulfo Romero).
During the con ict, the health budget was cut in half and many health posts were abandoned. NGO-
trained CHWs became the backbone of health care, covering approximately one third of the country.
However, after the Peace Accords were signed in 1992, with the health care system in shambles, the
Ministry of Health refused to hire these workers, arguing that they were communists and had been part
of the insurgency (Smith-Nonini 2010).
In the mid-1990s, Doctors for Global Health (DGH) was invited by several communities in the rural region
of Morazán—which had experienced extreme violence and devastation—to work with them in
addressing the underlying causes of ill health. Following the principles of a community-based grassroots
approach and accompaniment (working directly and in solidarity with local communities), DGH
responded to the issues and projects prioritized by the community: construction of a bridge to reduce
deaths from river crossings, nutrition, soil conservation, community gardens, rehabilitation, women’s
rights, early childhood education, childhood preventive care, and veterinary, dental, and medical care.
Clinics were built, and local health care providers now work in the area.
Since 1995, DGH has grown from a small informal group working in northeast El Salvador to a formal
member-supported NGO with volunteers working together with communities in their struggles for social
justice and human dignity in Guatemala, Chiapas and Oaxaca (Mexico), Uganda, Peru, Burundi, and the
United States. A Salvadoran NGO was also created, Doctors for the Right to Health, which continues to
work to improve the lives of the rural poor (Smith, Kasper, and Holtz 2013).
El Salvador has recently made gains in delivering comprehensive PHC, enabling maternal mortality
reductions, high use of prenatal care, and declines in child and infant mortality (PHM et al. 2014). Under
the remarkable leadership of Dr. María Isabel Rodríguez, the former Minister of Health under a
progressive, if beleaguered, administration, El Salvador advanced a rights-based approach to health and
promoted “health sovereignty” in international cooperation to ensure nationally-de ned agendas for
health equity (Rodríguez 2009). Yet 25 years later, and notwithstanding DGH’s ongoing solidarity, the
effects of civil war and societal divisions are still felt in terms of inequality, violence, and health and social
infrastructure de ciencies, especially in rural areas.

Inspiring as they are, these endeavors face many challenges. Although many social movements are engaged in
reforming trade, aid, and debt servitude, well-established organizations usually have more resources and
access to power than do social movements and can serve as in uential and “respectable” advocates for change.
p. 624 An important caveat is that as social movements grow they may be forced to seek more stable funding. For
example, the Informal Settlement Network (ISN), organized by a “bottom-up agglomeration” of urban poor
groups in South Africa, addresses lack of decent housing in the context of rapidly growing settlements on the
periphery of towns and cities. ISN has a local base in Durban and is also part of a global movement—the
Federation of the Urban and Rural Poor (FEDUP) and Shack/Slum Dwellers International (SDI). In recent years
SDI has accepted funding from several large philanthropies (e.g., Gates and Mott foundations), and while its
advocacy for land and proper housing for the poor has continued, the bottom-up approach representing the
demands of the urban poor is dissipating. This experience suggests a need for continuous renewal of activism.
To note, the three approaches outlined above are not mutually exclusive: you may work for a mainline
organization and be active in a social movement, and also volunteer with a social-rights-based NGO. All are
valid ways of contributing to health and social justice. That said, as you contemplate your potential or actual

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role in global health, it is essential to recognize the possibilities and limits of your own participation and
aspirations based on critical political economy analysis. In this sense, global health may be conceived of as
operating at three levels:
1. Motivations and involvement of individuals
2. Missions and actions of organizations
3. Logic and structures of the world order
The three levels operate simultaneously, but each is constrained by the next level. Individual motivations or
institutional missions may con ict with the logic of global capitalism, and the impact of individuals and
institutions is limited by the world order. Carried out together, efforts at each level can help in larger struggles
to transform market capitalism into a world order based on a shared commitment to equitably protecting
human well-being and reducing oppression according to truly democratic governance. Though individual
actions by themselves cannot transcend the world order, they can contribute to changing it, in part through the
formation of organizations and movements that challenge its logic and power (Box 14-5).

Box 14-5

Translating a political economy of health approach into action can take the form of dedicated research,
advocacy, teaching, and political engagement, or arise from the powerful realities of daily work. As an
illustration, DRC-based gynecological surgeon Denis Mukwege has long focused on improving childbirth
conditions for Congolese women to lower maternal mortality and prevent and treat the debilitating
problem of obstetric stulae. After the outbreak of the Second Congo War (see chapter 8), his hospital
began to receive numerous patients who had been subject to horri c sexual violence. He and his team
have treated some 40,000 women and girls who were raped and sexually brutalized, also offering legal,
psychological, and social assistance. But Dr. Mukwege, the recipient of multiple human rights awards and
other honors, has done far more. Risking his own life, he has become a spokesperson on the
responsibility both of all Congolese men to combat sexual violence and of the international community to
end the mineral-resource driven war in Eastern DRC (Right Livelihood Award 2013). As a result, Dr.
Mukwege faced an assassination attempt in which his bodyguard was killed. This reveals the potential
dangers of embedding medical work in a political economy framework, considered incendiary in many
quarters and engendering various kinds of professional and political hostility.
 Individual Level: Motivations, Training, and Work Experience

Motivations
Global health encompasses a wide array of activities, from working within agencies to social and political

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p. 625 activism “at home and transnationally” outlined ahead. Although clinical work is often highlighted in the
imaginary and visual imagery of the eld, working as a doctor, nurse, or medical technician is not the sole
avenue to a meaningful contribution. Community organizing, social mobilization, health promotion, policy
development, laboratory and social science investigation, economic analysis of the impact of trade treaties, and
epidemiological research are all key roles that need to be lled, domestically and internationally.
For those with limited experience, there may be numerous personal reasons for wanting to partake in global
health work: research and professional opportunities, idealism around changing the world and helping the
world’s poor, learning from abroad, and humanitarianism motivated by charitable or religious values. While the
desire to be of service on some level may seem laudable, validating overseas engagement based on generosity
and “helping” people is illusory, especially when “help” has not been sought and when it does not address the
factors shaping the presumed need for help (Tiessen and Huish 2014). Key questions students and others
should ask themselves include (Pinto and Upshur 2009): Is the proposed global health effort feasible,
necessary, sustainable, and justi ed? What are the viable local or transnational alternatives? What are the
bene ts and who will gain from them? What are the costs and risks (e.g. impact on inequities) and who will
bear them? What do you hope to bring home and how will you share these learnings?
People who undertake health-related work or volunteer experience in another country—that is, those in the
privileged position to travel abroad—may be surprised to discover that the greatest bene t is to themselves.
Countless medical relief trips run every year by well-meaning organizations are nothing more than “global
health tourism” or “voluntourism.” Such trips are usually nanced by the participants themselves, who may
pay large sums of money for the chance to sew up wounds in the Amazon (complete with rainforest river
cruises on the weekend), treat exotic diseases in the jungles of Rwanda (with side tours to see silver back
gorillas), or distribute eyeglasses to Tibetan refugees in the foothills of the Himalayas (with the possibility of an
audience with the Dalai Lama).
Exciting as these opportunities may be, it is important to recognize that international placements can put an
enormous burden on settings with already stretched resources. Health workers in LMIC programs and
institutions are typically given little or no compensation for acting as supervisors or trainers for those from
overseas. Such expeditions often do more harm than good, leaving behind no capacity for follow-up and
applying “band-aids” to deep problems and ultimately justifying the political status quo (McLennan 2014). In
addition, outsiders may disrupt social services by bringing in short-term treatments and solutions that are not
available once they leave (Lasker 2016).
Residents of HICs may not typically consider people working in their home country, year after year, as taking
part in global health: clearly the perspective and relative contribution of those engaged in a lifetime of work
differs greatly from those of outsiders ying in and out. Likewise, many health and social justice actors in the
Majority World may not view their work in terms of global health, as this is predominantly an HIC term. It is
equally important for HIC nationals working in LMICs to recognize that they are in a position of power and
need to be very careful not to abuse this power. Foreigners and transnationals enjoy relative wealth, advanced
education, the possibility to leave (the country or community), and the luxury to challenge decisions without
jeopardizing their livelihoods, as well as organizational access to resources and in uence over policymaking.
All of these factors shape the interactions of transnational and foreign health professionals and students with
government of ces, communities, local health workers, leaders, and educators.
 Pinto and Upshur (2009) outline four core ethical principles for persons entering the global health eld. The
rst is introspection, beginning with articulating your positionality and personal motivations, and
contemplating the potential impact of your global health involvement. Whether you are embarking on or
redirecting your career in global health, excessive idealism, overcon dence (in your tools, role, abilities, or
approach), and ignorance about the realities of global health politics and power can be impediments and even

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cause grave damage to local populations.
A second core ethical principle is humility. It is commonplace for people from HICs to display ethnocentrism,
p. 626 paternalism, or condescension toward people from LMICs (prejudices they may not recognize in
themselves). Students might assume that they can provide some bene t to a community without knowing the
setting, understanding the political, cultural, and economic history, social dynamics, language, or the role and
limits of outside organizations (Gupta and Farmer 2005; Ventres and Fort 2014). Local inhabitants and health
practitioners invariably know their context better than anyone and have thought profoundly about the best
ways to approach problems. Keeping an open and humble mind is essential to foreigners’ appropriate
involvement (Ventres and Gusoff 2014). For clinicians, this also means understanding the broad political and
social context of prevention and treatment, not simply the biomedical encounter (Gupta and Farmer 2005).
Next is fostering solidarity, including “developing a sensitivity to the suffering of others and working to
prevent their marginalization” (Pinto and Upshur 2009, p. 9). Solidarity means establishing on-going
relationships and exchanges, supporting local movements in their struggles and aspirations, not
superimposing your or your organization’s ideas of community needs. As the People’s Heath Movement (PHM)
argues, “true solidarity exists when citizens of the community are mobilized, when capacity building of local
organizations and strengthened links within civil society occurs, and when attempts are made to bridge power
imbalances between the wealthy and the poor” (ibid).
The last in the quartet of ethical principles outlined by Pinto and Upshur (2009) is social justice, recalling its
earlier framing in terms of contesting oppression and societal asymmetries of power and resources, addressing
inequity, working extensively in solidarity with communities and responding to their priorities, and
understanding the nature of global political and economic forces, such as militarism and corporate power.
Social justice approaches may also draw from the notion articulated by practitioners of liberation theology in
Latin America: a “preferential option for the poor” (Gutiérrez 1973), that is, solidarity with, and giving voice to,
oppressed people in their struggles for justice, re-cast by DGH co-founder Lanny Smith (et al. 2013) as
“liberation medicine.” In addition, Gupta and Farmer (2005) emphasize the importance of continued
engagement with global health struggles wherever you are located, a point we will expand upon ahead.
Accordingly, international placements should not be voyeuristic episodes to see “how the majority lives” but
bestow a continuing responsibility to work through advocacy, activism, education, and other solidarity
measures, recognizing how (and mobilizing around) the policies of powerful HICs (and lead global health
actors) affect the health and health inequities of populations across the world.
Of course many readers likely have sophisticated understandings of how social change works and recognize
that there are numerous ways to be involved in global health through activism and solidarity (Hanson 2015). At
whatever degree of experience and level of involvement, appreciation of the political and economic
underpinnings of global health is pivotal to making you more informed and your work more effective. Such
understanding, we hope, may also move you to challenge the forces that produce and reproduce local, national,
and international inequalities as part of the uphill struggle against global social injustice.
 Knowledge, Training, and Work Experience
Though many people who consider themselves global health professionals and activists have entered the eld
circuitously, a common question for young professionals is when or whether to invest time and resources in
formal training in global health. This could involve pursuing a master’s of public health (or global health) to
acquire speci c skills, a doctorate in anthropology or social epidemiology to deepen research abilities, courses

