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Abstract

Jeremy Shiffman’s editorial appropriately calls on making all forms of power more apparent and accountable, notably productive power derived from expertise and claims to moral authority. This commentary argues that relationships based on productive power can be especially difficult to reveal in global health policy because of embedded notions about the nature of power and politics. Yet, it is essential to recognize that global health is shot through with power relationships, that they can take many forms, and that their explicit acknowledgement should be part of, rather than factored out of, any reform of global health governance.

For any student of political science, the first and foremost concept to be grappled with is power. Politics, by definition, is the theory and practice of influencing others, spanning social relationships from the interpersonal to global levels. As such, the distribution and exercise of power lies at the heart of politics. Political scientists spend much of their time defining, identifying, measuring and explaining power – especially how it is exercised in varied domains and with what consequences (1).

In the health field, however, politics and power evoke a love-hate relationship. Biomedical approaches, which have been traditionally dominant, seek to apply principles of the natural sciences to identify and treat disease through evidence-based interventions. For those striving for scientific truths, to be applied without normative bias, politics is an interference with rational decision-making. The exercise of power is thus perceived in disparaging terms as a factor to be minimized or excluded. Social medicine approaches, in contrast, seek to understand how social and economic conditions shape patterns of health and disease. Health policy goes far beyond finding and applying scientific facts. Power and politics are recognized as central to, and even intertwined with the task of, addressing the broad determinants of health. As Rudolph Virchow famously wrote, “Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician...must find the means for their actual solution” ().

This tension, between efforts to rationalize power out of health policy, and to embrace it as a necessary evil, is acutely evident in global health policy. There is perhaps no other field of collective action, in recent decades, that has attracted more public attention, resources and commitments to action. Since the 1990s, there has been an explosion of new actors and institutional arrangements seeking to protect and promote health across the world. This collective action has yielded some remarkable successes, most notably the steep decline in maternal and under five infant mortality. There have also been disappointments in the form of neglected diseases, belated global outbreak responses, and the alarming rise in non-communicable diseases among others. Interestingly, while the former are frequently attributed to scientific and technological breakthroughs, the latter are often blamed on political interference and related failings.

These limited notions of power in global health are what Jeremy Shiffman () seeks to challenge in his thought provoking editorial. His core argument is that power takes many different forms, from its overt exercise by the “haves” to coerce the “have-nots” (might equals right), to more subtle forms that can elude detection. Shiffman challenges us to interrogate the role of structural power, exercised through “how we define ourselves in relationship to one another”, and productive power, expressed in “how we create meaning, particularly through the use of categories that lead us to think about the world in some ways but not others”. These forms of power are often hidden, even to those who hold and exercise them. Yet they are no less potent, and perhaps even more concerning, because they can lead to unintended consequences.

Shiffman’s call for a fuller unveiling of power is critically important for better understanding global health policy and outcomes. Of particular significance is his concept of productive power which has so far been least scrutinised. His three examples – the Institute for Health Metrics and Evaluation (IHME), The Lancet, and the post 2015 Sustainable Development Goals (SDGs) – call for greater reflexivity at the very pinnacles of the global health community. Researchers may shy away from studying certain subjects for fear of compulsory power being used to exclude scholars from publishing or receiving grant funding. Structural power enables certain state and non-state actors in global health development, well-intended or otherwise, to shape the behaviour of aid recipients. Both forms of power deserve our concern. However, few have interrogated the impact of productive power in global health whereby purveyors of “truth” emerge, gain legitimacy and define the validity of certain problems and solutions. Shiffman’s examples illustrate how the perceived scientific or moral legitimacy held by a few leads to wider acceptance of what should be done in global health policy, but often without sufficient accountability. At best, this can lead to a narrowing of perspective and a failure to ask how things might be done better or how better things might be done. At worst, this can lead to suboptimal health outcomes that serve the interests of some over others.

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As examples of productive power, it is important to go even further and recognize how the three examples engage with politics in different ways. The stated aim of the IHME, the impartial collection and application of health metrics “unimpeded by political, financial, or other types of interference” (4), explicitly seeks to remove politics from its work. The Lancet (one weekly journal plus nine monthly specialty journals), which describes itself as “without affiliation to a medical or scientific organisation” (5), does not shy away from publishing firm views about global health. However, the editors seek to improve the transparency and accountability of political processes, but claim to do so with an “independent and authoritative voice in global medicine” (5). For example, by profiling candidates during World Health Organization (WHO) elections, the journal sees itself as playing the important role of speaking truth to power. The negotiation of the 2015 SDGs is invariably a political process, but it is curious that politics is rarely mentioned in official accounts. The process is described as an “inclusive and transparent intergovernmental process open to all stakeholders, with a view to developing global SDGs to be agreed by the [United Nations] General Assembly” (6).

