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Int
Int JJ Health
Health Policy
Policy Manag
Manag 2016,
2016, 5(2),
5(2), 117–119
117–119
doi
10.15171/ijhpm.2015.188
doi 10.15171/ijhpm.2015.188
Commentary
doi 10.15171/ijhpm.2016.79
http://ijhpm.com
Int J Health Policy Manag 2016, 5(10), 571–573
Politics and Power in Global Health: The Constituting
Editorial Role
of Conflicts
Comment on “Navigating Between Stealth Advocacy and Unconscious Dogmatism: The
Comment on “Navigating Between Stealth Advocacy and Unconscious Dogmatism: The
Diabetes
Dictating
Policy:
An
Editorial
Challenge
of Researching
the Norms,
Politics
and Power Commemorating
of Global Health”
World
Health
DayHeggen,
2016
Clemet
Askheim, Kristin
Eivind Engebretsen
**
Amirhossein Takian1,2,3, Sara Kazempour-Ardebili4*
Abstract
In a recent article, Gorik Ooms has drawn attention to the normative underpinnings of the politics of
Abstract In a recent article, Gorik Ooms has drawn attention to the normative underpinnings of the politics of
global health. We claim that Ooms is indirectly submitting to a liberal conception of politics by framing
The 21st century is an era of great challenge for humankind; we are combating terrorism, climate change,
the politics of global health as a question of individual morality. Drawing on the theoretical works of
poverty, human rights issues and last but not least non-communicable diseases (NCDs). The burden of the latter
Chantal Mouffe, we introduce a conflictual concept of the political as an alternative to Ooms’ conception.
has become so large that it is being recognized by world leaders globally as an area that it is in need of much
Using controversies surrounding medical treatment of AIDS patients in developing countries as a case we
greater attention.
light
of this concern,
the World
Health
Organization
(WHO) dedicated
World
underlineInthe
opportunity
for political
changes,
through
political articulation
of an issue,this
andyear’s
collective
Health Day
(held on April
2016)
international awareness on diabetes, the fastest growing NCD in
mobilization
based7,on
suchtoanraising
articulation.
the world.Keywords:
This editorial
is anHealth,
accountLiberal
of the Politics,
macro politics
place forConflict,
fighting AIDS,
diabetes,
both internationally
Global
ChantalinMouffe,
Antiretroviral
(ARV)
and nationally.
Treatment
© 2016
by Diabetes,
Kerman University
of Medical
Sciences
Keywords:Copyright:
World Health
Day,
Health Policy,
Non-communicable
Disease (NCD)
Citation:
C, Heggen
K, Engebretsen
Politics and power in global health: the constituting role of
Copyright:
© 2016Askheim
by Kerman
University
of MedicalE.Sciences
conflicts:
on “Navigating
between stealth
advocacy
unconscious
dogmatism: theworld
challenge
Citation: Takian
A, Comment
Kazempour-Ardebili
S. Diabetes
dictating
policy:and
an editorial
commemorating
health
of researching
the norms,
and power of global
health.” Int J Health Policy Manag. 2016;5(2):117–
day 2016. Int
J Health Policy
Manag.politics
2016;5(10):571–573.
doi:10.15171/ijhpm.2016.79
119. doi:10.15171/ijhpm.2015.188
DI
Article
Article History:
History:
Received:
2015
Received: 55 September
Article September
History: 2015
Accepted: 13
Accepted:
13 October
October 2015
2015
Received: 19
April 2016
ePublished:
ePublished: 15
15 October
October 2015
2015
Accepted: 11 June 2016
ePublished: 18 June 2016
View
View Video
Video Summary
Summary
*Correspondence to:
*Correspondence
to:
*Correspondence
to:
Sara Kazempour-Ardebili
Eivind
Engebretsen
Eivind
Engebretsen
Email:
[email protected]
Email:
Email: [email protected]
[email protected]
iabetes is a leading public health concern worldwide,
a campaign that aims to increase awareness about the rising
take the political as the primary level and the normative as
a recent contribution to the ongoing debate about the
andndespite
years of research and development on
prevalence
of diabetes and trigger a specific set of actions
secondary, or derived from the political?