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in community planning or political organizing, or a degree in economics to be able to understand the world
trade regime, nancialization trends, and how these affect health in both HICs and LMICs.
Among the best ways for neophytes to become exposed to social justice and global health efforts is through the
courses (e.g., on trade, PHC and political economy of health, equity and health rights, and movement building)
run by the International People’s Health University (IPHU) in dozens of countries across South Asia, Africa,
Europe, the Americas, the Middle East, and the Paci c. The IPHU “aims to contribute to ‘health for all’ by
strengthening people’s health movements around the globe, by organizing and resourcing learning, sharing
p. 627 and planning opportunities for people’s health activists, particularly from Third World countries.” The IPHU
also “sponsors research into the barriers to Health for All and strategies to support the people’s struggle for
health” (IPHU 2016).
More formal academic global health training from a critical perspective exists in various settings. Brazil’s
National School of Public Health, based in Rio de Janeiro, has foci in social program implementation and
environmental health and justice. In Mexico City, the Universidad Autónoma Metropolitana offers a master’s
degree in social medicine and publishes Revista Salud Problema, highlighting health-disease processes from a
critical perspective. Similarly, the Centre of Social Medicine and Community Health at Jawaharlal Nehru
University in New Delhi analyzes health needs and interventions in the context of structural constraints. At
Johns Hopkins Bloomberg School of Public Health (Baltimore, USA), jointly with Pompeu Fabra University in
Barcelona, a range of courses examine the political economy of social inequalities and their consequences for
health, and the impact of nancial, economic, and political crisis on health. South Africa’s University of the
Western Cape School of Public Health trains policymakers and implementers “whose practice is based on
research, in uenced by informed and active communities, and implemented with a commitment to equity,
social justice and human dignity” (UWC 2013). Courses (and sometimes programs) at the Universities of
Saskatchewan (e.g., on global health and social inequalities), Bologna (Centro Studi e Ricerche in Salute
Internazionale e Interculturale), Oslo, Thammasat (Thailand), British Columbia, Washington, Sussex, and
Harvard, among others, marshaled by committed faculty involved in progressive transnational movements, are
similarly illuminating.
Many of these classroom experiences incorporate health advocacy, activism, and alliance-building
components. At the same time, some of the most useful training for the key (health justice) solidarity activities
of monitoring, witnessing, and speaking out take place through apprenticeship or participation in activism
itself, as discussed in the next section of the chapter. You might also contemplate how university and other
training venues can help bridge the academic–activist divide by studying health activism (historically, in policy
terms, or as a participant-observer) or working with and helping forge alliances, such as the student-led
Universities Allied for Essential Medicines, which works to improve accessibility and affordability of medicines
globally.
Likewise, spending time learning about grassroots organizing (e.g., at the Highlander Research and Education
Center in the Appalachian mountains of Tennessee, USA) and research methods for social change (e.g., at the
Center for Social Well Being in the Peruvian Andes; and political economy and activist-oriented Centre for Civil
Society at the University of KwaZuluNatal, South Africa) can provide the building blocks for lifelong organizing
skills and collective action. Staying informed via news, advocacy platforms, and social media outlets that
provide in-depth political and social coverage is also indispensable (Box 14-6).
Box 14-6

A small sample of independent, critically-minded news and activist sources (to be expanded with your
own suggestions from other places/languages):

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Zimbabwe-based
EQUINET: [Link]
Kenya/Senegal-based
Pambazuka News: [Link]
India-based
The Economic and Political Weekly: [Link]
Vikalp: [Link]
Malaysia-based
Third World Resurgence magazine: [Link]
Australia-based
Green Left Weekly: [Link]
Latin America-based
La Izquierda Diario (network of news outlets in Venezuela, Bolivia, Argentina, Chile, Uruguay, Brazil,
Mexico, United States, Germany, France, Spain): [Link]
Argentina-based
Resumen Latinoamericano: [Link]
Canada-based
Socialist Project: [Link]
briarpatch magazine: [Link]
[Link]: [Link]
UK-based
Open Democracy: [Link]
US-based
Democracy Now: [Link]
Portside: [Link]
Real News: [Link]
 It is important to be conscious, nonetheless, of the cooptation of progressive language and the hypocrisy that
may surround it. Remarkably, some authors and academic institutions invoke issues around politics, power,
and privilege in global health without considering the role of global capitalism as the overarching political
economy context (Ooms 2015; Shiffman 2014). Others may promote “safe spaces” for discussion of social
justice and critical political economy perspectives, shamefully hiding or ghettoizing these debates. Conversely,

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holding such conversations in the open may lead to deeper understanding and underscore the contradictions
around mainstream global health activities that characterize much academic work in this area.
One of the most important dimensions of being an effective global health justice advocate and practitioner is
communication: speaking local languages is essential. A good start is learning one or more important regional
languages such as Arabic, Swahili, Hindi-Urdu, French, Russian, Spanish, or Mandarin. In most LMICs, this still
limits communication to dominant social and cultural groups. While mastering local languages is not always
feasible, at the very least, it is important to acknowledge that a great deal will be missed without knowing the
language. Many English speakers are accustomed to communicating in their native tongue wherever they go,
yet over half the world’s population is bilingual. For those whose work takes place internationally or involves
people from many different places, language skills are an imperative companion to being historically,
culturally, and politically aware.
p. 628 Every country has laws and regulations governing the practice of different types of health professionals.
Students who nd themselves in clinical settings in another country should not expect to examine patients,
prescribe medicines, or engage in any other clinical activity that they would not legally be allowed to do at
home. This dictum, however, may be de ed by HIC students who see LMICs as a training ground to hone their
skills. Licensed health professionals, too, frequently violate this rule, assuming that their training is equivalent
or superior to that of local clinicians. Not only is practicing without a local license illegal, it may be dangerous:
different treatment standards in each country mean that outsiders cannot presume that what they have been
trained to do is appropriate (Hanson, Harms, and Plamondon 2011).
As well, those trained or acculturated in Western biomedicine often overlook the many Indigenous practices,
including acupuncture, Ayurveda, and homeopathy that have been adopted and accepted as complementary or
superior to biomedicine for various health problems. Persistent ethnocentric attitudes can result in failure to
appreciate local understandings of disease and ill health. This goes well beyond issues of cultural sensitivity. As
discussed in chapters 3 and 11, the Western biomedical model has conceptual and practical limitations and
p. 629 biases—it is individualistic, mechanistic, invasive, generally ignores holistic understandings and the
societal context of health, can do little for many chronic conditions, frequently represents pro t-making
interests, can be dangerous/lead to iatrogenic disease (see chapter 6)—and thus should be avoided in many
instances.
When traditional healing and biomedicine cooperate as equal partners based on mutual respect, they can be
complementary. For example, Jambihuasi, a community-based clinic in Otavalo, Ecuador founded in 1984 by
Quichua traditional healers and biomedically-trained Quichua health professionals, takes a patient-led
approach. Those attending the clinic can choose either or both traditional and biomedical services, and healers
from each of these traditions communicate closely around patient care (Bouchard 2009).
In addition to understanding local traditions and needs, any person interested in global health needs to be
tolerant, self-critical, a good listener, patient, able to work with people in diverse elds and with varied
backgrounds, broad-minded, modest, and have or be able to develop expertise that is relevant. Ultimately, the
contribution of global health workers and, by extension, the programs they support, depends as much on
understanding broad sociopolitical issues as on possessing particular technical skills. Decentered solidarity
actions, abroad and at home, are perhaps the most effective approach of all.
 Nevertheless, we all ought to consider that admonishments, thoughtful approaches, and well-intentioned
efforts still do not remove—and may even exacerbate—the incongruities of engaging in international work in
the context of personal, organizational, and global power asymmetries. Reminding ourselves of this reality
through continual re exivity and “critical consciousness” (Freire 1970) is thus a crucial aspect of global health
justice efforts.

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Organizational Level: Missions and Actions
Because many readers of this text are or will go on to become global health advocates/activists, and/or work or
volunteer in this area, a few words of advice may be warranted around how individuals and organizations inter-
relate. The term organization serves as a broad umbrella encompassing a gamut of actors of all shapes and sizes
that are valuable and intersect in different ways, from small-scale grassroots activities to established local
groups, medium and large-sized regional and national entities—both longstanding and more recent—and
global and transnational agencies and movements. Involvement at personal, professional, and political levels
can be considered a continuum with overlapping elements and categories, but generally moving from one’s
own advocacy to institutional efforts and acting in solidarity with and for movements that can be global in
scale.
When deciding on an organization to work or volunteer for, one should learn as much as possible, formally and
informally, about the entity’s mission and funding sources, its past and current activities, and the larger
context of its role. For example, during the Cold War many social-justice committed US Peace Corps volunteers
in LMICs did not realize that they were often perceived by local residents to be part of the US’s (particularly the
Central Intelligence Agency’s) response to the “communist threat.”
In a similar vein, re ecting on his role as a graduate student consulting with the Aga Khan Foundation in post-
USSR Tajikistan in the mid-1990s, physician-anthropologist Salmaan Keshavjee learned that his health and
development work was part of a larger trend to foster civil society as a neoliberal alternative to the strong state
that marked the Soviet era:
… after spending time in Badakhshan, I realized that the rise of NGOs as major regional and global
development actors, a social apparatus hitherto unknown in the Soviet world, was no accident. Their
rise was linked to profound changes in economic and political thinking … which combined neoliberal
economics and, at least on paper, a commitment to liberal democratic theory and good governance
(Keshavjee 2014, pp. 6–7).
Analyzing such political and ideological tentacles is a complex endeavor. On one level, US foreign policy goals
and global health efforts, most prominently PEPFAR (see chapter 4), should not be considered “strange
bedfellows.” After all, US global security concerns and the “political capital” garnered through funding HIV
p. 630 control, as well as (at least initially) the commercial interests of Big Pharma, t together well with this
program. Yet on another level, even as former US President George W. Bush’s (and his successor US President
Barack Obama’s) PEPFAR billions are consistent with US strategic priorities, they also represent the
culmination of years of struggle for access to ARVs and health equity on the part of local movements such as
South Africa’s Treatment Action Campaign, transnational activist efforts including Health GAP, and by
committed WHO leaders and staff members, who campaigned for global AIDS treatment access in the early
2000s before adequate funding was allocated (Messac and Prabhu 2013).
By pursuing such questions, a critical political economy (of health) perspective can be infused into almost any
work or activist setting. Though challenging an organization or movement to be true to its mission, better
de ne its goals, or demonstrate how it is publicly accountable can potentially imperil both the challenger and
 the entity, it is one of the most important means of effectuating equitable global health change both at home
and abroad.
At the very least, consulting the International Aid Transparency Initiative, which tracks information on aid
spending of over 400 organizations around the world, might be helpful. The watchdog organization Charity
Navigator gauges the quality of organizations based on a number of nancial, spending, and transparency