The key point is that, the notion that scientific truth (defined by selected forms of evidence), independence and multi-stakeholder processes somehow keep politics at bay, ignores how power is embedded within these perspectives. The selected methodologies and use of health metrics is far from value-neutral in its judgements about the economic worth of different stages of life and health conditions. What qualifies as “truth” is reduced to quantifiable measures of problems, such as disability-adjusted life years, and their solutions such as randomized control trials and impact evaluations. The publication by The Lancet of editorials and special series highlighting selected health issues has become, by virtue of the journal’s standing, a potent expression of ideational power. The political nature of the SDG process goes far beyond negotiations to the ways in which proposed goals reach (or do not reach) the final agenda for discussion. What is needed is an understanding of how power shapes what is legitimized and embedded in global health policy as truth.

Shiffman’s typology leads us to ask new questions about how power might be used, and not just abused, in global health. Can a fuller understanding of power actually help improve global health outcomes? We know that power, especially hidden forms, can help explain why interventions may not work as intended. Recognizing power encourages us to reach self-truths about one’s own interests, social position and normative frameworks. Most intriguingly, can power be recognized as a variable, not to be denied or factored out of decision-making, but as integral to getting things done. Responding to Shiffman’s important question of whether anything practical can actually be achieved without power, of course, the strong armed tactics associated with coercive power is frowned upon today in most settings. But we might go further and ask how structural or productive power might be harnessed to serve, rather than obfuscate, global health efforts? Two-thirds of childhood deaths annually in the developing world, for example, could be prevented by implementing proven interventions such as vaccines, antibiotics and oral rehydration therapy (7). While scientists scratch their heads, wondering why so many technically proven interventions fail to be implemented, we might be better off asking explicitly how power needs to be harnessed and used to facilitate action.

It is this challenge which is arguably at the centre of the current transition from international to global health governance. The precipitous decline of WHO can be described as reflecting a loss of material power, as the organization has become starved of resources, but also the loss of productive power. A concentration of technical expertise in WHO underpinned the organization’s leadership role for decades. Since the 1990s, this position has been eroded by experts working outside WHO offering new types of knowledge and competing ideas. The World Bank was the first pretender to the throne, using its material resources to wield ideational power over loan recipients. Over the past two decades, at least 40 bilateral donors, 26 United Nations (UN) agencies, 20 global and regional funds, and 90 global health initiatives have emerged (). It might be argued that the proliferation of new initiatives has been a success story, a reflection of increased support and priority given to global health issues. Alongside the influx of resources, however, has come a dispersal of material and ideational power across a large number of players. Is this laissez-faire approach to global health achieving desired outcomes or would a system of global governance that concentrates power achieve collective action more effectively ?

The flawed response to health emergencies, such as the Ebola virus outbreak, the plateauing of budgets after a tripling of global health aid over the past fifteen years to 31 billion US dollars (), and growing demands to demonstrate impact have intensified calls for more effective global health governance. Building on Shiffman’s editorial, we need to see this task as one, not of creating a value-neutral arbiter, which applies scientific facts, to mediate among stakeholders. Rather, global health is shot through with power relationships, that it takes many forms, and that their explicit acknowledgement should be part of, rather than factored out of, any reform of global health governance. In some situations, such as public health emergencies of international concern, it might be desirable to concentrate power to enable decisive action. For other tasks, such as the setting of normative frameworks, power should be distributed widely to enable broad participation. In all cases, power must be continually revealed, managed and adjusted. In this context, it is productive power that will be most important in a world defined increasingly by global interconnectedness, social networks and open sourcing. We must be prepared to speak truth to power. But, we must also be capable of recognizing power within what we hold to be true.

Acknowledgments

The author is supported in part by the National Cancer Institute, US National Institutes of Health under award number R01-CA091021; and the Canadian Institutes of Health Research, Funding Reference Number 126667. The contents of this paper are solely the responsibility of the author and do not necessarily represent the official views of the funders.

Competing interests

Author declares that she has no competing interests.

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Author’s contribution

KL is the single author of the manuscript.

Notes

Citation: Lee K. Revealing power in truth: Comment on 'Knowledge, moral claims and the exercise of power in global health'. Int J Health Policy Manag 2015; 4: 257–259. doi: 10.15171/ijhpm.2015.42

References