Rethinking Global Health: Frameworks of Power

Book Title: Rethinking Global Health: Frameworks of Power

Author: Rochelle A. Burgess

Publication Details: Routledge, 2024, 140 pp., $39.99 paperback

Global health means a wide variety of things to different people. To Professor Rochelle Burgess, it is largely defined by power. Yet in the first paragraph of the book, she points out that even power lacks a single definition.

In the introduction, the author defines global health—in its purest idealism—as a discipline that exists to respond to struggles faced by individuals, families, and communities. However, global health has become fashionable and has attracted significant financial resources, which have not benefited its original mission.

Equally unsurprising is that the influx of interest and funding have introduced a variety of different exercises of power into play in the discipline: economic power, decision-making power, structural power, productive power, institutional power, moral power, expertise power, discursive power, and network power. The majority of these are extrinsic to the populations that are being “helped,” resulting in priorities and agendas being set by stakeholders who are not integral to the communities being served.

This imposition from outside was the theme of a book recently reviewed in this column. ¹ While some exercise power with good intentions, its exercise is not always of benign intent, as was the topic of another book recently reviewed here. ²

Within the first chapter, the author presents an excellent overview of the topics that are fleshed out throughout the book as specific case studies illustrating broader principles. Especially valuable is Table 1.2, which summarizes the principles and directs the reader to the specific chapters where their concepts are more fully developed. More informative than a table of contents and more intuitive than an index, I wish more books provided such a logical guide to their reading!

The case studies range from sex-based violence to mental health to public health emergencies to repeating history. While the first chapter sets the stage, and the last chapter summarizes the book’s objectives—both in a fairly cerebral fashion—the intervening chapters provide the personal, up-close, emotional motivation to strive to do things better.

Each of the cases reviewed illustrates how misapplication of power results in erroneous assumptions, incomplete solutions, and imposition of foreign values and priorities upon vulnerable populations. The outcomes are as might be expected: largely failure.

As an example, Chapter 5 reviews the United Nation’s two-tracked effort to eliminate cholera from Haiti following the nation’s first outbreak, introduced by humanitarian efforts in 2010. Track 1 employed typical top-down public health tools and got the most press. However, the second track was founded on community-led activities to rebuild the livelihoods of those most affected. This bottom-up approach was highly successful, prompting a Haitian leader to comment,

Outside of Haiti, though, news of Track 2’s success was scarce, relegated to internal reports buried in the depths of the file rooms. The author suggests that the success of such community-directed programs directly conflicts with the current paradigm where health interventions are planned by powerful external experts outside of the countries where the problems exist.

The closing chapter summarizes some of the lessons that should have been learned from the past and offers suggestions toward what the author calls a transformative global health paradigm. This paradigm is based on community psychology, which is not unexpected given the author’s pedigree as a community health psychologist. Community psychology is defined as

Essentially, this means true partnerships with the local communities rather than an invasion by experts toting the latest western outcome measures to be foisted upon the population.

Table 6.1 echoes Table 1.2 but substitutes for a map of case studies a map to transformative global health. These two tables form effective bookends to the subject of frameworks of power in global health.

This book is a worthy addition to the growing collection of volumes addressing the use and misuse of power in the practice of global health. This perspective of a psychologist is a valuable addition to the voices of physicians, anthropologists, economists, journalists, and others who have contributed on this subject.