Print version ISSN 0042-9686
Bull World Health Organ vol.87 n.8 Genebra Aug. 2009
POLICY & PRACTICE
Explication sociale de la montée ou de la baisse de l'intérêt pour un problème de santé d'ampleur mondiale
Explicación social del auge y caída de los problemas sanitarios mundiales
The Maxwell School of Syracuse University, Syracuse, NY, United States of America
This paper proposes an explanation concerning why some global health issues such as HIV/AIDS attract significant attention from international and national leaders, while other issues that also represent a high mortality and morbidity burden, such as pneumonia and malnutrition, remain neglected. The rise, persistence and decline of a global health issue may best be explained by the way in which its policy community - the network of individuals and organizations concerned with the problem - comes to understand and portray the issue and establishes institutions that can sustain this portrayal. This explanation emphasizes the power of ideas and challenges interpretations of issue ascendance and decline that place primary emphasis on material, objective factors such as mortality and morbidity levels and the existence of cost-effective interventions. This explanation has implications for our understanding of strategic public health communication. If ideas in the form of issue portrayals are central, strategic communication is far from a secondary public health activity: it is at the heart of what global health policy communities do.
Le présent article propose des raisons expliquant pourquoi certains problèmes de santé d'ampleur mondiale, tels que le VIH/sida, suscitent une attention notable de la part des dirigeants internationaux et nationaux, tandis que d'autres, également responsables d'une mortalité et d'une charge de morbidité élevées, telles que la pneumonie et la malnutrition, demeurent négligés. La montée, la persistance ou le déclin de l'intérêt apporté à un problème mondial de santé publique peuvent s'expliquer par la façon dont la communauté politique associée à ce problème - à savoir le réseau d'individus et d'organisations concernés - parvient à le comprendre et à en donner une représentation et met en place des institutions capables de soutenir cette représentation. Cette explication souligne le pouvoir des idées et conteste les interprétations de la montée et du déclin de l'intérêt pour un problème qui mettent l'accent principalement sur des facteurs matériels et objectifs, tels que les niveaux de mortalité et de morbidité et l'existence d'interventions d'un bon rapport coût/efficacité. Cette explication a des conséquences sur notre conception de la communication stratégique en santé publique. Si les idées qui décrivent un problème sont centrales, la communication stratégique est loin d'être une activité de santé publique secondaire : elle est au cœur de l'activité des communautés responsables des politiques sanitaires mondiales.
El objetivo de este artículo es explicar por qué algunos problemas sanitarios de alcance mundial como el VIH/SIDA atraen vivamente la atención de los dirigentes nacionales e internacionales, mientras que otros problemas que también suponen una elevada carga de morbimortalidad, como la neumonía y la malnutrición, siguen desatendidos. La mejor manera de explicar el auge, la persistencia y el declive de un problema sanitario mundial es quizá observar la actitud de la comunidad de responsables de las políticas relacionadas (la red de personas y organizaciones que se ocupan del tema), para determinar cómo interpretan el problema, qué imagen presentan del mismo y qué instituciones establecen para sustentar esa imagen. Esta explicación destaca el poder de las ideas y cuestiona las interpretaciones del auge y caída de los problemas que atribuyen especial importancia a factores objetivos y materiales como las cifras de mortalidad y morbilidad y la existencia de intervenciones costoeficaces. Además, tiene implicaciones para nuestra concepción de una comunicación de salud pública estratégica. Si en efecto las ideas vehiculadas por la imagen del problema tienen una importancia decisiva, cabe deducir que la comunicación estratégica no sólo dista mucho de ser una función de salud pública secundaria, sino que constituye el núcleo de la labor de las comunidades responsables de las políticas de salud mundial.
