High expectations are raised about stem cell transplantation as the hopeful answer to a large number of acute and chronic disease conditions for which modern and conventional medicines have little to offer. These stem cell transplants mainly take place in private sector research-cum-hospital set-ups, although some public or state hospitals have also ventured into this field. In recent years, India has emerged as a new global player in this field. Although the evidence of the efficacy of adult stem cells in curing a wide range of disease conditions is questionable, many Indian and Chinese healthcare centres have been carrying out such therapies as experimental research or experimental therapy.
Unable to display preview. Download preview PDF. Skip to main content. Advertisement Hide. This process is experimental and the keywords may be updated as the learning algorithm improves. Any particular analysis thus entails the question of how wide to span the 'vector space'. One could think of distinguishing 'positive' and 'negative' constellations of 'assemblages'. The important entry points and pathways of as well as interactions between the single 'positive' and 'negative' vectors before 'reaching' the ultimate level, however, remain from the author's point of view a 'black box'.
The problem of 'organizing the evidence into a coherent story' by building the evidence up 'link by link' [ 25 ] is not solved if the 'global' itself represents the 'whole picture'. On the other hand, the concept of 'global-as-supraterritorial' adds 'new' objects to existing health related disciplines. With this concept, diseases and illnesses remain what they have been before, that is either medical, public or international health problems; or all of them.
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The disease specific aspects, however, become symptoms of underlying structural determinants AND their supraterritorial links. The object of 'global health', with global-as-supraterritorial, is the analysis of the 'new' social space created by globalization. Globality, in the context of health, then refers to supraterritorial links between the social determinants of health located at points anywhere on earth. As such, representatives of the medical, the public health, or the international health community can engage in 'global health' education, research or practice without producing redundancy.
Building on the generic expertise of their field, representatives of those communities - or the health workforce in general - can broaden their focus towards 'global health'. They can impart and gain knowledge, produce new insights, or develop solutions related to global read: supraterritorial links between the social determinants of health, which are in themselves global read: universal determinants. This concept is adapted from and builds upon the 'social determinants of health model' of Dahlgren and Whitehead [ 27 ] and a model of 'globalisation and health' of Huynen and colleagues [ 28 ].
These models schematically separate determinants of health in layers, beginning with individual and 'proximal' determinants of health and reaching more 'distant' layers.
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It is crucial to note, however, that with the above definition of 'global-as-supraterritorial', the 'distant' layers are not 'distant'. Instead, 'global' read: supraterritorial layers link the determinants of health horizontally anywhere in the world and impact on them through complex pathways, while being influenced by the same or other determinants in a mutual relationship.
Concept of global health. The following underpins the applicability of the concept of 'global-as-supraterritorial' to health, particularly related to the aspects emphasised by Scholte see above notes 1- 4 :. In the context of HIV, malaria and tuberculosis, access to essential medicines is a global read: universal determinant of health and a major public or international health concern.
With 'global health' focusing on the supraterritorial links between this determinant anywhere in the world, the object becomes inevitably linked with international agreements and trade regimes, such as the Trade-Related Aspects of Intellectual Property Rights TRIPS. This agreement, formulated by the World Trade Organization WTO as an international read: interterritorial organization and signed by national read: territorial governments, has a global read: supraterritorial character, since it links the determinant 'access to medicines' anywhere in the world i.
In the context of maternal mortality MM , while global-as-worldwide was not capable of creating 'new' objects for research, education or practice, the concept of global-as-supraterritorial creates interesting and powerful ones see Additional file 1 for analysis, teaching or action for the 'global health community'.
Some examples from the literature are: the role of global read: supraterritorial institutions in impeding [ 29 ] or catalysing efforts to control MM; the impacts of the global read: worldwide and supraterritorial food and economic crises on the determinants of MM, such as nutrition, diet and food availability [ 30 ]; the role of territorial policies with supraterritorial impact on shortages of health professionals [ 31 , 32 ] and thus on quality of care; or legal frameworks and human rights connections of the determinants of MM [ 33 ].
With global-as-supraterritorial, the 'global-health-part' of MM are the social links between the underlying structural determinants of maternal health anywhere in the world. Supraterritorial links between the Social Determinants of Maternal Mortality. This concept adds 'new', namely non-redundant, objects to conventional approaches that analyse maternal mortality via 'global health' concepts with global-as-worldwide or -as-transcending-national-boundaries.
It produces 'clearer', namely more distinct, objects compared to concepts building on global-as-holistic see Additional file 1. This switch of concepts can be observed, for example, when Janes and Corbett explicate key-arenas of research and practice at the interface of 'global health' and anthropology [ 16 ]. While following their line of arguments one realizes that they switch between global-as-worldwide, global-as-transcending-national-borders, and what has been described here as global-as-supraterritorial - whether they are always aware of this fact or not.
