Health reforms that don’t address the global sources of health inequality are counterproductive – we need to change the roadmap, not fix potholes.

I have been arguing above that when we engage in debate over global health policy and practice we would do well to have a clearer sense of the way in which particular approaches to global health relate to underlying models of justice. This is not just because global health problems raise difficult normative questions but because recourse to competing models of justice shapes political outcomes too. When it comes to the question of global health inequality in particular, the particular model of justice that is in play matters greatly: more so, even, than the particular instruments and levers (be it market mechanisms, states, or anything else) that are the immediate subject of the policy. As also alluded to above, it is in relation to inequality that some of the weaknesses of the dominant mainstream approach to global health are most starkly revealed. Mainstream global health today seeks to fill in the potholes of global ill health; it does not seek to reconstruct the road itself. ‘[M]odern conceptions of global health rarely focus on fundamental public health services’, Lawrence Gostin reminds us (2015: 415). But this is not because, as he suggests, global health actors ‘forget’ to provide the basics of good health (ibid.: 416). Rather it is because, like its twin sisters, humanitarianism and human rights, global health quite explicitly seeks to avoid challenging the systemic aspects of global health problems on the assumption that to do so is to raise the spectre of a possible greater harm (cf. Easterly, 2014). Global health policies today may well achieve considerable targeted success, therefore (indeed, it is hard to obtain funding for global health programmes unless there is a clear pathway to just such measurable progress). Since good health is a function of many things (even if not quite as many things as can be envisaged in the WHO's founding declaration) hitting one's targets may indeed be the quickest way to missing the goal (Freedman, 2003). Successfully providing a certain percentage coverage of anti-retrovirals, or even successfully eradicating smallpox in a given territory, does not necessarily impact upon the wider health landscape, nor alter which people are most affected by it. The core of the problem, then, is that there is — and will always be — plenty of scope to increase the floor of protection for a given health problem, while leaving the wider canopy of the social determinants of ill health largely untouched, if not expanding (Moyn, forthcoming). This is not just a technical issue, or a consequence of the wrong political priorities (and this is the big weakness of a debate that at present always falls back on a dualism of market versus state). It is an historical problem and a geographical problem. Let me take each of these in turn by way of explaining how it is that mainstream global health has increasingly extracted itself from the question of health as a social or public good, one deeply embedded in wider social and political structures, how it has leveraged the model of ‘market justice’ as a way of doing this, and why re-embedding it may be a useful first task for ‘social-justice’ approaches to undertake. Historically, international health was taken up as a question of sovereign necessity. In the nineteenth century liberal societies would intervene on behalf of ‘public’ health only in times of emergency (outbreaks of disease) or in relation to wider questions of political economy (standards of hygiene in urban and industrial spaces). During the late nineteenth and early twentieth century ‘progressive era’ and in particular in the ‘embedded liberal’ era of international health following World War II, that changed (Rodgers, 1998; Ruggie, 1982). From around the 1970s, in particular, in step with changes then underway within the liberal democratic West, interest in global health began to shift towards a more market-based rationality, emphasizing, as Beauchamp put it, ‘individual responsibility, minimal collective action and freedom from collective obligations except to respect other persons’ fundamental rights’ (Beauchamp, 1976: 102–3). Beauchamp was writing here in the 1970s, and in relation to the American domestic context. But this emphasis on negative rights is precisely where global health is today. Global health today is the product of an epochal shift in political values whose combined effect has been to persistently separate off the problem of global ill health from wider social forces. This raises, in turn, the matter of geography. Geographically, the separation of global health from its public arises from the way that the mainstream global health specifies its proper object. The ‘problems’ that contemporary global health seeks to address are invariably located in poor countries. This works to deflect attention from what has changed in rich countries too, changes which impact upon the wider global health landscape. In so doing, it enables partially grounded diagnoses to sustain universal solutions: the solutions of market justice. This is the problem of ‘the poverty of elsewhere’ that I have raised in another setting (Reid-Henry, 2015). It is important that we bear it in mind in considering the way in which global health today operates. It is one of the reasons why only particular sorts of problems get to count as ‘global health’ problems (tuberculosis and not mental health or blindness, for example) and in certain sorts of ways (as an epidemiological problem of projected future infection, rather than as a function of existing social inequalities — for all that many national AIDS programmes are very clear on this). Mainstream global health is thus best thought of not so much as a solution to the problem of actual health need, but as a solution to the problem of ill health as an externality of global capitalism. The difference is subtle but significant. The logic of prevention largely disappears in the latter, along with any commitments to institutionalized forms of welfare provision: the tax regimes that might pay for health services ante, or the commitments to underwriting healthier environments ex post. Instead what the market-based model of justice resolves to is the principle of ‘equal inequality’ (Donzelot, 2008): the principle that inequalities are to be maximized to the extent that they are effective because they then operate most powerfully as corrective incentives. Health policy, which is so open to the discourse of incentives, is particularly vulnerable to this. This presents the inverse of Rawls's condition that inequalities are to be tolerated to the extent that they work to the benefit of the least well-off. Rawls's theory of justice may have been avowedly liberal but it was also an avowedly social theory of justice concerned with society in the round. This is of course precisely what contemporary global health is so reluctant to address. How does such reluctance come to be seen as reasonable and right-thinking behaviour? It is here that we glimpse the true value of the market-justice approach in action. Global health requires the vernacular of market justice in order to be able to exclude these wider social obligations. Dis-embedded as it has now become, market justice enables global health to present itself as concerned with the problem of global health inequality without committing itself either to addressing the upstream ‘social determinants’ of that or needing to concern itself with those health issues and interventions that might do most to enable the greatest endowment of individual capability. Like all divestitures it is ultimately a way of saving money as much as it is of saving lives. It is for this reason that global health has become — seemingly unaware of the paradox — both an intensely moralized domain (so many advocacy coalitions, global compacts, Commissions and so on) and ethically monotone. Yet it is only by confronting this paradox that we can appreciate why it is that global health, conceived of as market justice, will always fail to address the issue of health inequality as understood within the terms of Daniels's ‘realist’ theory of health justice. That being so, where might an approach to global health that conformed to ‘social-justice’ principles in a ‘market-justice’ world best begin? This is the question I now want to take up in the final part of this article.