This paper proposes an explanation concerning the rise, persistence and fall of issues in global health: a way to understand the reasons some health issues come to attract attention from leaders of international organizations and national political systems, while others are neglected. One reason for pursuing this question is that many global health analysts present evidence that material factors such as mortality and morbidity burden and the availability of cost-effective interventions may not explain the variance in the levels of attention health issues receive.1-4 For instance, in the early 2000s HIV/AIDS received more than one-third of all major donor funding for health,5 despite representing only around 5% of the mortality and morbidity burden in low- and middle-income countries.2 Also, severe acute respiratory syndrome (SARS) attracted enormous resources despite causing the deaths of only several hundred people.6 Meanwhile, other communicable diseases, such as pneumonia and diarrhoeal diseases, that kill millions of people each year and for which cost-effective interventions exist, attract minimal donor resources.7
These and other observations lead me to explore a social rather than a material explanation for ascendance and decline of issues in global health, and to question presumptions shared by many medical and public health scholars and practitioners on the strong influence of objective reality on public health outcomes. I draw on a paradigm - social constructionism - used by only a handful of scholars concerned with global health8-10 to suggest that the rise and fall of a global health issue may have less to do with how "important" it is in any objective sense than with how supporters of the issue come to understand and portray its importance. Specifically, those issues that attract attention may be ones in which policy community members have discovered frames - ways of positioning an issue - that resonate with global and national political elites, and then established institutions that can sustain these frames. Policy communities are networks of individuals (including researchers, advocates, policy-makers and technical officials) and organizations (including governments, non-governmental organizations, United Nations agencies, foundations and donor agencies) that share a concern for a particular issue. When policy communities develop convincing ideas and strong institutions, attention and resources may follow. I do not imply that there is no connection between material conditions and issue attention in global health. I do mean to suggest that the connection may be loose and that it is always mediated by social interpretations.
A previous framework sought to address the same question of attention and neglect of issues in global health.11 In that paper we reviewed scholarship on collective action and presented a case study on the difficulty the global maternal mortality policy community has had in generating political attention. We proposed a set of 11 factors to explain the lack of global political attention for reducing maternal mortality and suggested that these factors might apply more broadly to explain why some health issues attract attention and others are neglected. We grouped these factors into four categories: (i) the strength of the actors involved in an issue; (ii) the ideas they use to understand and position the issue; (iii) the nature of the political contexts in which these actors operate; and (iv) inherent characteristics of the issue itself.
While the list provides a starting point for investigating the causes of issue attention and neglect in global health, it has a number of limitations. First, a list lacks theoretical grounding, leaving it unclear where these factors come from. Second, it does not specify the primary factors, a hindrance to developing a parsimonious explanation. It is with these concerns that I propose a social constructionist explanation based on three of the 11 factors from the original framework: policy communities, ideas and institutions.
Many biomedical scientists operate from a specific set of presumptions about the world and its nature. They believe that through their research they are detecting an objective, material reality that exists independent of human observation. While this set of beliefs is sometimes labelled "positivist", I do not use this term because some social constructionists, myself included, also consider themselves to be positivists, accepting that truth claims about the world can be examined empirically. Instead, in line with existing scholarship, I call this set of beliefs "materialist", a term that emphasizes that the world is constituted by material matter, exists entirely independently of human observation and can be perceived directly through this observation.
Social constructionists question materialist assumptions (some also question positivist assumptions).12-14 They argue that what human beings call "reality" is not something objectively "out there" waiting to be discovered but is constructed through social interactions. People are largely unaware of this mediated process, perceiving themselves to be observing and describing external facts.10
Many constructivist ideas have unacknowledged roots in the work of the 18th century philosopher Immanuel Kant, who argued that knowledge of objective reality is not possible, for it is always refracted through our senses and cognitions.15 But he maintained that we can have a common understanding of the world because we hold a uniform set of conceptual categories, ideas such as causality, space and time. In the 20th century, Thomas Kuhn most famously injected constructivist ideas into our understanding of the history of science, arguing that scientific enquiry itself was shaped by socially constructed categories and changed as much through radical shifts in conceptual frameworks as through a perceived steady accumulation of objective knowledge.16
An example of the social construction of our world is how people perceive some phenomena as "risky". As Stallings puts it, "risk and safety are not objective conditions 'out there' simply waiting to be perceived by citizens or calculated by professional risk analysts".12 He adds, "'data'... [do not] interpret themselves". Rather, human beings process information selectively, constructing some phenomena as risky and others as safe.
Similarly, issues do not designate themselves as "important". Rather, human beings engage in "strategic social construction", advancing claims concerning what does and does not deserve to become a public problem.13,17 Some of these claims are pushed forcefully and effectively, attracting public resources. Other claims never even make it to the table.
Those operating in this paradigm challenge materialist presumptions on how social problems emerge. On a materialist account, a condition or risk is a problem when it becomes serious; a problem becomes a priority if it grows in scope and gravity; a solution to a problem is shown to be correct because it alleviates the problem; and an individual is an expert because he or she has appropriate training and experience and demonstrated capacity to define the problem accurately and discern the correct solution. In a social constructionist stance, these issues are not as straightforward. There may be disagreements over what qualifies as a problem, risk or solution and who is an expert, and objective, uniform criteria are not easily discernible to resolve these disagreements.