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criteria. For example, Partners In Health receives a high rating due to its accountability, transparency, and large
proportion of resources spent on programs versus administrative and fundraising activities.
Of course, organizations (anthropomorphically speaking) want to survive. Thus, NGOs, government agencies,
and consulting rms write grant proposals and bid on contracts for things that they know how to do, or hope
to learn to do, for which funding is available, and for which they can demonstrate success so they can seek
further funding.
Herein lies the yoke of short-term, narrowly technical, measurable interventions that characterize mainstream
global health and often impede social justice approaches. Even organizations that act in solidarity with local
knowledge and social justice priorities can be severely constrained by the funding milieu. In that sense, helping
an organization to nd alternative funding sources or ways of working (i.e., via committed volunteers),
especially sources that are locally accountable, can make all the difference.
But it is also important not to let governments and international agencies and their staff members eschew
responsibility, given that they (are meant to) serve the public interest, and have a role to play, together with
local and transnational movements, in both calling for and supporting policies that move countries toward
greater social justice. Voting, advocating, and struggling for public support for long-term equitable policies,
services, and politics, at every level, from within and outside organizations, are thus vital activities.
Some individuals, perhaps due to frustrations with other organizations or motivated by un lled needs, decide
to establish their own NGO. While sounding appealing, it is important to decenter one’s own desires and
consider, for example, why an international NGO is preferable to a local organization—such as Jamkhed’s
Comprehensive Rural Health Project, operating in Maharashtra state, India since 1970 (Arole and Arole 1994)—
or advocating for public efforts, and what other avenues might be pursued.
The proliferation of thousands of small and large NGOs operating at local, national, and transnational levels
has had numerous negative consequences, including duplication of efforts, the draining of enormous logistical
and administrative resources, and lack of sustainability. Moreover, NGOs often become dependent on funding
and interests of larger donors, turning them into unwitting interlocutors or implementers of dominant
priorities (Pfeiffer 2003) and displacing social movements (Roy 2004).
Rather than founding a new organization, you might consider participating and helping form coalitions and
networks of existing organizations and political movements that pressure for universal access to water, health
care, education, and other basic human needs, against gender-based violence (Box 14-7 ), ethnic, racial, and
caste-based discrimination (e.g., the Dalit Movement in India), against illicit nancial ows (e.g. the Global
Alliance for Tax Justice), for worldwide labor standards and occupational health protections (e.g., Institute for
Global Labour and Human Rights), SDOH-grounded fair trade (Hanson et al. 2012), and so on. For instance, the
Third World Network, based in Penang, Malaysia, with of ces in Kuala Lumpur, Geneva, Montevideo, and
p. 631 Accra, and af liates in various other LMIC settings, is an independent, non-pro t research and activist
network that effectively focuses attention on trade, development, health, and other social and political issues
that affect the lives and livelihoods of the majority of people in LMICs.
 Box 14-7

For decades, women’s movements have been calling for action on the unacceptably high rates of gender-
based violence (GBV) (Michau et al. 2015). Challenging the status quo of harmful gender norms requires

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engagement of multiple actors and actions, including government commitment to intersectoral policies
that address women’s political, social, and economic subordination (García-Moreno et al. 2015b), so that
both the practice of GBV and the larger context shaping this harmful behavior are addressed (see chapter
7).
In Spain, for example, following a broad 2006 national GBV awareness and prevention plan involving
social services, the judicial system, and the media, the health care system began training providers to
identify GBV and provide psychosocial and post-rape care for sexual assault survivors. Two critical
components of the health system protocol are addressing gender-based discrimination among providers
themselves, and emphasizing providers’ role in connecting women with other services (such as housing
and legal services) in order to prevent further abuse (García-Moreno et al. 2015a).
Increasingly, GBV prevention programs engage boys and men to critically re ect on masculinity (i.e.,
norms and behaviors associated with manhood) in order to raise awareness and transform beliefs and
practices toward gender-equitable relationships (Casto and Messner 2016; Jewkes, Flood, and Lang 2015).
Gender equity and GBV prevention approaches have also been adopted in some HIV prevention programs.
The South African organization Sonke, for example, delivers “One Man Can” workshops to guide men and
boys through analysis and discussion of how masculinity is embedded in gender ideologies in their
families and communities, as well as in historical and contemporary race and class relations in South
African society. Sonke’s workshops have helped increase men’s support for women’s rights and equitable
gender relations, transforming both HIV and GBV prevention (Dworkin et al. 2013).
The challenges ahead rest on consolidating integrated anti-GBV efforts and extending them to every
society where GBV remains a problem.

National and transnational alliances against militarism (see chapter 8), or for binding codes of conduct to hold
TNCs accountable for their practices, or the Tobin tax—a proposed levy on cross-border currency transactions
that would be channeled to environmental and human needs—also have great potential for improving global
health (equity). A particularly effective network is Help Age International, which works with some 180 partners
across over 65 countries to support healthier, more digni ed lives of older persons. In most instances, building
on existing social justice efforts is likely to be more effective and sustainable than founding new organizations.
Another approach has to do with monitoring and holding to account the actions and policies of government
and international organizations. ActionAid International, based in South Africa, is a social auditing group that
works with communities to hold governments accountable on a range of issues such as food and land rights,
women’s rights, democratic governance, and climate change. Its counterpart ActionAid USA monitors TNC tax
evasion, shedding light on the injustice of lost tax revenues for health, education, and other social sectors in
LMICs. India’s Centre for Health and Social Justice also carries out social auditing; its health-related work
includes gauging community participation in policymaking and the realization of health rights. PHM,
meanwhile, sponsors WHO Watch and PAHO Watch activities, which monitor the governing bodies of global
health’s designated multilateral agencies and report publicly on policy debates, agenda-setting, and budgetary
p. 632 decisions to make these agencies accountable to broad constituencies well beyond the usual insider
“stakeholders.” In different ways, these monitoring organizations serve as both ends and means for health
advocacy and activism.
 How can we ensure that the global health projects/programs we participate in further the goals of solidarity
and social justice in health? Good intentions are insuf cient: also needed is political economy analysis of the
profusion of bilateral and multilateral aid agencies and the international and local NGOs they support. All are
ostensibly working to improve the health of local residents, yet they often work at cross-purposes with
population needs or in competition with one another. From Nicaragua to Mozambique, the aid milieu has

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proved problematic, leading to hierarchies of inclusion and exclusion within and beyond the health care sector
(see chapters 2, 3, 4, and 12).
As analyzed by Health Alliance International (HAI) medical anthropologist James Pfeiffer (2003, pp. 725–726):
The Mozambique experience reveals that the deluge of NGOs and their expatriate workers over the
last decade has fragmented the local health system, undermined local control of health programs, and
contributed to growing local social inequality. Since national health system salaries plummeted over
the same period as a result of structural adjustment, health workers became vulnerable to nancial
favors offered by NGOs seeking to promote their projects in turf struggles with other agencies … The
multiplicity of competing organizations that duplicate program support, create parallel projects, pull
health service workers away from routine duties, and disrupt planning processes has generated
concern for both donors and recipients …
In this engagement, the exercise of power by wealthy donors over their target populations, including
local health workers, is laid bare and the disempowerment of public sector services by international
agencies is most visible. … In addition to their expatriate staff, agencies usually employ small armies
of ‘nationals,’ from trained health professionals and of ce workers to drivers and guards. … paid far
more than their counterparts in the public sector.
Whether knowingly or inadvertently exacerbating these problems, global health organizations and expatriate
personnel should ensure that they do not contribute to poaching of health professionals, fragmenting of
services, or skewing of priorities but rather assist in strengthening the host country’s organization and
delivery of services and activities on its own terms.
A key to equitable and transformative global health work, either by individuals or organizations, is sustained
p. 633 commitment to a speci c population or country. HAI, for example, has been working in Mozambique for
decades, maintaining its support through war, political strife, government change, structural adjustment
pressures, and funding challenges (Box 14-8). This contrasts considerably with donors that pursue high-pro le
efforts and do little to work in solidarity with national or local needs.
 Box 14-8

The global health groups that have most contributed to the making of healthy societies are those that
adhere to principles of solidarity and “horizontal” cooperation for the long haul. Over the past three

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decades, members of Health Alliance International (HAI), mostly from the United States, have worked to
promote public health and social justice in Mozambique, with a shared commitment to local and national
goals of strengthening public infrastructure and the country’s health system.
Following Mozambique’s independence in 1975, the Ministry of Health (MOH) developed a comprehensive
national plan to rapidly extend health care to its rural population, despite scarce human and nancial
resources—with only 40 physicians for 11 million people. In the late 1970s numerous foreign physicians
and public health advocates moved to Mozambique to support the new socialist government’s ambitious
PHC plans. As cooperantes, they worked as MOH employees paid at local rates and accountable to local
authorities. Though widely supported by the public, the country’s social programs were soon undermined
by a 14-year proxy war backed by South Africa’s apartheid government. Health infrastructure and
personnel became military targets.
In 1987, heeding a request from the Mozambican government, a group of US cooperantes came together to
form the Mozambique Health Committee (later HAI) to support the rebuilding of severely damaged health
infrastructure. In the 1980s and 1990s, HAI provided technical assistance and material support to the
MOH, strengthening primary care provision in the central provinces of Manica and Sofala. By this time,
the country was faced with new threats to the health system, including structural adjustment programs
and privatization.
Starting in 2003, Mozambique’s MOH was one of the rst in Africa to initiate a national HIV treatment
program, with HAI a strong partner in this effort ever since. Mozambique experienced a large in ux of
foreign aid, stretching the MOH’s management capacity and already inadequate workforce, motivating
HAI’s move into the realm of advocacy. One key advocacy effort has been leading development of an
International NGO Code of Conduct for Health System Strengthening that calls on NGOs to support, not
usurp, MOH health sector leadership. Adhering to the Code, HAI’s integration of its efforts around health
system strengthening, immunization, and HIV, TB, and malaria treatment into Mozambique’s
government-purveyed PHC system serves as an important counterexample to the prevailing model of
NGOs competing against or displacing publicly provided health services. Yet since HAI—which has
expanded its work to Côte d’Ivoire, East Timor, and Sudan—began accepting US donor funding, it has
faced mounting dilemmas around ensuring organizational survival while maintaining its solidarity-
based principles (Gloyd, Pfeiffer, and Johnson 2013).