In light of their definition of 'global health' see above or [ 16 ] , switching between different concepts is completely legitimate and highly inclusive.
Rethinking the 'global' in global health: a dialectic approach
At the same time, however, the flexibility constitutes the Achilles' tendon of their definition. This soft spot offers a contact point for the same strong critique invoked by Fried and her colleagues, arguing that original fields of 'public health' are repackaged into 'global health' [ 2 ].
As an example: the described conflict could erupt when Janes and Corbett argue that anthropologists' contribution in the field of 'global health' would be to explicate or ground 'health inequities in reference to upstream constellations of international political economy, regional history, and development ideology' [ 16 ] p. Beyond doubt, all contributions cited by them in this particular context have their merit and importance in, what they call, 'exposing processes by which people are constrained or victimized or resisting external forces in the context of local social worlds' ibid.
Nevertheless, the engagement with these unspecified upstream constellations could also pertain to a critical 'public health' discipline, conceptualised as an equity focussed, investigative and confronting discipline, aimed at improving the lives of the vulnerable by identifying, mitigating or opposing structural violence on 'local social worlds'.
On the contrary, a 'global health' approach that consciously and explicitly applies the concept of global-as-supraterritorial would focus on exposing the links between processes by which people anywhere in the world 'are constrained or victimized or resisting external forces'. An important part of the force of this specification would be that the 'global-health-part' of explaining health inequities [ 16 ] would, firstly, not completely overlap with public health or other disciplines.
Secondly, it would move the view of the 'global health community' per definition on to the burning supraterritorial issues, which Janes and Corbett indentify in their 'key-arenas' such as ecosocial epidemiology, climate change, circulation of science and technology, pharmaceutical governance, patent protection or the power of consultancy agencies [ 16 ]. Another exercise of re-thinking the 'global' demonstrates the applicability of the proposed concept.
Apply the global-as-supraterritorial in context with the notion of 'inherently global health issues' IHGIs , a term coined by Labonte and Spiegel [ 36 ]. Now ask yourself, both in light of all the above and the reasoning presented for IGHIs [ 36 ], why the issues presented there could be regarded as 'global' health issues. The issues are indeed IGHIs see also under "Global as supraterritorial" , but not only because of their inherent quality of being of 'universal' importance for people everywhere or worldwide.
Also not because of their ability to 'transcend national borders' [ 36 ], which again entails the how-many-borders-question leading to nowhere. More specifically, and less redundantly, it is because the IGHIs either constitute, house or draw our attention to distinct links between social determinants of people's health anywhere in the world.
In this context, it is worthwhile to have a look at Labonte and Torgerson's complex framework for health impacts of globalization see Figure 2 in [ 25 ] , in which the IGHIs extend from household to global 'levels'. Their illustration of the framework indicates that they also attribute to the IGHIs the 'holistic' concept, including the ambiguous quality of local-global-simultaneity on this quality see above notes and the below ' Reflections on global-local- and global-global-relationships '. But even with this reasoning we are again at the same point of discussion: the global-as-universal, -as-transcending-national-borders, or -as-holistic alone does not allay the critique invoked by a critical 'public health' or 'international health' discipline claiming to be coequally concerned with IGHIs.
Introducing the 'supraterritorial' in the analysis of pathways towards the territorial manifestations e. It can unite different disciplines in analysing these links, namely the supraterritorial part of the IGHIs for example: virtual water in 'water shortage'; the military-industrial-academic complex or arms trade in 'war and conflict'. Admittedly, the concept of global-as-supraterritorrial is very close to global-as-transcending-national-boundaries see Additional file 1.
In contrast to the latter concept, however, the 'supraterritorial' is more specific about the character of the process and does not cause redundance with inter- or trans-nationality by falling back into methodological territorialism. Methodological territorialism here means getting caught in the trap of thinking in pure geographic terms, e.
By avoiding this, health policies in the European Union see Introduction remain transterritorial policies as long as they influence the determinants of health in a specific transnational territory ; and do not become global read: supraterritorial ones per definition as long as the health policies do not link determinants anywhere in the world.
From all the above-mentioned definitions of 'global health', the character of global-as-supraterritorial is most closely aligned to the above definition of the agent described by Dodgson and colleagues, which makes an issue a 'global health issue' [ 15 ]. It is also close to Spiegel and Labonte's notion of 'globalization as determinant of health determinants' [ 37 ]. However, with globality as the supraterritorial link between the social determinants of health located at points anywhere on earth, this agent and the notion of 'globalization' receive more substance for researchers and educators in the field of 'global health'.
This undertaking opens far more chapters than can be addressed here in depth and as such does not claim to be exhaustive for more comprehensive reviews see [ 40 , 45 ]. Does the global-local-relationship inherent in global-as-supraterritorial see above notes 1 - 5 cohere or collide with other views on this relationship? Does the 'global' in global-as supraterritorial cohere or conflict with other views of 'global'?
