Global Health Warning: Definitions Wield Power; Comment on 'Navigating between Stealth Advocacy and Unconscious Dogmatism: The Challenge of Researching the Norms, Politics and Power of Global Health'

Gorik Ooms recently made a strong case for considering the centrality of normative premises to analyzing and understanding the underappreciated importance of the nexus of politics, power and process in global health. This critical commentary raises serious questions for the practice and study of global health and global health governance. First and foremost, this commentary underlines the importance of the question of what is global health, and why as well as how does this definition matter? This refocuses discussion on the importance of definitions and how they wield power. It also re-affirms the necessity of a deeper analysis and understanding of power and how it affects and shapes the practice of global health.

I n this journal, Gorik Ooms recently made a strong case for considering the centrality of normative premises to analyzing and understanding the underappreciated importance of the nexus of politics, power and process in global health. 1 Here and elsewhere, 2 he argues that if global health scholars continue to avoid acknowledging and debating normative notions, they "not only mislead each other, " but risk limiting the evolution and maturation of the field of global health. Ooms recognizes that while public health at the national level is usually predicated on the norm that it is the state's responsibility for improving health, there is no such equivalent norm for global health. This lack of a unified narrative normative framework at best limits the evolution of global health as a field and at worst endangers the coherence and maturation of the field. Building on Ooms, there are numerous normative narratives within global health which compete to capture policy-makers' attention and resources. Consider the recent example of the Ebola outbreak in West Africa to illustrate what this means and why it matters. Some advocates within global health call and have been calling for using burden of disease analysis to be used for setting priorities, but as Grepin recently noted, "if burden of disease metrics are the only criterion that should be used to set resource allocation priorities, then, according to this logic it was perfectly acceptable that the world invested so little in epidemic preparedness, such as Ebola. " 3 Given the impact of the outbreak, this now appears questionable. Other actors within global health advocate adherence to the International Health Regulations for determining which health challenges constitute priorities in terms of a Public Health Emergency of International Concern (PHEIC); however, as Yach et al recently described, "the current framing of health security focuses almost entirely on infectious diseases" and largely overlooks other threats to global health like non-communicable disease (NCD). 4 The case of HIV/AIDS also offers a few different examples with advocates arguing alternatively that HIV/AIDS was a security threat, a looming economic disaster or a challenge to human rights and law. In these examples, as Ooms warns, actors and advocates avoid stating their normative values and risk serving as "stealth advocates" overstating their case. But what does this mean, why does it matter and how does it limit the maturation of global health as a field? Ooms' commentary raises critical questions for the practice and study of global health and global health governance. First and foremost, this underlines the centrality of the question of what is global health, and why or how does this definition matter? This refocuses discussion on the importance of definitions and how they wield power. It also re-affirms the necessity of a deeper analysis and understanding of power and how it affects and shapes the practice of global health.

What Is Global Health and Why Does It Matter?
Defining and determining what is and what is not considered global health remains contested. Global health was coined partly in response to globalization and the rise of the field of global governance, which explicitly identified the rise of other actors alongside or beyond the state. Whereas public health acknowledges the state as a dominant actor, global health recognizes the rise of other actors like international institutions, civil society and the private sector affecting health and health policies transcending states. Yet in reality, the practice of global health often focuses on health in poor countries in Africa and Asia, and still represents more of a continuation of the field of international health. 5 The field of global health rarely addresses the interconnected nature of truly "global" health challenges between and across continents. As Frenk et al argue, "the notion of global health fails itself to capture the essence of globalization [and there is a real] need to globalise the concept of global health. " Largely influenced and shaped by the HIV/AIDS emergency, 6 the current field of global health is, as Kleinman argued, "more a bunch of problems than a discipline. " 7 Lacking a clear definition limits research, which inhibits understanding as well as the possibility of improving health. While an agreement on a single definition of global health remains contested and elusive, there is a growing consensus around the importance of why and how a definition matters. 8,9 It matters for which issues are and are not considered, which issues receive funding and accordingly which issues are studied and addressed. How global health is understood influences which health challenges are addressed, the design of how funds are raised and allocated, the public discourse and how policy-makers consider issues, the education of students as well as the creation of institutions. 10  normative global health agenda. In fact, the MDGs became the overarching framework for global development efforts and are "arguably the most politically important pact ever made for international development. " 11,12 Fukuda-Parr and Hulme argue the MDGs represent a new "super-norm. " 11,13 The MDGs both reflected an emerging conceptualization of global health, and contributed to advancing this conceptualization. Indeed, even in 2014, roughly $23 billion out of a total of $36 billion of Development Assistance for Health (DAH) was directed towards MDGs Four, Five, and Six whereas only $611 million was directed towards NCDs. While the spending of DAH is one way to exert influence, this conceptualization of global health in line with the MDGs, a new normative framework to end poverty, also shapes and determines which issues and challenges are considered and researched. In other words, normative views and frameworks can exert power, and as Shiffmann cogently argues, "power is exercised everywhere in global health although its presence may be more apparent in some instances than others. " 14

Understanding Power and How It Affects Global Health
The role of politics and power in determining policy are often underappreciated and underutilized. As Ooms' commentary as well as others in this journal demonstrate, there is a need for a much deeper and more nuanced understanding of power in global health. As Erasmus and Gilson argue, "power, a concept at the heart of the health policy process, is surprisingly rarely explicitly considered in the health policy implementation literature. " 15 Who has and exerts power, and how? What are the resources of power? The most obvious resource in global health are financial or material resources, but there are also other resources and ways to express power. To better understand how power is exerted, there is a need to identify and develop methodologies for assessing power in global health. Global governance scholars Barnett and Duvall present a useful framework for understanding power, which they define "as the production, in and through social relations, of effects that shape the capacities of actors to determine their circumstances and fate. " 16 They differentiate between specific and diffuse relations as well as direct and indirect forms of power-namely, compulsory (direct power, such as use of military or legislative force), institutional (indirect power, such as how international institutions are designed to favor one actor over another), structural (the overall constitution or framework of actor and their roles) or productive (control over the possession and distribution of resources) power. 17 Beyond methodologies, there is a need for a number of case studies to illustrate how different actors -institutions, states, non-governmental organizations (NGOs), private sector organizations, and networks -use and exert power to establish authority and legitimacy in global health. One of the classic examples is the role of the tobacco industry in exerting power to manipulate global health policy, but more recently, evidence of other private sector actors, like Coca Cola, have come under greater scrutiny for their efforts to fund research and shape public discussions. But there are many other examples that are less prominent and less well-understood. For example, consider the role of various NGOs working across Africa-these often work on behalf of the foreign governments or wealthy individuals advising governments and delivering health services, or the role of states like Germany or Japan using the G7 to shape new priorities for global health spending. Alternatively, institutions like the World Bank try to shape and influence discussions around responding to the Ebola crisis and reforming global health governance. Having a more robust understanding of how power is exerted also enables a discussion to consider effectiveness. While there are some frameworks that examine agenda-setting in global health, 18 there is not yet an established methodology or framework to assess and measure effectiveness in exerting power to influence and shape global health policy. Of course, understanding the importance of the definition of global health and how it exerts power requires some reflection on who is practicing global health and how. While some argue that "global health is usually more inclusive of social sciences than public health or international health" it will require much greater efforts to ensure that global health is truly multi-disciplinary. How might this happen? How could we accelerate the evolution and maturation of global health? This question should be at the top of the agenda in academic centers of excellence and the leading journals in global health.

Ethical issues
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Competing interests
Author declares that he has no competing interests.