Box 14-9 presents critical questions any individual or organization should consider before embarking on
transformative global health work. A cardinal rule for global health work is the same as it is for medicine:
primum non nocere— rst do no harm. Organizations and individuals involved in global health must be
prepared to shed their own prejudices and opinions, work together with organizations and people from the
host country as true partners, and understand that the appropriate role of outside groups is supportive and
subsidiary to what national and local health and social justice movements wish to achieve.
 Box 14-9

• How are the country, population, and activity selected? For what purpose?
• How are problems conceptualized by local residents, policymakers, and global health workers?

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• What are the central political, economic, and social issues locally and nationally (and what historical
factors are at play)?
• Who de nes the agenda for work and how are priorities selected? How have similar activities been
carried out in the past?
• What is the approach to cooperation? Is it technical, environmental, political, social, or a mixture?
How are ethical issues taken into account?
• Is this a one-time intervention or is it sustained over time? What are its longer-term social and
environmental effects?
• How is the program funded and over what time frame? To what extent might national or local health
systems and priorities (and other institutions) be distorted by the program?
• What are the bene ts and drawbacks for the communities, organizations, and health workers
participating in the initiative?
• How will power differentials between players be identi ed and mitigated?
• Is the program tackling the SDOH? In what ways?
• How is the program evaluated, by whom, and when? (What constitutes success? Who decides?)
• What is the potential for the program to do harm to or jeopardize local participants or implementing
organizations? What are the short- and long-term responsibilities of cooperating organizations?
• How is the activity linked to transformative change? What is the role of ongoing transnational
solidarity in this effort?

For instance, consider the role of outsiders versus local efforts in the situation of military regimes that in ltrate
the health sector. In 2015 in Myanmar, health care workers protested the appointment of military of cers
without health expertise to the Ministry of Health. The protest, called the Black Ribbon Movement, also
spurred parallel protests against militarization of other sectors, such as education. Although the movement did
not achieve removal of current military of cers, the Minister of Health promised no additional military
appointments (Palatino 2015). What might foreigners do in solidarity with this important effort? Joining it
would be inappropriate or potentially dangerous. Supporting from afar, talking over the situation with students
and colleagues, and participating in a solidarity campaign might all provide important succor to Black Ribbon,
while recognizing that the movement remains very much national.
Indeed, even the most sensitive, solidarity-minded, noble, and knowledgeable persons and organizations
cannot transcend the larger context—or world order—of oppression and unequal power, recognizing that
leadership on these questions is important at every level of society. For this reason, working collectively based
p. 634 on shared values around health and social justice—as illustrated in the innumerable current acts
undertaken every day by various groups and movements that create the micro-revolutions that pre- gure and
contribute to larger changes—is so important. But this involves more than tweaking at the margins,
 notwithstanding enormous good will (Panter-Brick, Eggerman, and Tomlinson 2014). Addressing the
structures of power, at every level and from every angle far beyond global health, per se, has the potential to be
truly transformative.

The Logic of the World Order: Movements, Local and Transnational, and their

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Relation to Global Health
Over 100 years ago, the socialist philosopher and revolutionary Rosa Luxemburg posed the question of whether
reform (change from within) was useful and possible or whether it impeded revolution (change from without).
Her espousal of the latter position, leading to her participation in the Berlin revolution, cost her her life in 1919
when she was captured by German authorities and tortured to death. The “reform versus revolution” question
continues to be evoked today. Davidson Gwatkin, a prominent advisor on health and poverty to the World Bank,
has argued, “The health of the world’s poor would be best served by a series of revolutions that bring into
power national leaderships that are centrally concerned about the well-being of disadvantaged groups within
their borders” (Yamey 2007, p. 1558). The World Bank, however, has long supported private enterprise, not
socialist revolution, as the formula for progress. How might this paradox be reconciled?
p. 635 Today, many regard the reform versus revolution dichotomy to be false or at least exaggerated, instead
viewing transformative reforms—especially the creation or resurrection of social justice-based welfare states
with universal rights to safe housing, employment, neighborhoods, environmental conditions, water and
sanitation, education, health care, and nondiscrimination—together with a robust and equitable reorientation
of power and decisionmaking to combat multiple forms of oppression, as the scaffolding of structural change.
Returning to the previous example, as an alternative to more revolutionary calls for the World Bank’s
elimination, reform might be pursued to ensure that it democratically represents not only all countries but
people of distinct social classes, racial and ethnic groups, genders, and other dimensions of social, economic,
and political power. In this way, the World Bank would become a people’s bank, rather than a bank representing
elite interests. Pushing this point further, every multilateral or UN agency might be reformed through such
policies, enabling priority-setting and scienti c expertise to be grounded and integrated into larger anti-
oppression efforts.
How might democratization change the World Bank? The widespread misery caused by its loan and
development packages could be addressed not through tinkering with loan programs or symbolic debt
forgiveness, but through: total and unconditional debt cancellation; abolition of loan conditionalities; payment
of reparations for centuries of enslavement, plundering, and exploitation; and the creation of reverse
conditionalities (i.e., no loan would be approved unless it decreased a country’s Gini coef cient, increased
access to water or education, and fostered equitable power over decisionmaking, etc.), as decided through
genuinely democratic and accountable governance processes (Jubilee Debt Campaign 2014). While this may
seem like wishful thinking, Jubilee, Centre Europe Tiers Monde, and other public interest civil society groups
call for IFIs to be completely revamped and become responsible lenders, a Sisyphean challenge, to be sure, but
not a hopeless one.
Another key group that straddles reform and revolution particularly in relation to global health is PHM.
Founded by health workers in 2000 in Bangladesh, PHM has become an international movement with national
counterparts, struggling for health as a human right in the context of global solidarity (Figure 14-1). Its People’s
Charter for Health has been translated into dozens of languages and endorsed by thousands of people and
organizations across the world, becoming the “most widely endorsed consensus document on health since the
Alma Ata Declaration” (PHM 2016). PHM employs a political economy of health analysis as a call for multilevel
action to collectively tackle the broad determinants of health in order to achieve Alma-Ata’s vision of “health
p. 636 for all.” For PHM (2016):
 Equity, ecologically‐sustainable development and peace are at the heart of [their] vision of a better
world ‐ a world in which a healthy life for all is a reality; a world that respects, appreciates and
celebrates all life and diversity; a world that enables the owering of people’s talents and abilities to
enrich each other; a world in which people’s voices guide the decisions that shape our lives.

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Figure 14-1 Peopleʼs Health Assembly, Cape Town, South Africa, July 2012.

Source: PHM (2012).

PHM is also involved with the activist organizations Medact, Medico International, Third World Network,
Health Action International, and ALAMES in bringing together hundreds of health practitioners, scholars, and
advocates to produce the triennial Global Health Watch: An Alternative World Health Report. In four editions to
date, the report has critically assessed the state of global health and the current paradigm of development and
provided an alternative array of achievable solutions for “a society that is more just, more equal and more
humane” (PHM et al. 2014, p. 1).
So, too, might you see your own work in global health as a micro-transformation en route to improving the
determinants of health at each level of the political economy of global health framework explored in this book.
Should you nd yourself working—or advocating for change—within an organization that follows “business
as usual” in global health, your efforts, together with those of colleagues and supporters, could help reform the
organization in a variety of ways. For example, as an epidemiologist employed by an international disease
surveillance agency, you might insist that surveys of HIV prevalence include variables regarding living and
work conditions, food sovereignty, and wealth and social strati cation. Or if you live in an HIC, you may decide
that your efforts will be more effective through activism with a transnational movement that calls for changes
in trade and investment rules, challenges foreign aid strategies that further entrench power imbalances, or
defends occupational health conditions worldwide.
How might such activism be harnessed to transform the eld? Individual motivations of social justice and
shared well-being are a good start but they are not enough. Pushing organizations to improve the
accountability and equity of their actions is also important, yet still not enough. Understanding the nature and
structures of power and oppression, and how the skewed distribution of political, social, and economic
resources affects the determinants of health and well-being—alongside participating in committed efforts to
upend the concentration of power and resources—are fundamental to improving global health equity and
social justice.
 Practicing Global Health “At Home and Transnationally”
Global health can also be practiced without a passport: in many ways, working to transform the “foreign”
policies of powerful HIC governments, which have tremendous sway over the rules and arrangements of the
global order, may have a far greater impact than working in another country. Not only is activism at home (for

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those based in HICs) among the best forms of solidarity with progressive social movements transnationally,
but educating fellow residents/citizens and organizing for socially just change can profoundly in uence the
underlying determinants of global health inequity. This entails both visible and behind-the-scenes activism:
• Helping build mass movements at home that practice health and social justice and struggle for political
transformation domestically and globally (Stedile 2002) by participating through supportive campaigns,
logistical help, collecting funds and supplies, providing needed information and advocacy; and informing
the public of HICs about the damages caused by their governments’ economic policies, foreign aid, and
military policies
• Participating in struggles for: truly equitable systems of trade and investment; solidarity cooperation;
ensuring systems of fair and adequate taxation and redistribution; ending illicit nancial ows;
strengthening domestic and transnational regulations and protections; and other forms of “mobilizing
against global capital” (Labonté 2013, p. 2159)
• Campaigning against nancialization (promulgated by IFIs, private banks, and insurance corporations)
p. 637 • Working to eliminate patent protections that limit access to needed drugs and devices
• Organizing against harmful and exploitative TNC practices
• Working to change HIC health care system and training policies to prevent poaching of professionals from
other countries
• Forming truly collaborative partnerships with colleagues and students around the world involved in
global health and social justice research and activities
• Mobilizing around “global health” issues at home—for example, against classist, gender-based, and racist
violence and institutionalized discrimination; in favor of just societies that prioritize the needs of all
oppressed populations including migrants and refugees; for equitable and adequate nancing of and
access to public medical care, housing, employment, quality education, and other entitlements; and for
radically democratic forms of societal decisionmaking
• Struggling against past and present human rights violations at home—against Indigenous and other
oppressed populations (Box 14-10)—by law enforcement and other public institutions
• Working to combat climate change and environmental degradation by ghting for stronger standards—
and enforcement mechanisms—on reduction of greenhouse gas emissions, extractive industries,
industrial pollution, and production and export of toxic substances
• Working to reform international organizations (beginning with WHO) so they represent the interests of
people, not corporations, and are true to their public mandates
p. 638 • Fighting domestically and transnationally to protect workers from labor that is exploitative, hazardous,
and precarious and to improve occupational health and safety
 Box 14-10