Studies in the fields of anthropology [ 41 ] and sociology [ 42 ] have applied and provided useful concepts in this context. Building on attempts to 'ground globalization' along the three axes of 'global forces', 'global connections' and 'global imagination', Burawoy stresses that 'globalization is produced' in 'real organizations, institutions and communities' and is thus 'manufactured' [ 43 ].
He emphasises the ambiguous character of the 'global' by noting that '[w]hat we understand to be 'global' is itself constituted within the local; it emanates from very specific agencies [.. According to Burawoy, the 'local' does not oppose the 'global'. Rather, globalization is produced through a chain of connections and disconnections, 'a local connected to other locales' [ 43 ]. Similar to Scholte, he thereby rejects global-local antinomies see above notes 1 - 5.
By stating that the connections all look 'different from different nodes in the chain' [ 43 ], he also emphasises another important issue, namely the position-dependence of observations and the importance of the perspective from which we look at or evaluate the 'global as produced in the local'. The issue of position-dependence is central to the further debate on 'objectivity' in this manuscript and will be taken up again in reflections on normative objectives. The above is also in line with Ginsburg and Rapp's understanding of 'the local' also invoked by Janes and Corbett [ 16 ].
Their understanding of this term 'is not defined by geographical boundaries but is understood as any small-scale arena in which social meanings are informed and adjusted through negotiated, face-to-face interaction.
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By stating that 'transnational or global processes are those through which specific arenas of knowledge and power escape the communities of their creation to be embraced by or imposed on people beyond those communities' ibid. This sense of 'local', although not defined by pure geography in form of national or subnational units, has undoubtedly a territorial quality. Decisions made locally can either have only local read: territorial or both local and global read: supraterritorial impacts. To apply the proposed terminology: decisions, made on Ginsburg and Rapp's 'small-scale arenas', on 'the local' [ 41 ] or on the 'territorial' [ 20 ] must not necessarily, but can influence people's social determinants of health anywhere in the world.
In this case, the decisions themselves, the particular processes, institutions, agencies, legal frameworks and channels through which they are translated, realised, established or imposed constitute the supraterritorial link and thus the 'global' in 'global health'. Framing these links as random 'assemblages' might produce somewhat misleading associations, since they are not passively assembled.
These links and their operational channels and pathways are actively constructed, planned, governed and maintained. They are 'manufactured' [ 43 ] by social actors, formed and coined by their interests, motives and values. These links should be regarded as the 'global' in 'global health' and need the attention of researchers, educators and practitioners. The ambiguity of the 'global' as being both territorial and supraterritorial clarifies how 'local' engagement in 'global' health can be possible. Global-local antinomies and micro-macro binaries are also rejected by Latour [ 44 ], who - from the perspective of Actor-Network Theory see p.
Thus, he draws our attention, firstly, at the 'connectors' that will '[.. Marcus, from an anthropological perspective, also places an emphasis on 'connections' when he argues that '[f]or ethnography, there is no global in the local-global contrast now so frequently evoked. The global is an emergent dimension of arguing about the connection among sites [.. Latour's axiomatic argument that '[n]o place dominates enough to be global and no place is self-contained enough to be local' p.
As such, his call to keep the social flat p. This is especially the case if the above notes 1 - 5 are not actively kept in mind in this context. Recalling that the 'supraterritorial' is understood as 'social links between people anywhere in the world' [ 20 ], or as proposed in the context of health as links between social determinants of people's health anywhere in the world, might ease this apparent?
The following example illustrates this point. Their actions can influence the 'supraterritorial' aspect of the determinant 'access to essential medicines' by framing 'knowledge' as a global read: universal public good. As such, local initiatives or their produced ideas [ 47 , 48 ] can shape or re-frame a global read: supraterritorial social space by influencing or adding to existing determinants and solutions. Supraterritorial associations of locally read: territorially working civil-society organisations can impact on determinants of health locally and at the same time influence determinants globally read: supraterritorially , but not necessarily worldwide or everywhere.
Thus, in response to the first question addressed by this section: the 'global-local-relationship' inherent in the concept of global-as-supraterritorial [ 20 ] coheres with some anthropological and sociological views despite the use of different terminology [ 16 , 41 - 43 ]. But it apparently? Where coherence can be found [ 16 , 20 , 41 - 43 ], the authors argue - in Scholte's words - that 'local sites' can be territorial and supraterritorial at the same time namely when they constitute or produce social links between people anywhere in the world.
So what about the second question, which is concerned with other views on 'global'? The above section titled ' Applying the 'global' to health ' has already shown that i the global-as-supraterritorial collides with notions of global-as-worldwide and -as-transcending-national-boundaries, but ii can be seen as an element of global-as-holistic, or as 'assemblages' see [ 16 , 17 ].
