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Towards a common defi nition of global health Jeff rey P Koplan, T Christopher Bond, Michael H Merson, K Srinath Reddy, Mario Henry Rodriguez, Nelson K Sewankambo, Judith N Wasserheit, for the Consortium of Universities for Global Health Executive Board*

Global health is fashionable. It provokes a great deal of media, student, and faculty interest, has driven the establishment or restructuring of several academic programmes, is supported by governments as a crucial component of foreign policy,1 and has become a major philanthropic target. Global health is derived from public health and international health, which, in turn, evolved from hygiene and tropical medicine. However, although frequently referenced, global health is rarely defi ned. When it is, the defi nition varies greatly and is often little more than a rephrasing of a common defi nition of public health or a politically correct updating of international health. Therefore, how should global health be defi ned?

Global health can be thought of as a notion (the current state of global health), an objective (a world of healthy people, a condition of global health), or a mix of scholarship, research, and practice (with many questions, issues, skills, and competencies). The need for a commonly used and accepted defi nition extends beyond semantics. Without an established defi nition, a shorthand term such as global health might obscure important diff erences in philosophy, strategies, and priorities for action between physicians, researchers, funders, the media, and the general public. Perhaps most importantly, if we do not clearly defi ne what we mean by global health, we cannot possibly reach agreement about what we are trying to achieve, the approaches we must take, the skills that are needed, and the ways that we should use resources. In this Viewpoint, we present the reasoning behind the defi nition of global health, as agreed by a panel of multidisciplinary and international colleagues.

Public health in the modern sense emerged in the mid- 19th century in several countries (England, continental Europe, and the USA) as part of both social reform movements and the growth of biological and medical knowledge (especially causation and management of infectious disease).2 Farr, Chadwick, Virchow, Koch, Pasteur, and Shattuck helped to establish the discipline on the basis of four factors: (1) decision making based on data and evidence (vital statistics, surveillance and outbreak investigations, laboratory science); (2) a focus on populations rather than individuals; (3) a goal of social justice and equity; and (4) an emphasis on prevention rather than curative care. All these elements are embedded in most defi nitions of public health.

The defi nition of public health that has perhaps best stood the test of time is that suggested by Winslow almost 90 years ago:3

“Public health is the science and art of preventing disease, prolonging life and promoting physical health and effi cacy through organized community eff orts for the sanitation of the environment, the control of

Lancet 2009; 373: 1993–95

Published Online June 2, 2008 DOI:10.1016/S0140- 6736(09)60332-9

See Editorial page 1919

*Members listed at end of paper

Emory Global Health Institute (Prof J P Koplan MD), and Department of Epidemiology, Rollins School of Public Health (T C Bond PhD), Emory University, Atlanta, GA, USA; Duke Global Health Institute, Duke University, Durham, NC, USA (Prof M H Merson MD); Public Health Foundation of India, Delhi, India (Prof K S Reddy MD); Instituto Nacional de Salud Publica, Cuernavaca, Mexico (Prof M H Rodriguez MD); School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda (Prof N K Sewankambo FRCP); and Department of Global Health, University of Washington, Seattle, WA, USA (Prof J N Wasserheit MD)

Correspondence to: Prof Jeff rey P Koplan, Robert W Woodruff Health Sciences Center, Emory University, 1440 Clifton Road Suite 410, Atlanta, GA 30322, USA [email protected]

communicable infections, the education of the individual in personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure every individual in the community a standard of living adequate for the maintenance of health; so organizing these benefi ts in such a fashion as to enable every citizen to realize his birthright and longevity.”

The US Institute of Medicine (IOM), in its 1988 Future of public health report,4 described public health in terms of its mission, substance, and organisational framework, which, in turn, address prevention, a community approach, health as a public good, and the contributions of various partners. The IOM report defi ned the mission of public health as “fulfi lling society’s interest in assuring conditions in which people can be healthy”.4 In the Dictionary of epidemiology (2001), Last5 defi ned public health as “one of the eff orts to protect, promote and restore the people’s health. It is the combination of sciences, skills and beliefs that is directed to the maintenance and improvement of the health of all the people through collective or social actions”.

