Can the Sick Speak? Global Health Governance and Health Subalternity
Round 1
Reviewer 1 Report
The author of this work is obviously very passionate about the failures of the global health institutions and agenda and provides many valid points of critique. However, there is little original or innovative approach to such critique as there are no original research findings presented which could support the critique and provide either empirical or theoretical contributions. Anthropologists have been engaging with the dissonance between local on-the-ground realities and global health projects and programmes for decades and even though there has been some reference to these works, there is no engagement with this scholarship.
This article seems to be a commentary or an academic essay on a given topic without focussing on either a theoretical or an empirical context. I would suggest focussing on one aspect/issue of GHG and develop it throughout rather than try covering everything in a rather superficial manner. While the anger with injustice perpetuated by the GHG is evident throughout this work, the on-the-surface engagement with such a wide range of issues loses its intention to speak the truth to (or rather about) power. This is clearly not an original research article as there are no research findings to support the work. The author makes a lot of propositions and suggestions (for definitions, actions, etc.) but there are no explanations of how the author came up with them and no findings to support these suggestions. A lot of suggestions are made as if they originate as innovative insights stemming from the author, but many of them are not new at all and have been areas of investigation for many researchers. For instance, the exclusion of local communities from GH agenda-setting, the silence and passivity of patients when confronted with biomedical institutions, necropolitics––all these are established research agendas with decades of established and emerging scholarship. Focussing on one issue (or context) would, once again, resolve this problem and would allow you to engage with more issue-related scholarly work.
The idea of “sick-worlds” sounds interesting but it is not yet fully developed in this paper. How is it different from deprivation, health inequalities, and other terms used to describe similar patterns? The author provides the definition at the beginning that people in sick worlds are “arrested by their all-consuming occupation with their health and wellbeing and those of their families and communities.” This definition also applies to “the worried well”: the privileged and healthy sections of population who are preoccupied with their health and its enhancement, often more than the sick. Who are the people in these sick-worlds? Can we talk about “people in the sick worlds” as losing cultural definitions, autonomy, and future potential in any uniform way? How useful is the term that simply describes sick people in the whole world? While illness, negative health outcomes, and exposure to risk are undoubtedly distributed alongside the axis of economic and political inequality, where the most politically marginalised sections will often have the worst health outcomes, it does not seem reasonable to label all countries in the global south as sick-worlds. What about those who are economically, socially, and politically privileged within these countries? For the concept of sick-worlds to work (in some way), it needs to be contextualised and grounded in particular social and political worlds. If the author aims to make an argument that global health programmes should be more in line and according to the needs of local populations, then the same should apply to the concept of sick-worlds. In its current form, the sick-worlds concept does the same thing as institutions of global health by providing a one size fits all solutions. It further divides the world into a binary opposition between “rich” and “poor” countries by making them into “healthy” and “sick.” Avoiding binary thinking allows complexities and differences in local, regional, and national contexts to emerge.
Section “Trickle down moral failure” needs to be contextualised via discussions on the researcher’s positionality: why were the author in these described spaces? Is the author part of the GHG establishment? Was the author conducting research in these locations? Could we hear more about the reasons that the author witnessed these encounters and how their interpretation relates to their training and research agenda? Such vignettes would often be used to illustrate arguments within certain methodological traditions, for instance, in ethnographic writing, but the strength of such illustrations stems from the method itself: one vignette usually illustrates the trends that have been observed during a long-term fieldwork. In this article, it remains unclear where the “authority” of these vignettes and author’s arguments more generally stems from.
Author Response
Dear Reviewer,
Thank you very much for your suggestions. I have improved this paper in the new version.
Reviewer 2 Report
This is a good critical analysis of the current Global health governance environment and dynamics. It proposes a valid argument which however is not a truly original one as empowerment/emancipation of local actors "the sick" is an old concept (and discourse) since Alma-Ata, rather most powerful Global health Actors have driven policy and action apart from that approach and recentered the agenda in a biomedical, western, neoliberal perspective. Nevertheless the paper offers food for thought and is wellcome.
In section 4 epistemic challenge, the author affirms that alternative sets of assumptions are required, indeed there are studies from the Global South that offer such alternative sets of assumptions and space for debate. (see for example ALASAG - Alianza latino americana de salud global). Look at literature for "decolonizing GH" . Thus, it would be more appropriate to say that more is needed.
The author also says in the same section that "GHG situates itself in a space of sovreign-nation states..." indeed in other parts of the paper it becomes clear that GHG is very much under the increasing influence of global corporate-philanthropic- hybrind public-private organizations and other actors. This is indeed one of the main changes from research and practice in international health to global health understood as "globalization and health (its determinants, positive and negative impacts and responses). This should be clarified from the beginning.
Regarding Covid 19 the authors follows the mainstream idea of vaccine hesitancy being mainly a consequence of an ideological battle (possibly true mainly in the USA) instead it must be recognised that there is strong global governance censorship (serving the neoliberal mantra and interests) on any alternative scientific view or discussion on safety and efficacy of the current genetically engineered vaccines, community based care and therapy, etc., as well as lack of transparency, control of the regulator, conflicts of interests,... all aspects that enhance doubts about the imposed vaccine strategy and reject coercion exerted in many countries to impose it. I was surprised that a paper criticizing the neoliberal hegemony in GHG fails to see how it has determined the management of the pandemic, and how the crisis is used to consolidate the neoliberal system. I would suggest to analyse this aspect more in depth. About the different classification of Governance (Global health governance, Global governance for health, Governance for Global health) please see also Kickbusch. Indeed a number of authors would suggest that Global governance for health is NOT limited to health authorities and the system of global health actors (defined as Global health governance) but extends ti non health sectors with an impact on health of the population (see also Frenk and Moon) That you quote in your paper. This would slightly change the organization of the table in the paper. Finally, altogether thank you for this comprehensive analysis of the global health narrative and governance. Indeed GH is too often used simply as a cosmetic approach to reaffirm neo-colonial perspectives.
Author Response
Dear Reviewer,
Thank you very much for your suggestions. I have improved this paper in the new version.