Further notions describe the phenomenon of territorialisation, de-territorialisation and re-territorialisation elsewhere as 'transversal' movement see [ 18 ] and [ 49 ] cited in [ 50 ] or in [ 45 ]. The term refers to a 'movement' that takes place between the intra- and interstate and extends into different political spaces. By invoking this term, Debrix uses an example of the international aid machinery to illustrate how organisations occupy and chart new 'territories', while escaping the spatial confines e.
Territory seems here to be used both in terms of 'social space' and pure geography. If we accept that every de-territorialisation calls for a re-territorialisation [ 18 ] cited in [ 50 ] , one wonders what happens in between these two conditions? Due to the ambiguity and simultaneity of the global-local-relationship inherent in global-as-supraterritorial see above notes 1 - 5 , the supraterritorial space can take a bridging function between the relativist binaries, which are local-as-purely-territorial or un-global and global-as-purely-un-territorial or un-local. So Debrix is right when he concludes in his analysis of MSF's work that 'sociopolitical inclusions and exclusions, and the redistribution of power and knowledge [..
But between the binaries of 'territorial' and ' de- territorial' is what can be understood as the 'global', the 'supraterritorial', the social link between people anywhere in the world, which is not completely bound to territory in terms of geography , but is also not detached completely from the same, especially not in terms of social space.
Debrix thus describes a social space, supra territorial, not de -territorial, created by MSF. This space constitutes a link between people's social determinants of health - namely access to health care - anywhere in the world. Invoking Appadurai's notion of '-scapes' ethno-, media-, techno-, finance-, and ideoscapes [ 51 ] at this place can even help to striate or specify particular social spaces in the yet 'empty' supraterritorial land scape and help to overcome this conflicting constellation supra territorial vs. This notion has been used by Spiegel and colleagues to specify 'globalization' in its interaction with population health see Figure 1 in [ 37 ].
Focusing on 'flows', the notion has been criticised for being theoretically too detached from political economy [ 45 ] and, in the author's view, seems detached from views of the 'global' as produced in the 'local' [ 40 , 43 ]. Bringing both notions global-as-supraterritorial and xy-scapes together, however, helps to attach the '-scapes' in a political social space see above note 5. In the case of Debrix's example of the international aid machinery, the 'transversal movements' take place by creating 'victimhood' [ 50 ], by using or becoming part of mediascapes, by feeding the ideoscapes with ideas of humanitarianism, by exercising power in identifying who is the victim and who not and thereby linking the determinant 'access to health care' of people anywhere in the world.
Thus, in response to the second question of this section: The global-as-supraterritorial might not cohere completely with other notions of 'global', which is fine since complete coherence means redundancy. But it may be assembled with other notions [ 51 ] or amend apparently conflicting ones [ 50 ] to bridge the conceptual gaps and overcome conflicts. Some definitions of 'global health' encapsulate the pursuit of normative objectives, claiming validity for those engaged in the field.
For example, the goal of 'equitable access to health in all regions of the globe' [ 13 ], 'equity in health for all people worldwide' [ 1 ] or the reduction of 'global health inequities' [ 16 ]. Notably, this is not the case for 'global health' composed of 'global-as-supraterritorial' and 'health' if the latter is kept undefined. Although there are no normative imperatives attached, the supraterritorial social space is by no means 'neutral', but houses power relations and power struggles, conflict and cooperation, hierarchy and equality [ 20 ], equity and inequity.
The normative objectives prevalent in existing definitions [ 1 , 13 , 16 ] are surely all reasonable and desirable. Their inclusion in 'global health' definitions can be regarded as an applaudable move. It reflects the 'shift from international health' and concerns associated with colonialism toward the 'good intentions' of the actors involved in the field and the solidarity they share with poor, deprived and vulnerable populations worldwide.
But do these normative objectives de facto reflect the objectives of actors involved in the 'global health' landscape, i. The term 'health-scape' is used here following Appadurai's terminology of '-scapes' [ 51 ] in order to avoid the conflicting constellation of ' supraterritorial health land scape'. In other words: does the attachment of normative objectives to definitions of 'global health' constitute an effective 'line of division' between those who share these objectives and those who don't?
And if not, which problems arise from ineffective 'lines of division'? The following section reflects on problems and merits inherent in the different approaches. The attachment of normative objectives to definitions of 'global health' can be seen as 'fact-value entanglement', a shorthand term for the entanglement of facts, conventions and values in the language we use to describe something see [ 52 ] and [ 53 ] p.
These entanglements and 'common goals' in prominent definitions of 'global health' can be seen as important successes in the 'battle of theories' for a just world. There is no homogenous 'global health community', but there are many diverse 'global health communities', propelled and formed by their own motivations, values and drivers. Thus, the author argues that definitions with attached normative objectives do not truly or 'objectively' reflect what the field of 'global health' actually is , but rather what it should be.