Across the world, Indigenous movements have made concerted efforts to protect the well-being, cultural
traditions, and livelihoods of their communities with broad (though not necessarily intended)

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repercussions for health, including for the larger society. Some efforts combine local acts of sabotage and
engagement with state institutions, such as the Khmu resistance to Chinese-owned rubber concessions
in Northern Laos (McAllister 2015); other movements struggle against corporate impunity from
environmental damages, among them the decades-long battle of the Movement for the Survival of the
Ogoni People in Nigeria against Shell Oil Company (see chapter 10).
In Canada, Idle No More sprang into motion in 2012 in response to attacks on Indigenous sovereignty and
the weakening of environmental regulations by the conservative government then in power, allowing
industrial projects—including pipelines and mining expansion in Western Canada (mega-mines and tar
sands; see chapter 10)—to proceed without community input, water and ecosystem protections, or
environmental assessments. Starting from the province of Saskatchewan, the grassroots Idle No More
movement—brainchild of three local Indigenous women, Jessica Gordon, Sylvia McAdam, and Nina
Wilson, plus white settler ally Sheelah McLean (Caven 2013)—took a range of actions to protest the
dismantling of environmental protection. These consisted of: Indigenous leaders going on hunger strikes,
rallies, teach-ins around the “historical and contemporary context of colonialism,” the blockading of
roads and railways, and ash-mob style traditional dance performances in public areas (Idle No More
2016). Idle No More soon gained support from trade unions, students, and other groups across Canada,
inspiring and standing in solidarity with movements in the United States, Ukraine, New Zealand, and
beyond (Klein 2014). While not aimed at protecting health per se, this struggle to protect Indigenous
rights to water and to traditional ways of life has enormous resonance for the SDOH, from historical
legacies of oppression, to land and resource protections, and the right to self-determination.

Many people, not only those at the beginning of their careers, may not recognize that participating in global
health struggles without leaving home may be far more signi cant than going abroad under the auspices of a
humanitarian agency. While not appearing as exciting as an international experience, these efforts have the
potential to effectively address the root causes of ill health across the world (Labonté 2013), leave less of a
carbon footprint, and may waste fewer local resources than a stint overseas. For example a 2015–2016
campaign bringing together environmental organizations, consumer watchdogs, and scientists, with the
transnational support of millions of people from home bases around the world, successfully pressured the EU
(in the face of an army of corporate lobbyists) to ban Monsanto’s herbicide Roundup, a probable carcinogen.
Various activist organizations and movements that take on corporate impunity for unethical, unhealthy, and
illegal behavior have had a dramatic impact in the political sphere and in global health, for instance: the Global
Campaign to Dismantle Corporate Power; US-based Corporate Accountability International, which has a
campaign to stop TNC junk food marketing to children; and the European Coalition for Corporate Justice,
whose work focuses on TNCs and their excesses, including in relation to the UN’s uncritical embracing of
corporate interests in the realization of the SDGs.
Undoubtedly, as discussed in various chapters, public-interest civil society organizations, social movements,
and the activists and advocates involved in these, such as IBFAN, Acción Ecológica, Treatment Action
Campaign, and 50 Years is Enough, have played a critical part in ongoing struggles to make governments
transparent, representative, and accountable for equitable policies protective of people’s needs. They have also
pressed multilateral organizations to act in—and trade treaties adhere to—the interests of human well-being,
 not the private sector, and regulators to keep toxins out of food supplies and the environment, among other
recent mobilizations. These efforts are hugely important, worthwhile, and necessary.
Yet the growing emphasis on social justice-oriented advocacy and activism has led to reliance on civil society
as a principal realm where transformative change will occur. Not only has this resulted in the sometime
lumping of public interest groups with philanthropies and TNCs (as has played out at WHO around its

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problematic framework for interacting with nonstate actors [Lhotská and Gupta 2016]; see chapter 4), but such
reliance can let local, national, and international civil servants, large organizations, and academics off the hook
in terms of battling inequity and ghting for health justice. Public interest groups and social movements can
be extremely in uential—and involve incredibly committed and formidable, if often exhausted, individuals—
but they are also fragile, usually lacking the resources, access, legitimacy, permanence, and even protection
from repression that academic, national, and international organizations possess. Just obtaining information
and entrée to decisionmaking fora consumes tremendous energy, before substantive issues are even broached.
For these reasons, action around—and courageous stances for—health and social justice need to happen on
every level and at every kind of institution, not just via civil society efforts.
As a reminder of the importance of using institutional platforms to speak out, we turn to Dr. Mary Travis
Bassett, the New York City Health Commissioner, who spent several decades as a physician-scholar-activist in
Zimbabwe. She brought back to the United States new understandings of the challenges of collective struggles
for health and the insight that notwithstanding the enormous poverty generated under structural adjustment
that she witnessed, researched, and sought to address in Zimbabwe, she never saw worse health conditions
than in Harlem Hospital—in one of the poorest and most racially oppressed parts of New York City. These
experiences have moved Dr. Bassett to use her stage as Health Commissioner to invest in mapping racial,
economic, and social inequities across neighborhoods to marshal resources to concretely implement Health in
All Policies. In the wake of brutal police force violence and racism across the United States, she has publicly
asked:
Should health professionals be accountable not only for caring for individual black patients but also
p. 639 for ghting the racism—both institutional and interpersonal—that contributes to poor health in
the rst place? Should we work harder to ensure that black lives matter… .? In terms of broader
advocacy, some physicians and trainees may choose to participate in peaceful demonstrations; some
may write editorials or lead “teach-ins”; others may engage their representatives to demand change
in law, policy, and practice. Rightfully or not, medical professionals often have a societal status that
gives our voices greater credibility… . (Bassett 2015, pp. 1085–1087).

Conclusion: What Is to Be Done?

Learning Points:
• While mainstream approaches dominate the global health eld, there are also inspirational approaches to
global health’s ongoing challenges, including social justice-oriented South–South cooperation, social and
environmental movements operating locally and transnationally, and social auditing to hold
governments, corporations, and non-state actors publicly accountable.
• Engaging in social justice approaches to global health requires critical self-re ection and decentering
one’s role, desires, and expectations, as well as understanding the profoundly political underpinnings of
most global health action.
• Working toward health and social justice globally rests on solidarity and sustained commitment with
local, national, and transnational organizations and movements that represent the needs of ordinary
 people rather than donors or TNCs.
• Participation in organizations—whether grassroots endeavors, large humanitarian entities, government
agencies, or transnational social movements—can spark important micro-level changes, as part of larger
uphill struggles essential to the making of healthy societies.

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• Transformative work in global health involves a critical understanding and commitment to challenging
the world political and economic order so as to improve the SDOH and build more equitable and socially
just societies.
• Some of the most effective social action for global health justice can be done from home and in solidarity
with movements elsewhere, on issues ranging from corporate impunity, to harmful military and foreign
policy, inadequate and under-enforced worker and environmental regulations, and illicit nancial ows.
At this point it is useful to revisit the three levels at which global health work can be conceptualized: individual
actions and motivations, organizational missions and interventions, and the logic and structures of the world
order. It is not uncommon to become frustrated that your own heartfelt motivations and hard work are not
changing the public health reality in a marginalized community. Yet given the complexity of political, social,
and economic forces that affect health at local, national, and global levels, this is to be expected. On the other
hand, your own work, and that of the organizations and networks in which you participate, can also in uence
the logic of the world order, whether by ghting for comprehensive welfare states that go beyond
redistribution and enable a just sharing of political and social power, for fair rules of international trade and
nance, or for local and global political accountability. This kind of activity requires long-term commitment
and patience, as change usually occurs slowly. That said, being part of such an effort is the most human,
humane, and social justice and human rights-infused endeavor imaginable.
Ultimately, the global health community should be:
a catalyst, a world health conscience behind national change, and, when requested, a helper giving
visible expression to progressive ideas and decisions within national social policies… . this means the
end of well-intentioned international technical paternalism in health and its replacement by an era of
[global] collaboration and cooperation (WHO 1976, pp. 80–81).
Before or while reading this textbook, you might have asked: who could possibly critique global health actors
p. 640 and actions—a heartwarming domain involving committed advocates, specialized practitioners, and
glamorous celebrities (Kapoor 2013)? Yet, as we have seen, global health and development activities are not
neutral, technical endeavors but embedded in larger political structures and considerations. This helps
explains the presence of institutions and activities within the ambit of global health that: squeeze out local
priorities; come with conditions; interfere with democratic processes; increase inequity and social injustice;
and perpetuate dependency and power differentials, while legitimating neoliberal capitalism. Paradoxically,
mainstream health aid often violates the “do no harm” ethic despite the typically good intentions of the
individuals and agencies participating. To put it differently, imagine if public health in your own community or
country were in uenced by, or dependent on, the charity of an international philanthropist, the interests of
TNCs, the whims of a famous rock star, or the strategic foreign policy priorities of another country, paying little
heed to locally de ned needs.
As Paulo Freire (1978, p. 8) put it:
Authentic help—this can never be said enough—is that in which all who are involved help each other,
growing together in the common effort of understanding the reality they seek to transform. Only
such a practice, in which those who give help and those who are helped simultaneously help each
 other, is the only kind in which the act of helping is not distorted into the dominance of those who
help over those who are helped.
Above all, as the authors of this textbook, we believe that naïveté, willful ignorance, or rhetorical cooptation of
global health are unacceptable. We nd that continuous learning about—and engaging with to the extent

