Opinion Pieces

Global health knowledge production

For the ordinary citizen, health is a major concern. This is true in countries at all different income levels. Obviously, society at large sets many of the conditions for maintaining health, with an increasingly complex background. In Europe values of equity, solidarity and access to quality health-care are important components of this back-ground. Europe, being one of the major financial markets globally has not been very effective in promoting these values globally. It may also be argued that Europe has not taken its global responsibility as seriously as should be anticipated. Today organizations like EU, UN and WHO express the political will to include health issues in a broader global perspective. To live up to these ambitions, it is essential that Europe has the professional knowledge that is required.

The context

The European commission states in its communication “The EU Role in Global Health” that “The EU needs to act in coordination with the rest of the world in order to generate greater coherence and impact on a global scale”. The Oslo ministerial Declaration on global health states “We believe that health as a foreign policy issue needs a stronger strategic focus on the international agenda”. The UN Secretary General noted at the 64th Session of the UN General Assembly that “Increased dialogue on foreign policy and health, joint analyses of problems and cooperation, at the international, regional and national levels, among key concerned institutions, organizations, ministries and other interested stakeholders can improve policy coherence across sectors and international organizations and lead to better outcomes for global health and foreign policy”. Thus, there is a broad expression of the political will towards a wider integration of various activities to improve health globally. There is also recognition that health may affect foreign policy and relationships between nations. This requires new forms of governance, which include a wide range of actors. We need to ask ourselves whether the knowledge required to support these new demands on governance is provided by the academic systems in Europe.

Disciplinary Ownership

Many different academic disciplines have claimed a stake in global health. Recently, a debate has been raging about what discipline global health should be attributed to. It is obvious that global health is an important component of public health. It is also obvious that the same is true for medicine, as tropical medicine includes many important questions central for global health. It is difficult to exclude political science as it is the knowledge basis for many of the organizations today engaging in global health. Law is the discipline engaged in human rights issues, so it is also central for many of the problems encountered in global health. Social science describes and studies many of the central issues in global health, like gender and equity. Economic sciences present the prerequisite for development and business not only between nations but also inside nations. We believe that none of these disciplines can claim hegemony over global health, but all could and should contribute to it. The classical academic organization which tends to promote a silo structure with little interaction between subjects presents a problem for an area like global health that includes knowledge from many subjects is. Therefore, a new way of organizational thinking must develop to include all aspects and perspectives of global health.

Interdisciplinary Knowledge Production

Knowledge in society is produced and propagated in different ways. The individual acquires knowledge by learning what is already known from text books, lectures and mass media. This process has been called individual knowledge production by Gibbons and Nowotny and is the responsibility of schools, universities and society at large. Although individual knowledge production, or more straightforward – learning – has been a responsibility of the school and university systems, much learning also takes place outside of these systems. This is particularly true if the knowledge required and in demand is not available in the disciplinary systems of traditional teaching institutions. The problem with learning outside of the traditional education institutions is one of quality assurance. The tradition of university teaching has been very firmly based on quality standards, where the knowledge content is based on critical scientific standards. Therefore, we would argue that the academic system should live up to the challenge of teaching global health in an interdisciplinary setting.

Society has acquired knowledge through research, leading to new knowledge which may later be presented in textbooks lectures and so forth to the individual. The scientific publication process also includes critical evaluation of the new knowledge, by peers and by the scientific community at large. This process has been called collective knowledge production by Gibbons and Nowotny. Between collective and individual knowledge production, there is an essential step of translation of knowledge. Research has been organized largely through academic disciplines and is only indirectly affected by the context of needs of new knowledge. There is an increasing awareness that new knowledge production outside of academia and independent of disciplines may be necessary for many of the problems we encounter in the modern society. The traditional forms of knowledge production may be particularly inappropriate to meet the global challenges for health today. Likewise, new ways of presenting knowledge to the individual citizen must be developed to promote health to the individual citizen. The knowledge required for this has a global dimension, but in the relationship to the individual citizen, the responsibility lies in each society.

Transcending disciplines

Traditionally, education is based on disciplines, such as medicine, mathematics, political science and so on. This leads to professions, like physicians, teachers, administrators. In some cases, developing areas of knowledge have required new organizational structures, stretching over several disciplines. This is true for example in public and environmental health. However, in those cases it has been difficult to define and recognize a corresponding profession, even though the knowledge is essential for the development of society. It is obvious from the quotations in the introduction that global health is dependent on interaction between many stakeholders and organizations and a key component of foreign policy. The knowledge required to promote global health therefore comes from many different disciplines. Thus, professions based only on one discipline are not suited for the new challenges of global health, where medicine, public health and political science and many other disciplines all carry weight.

The knowledge of the global health worker is broader than could be acquired by traditional professional educations. New professions, as for example, that of a health diplomat, or a health administrator, are essential for many of the tasks discussed above and this requires new educational programs. An example of this is provided in the new global health program in Maastricht. Such new programs could provide the man-power to translate knowledge to governments and organizations involved in global health issues. The relationship to public health is not self-evident but we believe that the competencies required for global health are broader than those in public health and that attempts to merge public and global health might be negative for the profiles of both areas, Still, a fruitful development of global health would require close interactions with public health.