A construct of 'global health', loaded with desirable, normative, but ineffective 'lines of division' can too easily encapsulate those who de facto , viz. As such, the fate of 'global health' might too easily parallel that of buzz- words like 'participation' and 'empowerment', which are meanwhile emptied and partially perverted from their original meaning [ 54 ]. Furthermore, worrying developments in the global health-scape can occur under the cover of desirable, a priori attached normative 'ideals'. These developments cannot be discussed here in depth for all areas, but shall be outlined in the following.
Examples of worrying arenas erupting in research and education are the 'exploding popularity' of 'global health' in Europe and North America [ 3 , 16 , 63 ] and the current asymmetrical 'manner of knowledge creation, exploitation, and exchange' [ 16 ]. Janes and Corbett thus reminiscently forewarn of 'a new form of colonialism' aimed at satisfying 'the needs of science' [ 16 ] rather than the needs of the affected. Massive, unprecedented amounts of funds from private and 'philanthropic' foundations pour into the as yet poorly conceptualised field of 'global health' education [ 64 , 65 ], building on well-attempted but vague and obviously contested [ 2 ] definitions [ 1 ].
The massive involvement of universities in these areas is pushed not only by motives in line with the desirable normative objectives, but apparently also by commercial interests, interests of national security, foreign policy and soft power, blue-washed by human rights rhetoric [ 3 , 64 ]. Too easily may students' highly praised 'interest in global health' [ 63 , 64 ], and with that the potential power of education in this field [ 8 , 66 - 70 ], be hijacked via 'new career paths', the creation of 'global health experts' and 'old' re-labelled patterns of sending institutions [ 64 ] and instrumentalized for not totally un-selfish interests openly [ 11 , 64 ] or less openly [ 58 , 59 , 71 - 74 ] communicated.
Admittedly, some might regard these developments as not 'worrying'. Taking a view from 'some distance' and attempting not to take side between 'worrying' and 'not worrying' leads to an incontestable, 'objective' i. This observation directly follows from the above-outlined i.
As for practice, it is obvious and incontestable that policies, programs and actions are negotiated, implemented or opposed in a highly political environment [ 31 , 58 , 75 - 80 ], worldwide as well as supraterritorially. As indicated above, however, these institutions themselves are nested and operate within higher-level social structures and not in a political vacuum [ 81 ] p. Setting 'global health' research priorities is as a political issue [ 36 , 61 , 82 ] as determining learning objectives and 'career paths' in 'global health' education [ 64 ]. Knowledge, the product of research and substance of education, entails its own political economy in terms of the way it is produced and for what it is imparted.
At the bottom line: 'global health', research, education and practice are nested in a highly 'politicised' environment, locally as well as supraterritorially. All areas accommodate their own , but interdependent political economy. So, what follows from this 'objective' observation for the first 'entanglement-problem'? Allegations claiming that a field, which is inherently 'politicised', becomes 'politicised' by attaching normative objectives can be regarded as annulled. The question is not whether or not 'politicisation' but which 'politicisation'?
Consequently, what remains of the first 'entanglement-problem' as a respectable claim is closely related to the latter question, and is that of 'impartiality' and 'objectivity'. Both of these are not, however, to be blended with ' un- or de- politicisation', as the following illustrates. This 'politicisation', he argues, is not only legitimate, but is the pre-condition of autonomy in science, which cannot be preserved any more un politically today ibid.
The 'politicisation' that he calls for can be regarded as a self-enlightenment of sciences as essential prerequisite of 'autonomy' ibid. The ultimate question is thus, how can we 'impartially' and 'objectively' define objectives in a 'politicised' field of 'global health'? Where can this 'self-enlightenment' in the field of 'global health' be expected to come from?
These questions overlap with the fields of moral and political philosophy and need thorough consideration of the term 'objectivity'. In his book The View from Nowhere , Thomas Nagel characterises 'objectivity' in the following way: 'A view or form of thought is more objective than another if it relies less on the specifics of the individual's makeup and position in the world, or on the character of the particular type of creature he is' [ 83 ]. The merits of seeing objectivity in this way is - as Amartya Sen notes in The Idea of Justice [ 53 ] - that it focuses on 'position independence' ibid.
In contrast to Nagel's characterisation, which requires 'a view from nowhere' to achieve 'objectivity', Sen invokes the term 'positional objectivity' ibid. This term describes the 'objectivity' of person-invariant but position-dependent observations. In an illuminating way ibid. The quality of observations that are made is thus dependent on the observer's positional characteristics e. That is, any person occupying the same position or facing the same conditions would come to the same quality of observations therefore person-invariant and not equal to 'subjective'. This kind of 'objectivity', however, is prone to 'objective illusions'.