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possible—micro-level everyday acts, national policies and struggles, and the geopolitics and economic
imperatives shaping global health are essential.
We agree with activists that responsibility for—and civil courage around—speaking out at injustice is vital and
that global health actors of all kinds and at all levels share in this responsibility. Certainly this is the case within
academia, where research and evidence produced on global health typically sidesteps discussion of capitalism,
oppression, and injustice, instead re ecting the priorities of powerful funding agencies (and global health itself
is increasingly viewed as a pro table realm, including for patentable interventions). This is also a responsibility
shared by government and UN agencies, where—despite mandates for equity and openness—secretive, non-
transparent processes enable private actors to squeeze out the public interest.
Recognizing the need to challenge global health power helps us decenter our own work and view it as
subsidiary to larger movements for health and social justice. The solidarity we strive for is not channeled
through one avenue; we seek to contribute on multiple levels based on our skills and expertise, always bearing
in mind long-term and transformative goals. As slain US civil rights leader Martin Luther King Jr. powerfully
put it, “the arc of the moral universe is long, but it bends towards justice” (King, Jr. 1965).
In this sense, global health and social justice activism can serve as both a rallying cry and a brick in building
solidarity movements across stages of change—from decrying unjust political and social systems, to reforming
them, radically altering them, and building from anew, all with contextualized rationales at particular
moments in time.
The activities and campaigns we have covered here, causing smaller and greater ripples both within the health
realm and outside it suggest how global health might be better practiced well into the 21st century. This
chapter, and the book as a whole, also propose that a critical political economy approach cognizant of the
structural factors, arrangements, and rules generating poor health and enormous inequities, is valuable—or
rather invaluable—for re ection, a keen appreciation of, and action on these issues (ultimately for purposes of
transforming society—praxis, in Freire’s terms). Individual and institutional motivations and principles to
combat all forms of oppression, discrimination, exploitation, and harm at an interpersonal and organizational
level are necessary to improve global health justice. But they are not suf cient. Understanding how to make
global health transformative for the majority of humanity beset by the unfair distribution of local and global
resources and social and political power—and associated ill health and premature death—requires a further set
of conceptual and analytic tools and perspectives that are not often taught in global health programs or to
health professionals.
p. 641 It is our hope that this book will serve as a primer for such understanding and help inspire readers’ lifelong
commitment to equitable engagement in global health as a social justice endeavor. Now it is up to you to
harness your imagination, drive, commitment, persistence, knowledge, and skills to bettering and
transforming global health in solidarity with the struggles of billions of people.
References
Adams V. 2013. Evidence-based global public health: Subjects, profits, erasures. In Biehl J and Petryna A, Editors. When People
Come First: Critical Studies in Global Health. Princeton, NJ: Princeton University Press.
Google Scholar Google Preview WorldCat COPAC

Downloaded from [Link] by University of Washington Law School - Gallagher Law Library user on 02 October 2025
Arole MR and Arole R. 1994. Jamkhed: A Comprehensive Rural Health Project. London: Macmillan.
Google Scholar Google Preview WorldCat COPAC

Askheim C, Heggen K, and Engebretsen E. 2016. Politics and power in global health: The constituting role of conflicts.
International Journal of Health Policy and Management 5(2):117–119.
Google Scholar WorldCat

Bassett MT. 2015. #BlackLivesMatter—A challenge to the medical and public health communities. New England Journal of
Medicine 372(12):1085–1087.
Google Scholar WorldCat

Beauchamp D. 1976. Public health as social justice. Inquiry 13(1):3–14.

Google Scholar WorldCat

Beldarraín Chaple E. 2006. Public health in Cuba and its international experience (1959-2005). História, Ciências, Saúde –
Manguinhos 13(3):709–716.
Google Scholar WorldCat

Biehl J and Petryna A, Editors. 2013. When People Come First: Critical Studies In Global Health. Princeton, NJ: Princeton University
Press.
Google Scholar Google Preview WorldCat COPAC

Birn A-E. 2005. Gatesʼs grandest challenge: Transcending technology as public health ideology. Lancet 366(9484):514–519.
Google Scholar WorldCat

———. 2017. Little agenda-setters: Uruguayʼs International Institute for the Protection of Childhood and rights approaches to
child health, 1920s-1940s. Journal of Social History of Medicine and Health [in Chinese] 2:1 [forthcoming].
WorldCat

Birn A-E, Aguilera M, Brisbois B, and Holtz TH. 2015. Why addressing climate change is not enough. Hu ington Post Blog,
December 25.
WorldCat

Birn A-E and Brown TM, Editors. 2013. Comrades in Health: U.S. Health Internationalists, Abroad and at Home. New Brunswick,
NJ: Rutgers University Press.
Google Scholar Google Preview WorldCat COPAC

Birn A-E, Muntaner C, and Afzal. 2016. La cooperación sur-sur en salud en América Latina: ¿aporte a la justicia social o
continuidad de padrones dominantes de la asistencia norte-sur? [Unpublished manuscript]

Birn A-E, Nervi L, and Siqueira E. 2016. Neoliberalism redux: The global health policy agenda and the politics of cooptation in
Latin America and beyond. Development and Change 47(4):734–759.
Google Scholar WorldCat

Bliss K, Editor. 2013. The Changing Landscape of Global Health Diplomacy. Washington, DC: CSIS Global Health Policy Center.
Google Scholar Google Preview WorldCat COPAC

Bond P and Garcia A, Editors. 2015. BRICS: An Anti-Capitalist Critique. London: Pluto Press.
 Google Scholar Google Preview WorldCat COPAC

Bouchard L. 2009. The awakening of collaboration between Quichua healers and psychiatrists in the Andes. In Incayawar M,
Wintrob R, Bouchard L, and Bartocci G, Editors. Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health.
Hoboken, NJ: John Wiley & Sons, Ltd.

Downloaded from [Link] by University of Washington Law School - Gallagher Law Library user on 02 October 2025
Google Scholar Google Preview WorldCat COPAC

Burgess LJ and Pretorius D. 2012. FDA abandons the Declaration of Helsinki: The e ect on the ethics of clinical trial conduct in
South Africa and other developing countries. South African Journal of Bioethics and Law 5(2):87–90.
Google Scholar WorldCat

Buss PM and Ferreira JR. 2011. Cooperação e integração regional em saúde na América do Sul: a contribuição da Unasul-Saúde.
Ciência & Saúde Coletiva, 16(6), 2699–711.
Google Scholar WorldCat

Bustreo F, Hunt P, Gruskin S, et al. 2013. Womenʼs and Childrenʼs Health: Evidence of Impact of Human Rights. Geneva: WHO.
Google Scholar Google Preview WorldCat COPAC

Cabral L, Russo G, and Weinstock J. 2014. Brazil and the shi ing consensus on development co‐operation: Salutary diversions
from the ʻaid‐e ectivenessʼ trail? Development Policy Review 32(2):179–202.
Google Scholar WorldCat

Cantwell B and Kauppinen I, Editors. 2014. Academic Capitalism in the Age of Globalization. Baltimore: Johns Hopkins University
Press.
Google Scholar Google Preview WorldCat COPAC

Casto J and Messner LA. 2016. Gender-based Violence Initiative Synthesis Report. Arlington: Strengthening High Impact
Interventions for an AIDS-free Generation (AIDSFree) Project.
Google Scholar Google Preview WorldCat COPAC

Caven F. 2013. Being Idle No More: The Women Behind the Movement. [Link]
survival-quarterly/being-idle-no-more-women-behind-movement. Accessed June 8, 2016.
WorldCat

Chakma J, Sun GH, Steinberg JD, et al. 2014. Asiaʼs ascent—global trends in biomedical R&D expenditures. New England Journal
of Medicine 370(1):3–6.
Google Scholar WorldCat

Chu KM, Jayaraman S, Kyamanywa P, and Ntakiyiruta G. 2014. Building research capacity in Africa: Equity and global health
collaborations. PLoS Medicine 11(3):e1001612.
Google Scholar WorldCat

p. 642 Cole T. 2012. The White-Savior Industrial Complex. The Atlantic, March 21.
Google Scholar WorldCat

Cruikshank LW, Clark C, and Bartlett R. 2014. Fundraising for Global Health Social Enterprises: Lessons from the Field. Durham:
Center for the Advancement of Social Entrepreuneurship.
Google Scholar Google Preview WorldCat COPAC

Durisch P and Gex M. 2013. Clinical Trials: Human Guinea - Pigs on the Cheap. Zurich: Déclaration de Berne.
Google Scholar Google Preview WorldCat COPAC

Dworkin SL, Hatcher AM, Colvin C, and Peacock D. 2013. Impact of a gender-transformative HIV and antiviolence program on
gender ideologies and masculinities in two rural, South African communities. Men and Masculinities 16(2):181–202.
Google Scholar WorldCat
Feinsilver J. 2010. Fi y years of Cubaʼs medical diplomacy: From idealism to pragmatism. Cuban Studies 41:85–104.
Google Scholar WorldCat

Ferreira JR, Hoirisch C, Fonseca LE, and Buss PM. 2016. International cooperation in health: The case of Fiocruz. História,
Ciências, Saúde-Manguinhos 23(2):267–276.

Downloaded from [Link] by University of Washington Law School - Gallagher Law Library user on 02 October 2025
Google Scholar WorldCat

Fleury S. 2010. What kind of social protection for what kind of democracy? The dilemmas of social inclusion in Latin America.
Social Medicine 5(1):34–49.
Google Scholar WorldCat

Forman L. 2016. The ghost is the machine: How can we visibilize the unseen norms and power of global health? International
Journal of Health Policy and Management 5(3):197–199.
Google Scholar WorldCat

Forman L, Ooms G, Chapman A, et al. 2013. What could a strengthened right to health bring to the post-2015 health development
agenda?: Interrogating the role of the minimum core concept in advancing essential global health needs. BMC International
Health and Human Rights 13(48).
WorldCat

Freire P. 1970. Pedagogy of the Oppressed. New York: Continuum.

Google Scholar Google Preview WorldCat COPAC

———. 1978. Cartas a Guiné-Bissau. Registros de uma Experiencia em Processo. Rio de Janeiro: Ed Paz e Terra.
Google Scholar Google Preview WorldCat COPAC

———. 1992. Pedagogy of Hope: Reliving Pedagogy of the Oppressed. London: Bloomsbury.
Google Scholar Google Preview WorldCat COPAC

Gamble V. 1997. Under the shadow of Tuskegee: African Americans and health care. American Journal of Public Health
87(11):1773–1778.
Google Scholar WorldCat

Garcia A and Kato K. 2015. The story of the hunter or hunted? Brazil's role in Angola and Mozambique. In Bond P and Garcia A,
Editors. BRICS: An Anti-Capitalist Critique. London: Pluto Press.
Google Scholar Google Preview WorldCat COPAC

García-Moreno C, Hegarty K, dʼOliveira AFL, et al. 2015a. The health-systems response to violence against women. Lancet
385(9977):1567–1579.
Google Scholar WorldCat

García-Moreno C, Zimmerman C, Morris-Gehring A, et al. 2015b. Addressing violence against women: A call to action. Lancet
385(9978):1685–1695.
Google Scholar WorldCat

Geiger HJ. 2013. Contesting racism and innovating community health centers: Approaches on two continents. In Birn A-E and
Brown TM, Editors. Comrades in Health: U.S. Health Internationalists, Abroad and at Home. New Brunswick, NJ: Rutgers
University Press.
Google Scholar Google Preview WorldCat COPAC

General Comment 14 [Committee on Economic, Social and Cultural Rights, 22nd session]. 2000. The Right to the Highest
Attainable Standard of Health – Article 12 of the International Covenant on Economic, Social and Cultural Rights (CESCR)
(E/C.12/2000/4). Geneva: United Nations Economic and Social Council.
Google Scholar Google Preview WorldCat COPAC
 GHSA. 2016. About. [Link] Accessed June 2, 2016.
WorldCat

Global Polio Eradication Initiative. 2012. What are people saying about polio eradication?
[Link] Accessed June 2, 2016.