role of power in global health, Gorik Ooms emphasizes
diabetes care and prevention, it is still one of the
for combating diabetes. The WHO has also launched its
That is what we will try to do here, by introducing an
the normative underpinnings of global health politics.
fastest growing
conditions
in theproblems:
world; according
the
first alternative
Global Diabetes
Report onof this
day, a document
conceptualization
the political
and hence that
free
He identifies
three related
(1) a lack oftoagreement
World Health Organization (WHO) the number of people
outlines
not
only
the
importance
of
battling
diabetes,
but
us from the “false dilemma” Ooms also wants
to escape.
among global health scholars about their normative premises,
living with
diabetes
has
quadrupled
since
1980
and
in
2014
also
a
framework
for
surveillance,
prevention,
and
effective
“Although constructivists have emphasized how underlying
(2) a lack of agreement between global health scholars and
there were
an estimated
422 million
adults with
diabetes
in
management
the condition.
normative ofstructures
constitute actors’ identities and
policy-makers
regarding
the normative
premises
underlying
1
the world.
Thisand
is a(3)staggering
to better
this to Diabetes
is one
fourrarely
non-communicable
diseasesstructures
(NCDs)
interests,
theyofhave
treated these normative
policy,
a lack ofstatistic;
willingness
amongput
scholars
number clearly
into perspective,
diabetes premises
can be addressed
as the This targeted
in the as2011
Political
Declaration
on the
Prevention
themselves
defined
and infused
by power,
or emphasized
state their normative
and assumptions.
constitutive
effects
alsoother
are expressions
power.”22 This
confusion
is for country
Ooms oneinofthe
the world,
explanations
third most
populated
after “why
Chinaglobal and how
Control
of NCDs
(the
three are of
cardiovascular
2
is thecancer,
starting point
for the political
theoristdiseases),
Chantal Mouffe,
health’s
are notdiabetes
implementing
the knowledge
and India.
Thepolicy-makers
rise in worldwide
prevalence
has
disease,
and chronic
respiratory
which
and her response
an ontological multisectoral
conception of
by overweight
global health’s
scholars.
” He calls recognizes
mirroredgenerated
the rise in
and empirical
obesity, with
a greater
the needis tofordevelop
population-wide,
the political,towhere
“the and
political
belongs
to ourInontological
unity between
scholars
between scholars interventions
increase for
in greater
these conditions
in lowandand
middle-income
prevent
reduce
NCDs.
2013, a
33
According
to
Mouffe,
society
is developed
instituted
condition.
”
and
policy-makers,
concerning
the
underlying
normative
3
countries. Unfortunately, the WHO Eastern Mediterranean
comprehensive
Global
Monitoring
Framework
was
11
political’
I mean the
dimension
of
premises
openness
when
comesleader
to advocacy.
Region, to
which and
Irangreater
belongs
to, is now
theitworld
in
and through
adoptedconflict.
by the “[B]y
World‘the
Health
Assembly
(WHA),
which
We commend the effort 4to reinstate power and politics in
antagonism which I take to be constitutive of human societies,
increasing diabetes prevalence.
included nine voluntary targets to be reached by member states
global health and agree that “a purely empirical evidence-based
while by ‘politics’ I mean the set of practices and institutions
But why is diabetes important? Because it is a lifelong
2025: a 25% reduction in mortality caused by cardiovascular
approach is a fiction,” and that such a view risks covering up
through which an order is created, organizing human
condition,
established
definite
has costly
diabetes,
cancer,
andofchronic
respiratory
diseases,
“thewith
role ofnopolitics
and power.
” But bycure,
contrasting
this fiction disease,
coexistence
in the
context
conflictuality
provided
by the
short- and long-term complications, can lead to premature
10%political.
reduction
in
alcohol
abuse,
10%
reduction
in
33
become
” An issue or a topic needs to be contested tophysical
with global health research “driven by crises, hot issues, and
death and
other words,
is very
30%
in salt intake,
30%
reduction
in
political,
andreduction
such a contestation
concerns
public
action and
thedisability.
concerns ofInorganized
interestitgroups,
” asexpensive.
a “path we are inactivity,
There are
direct
medical
costs,
which
include
expenditure
smoking,
25%
reduction
in
high
blood
pressure
or
halt
the
creates a ‘we’ and ‘they’ form of collective identification. But
trying to move away from,” Ooms is submitting to a liberal
on prevention,
treatment
and management
of complications.