These can be understood as 'a positionally objective belief that is, in fact, mistaken in terms of transpositional scrutiny' ibid. That means that parochial position-dependent 'objective' observations, beliefs or decisions need transpositional correspondents, to weigh whether the observation is indeed 'objective' or an 'objective illusion' see for example 'Health, Morbidity and Positional Variations' in [ 53 ], p. To enable transpositional scrutiny, Sen by following Adam Smith's notion of the 'impartial spectator', see [ 84 ] cited in [ 53 ], p.
In these processes, impartial assessments not only can but often must invoke judgments and reasoning from outside a particular group ibid. In a nutshell, Sen regards public reasoning and 'democratisation', in terms of political participation, dialogue and public interaction, as means to reach this end ibid. Thus, we may regard 'democratisation' in this sense as enabler of 'open impartiality' which, in the special case of science and education, would fulfil Habermas's prerequisite 'politicisation' to progress toward a state of 'self-enlightenment' though Habermas's view of 'democratisation' in [ 81 ] was of more institutionalised nature.
Back to the remnant claims of the first 'entanglement-problem': what is the consequence of 'positional objectivity', 'objective illusions' and 'parochial bias' for the claim that goals in the highly 'politicised' field of 'global health' should be set 'impartially' and 'objectively'? With respect to the 'politics of the possible' i. The concept of universal human rights is such an example of 'partial orderings', obtained and accepted via long processes and struggles of 'open impartiality' ibid; pp. Claims of 'partial orderings' to enhance objectives, such as health equity and solidarity, dominate in contemporary definitions of 'global health' [ 1 , 13 , 16 ].
These claims can also be regarded as the congruent, surviving elements of continued - 'historical' [ 86 , 87 ] and contemporary [ 88 , 89 ] - public reasoning worldwide as well as supraterritorially. These objectives, although of normative and 'partial' nature, can be regarded as produced by processes of 'open impartiality' with minimised possibility of 'parochial bias'.
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These claims are, in terms of Nagel's 'objectivity', more objective i. As a consequence from the above, for the first 'entanglement-problem': to 'objectively' determine in which direction 'global health' research, practice and education should go, there might be no other way than 'politicisation' of the field through 'open impartiality', i.
As for the second 'entanglement-problem': in order to avoid that definitions of 'global health' blur the discrepancy between 'reality' and 'ideals', these definitions should abstain from attaching normative objectives a priori and factually describe what the field is , not what it ideally should be. Normative objectives are highly important to frame the debate and to hold all actors accountable to work toward the achievement of obtained 'partial orderings'.
However, as long as normatives neither constitute effective 'lines of division' nor effective enforcement mechanisms [ 62 ], framing should not be done via 'global health' definitions. Framing the debates via 'health' e. The following shows how this solves our entanglement-problems: health as a human right HHR as imperative for partial orderings is factually binding and enforceable though yet with limited effectivity via international law [ 90 ] but not yet fulfilled and violated globally read: worldwide and supraterritorially. Whether the prevailing culture of 'global health' however defined in research, education or practice fulfils the then resulting necessary steps and entailed normative objectives to fulfil HHR cannot be defined a priori.
The question remains subject to empirical and critical, self-reflective scrutiny of the 'global health community'. In this context, the major force of the definition of 'global health', consisting of global-as-supraterritorial and 'health' as defined above would lie in drawing our view:. Education and research in 'global health' thus implies an engagement with the question of how processes of acquiring, distributing and exercising social power in creating these links reduce or maintain violations of HHR.
Also, practitioners organisations, interest groups, politicians etc. By being disengaged from normative objectives, but not disengaged from the above imperative for partial orderings HHR , this definition would draw the attention on the bare political economy in and of 'global' read: supraterritorial and worldwide health actions and actors. With global-as-supraterritorial, the 'global' in 'global health' is both neutral i.
The field is about building and re-building, researching and analysing, teaching and learning the links between social determinants of people's health anywhere in the world. Before closing, it is necessary to reflect about three paradoxes involved in defining 'global health'. Definitions draw boundaries around institutional fields and are always simultaneously inclusive and exclusive; while some organisations, practitioners and practices will be inside, others will be outside those boundaries. Thus, the first paradox in attempts to define 'global health' is reflected in the effort to draw a boundary around a field, which has emerged due to its 'boundary-transcending' character.
The second paradox is that, by confining the focus of 'global health' on global-as-supraterritorial, the field is widened towards an object, which enables health related disciplines to engage therein while avoiding redundancy and conflicts. The field as such does not become a 'discipline', but rather a field highly inclusive of all health researchers, educators and practitioners from different backgrounds who focus on the supraterritorial links between the social determinants of health anywhere in the world. Thirdly, despite the dialectics of the presented concepts of the 'global', these are not exclusive of, but rather complementary to each other.