Downloaded from [Link] by University of Washington Law School - Gallagher Law Library user on 02 October 2025
WorldCat

Gloyd S, Pfei er J, and Johnson W. 2013. Cooperantes, solidarity, and the fight for health in Mozambique. In Birn A-E and
Brown TM, Editors. Comrades in Health: U.S. Health Internationalists, Abroad and at Home. New Brunswick, NJ: Rutgers
University Press.
Google Scholar Google Preview WorldCat COPAC

Gopinathan U, Watts N, Hougendobler D, et al. 2015. Conceptual and institutional gaps: Understanding how the WHO can
become a more e ective cross-sectoral collaborator. Globalization and Health 11(1).
Google Scholar WorldCat

Gruskin S, Bogecho D, and Ferguson L. 2010. Rights-based approachesʼ to health policies and programs: Articulations,
ambiguities, and assessment. Journal of Public Health Policy 31(2):129–145.
Google Scholar WorldCat

Gruskin S and Tarantola D. 2013. Bringing human rights into public health. In Grodin MA, Tarantola D, Annas GJ, and Gruskin S,
Editors. Health and Human Rights in a Changing World. New York: Routledge.
Google Scholar Google Preview WorldCat COPAC

Gupta R and Farmer PE. 2005. International electives: Maximizing the opportunity to learn and contribute. Medscape General
Medicine 7(2):78.
Google Scholar WorldCat

Gutiérrez G. 1973. A Theology of Liberation. Maryknoll, NY: Orbis Books.

Google Scholar Google Preview WorldCat COPAC

Hanefeld J. 2016. Advancing global health – the need for (better) social science. International Journal of Health Policy and
Management 5(4):279–281.
Google Scholar WorldCat

Hanlon J, Barrientos A, and Hulme D. 2010. Just Give Money to the Poor: The Development Revolution from the Global South.
Sterling, VA: Kumarian Press.
Google Scholar Google Preview WorldCat COPAC

Hanson L. 2010. Global citizenship, global health, and the internationalization of curriculum: A study of transformative potential.
Journal of Studies in International Education 14(1):70–88.
Google Scholar WorldCat

———. 2015. Experiences of creating internationalized curricula through global health programs at the University of
p. 643 Saskatchewan. In Green W and Whitsed C, Editors. Critical Perspectives on Internationalising the Curriculum in Disciplines.
Dordrecht, NL: SensePublishers.
Google Scholar Google Preview WorldCat COPAC

Hanson L, Harms S, and Plamondon K. 2011. Undergraduate international medical electives: Some ethical and pedagogical
considerations. Journal of Studies in International Education 15(2):171–185.
Google Scholar WorldCat

Hanson L, Terstappen V, Bacon CM, et al. 2012. Gender, health, and Fairtrade: Insights from a research-action programme in
Nicaragua. Development in Practice 22(2):164–179.
Google Scholar WorldCat
Harmer A and Buse K. 2014. The BRICS: A paradigm shi in global health? Contemporary Politics 2:127–145.
Google Scholar WorldCat

Harper I and Parker M. 2014. The politics and anti-politics of infectious disease control. Medical Anthropology 33(3):198–205.
Google Scholar WorldCat

Downloaded from [Link] by University of Washington Law School - Gallagher Law Library user on 02 October 2025
Harrison M. 1994. Public Health in British India: Anglo-Indian Preventive Medicine, 1859–1914. Cambridge: Cambridge University
Press.
Google Scholar Google Preview WorldCat COPAC

Health and Human Rights Journal. 2015. Special issue: Evidence of the impact of human rights-based approaches to health.
Health and Human Rights 17(2):1–179.
WorldCat

Horton R. 2013. O line: Is global health neocolonialist?. Lancet 382(9906):1690.

Google Scholar WorldCat

Huish R. 2013. Where No Doctor Has Gone Before: Cubaʼs Place in the Global Health Landscape. Waterloo, ON: Wilfrid Laurier
University Press.
Google Scholar Google Preview WorldCat COPAC

Hunt P, Yamin AE, and Bustreo F. 2015. Making the case: What is the evidence of impact of applying human rights-based
approaches to health? Health and Human Rights Journal 2(17):1–9.
Google Scholar WorldCat

Idle No More. 2016. [Link] Accessed June 8, 2016.

WorldCat

IPHU. 2016. Welcome to IPHU website! [Link] Accessed June 2, 2016.

WorldCat

Jewkes R, Flood M, and Lang J. 2015. From work with men and boys to changes of social norms and reduction of inequities in
gender relations: A conceptual shi in prevention of violence against women and girls. Lancet 385(9977):1580–1589.
Google Scholar WorldCat

Johnson CD, Noyes J, Haines A, et al. 2013. Learning from the Brazilian community health worker model in North Wales.
Globalization and Health 9(1).
Google Scholar WorldCat

Jubilee Debt Campaign. 2014. Election 2015: How to avert a new debt crisis. [Link]
briefings/briefing/election-2015-avert-new-debt-crisis. Accessed June 7, 2016.
WorldCat

Kapoor I. 2013. Celebrity Humanitarianism: The Ideology of Global Charity. Abingdon, UK: Routledge.
Google Scholar Google Preview WorldCat COPAC

Keshavjee S. 2014. Blind Spot: How Neoliberalism Infiltrated Global Health. Oakland: University of California Press.
Google Scholar Google Preview WorldCat COPAC

Keugoung B, Macq J, Buvé A, et al. 2011. The interface between health systems and vertical programmes in Francophone Africa:
The managersʼ perceptions. Tropical Medicine & International Health 16(4):478–485.
Google Scholar WorldCat

Kickbusch I. 2016. Politics or technocracy – what next for global health? International Journal of Health Policy and Management
5(3):201–204.
 Google Scholar WorldCat

King, ML. Jr. 1965. “How long? Not long.” Selma to Montgomery march. March 25, 1965, Montgomery, AL.

Klein N. 2014. This Changes Everything: Capitalism vs. The Climate. New York: Simon and Schuster.

Downloaded from [Link] by University of Washington Law School - Gallagher Law Library user on 02 October 2025
Google Scholar Google Preview WorldCat COPAC

Labonté R. 2013. Health activism in a globalising era: Lessons past for e orts future. Lancet 381(9884):2158–2159.
Google Scholar WorldCat

Lasker JN. 2016. Hoping to Help: The Promises and Pitfalls of Global Health Volunteering. Ithaca, NY: Cornell University Press.
Google Scholar Google Preview WorldCat COPAC

Laxminarayan R and Ganguly NK. 2011. Indiaʼs vaccine deficit: Why more than half of Indian children are not fully immunized,
and what can—and should—be done. Health A airs 30(6):1096–1103.
Google Scholar WorldCat

Lear WJ. 2013. American medical support for Spanish democracy, 1936-1938. In Birn A-E and Brown TM, Editors. Comrades in
Health: U.S. Health Internationalists, Abroad and at Home. New Brunswick, NJ: Rutgers University Press.
Google Scholar Google Preview WorldCat COPAC

Lhotská L and Gupta A. 2016. Whose health?: The crucial negotiations for the World Health Organizationʼs future. Asia & the
Pacific Policy Society, May 19.
WorldCat

Liang BA and Mackey T. 2010. Confronting conflict: Addressing institutional conflicts of interest in academic medical centers.
American Journal of Law & Medicine 36(1):136–187.
Google Scholar WorldCat

Lim YW and Chia A. 2016. Social entrepreneurship: Improving global health. JAMA 315(22):2393–2394.
Google Scholar WorldCat

Loewenson R, Modisenyane M, and Pearcey M. 2014. African perspectives in global health diplomacy. Journal of Health
Diplomacy 1(2).
Google Scholar WorldCat

Lurie P and Wolfe SM. 1997. Unethical trials of intervention to reduce perinatal transmission of the human immunodeficiency
virus in developing countries. New England Journal of Medicine 337(12):853–856.
Google Scholar WorldCat

Lyons M. 2002. The Colonial Disease: A Social History of Sleeping Sickness in Northern Zaire, 1900-1940. Cambridge: Cambridge
University Press.
Google Scholar Google Preview WorldCat COPAC

Mahmood Q and Muntaner C. 2013. Politics, class actors, and health sector reform in Brazil and Venezuela. Global Health
Promotion 20(1):59–67.
Google Scholar WorldCat

p. 644 Mann J, Gruskin S, Grodin MA, and Annas GJ, Editors. 1999. Health and Human Rights: A Reader. New York: Routledge.
Google Scholar Google Preview WorldCat COPAC

McAllister KE. 2015. Rubber, rights and resistance: The evolution of local struggles against a Chinese rubber concession in
Northern Laos. Journal of Peasant Studies 42(3-4):817–837.
Google Scholar WorldCat
McLennan S. 2014. Medical voluntourism in Honduras: ʻHelpingʼ the poor? Progress in Development Studies 14(2):163–179.
Google Scholar WorldCat

Medicus Mundi. 2010. La Participación Social en Salud: El Reto de Pasar del Discurso a la Práctica Marco Legal, Estratégico y de
Políticas Públicas que dan Énfasis en los Procesos de Participación e Incidencia Social Existente en los Sistemas Públicos de Salud

Downloaded from [Link] by University of Washington Law School - Gallagher Law Library user on 02 October 2025
de la Región Centroamericana. Ministerio de Asuntos Exteriores y de Cooperación/Medicus Mundi/AECID.
Google Scholar Google Preview WorldCat COPAC

Merson M. 2015. Why should North Carolinians care about global health? The Herald-Sun, July 15.
WorldCat

Messac L and Prabhu K. 2013. Redefining the possible: The global AIDS response. In Farmer P, Kim JY, Kleinman A, and
Basilico M, Editors. Reimagining Global Health an Introduction. Oakland: University of California Press.
Google Scholar Google Preview WorldCat COPAC

