The past several years have generated widespread concern among health professionals, politicians and the public about the potential for the cross-border spread of health risks, particularly infectious diseases. For example, international bodies such as the United Nations, the G8, the G77 and the European Union have accorded health high priority. The United States declared infectious diseases a security threat to its own people and others.

Important new international health entities since 1996 include the United Nations program on HIV/AIDS, the Global Alliance for Vaccines and Immunizations and its associated Vaccine Fund and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The increased attention to global health within the international community stems from two sources - higher disease prevalence (AIDS tops this list) and concern about growing national vulnerability to health threats that originate externally. Most commentary attributes the latter primarily to increasing interdependence and secondarily to weakening public health systems.

Often, all of the above processes are lumped together and called results of globalization. Global health is a relatively new term that also refers to health matters that transcend jurisdictional boundaries. However, it tends to refer to efforts initiated by a broader set of actors, which usually includes governments or international organizations, but also includes individuals and groups such as nongovernmental organizations, religious movements, philanthropic organizations and corporations.

Additionally, it connotes expanded geographical risk that governments cannot address by themselves (Lee, Fustukian, and Buse 2002). Often, but not always, the choice of the term global health implies an epistemological distinction from international health. As Dogson, Lee and Drager (2002) point out, "by definition, a global health issue is one where the actions of a party in one part of the world can have widespread consequences in other parts of the world" (p. 23).

Although a variety of health conditions and risks to health manifest themselves as transnational phenomena, infectious diseases generate the most concern. While infectious diseases are pervasive in human society, recent history shows that their social and political significance varies. The middle of the 20th century brought optimism that infectious diseases were waning. Better vaccines, including one for yellow fever, and decreasing incidence of typhus and relapsing fever after World War I signaled that infectious diseases could be controlled.

Following World War II, the success of DDT against malaria and other diseases heralded monumental progress in the fight against infectious disease (Zacher 1999b). The eradication of smallpox and dramatic advances in the control of other diseases seemed to indicate that infectious diseases could largely disappear. However, public health professionals and society at large now see the progress towards disease eradication as halted, if not reversed. Grady's (2002) comment typifies the altered viewpoint:

Since the mid-1970's - a time when it was widely assumed that most infectious diseases had been conquered or at least controlled - a troubling array of previously unknown diseases has emerged, including Lyme disease, AIDS, mad cow disease, the Ebola virus, Legionnaires' disease and a host of others. In addition, old diseases like yellow fever, malaria and dengue fever have reappeared in their former haunts and spread to new areas. Some microbes, like the ones that cause tuberculosis, malaria and food poisoning, have become dangerously drug resistant.

Epidemiological changes such as those listed by Grady result from natural forces including climate change and microbial evolution, as well as changing human patterns of settlement and travel. While epidemiological trends are important objects of study, the changing amount of concern attributed to transnational health risks, particularly infectious disease, is itself notable. Often, this concern focuses on changes attributed to globalization. As Lee (2000: 15) writes: Suddenly, globalization has come to be recognized as a highly important and defining feature of health policy in the late twentieth century.

In part, this has arisen from reform of international health cooperation, notably the role of the World Health Organization. Added to this has been awareness of changes in the nature of health issues as a result of transborder challenges (e. g. emerging and re-emerging diseases, environmental change, demographic trends, and technological developments). As a result, many voices have become united in their perceived need for a global approach to health. The call for global health arises from a sense of heightened risk due to increased trade and travel, and declining efficacy of disease control mechanisms.

This analysis in no way seeks to dispute the risks that such processes pose to public health. However, the argument is that contemporary public health discourse entails a growing emphasis on global interconnectedness that signifies changing ways of understanding disease ecology. While specific diseases may be new or apparent in places never before seen, the social-ecological processes that drive individual and population vulnerability to health threats have not been altered. Thus, the global health discourse is itself highly significant for two reasons.

First, it indicates that more people understand disease ecology in a more geographically complex manner. Second, since the discursive shift guides new types and levels of transnational health governance, it highlights a strong ideational component to international relations, at least within the health sector. Substantiating and further developing these assertions requires explication of (1) disease as a constructed phenomenon, (2) the relationship between globalization and health, particularly cognitive dimensions thereof, and (3) the relationship between conceptual shifts and policy in international society.

Health as a constructed phenomenon Central to understanding shifting concern about health is the fact that it is a deeply socially constructed phenomenon.

At first, this statement may sound absurd. How can a biological process be socially constructed, especially in this era of high science? Yet, scholars in many disciplines see health, particularly infectious disease, as a phenomenon that both reflects and creates social meaning and boundaries.

Within this broad category of research, key areas of study include the changing meaning of disease in societies, the role of scientific innovations, differences between societies and the way the meaning of disease affects individuals and groups within societies as well as relationships between them. This literature yields three particularly relevant insights. First, preexisting social norms and culture affect the understanding of health and illness. Disability, for example, can be seen as a social experience that arises from specific ways that society is organized.

Scientists showed that the discourse of microbiology reflects certain gendered and militarized elements of Western culture. Second, previous research has shown that specific diseases, particularly those that are least understood, become imbued with meanings, creating broad social ramifications. Historically, people saw diseases such as cholera as a sign of divine wrath. In more recent times, the associations are more secular, but still significant, often linking disease to stigmatized groups in society. Hence, scientists call AIDS an "epidemic of signification," because it has fluctuating social meanings.

First known as the "gay plague" and a disease of no risk to women, AIDS became known alternately as a Haitian disease, a disease that affects everyone, an African disease and now, increasingly, a disease of the former Soviet Union and of women. Third, changing ideas about health exist in a complex and dynamic relationship with technological developments and social institutions. As Tomes (2000: 192) writes, The historical study of disease teaches us, if nothing else, that a culture's attentiveness to a perceived health risk is determined not only by statistics but also by a broad range of other factors.

Whether a disease is deemed newsworthy, so that the media cover it and reinforce its importance; whether it has commercial potential to sell products or services, so that advertising amplifies concern about its avoidance; and whether its incidence reflects other social problems, so that activists and reformers become invested in its prevention are all factors that help to determine which disease phenomena stake a claim on the popular imagination.


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