Global-as-supraterritorial always needs two other 'global' concepts, namely the worldwide as well as the holistic. Similarly, global-as-supraterritorial is useless when regarded in isolation and in a reductionist way: this concept needs to consider the influences on health on international, national, regional, local, community, individual and the biomedical level to assemble the 'whole picture' in a global read: holistic concept to improve health worldwide in the final step.
Due to these three paradoxes, only positive definitions of what 'global health' includes seem to be possible, while negative definitions of what it does not include are highly questionable and depend on the concept of 'global' and frames of 'health'.
Rosemary A. Joyce and Joshua Pollard
That means that all of the above definitions are applicable in their particular context. Also, we have to accept that 'global health' not 'is' , but can be 'public health' [ 2 ] depending on the chosen concept of 'global' - but it can and should be more depending on the same. By this stage, some might be disappointed by the degree of ambiguity they faced throughout the manuscript: the 'local' as both territorial and supraterritorial; the 'global' as supra-territorial but not un- territorial; pursuit of 'objectivity' through 'politicisation' and 'democratisation'; and finally 'definition paradoxes'.
In this context i. Referring to the World Bank, she states that '[e]conomists seem to have succeeded in reaching more or less a commonly accepted definition of globalization, namely as international economic integration that can be pursued through policies of 'openness', the liberalization of trade, investment and finance, leading to an 'open economy'' [ 91 ]. Most of her substantive critique on definitions of 'globalization' can be allayed by reading Scholte [ 20 ].
But the above quote reveals an interesting phenomenon, overseen by Van Der Bly and maybe by readers of this manuscript, who feel uncomfortable with ambiguity and the entailed 'uncertainty'. This phenomenon could be called the omnipresence of ambiguity. Take the above statement as example: what is called 'policies of openness [.. The economic 'openness' is achieved by hard law and binding regulations , which restrict regulatory space see Table III in [ 25 ] for examples of WTO regulations and loss of domestic regulatory space. So the 'globalization' of 'policies of openness' are, at the same time, the 'globalization' of 'policies of restrictions'.
Without global restrictions or regulations, there is no global 'openness'. The apparently clear definition is revealed to be an ambiguous one. So, are ambiguous statements or definitions, theories, frameworks, etc. In this context, Amartya Sen defends the methodological point that '[..
As such, ambiguity is not at all a carte blanche for unreflexive pluralism. Beyond doubt, the plausibility of different concepts and meanings of the 'global' in different contexts is itself an argument against insisting unconditionally on one concept. But the inherent ambiguities, precisely captured and uncovered in this manuscript, call especially on researchers and educators to be clear about which 'global' they mean when researching or teaching 'global health'. Being aware of the ambiguities and controversies presented in this manuscript is necessary for not getting trapped in discussions on 'ins' and 'outs', but to research, teach and work together towards better health for all globally read: as you want, but be specific about it.
The implications of global-as-supraterritorial are not only of theoretical interest, they also have some practical importance for the areas of research, education and practice. One of the anonymous reviewers of this manuscript has argued that 'the definitions of global would be different for each of these three areas'. Acknowledging this fact, the author believes that the debate addresses questions with relevance at the interface of all these three areas.
Whether or not the proposed concept of 'global-as-supraterritorial' can be a common denominator for all three areas or for everyone involved in 'global health' is certainly a subject of debate and as stated above, not necessarily given. The concept, however, can be a starting point for discussing these differences in all three areas. Implications and challenges for 'global health' research can be found in the literature at the interface of social determinants and globalization [ 25 , 37 , 38 , 40 , 93 - 96 ]. These are not 'new' in light of the proposed concept, but gain momentum greatly from it in terms of rational validity when we speak about 'global health' priorities [ 36 , 82 , 97 ].
This manuscript has argued that current definitions of 'global health' lack specificity about the term 'global'. It has shown that common understandings of the element as worldwide or as transcending national boundaries are either misleading or produce redundancy with other health related fields and disciplines. As such, globality adds to the complexity of social space.
It links the social determinants of health and thus people horizontally anywhere in the world and impacts on them people and their SDH through complex pathways. The author has put the proposed concept in context with other views on 'global' and 'local', concluding that the 'global-local-relationship' inherent in the proposed concept coheres not with all but with influential anthropological and sociological views despite the use of different terminology.
Further attention has been paid to problems that follow from normative objectives a priori attached to definitions of 'global health'. The manuscript argues that definitions should abstain from attaching normative objectives a priori and factually describe what the field is , not what it ideally should be.
The author argues for 'democratisation' and 'politicisation' of the field, to obtain and maintain desirable underlying normative objectives of the field. The responsibility of the 'global health community' is then to assess via empirical and critical, self-reflective scrutiny whether the prevailing culture of 'global health' research, education or practice meets these objectives.