in high
bloodrelations
pressure
(depending
on national
the fixation
of social
is partial
and precarious,
since
conception
of politics
he implicitly criticizes
the outcomes increase
These encompass
outpatient,
inpatient,
emergency
care, longhalt
risepossibility.
in diabetes
and obesity,
view of politics
evades
the constituting
role of circumstances),
antagonism is an
everthe
present
To politicize
an issue
of.11 A liberal
conflicts
and reduces
it to either
a rationalistic,
and be of
able
to mobilize
support, one needs
to represent
the
term care,
medications
and medical
devices.
There are economic
also
expansion
preventive
cardiovascular
treatment
(including
calculation,
anassociated
individual with
question
norms. This glycemic
world control)
in a conflictual
manner
“with
opposed
camps with
indirect costs,
whichorare
loss of
ofmoral
productivity,
to at least
50% of
eligible
population
and
33
is echoed
in Ooms
whenand
he astates
that “it
is noton
possible
peopleofcan
identify.”basic
premature
death and
disability
negative
impact
the to 80%which
availability
affordable
technologies and essential
Ooms
uses
the
case
of
“increasing
international
aid spending
discuss
the
politics
of
global
health
without
discussing
the
countries’ gross domestic product (GDP). While calculation
medicines for the treatment of the
aforementioned
four
11
1
But
what
if
we
on
normative
premises
behind
the
politics.
”
7AIDS treatment” to illustrate his point.1 He frames the
of indirect health costs is difficult and quite complex, the
NCDs. The framework was accompanied by the WHO NCD
annual direct health costs associated with diabetes has been
Global Action Plan, endorsed by the 66th World Health
estimatedInstitute
in a of
meta-analysis
to of
US$825
billionof
Health
Society,
Medicine,
University
Oslo,
Institute
ofrecent
Health and
and
Society, Faculty
Faculty
ofbe
Medicine,
University
of Oslo,
Oslo, Assembly,
Oslo, Norway
Norwaywhich provides guidance on policies that help
globally.5,6
achieve the ambitious targets set in the framework.8
All of this is a testament to the need for global action where
NCDs, including diabetes, have also been recognized as a
diabetes is concerned. The importance of addressing the
threat to sustainable development and thus, addressed in the
problem of diabetes has been emphasized by the WHO in
2030 Agenda for Sustainable Development, adopted by world
naming the 2016 World Health Day ‘Beat Diabetes.’ This is
leaders at the 2015 United Nations Development Summit. The
Full list of authors’ affiliations is available at the end of the article.
Takian and Kazempour-Ardebili
Agenda includes 17 Sustainable Development Goals (SDGs),
the third of which addresses good health and well-being for
all. Among the objectives set for this goal, member states
have committed to ‘reduce premature mortality from NCDs
through prevention and treatment by one third by 2030,’ which
mirrors the first voluntary target set in the Global Monitoring
Framework for NCDs. By recognizing NCDs as an obstacle for
sustainable development and pledging to globally combat its
effects, world leaders have effectively raised the much needed
awareness of society as a whole towards the importance of
worldwide solidarity against NCDs.9
It is difficult to find a country that does not already have a
national diabetes plan, which underscores the enormity of
the global concern surrounding it. However, many nations
among those with lower incomes lack proper funding and
implementation of such plans and policies. The WHO Global
Action Plan for Prevention and Control of NCDs8 outlines
six specific objectives and recommends effective policies
for achieving those objectives and ultimately attaining
the NCD prevention and control targets set by the Global
Monitoring Framework. These objectives are: (1) to prioritize
(to a greater extent) NCD prevention and control in global,
regional, and national agendas and internationally agreed
development goals; (2) to strengthen the national capacity in
order to enhance national response for NCD prevention and
control; (3) to create, sustain and expand health-promoting
environments to reduce modifiable risk factors (namely
tobacco use, diet, physical activity and alcohol abuse); (4) to
strengthen and orient the health systems to address NCDs
through people-centered primary healthcare and universal
health coverage; (5) to promote high quality research and
development; and (6) to monitor trends and determinants
and evaluate progress. By adopting these policies and tailoring
them to their population’s needs, nations can move a step
closer to tackling NCDs, and among them diabetes.