International health has a more straightforward history. For decades, it was the term used for health work abroad, with a geographic focus on developing countries and often with a content of infectious and tropical diseases, water and sanitation, malnutrition, and maternal and child health.6 Many academic departments and organisations still use this term, but include a broader range of subjects such as chronic diseases, injuries, and health systems. The Global Health Education Consortium defi nes international health as a subspecialty that “relates more to health practices, policies and systems…and stresses more the diff erences between countries than their commonalities”.7 Other research groups defi ne international health as limited exclusively to the diseases of the developing world.8 But many fi nd international health a perfectly usable term and have adapted it to coincide with the philosophy and content of today’s globalised health practice.7,8 International health is defi ned by Merson, Black, and Mills9 as “the application of the principles of public health to problems and challenges that aff ect low and middle-income countries and to the complex array of global and local forces that infl uence them”.

Global health has areas of overlap with the more established disciplines of public health and international health (table). All three entities share the following characteristics: priority on a population-based and preventive focus; concentration on poorer, vulnerable, and underserved populations; multidisciplinary and

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interdisciplinary approaches; emphasis on health as a public good and the importance of systems and structures; and the participation of several stakeholders. In view of these commonalities, we are left with key questions that need to be resolved to arrive at a useful and distinctive defi nition for global health. We address some of these questions here.

What is global? Must a health crisis cross national borders to be deemed a global health issue? We should not restrict global health to health-related issues that literally cross international borders. Rather, in this context, global refers to any health issue that concerns many countries or is aff ected by transnational determinants, such as climate change or urbanisation, or solutions, such as polio eradication. Epidemic infectious diseases such as dengue, infl uenza A (H5N1), and HIV infection are clearly global. But global health should also address tobacco control, micronutrient defi ciencies, obesity, injury prevention, migrant-worker health, and migration of health workers. The global in global health refers to the scope of problems, not their location. Thus—like public health but unlike international health—global health can focus on domestic health disparities as well as cross-border issues. Global health also incorporates the training and distribution of the health-care workforce in a manner that goes beyond the capacity-building interest of public health.

Is global health mainly directed to infectious disease and maternal and child health issues or does it also address issues such as chronic diseases, injuries, mental health, and the environment? Infectious diseases and maternal and child health have dominated international health and continue to receive the most attention and interest in global health. However, global health has to embrace the full breadth of important health threats. This broad set of priorities might mean accepting that, for many countries, the epidemiological transition is a continuing process. Simultaneous eff ort needs to be expended on undernutrition and overnutrition, HIV/ AIDS and tobacco, malaria and mental health, tuberculosis and deaths due to motor vehicle accidents. Infectious agents are communicable and so are parts of the western lifestyle (ie, dietary changes, lack of physical

activity, reliance on automobile transport, smoking, stress, urbanisation). Burden of illness should be used as a criterion for global-health priority setting.

How does global health relate to globalisation? The spread of health risks and diseases across the world, often linked with trade or attempted conquest, is not new to public health or international health. Plague spread across Europe and Asia in the middle ages; quarantine was developed in 14th-century Venice; smallpox and measles were introduced to the New World by European invaders in the 16th century; the same explorers took tobacco from the Americas to Europe and beyond, leading to premature disease and death; and opium was sold to China in the 18th and 19th centuries as a product of trade and subjugation by imperial western powers. Never- theless, the rapid increase in speed of travel and communication, as well as the economic interdependency of all nations, has led to a new level and speed of global interconnectedness or globalisation, which is a force in shaping the health of populations around the world.

Must global health operate only within a context of a goal of social/economic equity? The quest for equity is a fundamental philosophical value for public health. The promotion of social and economic equity, and reduction of health disparities has been a key theme in domestic public health, international health, and global health. Up to now, most health initiatives in countries without suffi cient resources to deal with their own health problems have come about through the assistance of wealthier countries, organisations, and foundations. Although this assistance is understandable, it does not help us to distinguish global health as a specialty of study and practice.