The proposed concept, linked with health as a human right HHR , has been argued to be suitable also for this purpose. Social innovations are unlikely to evolve if 'global health' becomes or remains a cosmetic re-labelling of old patterns, objects and interests. Rather, by focussing on the globality of the social determinants of health and the power relations in global read: supraterritiorial social space, professionals involved in health research, education or practice can contribute to analysing, developing and teaching more innovative strategies worldwide toward fulfillment of HHR.
The paradoxes involved in attempts to define 'global health' finally demonstrate that the dialectics inherent in the different concepts of the term 'global' are not exclusive, but rather complementary to each other. The author has captured other ambiguities several times throughout the manuscript and argues against insisting unconditionally on one concept of 'global'.
It is unavoidable that terms have different meanings to different societal actors. The concept presented in this debate, however, has provided a rational validation for arguments to preserve the rhetorical power of the descriptor 'global health' for more 'innovative' forms of research, education and practice compared to common 'global health' discourses. With this manuscript the author hopes to provoke further debates on the crucial issue of conceptualising the field of 'global health'. The author declares that he has no conflict of interest.
This manuscript has been produced as part of the research thesis of KB to gain a scientific degree Dr. It has originally been developed and used by KB and Dr. Peter Tinnemann Dept. KB was responsible for content, conception and design of the manuscript. He drafted and edited the manuscript and produced the figures. He has been involved in student organisations on national Globalisation and Health Initiative, bvmd e.
The author is indebted to Prof. Donegan School of Oriental and African Studies, University of London, UK and two anonymous reviewers for the critical review of previous drafts of this manuscript and for their insightful comments and suggestions. All errors of interpretation are of course entirely the author's. Many thanks go to Victoria Saint for proof-reading and critically reviewing the final draft; Dr. The funding source played no role in the design and content of this paper. The views stated in this manuscript are not necessarily shared by the above individuals or organisations.
National Center for Biotechnology Information , U. Journal List Global Health v. Global Health. Published online Oct Kayvan Bozorgmehr 1. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Kayvan Bozorgmehr: moc. Received May 21; Accepted Oct This article has been cited by other articles in PMC. PDF 19K. Abstract Background Current definitions of 'global health' lack specificity about the term 'global'.
Discussion The manuscript identifies denotations of 'global' as 'worldwide', as 'transcending national boundaries' and as 'holistic'. Summary While global-as-worldwide and global-as-transcending-national-boundaries are misleading and produce redundancy with public and international health, global-as-supraterritorial provides 'new' objects for research, education and practice while avoiding redundancy. Background Last year in The Lancet , Koplan and his colleagues called for a common definition of 'global health' as being 'an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide' [ 1 ].
But, what exactly is 'global' about 'global health'? Discussion The 'health' in global health Since health is understood as physical, mental and social wellbeing and not merely as the absence of disease [ 5 ], it is clear that 'global health' does not mean 'the absence of disease worldwide'. Global health - the definition problem The newly coined term 'global health' reflects the attempt to differentiate the concerns of 'global health' from the traditional focus of interest associated with the term 'international health' [ 8 ].
As is pointed out in the following paragraph, their definition brings key aspects of the above mentioned definitions of 'global health' and 'health' together: "Global health is a field of practice, research and education focussed on health and the social, economic, political and cultural forces that shape it across the world. Denotations of the term 'global' As presented above, the 'global' in 'global health' can be understood in different ways. Global as supraterritorial The globalization process in contemporary history involves the spread of 'reductions in barriers to transworld contacts' and has thus enabled people to become physically, legally, culturally, and psychologically engaged with each other in 'one world'.
Before applying this concept of the 'global' on health, it is crucial to note the following five aspects emphasised by Scholte regarding the 'global-local-relationship' inherent in global-as-supraterritorial: 1. Applying 'global-as-worldwide' to health The 'global-as-worldwide' is misleading and, where applicable i. Applying 'global-as-transcending-national-boundaries' to health With 'global-as-transcending-national-boundaries', neither overnutrition nor undernutrition nor any other non-communicable diseases are directly 'global' health issues.
Applying 'global-as-holistic' to health Similarly, a 'holistic' understanding of the 'global' in 'global health', which includes all influences on health on molecular, individual, regional, national, international and global read: worldwide or transcending national boundaries levels see Additional file 1 is an analytical dead-end.
Applying 'global-as-supraterritorial' to health On the other hand, the concept of 'global-as-supraterritorial' adds 'new' objects to existing health related disciplines. Open in a separate window. Figure 1. Figure 2. The section is specifically concerned with the following two questions: 1.
Reflections on global-local-relationships 1. Reflections on global-global-relationships So what about the second question, which is concerned with other views on 'global'?
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