As one of the countries in the Eastern Mediterranean Region,
the world’s fastest growing hub of diabetes, Iran is a country
of 78.8 million population with the second largest economy
in the Middle East (after Saudi Arabia), and an estimated
GDP of US$393.7 billion, categorizing it as an upper middleincome country.10 The current life expectancy in Iran is 74
years, with 64 years healthy life expectancy.11 The greatest
burden of disease, as calculated by disability-adjusted lifeyears (DALYs) is attributed to cardiovascular disease and
diabetes. NCDs in general are responsible for 76% of total
deaths in the country, with diabetes and cardiovascular
disease directly responsible for at least 48% of total deaths.11
A large portion of the deaths caused by diabetes may be
prevented by better control of the condition, which relies on
increasing awareness and compliance among the patients and
advocating self-care, areas in which many Iranian patients are
sorely lacking. The Iranian government has long recognized
the nation’s vulnerability to NCDs and numerous national
plans, programs and policies have been implemented over the
years with little effect on reducing NCD burden. To effectively
overcome this burden, specific and clear policies are needed
not only to prevent diabetes, but also to optimize diabetic
patients’ control; this can be achieved by developing national
and local guidelines and auditing their use and misuse on
regular basis, as well as holding healthcare professionals
572
responsible when targets are not met.
Following the WHO’s call for global action against NCDs, an
Iranian National Committee for NCD Prevention and Control
was formed, chaired by the Minister of Health and Medical
Education (MoHME), and adopted by the Supreme Council
of Health and Food Security, which is a multidisciplinary
council including 3 vice-presidents and 10 ministers across
the government. The national committee is a policy-making,
regula­
tory, scientific, and planning committee that has
subcommittees to perform its duties in all areas related to the
control of NCDs and risk factors; the committee is regarded
as a decision-making body of the MoHME with respect
to NCDs. This committee has produced the first National
Action Plan for the prevention and control of NCDs,12 which
includes the voluntary targets set by the Global Monitoring
Framework and goes a step further by adding 4 new targets
that are specific to national circumstances: zero trans fatty
acid in food products, 20% relative reduction in mortality due
to traffic injuries, 10% relative reduction in mortality due to
drug abuse, and 20% increase in access to treatment for mental
diseases. The Action Plan has also changed the targets for
reducing physical inactivity from 10% to 20% and expansion
of preventive cardiovascular treatment to at least 70% instead
of the WHO’s proposed 50% of eligible population.12
The Iranian National Action Plan for the Prevention and
Control of NCDs sets out ambitious targets and specific
recommendations for attaining those targets. Whether
implementing the program and its related policies will be
feasible and/or effective in the nation’s war against NCDs
remains to be seen. There are undoubtedly numerous
obstacles hindering the achievement of these targets, not
least of which is securing the required financial resources
needed in an era of resilient economy, as well as the need
for safeguarding peoples’ health and well-being in the postsanctions Iran, where further Westernization threatens to
increase the prevalence of NCD risk factors. Ambitious
targets, limited resources and rising risk factors; these entities
summarize the challenge of facing NCDs not only in Iran, but
in every developing nation around the globe. Therefore, how
Iran goes forward and what it achieves from adopting and
building on the United Nations Development Programme
(UNDP), WHA, and WHO agendas for tackling NCDs will
undoubtedly be of immense educational value not only to its
neighboring countries, but to the broader global community.
Ethical issues
Not applicable.
Competing interests
Authors declare that they have no competing interests.
Authors’ contributions
AT conceived the manuscript and contributed to content and revisions. SKA
contributed to writing, content, and revisions of the manuscript.
Authors’ affiliations
Department of Global Health and Public Policy, School of Public Health,
Tehran University of Medical Sciences, Tehran, Iran. 2Department of Health
Management and Economics, School of Public Health, Tehran University of
Medical Sciences, Tehran, Iran. 3College of Health and Life Sciences, Brunel
University London, Uxbridge, UK. 4Diabetes Research Center, Endocrinology
1
International Journal of Health Policy and Management, 2016, 5(10), 571–573
Takian and Kazempour-Ardebili
and Metabolism Research Institute, Tehran University of Medical Sciences,
Tehran, Iran.
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