Global health has come to encompass more complex transactions between societies. Such societies recognise that the developed world does not have a monopoly on good ideas and search across cultures for better approaches to the prevention and treatment of common diseases, healthy environments, and more effi cient food production and distribution. The preference for use of the term global health where international health might previously have been used runs parallel to a shift in philosophy and attitude that emphasises the mutuality of

Global health International health Public health

Geographical reach Focuses on issues that directly or indirectly aff ect health but that can transcend national boundaries

Focuses on health issues of countries other than one’s own, especially those of low-income and middle-income

Focuses on issues that aff ect the health of the population of a particular community or country

Level of cooperation Development and implementation of solutions often requires global cooperation

Development and implementation of solutions usually requires binational cooperation

Development and implementation of solutions does not usually require global cooperation

Individuals or populations

Embraces both prevention in populations and clinical care of individuals

Embraces both prevention in populations and clinical care of individuals

Mainly focused on prevention programmes for populations

Access to health Health equity among nations and for all people is a major objective

Seeks to help people of other nations Health equity within a nation or community is a major objective

Range of disciplines Highly interdisciplinary and multidisciplinary within and beyond health sciences

Embraces a few disciplines but has not emphasised multidisciplinarity

Encourages multidisciplinary approaches, particularly within health sciences and with social sciences

Table: Comparison of global, international, and public health

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real partnership, a pooling of experience and knowledge, and a two-way fl ow between developed and developing countries. Global health thus uses the resources, knowledge, and experience of diverse societies to address health challenges throughout the world.

What is the interdisciplinary scope of global health? Professionals from many diverse disciplines wish to contribute to improving global health. Although global health places greater priority on prevention, it also embraces curative, rehabilitative, and other aspects of clinical medicine and the study of basic sciences. But these latter areas are less central to the core elements of public health than are its population-based and preventive orientations. Clearly, many disciplines, such as the social and behavioural sciences, law, economics, history, engineering, biomedical and environmental sciences, and public policy can make great contributions to global health. Thus, global health encompasses prevention, treatment, and care; it is truly an interdisciplinary sphere.

A steady evolution of philosophy, attitude, and practice has led to the increased use of the term global health. Thus, on the basis of this analysis, we off er the following defi nition: global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, deter- minants, and solutions; involves many disciplines within and beyond the health sciences and promotes inter- disciplinary collaboration; and is a synthesis of population- based prevention with individual-level clinical care.

We call for the adoption of a common defi nition of global health. We will all be best served (and best serve the health of others around the world) if we share a common defi nition of the specialty in which we work and to which we encourage others to lend their eff orts.

Contributors All authors contributed to the writing and editing of the manuscript. The

Consortium of Universities for Global Health (CUGH) Executive Board

developed the defi nition and reviewed and edited the manuscript.

CUGH Executive Board Haile Debas (University of California, San Francisco, CA, USA);

King Holmes (University of Washington, Seattle, WA, USA);

Gerald Keusch (Boston University, Boston, MA, USA); Jeff rey Koplan

(Emory University, Atlanta, GA, USA); Michael Merson (Duke University, Durham, NC, USA); Thomas Quinn (Johns Hopkins

University, Baltimore, MD, USA); Judith N Wasserheit (University of

Washington, Seattle, WA, USA).

Confl icts of interest We declare that we have no confl icts of interest.

Acknowledgments We thank George Alleyne, Lincoln Chen, William Foege, Andy Haines,

Mohammed Hassar, Venkat Narayan, Sharifa Saif Al-Jabri,

Barry Schoub, and Olive Shisana for their comments and suggestions.

References 1 Institute of Medicine. The US commitment to global health:

recommendations for the new administration. Washington, DC: Institute of Medicine, Dec 15, 2008. http://www.iom.edu/ CMS/3783/51303/60714.aspx (accessed Feb 19, 2009).

2 Porter R. The greatest benefi t to mankind: a medical history of humanity. New York: W W Norton & Company, 1997.

3 Winslow C. The untilled fi eld of public health. Mod Med 1920; 2: 183–91.

4 Institute of Medicine. The future of public health. Washington, DC: National Academy Press, 1988.

5 Last J. A dictionary of epidemiology. New York: Oxford, 2001.

6 Brown TM, Cueto M, Fee E. The World Health Organization and the transition from “international” to “global” public health. Am J Public Health 2006; 96: 62–72.

7 Global Health Education Consortium. Global vs international. http://globalhealthedu.org/Pages/GlobalvsInt.aspx (accessed Feb 19, 2009).

8 Brown University International Health Institute. Welcome to the International Health Institute. http://med.brown.edu/ihi/ (accessed Feb 19, 2009).