The need for new organizational structures

The traditional mode of research is also based on disciplines, often established decades or centuries ago. Academic carreers are traditionally based on intradisciplinary research. However, many of the challenges in global health are more complex than can be analyzed by the knowledge of a single discipline. These challenges require cooperation between several disciplines and therefore a new organizational structure. To understand why children in poor countries die from diarrhea, whereas those in rich countries survive, bacteriology is not enough. To understand why myocardial infarction is more prevalent and more lethal among the poor, cardiology is not enough. Other scientific disciplines are necessary as well to really understand these and many other complex global health problems. The traditional universities with the discipline-based hierarchic structure are not optimal for this purpose. It is not surprising that scientists with their foundation in such structures argue whether global health should be property of one or the other of the traditional disciplines, be it public health, medicine, tropical medicine, etc.

It is important for the future development of new knowledge in the field that we recognize that global health is complex and research requires input from many different areas. If universities cannot change to live up to these requirements, it is possible that other organizational structures, like dedicated research institutes are required to allow the development of global health research. Research and its organization should be closely associated with the context of global health, and the required input of knowledge from different disciplines dependent on the individual research question. Research resources for global health in Europe should increasingly be devoted to interdisciplinary research, with perspectives covering several disciplines.

The need to strengthen human resources

For health in society, human resources are a key requirement. Today, there is a shortage of the key health professions both in rich and in poor countries. The affluent countries satisfy their needs by recruitment from poor countries, leading to even more severe shortages there. The costs for training the migrants in the poorer countries are never compensated. Thus, the poor donor countries provide considerable financial support to the negligent rich countries. This is rarely considered in discussions about development aid and in relation to the processes to reach the health-related millennium development goals. In addition to the imbalance in human resources between rich and poor countries, there is an imbalance in human resources for health between rural and urban environments, both in rich and in poor countries. Higher salaries, better working conditions and a more rewarding social environment are driving these imbalances. Obviously, the individual should have the freedom to move to more rewarding conditions. However, for the individual in the countryside in a poor country, this is little consolation. Changes in health system organization may mitigate some of the problems, by task shifts, new forms for recruitment of students to health professions and other measures.

The crisis in human resources for health is affected by many areas of knowledge and politics. Human rights perspectives need to be considered in relation to both the health professionals and the population. Legal as well as illegal migration is affected by foreign policy. The desire for a peaceful and safe environment affects the decisions of health professionals offered a position elsewhere. Thus, the planning for an equitable global distribution of human resources for health requires knowledge from many areas and is not restricted to the traditional areas of medicine and public health. In Europe, there is little recognition about the problems that negligence in training of health professionals impose on other countries. This is in contrast with our stated values of equity, solidarity and access to quality health-care for all.

The need for political engagement

Knowledge in the area of global health needs to be translated to the political arena, and academics with an interest in the area must be open for political engagement to achieve change. It is obvious that the promotion of values which are generally accepted in Europe, like equity, health protection, access to prevention and health care, need coherence and coordination. In addition, these are values that Europe should promote on the global arena. A number of organizations, with an interest in global health issues, met in Geneva in 2008, to discuss what knowledge support would be needed to promote European interests and values in Global Health. As a result of those discussions a platform for further activities for Global Health in Europe was established. It is now named: Global Health Europe: A Platform for European Engagement in Global Health.

Global Health Europe includes academic stakeholders from all disciplines of significance for global health, but also wants to form a bridge to NGOs and the political systems. It is not marking a restricted territory but open to all those interested in the area. There are today a number of initiatives in global health. Global health Europe does not compete with these initiatives but offers a platform for further interactions. The profile of Global Health Europe is broader, and characterized by including more of political science and governance, and closer to the area of policy in particular foreign policy. The initiative is supported by WHO, by governments and NGOs. More recently, a number of academic institutions, primarily from Public Health and Tropical Medicine have formed the European Academic Alliance for Global Health. Both these initiatives would to some extent be European counterparts to the American Consortium of Global Health Universities. However, it is important to recognize that Global Health is not an area restricted to the traditional public health and medical paradigms, but should have a broader perspective including social sciences, political science, law and other knowledge areas.

New forms of organization for knowledge production

Thus, to meet the challenges in global health, new forms for education, new forms for organization of research should be developed. The academic community must be less territorial, and accept that knowledge essential for global health is found in many of the traditional disciplines as well as outside of these disciplines. Knowledge needs to be translated and communicated to the political arena and ultimately to the individual citizen. Global Health Europe is unique in linking policy communities that have not yet systematically worked together in order to forcefully advocate for a determined political and financial commitment to global health by European actors, individual countries, group of countries and European organizations. At its centre are the many European experts, institutions and organizations of excellence in health, social and political science, including foreign relations whose knowledge and insight will help drive a strong European global health agenda based on analysis and evidence. Using the platform of Global Health Europe they will engage as a policy oriented think tank and work directly on policy-based analysis and targeted outreach. The ultimate goal of such activities is to provide the optimal conditions for health for the ordinary citizen – be it within the European Union or in other less advantaged areas of the world. The tool to achieve this goal is the development of new professional education programs. Such programs, with the relevant transdisciplinary basis can be shaped in a fruitful way only through collaboration between different academic disciplines and the society at large.