Global Health and Global Hegemony

by Randall Kuhn

“We must reconcile ourselves to the role of American hegemony in perpetuating the very global inequalities that we hope to in some small way redress."

As the new director of a unique graduate program in Global Health Affairs, coming from the world of basic research, I have been faced with the need to reconcile a central paradox of American power and hegemony: I conduct my work as an American citizen and often with U.S. government funding in the hope that it will make a positive or at least neutral impact on my world. Yet my government (not only under the present administration) initiates imperial adventures that cause untold damage to the health, welfare, and survival of individuals throughout the world. Last year the work of Dr. Les Roberts and colleagues offered a startling quantitative accounting of the direct mortality consequences of the war in Iraq. In this month’s HRHW Roundtable selection, “Women Come Last in Afghanistan,” Ann Jones offers a personal account of the more lasting consequences of U.S. intervention for women in Afghanistan. A full account, whether via personal or statistical narrative, of the consequences of U.S. intervention for women’s health, mobility, opportunity, and safety necessitates serious introspection into the relationship between global health and global hegemony.

It is all the more fitting, then, that I read Jones’ piece on a flight home from a workshop on “Global Health Diplomacy” at the University of California at San Diego. As the attendees tried to imagine a meaningful and honest contribution for global health education to diplomacy, I could not help thinking of Herbert Marcuse, who spent his final days in sunny La Jolla railing against the deep psychological and moral toll of the exercise of power, and the Vietnam War in particular, on a society’s mental health:

The consequence is a “psychological habituation of war” which is administered to a people protected from the actuality of war, a people who, by virtue of this habituation, easily familiarizes itself with the “kill rate” as it is already familiar with other “rates” (such as those of business or traffic or unemployment). The people are conditioned to live “with the hazards, the brutalities, and the mounting casualties of the war in Vietnam, just as one learns gradually to live with the everyday hazards and casualties of smoking, of smog, or of traffic.”

The re-branding of “international health” into “global health” reflects a growing sense of shared risk, a sense that the “reservoirs of infection” precipitated by abject living conditions, emerging infectious diseases, and the sort of gross inequities in access to care witnessed on a daily basis in Afghanistan would literally blow back on rich and powerful nations in the form of global pandemics of Avian Influenza, Extensively Drug-resistant Tuberculosis, and the like. Of more immediate concern to Marcuse, however, was the toll these conditions would take on our mental health and our moral imagination. That argument is just as true now as it was when Marcuse reached San Diego in 1965—a potent argument in favor of an honest reckoning of global health and global justice.

America ’s awesome hegemony can numb us to some stark realities. First, American scientists and practitioners abroad are all, in the loosest sense of the word, diplomats representing our nation for better or for worse. Second, calling our own work “apolitical” is a highly political statement, not to mention an overt act of delusion. We must reconcile ourselves to the role of American hegemony in perpetuating the very global inequalities that we hope to in some small way redress. Finally, we must humbly recognize that some global health crises are so unspeakably awful, unforgivable, and seemingly irreparable that it is painful even to view them as part of the same package of basic research, intervention, policy, and evaluation that are the mainstays of the fields of international health and global health.

This is where I hope that programs in Global Health Affairs, in general, can make their mark. Not just by promoting better global health and encouraging “global health diplomacy,” whatever that may entail, through better policy. And not just by making difficult observations about the parlous state of global health politics and the key role of U.S. hegemony in creating these conditions. But by doing both at the same time, so that we may convince our citizens and our leaders that even the most effective policy and programs cannot undo the harm wrought by power wielded without thought or accountability.

Only through a coordinated and intensive combination of programming and political action is it possible to begin to address both the mundane and abject forms of discrimination that pervade our world. Otherwise, the NATO commander’s prognosis for the Afghan campaign will be equally relevant to global health and to the mental health of the American people: “We could actually fail here.”

Randall Kuhn is Assistant Professor and Director of the Global Health Affairs Certificate Program at the Josef Korbel School of International Studies at the University of Denver. A demographer and sociologist by training, Randall's research focuses on the impact of kinship, socio-demographic change, migration, and community on health and well-being in disadvantaged communities throughout the world. His key projects presently focus on the impact of migration on health in migrant-sending communities in Bangladesh and Indonesia, and on the impact of the Indian Ocean tsunami on community health and well-being in Sri Lanka.