9 Merson MH, Black RE, Mills AJ. International public health: diseases, programs, systems, and policies, 2nd edn. Sudbury MA: Jones and Bartlett Publishers, 2006.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

IN THE YEAR 2015, LEADERS FROM 193 COUNTRIES OF THE WORLD

CAME TOGETHER TO FACE THE FUTURE.

And what they saw was daunting. Famines. Drought. Wars. Plagues. Poverty.

Not just in some faraway place, but in their own cities and towns and villages.

They knew things didn’t have to be this way. They knew we had enough

food to feed the world, but that it wasn’t getting shared. They knew there

were medicines for HIV and other diseases, but they cost a lot. They knew

that earthquakes and floods were inevitable, but that the high death

tolls were not.

They also knew that billions of people worldwide shared their hope for a

better future.

So leaders from these countries created a plan called the Sustainable

Development Goals (SDGs). This set of 17 goals imagines a future just 15 years

off that would be rid of poverty and hunger, and safe from the worst effects of

climate change. It’s an ambitious plan.

But there’s ample evidence that we can succeed. In the past 15 years, the

international community cut extreme poverty in half.

Now we can finish the job.

The United Nations Development Programme (UNDP) is one of the leading

organizations working to fulfil the SDGs by the year 2030. Present in nearly

170 countries and territories, we help nations make the Goals a reality.

We also champion the Goals so that people everywhere know how to

do their part.

UNDP is proud to continue as a leader in this global movement.

Learn about the Sustainable Development Goals. What’s your Goal?

END EXTREME POVERTY IN ALL FORMS BY 2030.

Yes, it’s an ambitious goal—but we believe it can be done. In 2000, the

world committed to halving the number of people living in extreme

poverty by the year 2015 and we met this goal. However, more than

800 million people around the world still live on less than $1.25 a day—

that’s about the equivalent of the entire population of Europe living in

extreme poverty. Now it’s time to build on what we learned and end

poverty altogether.

END HUNGER, ACHIEVE FOOD SECURITY AND IMPROVED NUTRITION AND PROMOTE SUSTAINABLE AGRICULTURE

In the past 20 years, hunger has dropped by almost half. Many

countries that used to suffer from famine and hunger can now

meet the nutritional needs of their most vulnerable people. It’s an

incredible accomplishment. Now we can go further and end hunger

and malnutrition once and for all. That means doing things such as

promoting sustainable agriculture and supporting small farmers. It’s a tall

order. But for the sake of the nearly 1 out of every 9 people on earth who

go to bed hungry every night, we’ve got to try. Imagine a world where

everyone has access to sufficient and nutritious food all year round.

Together, we can make that a reality by 2030.

ENSURE HEALTHY LIVES AND PROMOTE WELL-BEING FOR ALL AT ALL AGES

We all know how important it is to be in good health. Our health affects

everything from how much we enjoy life to what work we can perform.

That’s why there’s a Goal to make sure everyone has health coverage

and access to safe and effective medicines and vaccines. In the 25

years before the SDGs, we made big strides—preventable child deaths

dropped by more than half, and maternal mortality went down by

almost as much. And yet some other numbers remain tragically high, like

the fact that 6 million children die every year before their fifth birthday,

or that AIDS is the leading cause of death for adolescents in sub-Saharan

Africa. We have the means to turn that around and make good health

more than just a wish.

ENSURE INCLUSIVE AND EQUITABLE QUALITY EDUCATION AND PROMOTE LIFELONG LEARNING OPPORTUNITIES FOR ALL

First, the bad news on education. Poverty, armed conflict and other

emergencies keep many, many kids around the world out of school. In

fact, kids from the poorest households are four times more likely to be

out of school than those of the richest households. Now for some good

news. Since 2000, there has been enormous progress on the goal to

provide primary education to all children worldwide: the total enrolment

rate in developing regions has reached 91%. By measures in any school,

that’s a good grade. Now, let’s get an even better grade for all kids,

and achieve the goal of universal primary and secondary education,

affordable vocational training, access to higher education and more.

We can celebrate the great progress the world has made in becoming

more prosperous and fair. But there’s a shadow to the celebration. In

just about every way, women and girls lag behind. There are still gross

inequalities in work and wages, lots of unpaid “women’s work” such as

child care and domestic work, and discrimination in public decision-

making. But there are grounds for hope. More girls a