Michau L, Horn J, Bank A, Dutt M, and Zimmerman C. 2015. Prevention of violence against women and girls: Lessons from
practice. Lancet 385(9978):1672–1684.
Google Scholar WorldCat

Minaya G and Roque J. 2015. Ethical problems in health research with indigenous or originary peoples in Peru. Journal of
Community Genetics 6(3):201–206.
Google Scholar WorldCat

Moyi Okwaro F and Geissler PW. 2015. In/dependent collaborations: Perceptions and experiences of African scientists in
transnational HIV research. Medical Anthropology Quarterly 29(4):492–511.
Google Scholar WorldCat

Nakad J. 2016. Care for where there is no justice: The modern history of street medics and how they support social movements.
Hesperian Health Guides Blog, January 6.
WorldCat

Okonta PI. 2014. Ethics of clinical trials in Nigeria. Nigerian Medical Journal 55(3):188.
Google Scholar WorldCat

Ooms G. 2015. Navigating between stealth advocacy and unconscious dogmatism: The challenge of researching the norms,
politics and power of global health. International Journal of Health Policy and Management 4(10):641.
Google Scholar WorldCat

Palatino M. 2015. Myanmarʼs ribbon movements challenge militarization. The Diplomat, October 10.
WorldCat

Pang T. 2011. Global health research: Changing the agenda. In Benatar S and Brock G, Editors. Global Health and Global Health
Ethics. Cambridge: Cambridge University Press.
Google Scholar Google Preview WorldCat COPAC

Panter-Brick C, Eggerman M, and Tomlinson M. 2014. How might global health master deadly sins and strive for greater virtues?
Global Health Action 7(10).
Google Scholar WorldCat

Parker M and Allen T. 2014. De-politicizing parasites: Reflections on attempts to control the control of neglected tropical
diseases. Medical Anthropology 33(3):223–239.
Google Scholar WorldCat

Pfei er J. 2003. International NGOs and primary health care in Mozambique: The need for a new model of collaboration. Social
Science and Medicine 56(4):725–738.
Google Scholar WorldCat

Pfei er J, Johnson W, Fort M, et al. 2008. Strengthening health systems in poor countries: A code of conduct for
nongovernmental organizations. American Journal of Public Health 98(12), 2134–2140.
Google Scholar WorldCat

Downloaded from [Link] by University of Washington Law School - Gallagher Law Library user on 02 October 2025
PHM. 2012. The final Cape Town call to action. [Link]
Accessed June 8, 2016.
WorldCat

———. 2016. Peopleʼs Health Movement. [Link] Accessed June 8, 2016.

WorldCat

PHM, Medact, Medico International, et al. 2014. Global Health Watch 4: An Alternative World Health Report. London: Zed Books
Ltd.
Google Scholar Google Preview WorldCat COPAC

Pinto AD, Cole DC, ter Kuile A, et al. 2014. A case study of global health at the university: Implications for research and action.
Global Health Action 7:24526.
Google Scholar WorldCat

Pinto AD and Upshur REG. 2009. Global health ethics for students. Developing World Bioethics 9(1):1–10.
Google Scholar WorldCat

Post L and Glassman A. 2016. Six ways the next US President can do better on global health. [Link]
ways-next-us-president-can-do-better-global-health. Accessed September 17, 2016.
WorldCat

Presidential Commission for the Study of Bioethical Issues. 2011. “Ethically Impossible” STD Research in Guatemala from 1946 to
1948. Washington, DC.
Google Scholar Google Preview WorldCat COPAC

Reid‐Henry S. 2016. Just global health? Development and Change 47(4):712–733.

Google Scholar WorldCat

Reverby SM. 2009. Examining Tuskegee: The Infamous Syphilis Study and its Legacy. Chapel Hill: University of North Carolina
Press.
Google Scholar Google Preview WorldCat COPAC

———. 2011. “Normal exposure” and inoculation syphilis: A PHS “Tuskegee” doctor in Guatemala, 1946–1948. Journal of Policy
History 23(1):6–28.
WorldCat

———. 2016. Restorative justice and restorative history for the sexually transmitted disease inoculation experiments in
Guatemala. American Journal of Public Health 106(7):1163–1164.
WorldCat

Riggirozzi P. 2015. Regionalism, activism, and rights: New opportunities for health diplomacy in South America. Review of
International Studies 41(2):407–428.
Google Scholar WorldCat

Right Livelihood Award. 2013. Denis Mukwege. [Link] Accessed June 2, 2016.
WorldCat

Roa AC and Silva FRB. 2015. Fiocruz as an actor in Brazilian foreign relations in the context of the Community of Portuguese-
p. 645 Speaking Countries: An untold story. História, Ciências, Saúde-Manguinhos 22(1):153–169.
Google Scholar WorldCat

Rodríguez MI. 2009. Construyendo la esperanza: estrategias y recomendaciones en salud 2009–2014. San Salvador: Ministerio de
Salud de El Salvador.

Downloaded from [Link] by University of Washington Law School - Gallagher Law Library user on 02 October 2025
Google Scholar Google Preview WorldCat COPAC

Roy A. 2004. Help that hinders. Le Monde Diplomatique. November. [Link] Accessed June 8,
2016.
WorldCat

Santana JP. 2011. Um olhar sobre a Cooperação Sul-Sul em Saúde. Ciência & Saúde Coletiva 16(6):2993–3002.
Google Scholar WorldCat

Schrecker T. 2016. ʻNeoliberal epidemicsʼ and public health: Sometimes the world is less complicated than it appears. Critical
Public Health 26(5):477–480.
Google Scholar WorldCat

Schu an C, Turiano L, and Shukla A. 2009. The right to health: A Peopleʼs Health Movement perspective and case study. In
Clapham A and Robinson M, Editors. Realizing the Right to Health Swiss Human Rights Book Vol. 3. Zurich: Rü er & Rub.
Google Scholar Google Preview WorldCat COPAC

Shi man J. 2014. Knowledge, moral claims and the exercise of power in global health. International Journal of Health Policy and
Management 3(6):297–299.
Google Scholar WorldCat

Simkhada P, Regmi PR, Pant PR, et al. 2015. Stipulating citizenʼs fundamental right to healthcare: Inference from the Constitution
of Federal Republic of Nepal 2015. Nepal Journal of Epidemiology 5(4):516–517.
Google Scholar WorldCat

Smith E, Hunt MR, and Master Z. 2014. Authorship ethics in global health research partnerships between researchers from low-
medium income and high income countries. BMC Medical Ethics 15(42).
Google Scholar WorldCat

Smith L, Kasper J, and Holtz TH. 2013. Applying liberation medicine and accompanying communities in their struggles for health
and social justice. In Birn A-E and Brown TM, Editors. Comrades in Health: U.S. Health Internationalists, Abroad and at Home. New
Brunswick, NJ: Rutgers University Press.
Google Scholar Google Preview WorldCat COPAC

Smith-Nonini S. 2010. Healing the Body Politic: El Salvadorʼs Popular Struggle for Health Rights from Civil War to Neoliberal Peace.
New Brunswick: Rutgers University Press.
Google Scholar Google Preview WorldCat COPAC

Snyder J. 2012. Exploitations and their complications: The necessity of identifying the multiple forms of exploitation in
pharmaceutical trials. Bioethics 26(5):251–258.
Google Scholar WorldCat

Stedile JP. 2002. A movement of movements: Landless battalions. New Le Review 15:77–104.
Google Scholar WorldCat

Tiessen R and Huish R, Editors. 2014. Globetrotting or Global Citizenship?: Perils and Potential of International Experiential
Learning. Toronto: University of Toronto Press.
Google Scholar Google Preview WorldCat COPAC

UN. 2015. Secretary-General, in Message for World Diabetes Day, Says People Must Take Steps towards Healthy Lives, while
 Governments Create Conditions to Stem Disease. [Link] Accessed June 2, 2016.
WorldCat

University of Western Cape. 2013. About the School of Public Health. [Link]
[Link]. Accessed June 2, 2016.

Downloaded from [Link] by University of Washington Law School - Gallagher Law Library user on 02 October 2025
WorldCat

Varmus H and Satcher D. 1997. Ethical complexities of conducting research in developing countries. New England Journal of
Medicine 337(14):1003–1005.
Google Scholar WorldCat

Velásquez G and Alas M. 2016. The slow shipwreck of the World Health Organization? Third World Network, May 19.
WorldCat

Ventres WB and Fort MP. 2014. Eyes wide open: An essay on developing an engaged awareness in global medicine and public
health. BMC International Health and Human Rights 14(29).
Google Scholar WorldCat

Ventres W and Guso G. 2014. Poverty blindness: Exploring the diagnosis and treatment of an epidemic condition. Journal of
Health Care for the Poor and Underserved 25(1):52–62.
Google Scholar WorldCat

Ventura D. 2013. Public health and Brazilian foreign policy. SUR International Journal On Human Rights 10(19):95–113.
Google Scholar WorldCat

Weigel J, Basilico M, Kerry V, et al. 2013. Global health priorities for the early twenty-first century. In Farmer P, Kim JY,
Kleinman A, and Basilico M, Editors. Reimagining Global Health an Introduction. Oakland: University of California Press.
Google Scholar Google Preview WorldCat COPAC

Wemos Foundation. 2010. The Globalization of Clinical Trials: Testimonies from Human Subjects. Amsterdam: Wemos Foundation.
Google Scholar Google Preview WorldCat COPAC

White HN and Dijkstra AG. 2003. Aid, debt and dependence: Programme aid in Nicaragua. In Programme Aid and Development:
Beyond Conditionality. London: Routledge.
Google Scholar Google Preview WorldCat COPAC

WHO. 1976. Introducing WHO. Geneva: WHO.

Google Scholar Google Preview WorldCat COPAC

———. 2016. Global Health Observatory Data Repository. [Link] Accessed June 2, 2016.
WorldCat

Wilson J. 2015. The village that turned to gold: A parable of philanthrocapitalism. Development and Change 47(1):3–28.
Google Scholar WorldCat

Yamey G, on Behalf of the Interviewees. 2007. Which single intervention would do the most to improve the health of those living
on less than $1 per day? PLoS Medicine 4(10):1557–1560.
Google Scholar WorldCat

Yamin AE. 2011. Power, su ering, and courts: Reflections on promoting health rights through judicialization. In Yamin AE and
Gloppen S, Editors. Litigating Health Rights: Can Courts Bring More Justice to Health? Cambridge, MA: Harvard University Press.
Google Scholar Google Preview WorldCat COPAC

p. 646 Young IM. 2011. Justice and the Politics of Di erence. Princeton: Princeton University Press.
Google Scholar Google Preview WorldCat COPAC