Ideas to generate attention
Materialists believe that the world consists largely of hard material facts. By contrast, social constructionists believe that the world consists largely of ideas. Our socially shared interpretations mediate and form our perceptions of reality.18 Think of a hundred dollar bill, for instance. It is just a piece of paper. It is only because we collectively ascribe a shared meaning to the note - a social and ideational process - that it acquires its purchasing power.
With respect to social problems, the central ideational variable is the "frame" - the way in which an issue is understood and portrayed publicly.19 Any issue can be framed in multiple ways. For instance, HIV/AIDS has been framed as a public health problem, a development issue, a humanitarian crisis, a human rights issue and a threat to security.20,21 Different frames may resonate with different actors. A finance minister may be swayed to address an issue by a cost-effectiveness argument, an epidemiologist by the potential for public health impact and a civil society activist by a rights-based claim.
Sociologists have explored why some frames resonate and others do not.22 They speak of two characteristics in particular: credibility and salience. Credibility has to do with how truthful people perceive the frame to be; salience with how central it is to their lives. For instance, global polio eradication has been positioned as a humanitarian crusade to rid the world of a scourge that has afflicted children for millennia.23 Many older advocates from industrialized nations may view this positioning as both credible, accepting the idea that polio is truly a problem the world can be rid of, and salient, remembering a time when polio caused havoc each year in their own countries.
Like those working in a materialist paradigm, those who embrace this alternative paradigm believe that interests and power heavily influence which issues emerge as social problems. The difference between the two paradigms is how each understands the substance of interests and power. Social constructionists, unlike materialists, see them as constituted by ideas rather than hard material facts. For instance, politicians in industrialized states may come to see disease X, but not disease Y, as a threat to their country's well-being and therefore in their interest to address. Such a conclusion may be ideational rather than a direct consequence of a hard material reality.
From a social constructionist perspective, the core activity of a global health policy community is ideational: it aims to secure attention for its issue by advancing truth claims about the issue. Global health policy communities follow remarkably similar ideational strategies in their advocacy efforts, whatever may be the actual material conditions (mortality burden especially) that underpin their claims. Almost all take the same two rhetorical steps: first making a "problem" claim surrounding severity and neglect of their issue, and then a "solution" claim surrounding the problem's tractability and the benefits that would accrue from addressing it.
The "problem" claim on severity and neglect almost always takes the following form:
"Problem X receives far less resources than it deserves given the serious harm it has caused (or may cause in the future)."
We can see some form of this claim made by virtually all global health policy communities. I illustrate this with the following claims from the former head of the Joint United Nations Programme on HIV/AIDS (UNAIDS):24
"AIDS...has become one of the make-or-break forces of this century, as measured by its actual impact and potential threat to the survival and wellbeing of people worldwide. Indeed, it is difficult to think of many other global problems that are in the same league as AIDS." (severity claim)
"AIDS is likely to persist as a worldwide epidemic for several generations unless a response commensurate with the problem is put in place and sustained." (neglect claim)
"Solution" claims on tractability and benefit take the following form:
"Problem X is surmountable (or if not yet surmountable, there is an urgent need to find ways to make it so). If it is surmounted there will be tremendous gains (and/or harm averted)."
An example is as follows:25
"National family-planning programmes have proved effective in reducing fertility and making progress towards population stabilization in most of Asia and Latin America..." (tractability claim)
"Family-planning promotion is unique among medical interventions in the breadth of its potential benefits: reduction of poverty, and maternal and child mortality; empowerment of women by lightening the burden of excessive childbearing; and enhancement of environmental sustainability by stabilizing the population of the planet." (benefits claim)
As these quotes illustrate, policy communities do not ignore material reality in their framing efforts. On the contrary, they use statements about material reality to advance their case. Their aim is to convince others to accept that the way they understand the evidence is the correct interpretation - an ideational act.
Some of the individuals who make these claims may believe them genuinely; others may see them as partial truths that they must nevertheless advance in order to acquire resources. The point is not to dwell on authenticity of belief but rather to highlight the similarities in the forms of the claims, to emphasize that they are ideational in nature and to suggest that the promotion of these claims is a core act of global health policy communities. Also, it is to suggest a reason why political leaders respond to some claims - by paying attention, developing programmes and providing resources - but neglect others. Social constructionists would explain this difference less in terms of the "actual importance" of the problem (i.e. questioning what such a phrase means) and more in terms of the effectiveness of global health policy communities in portraying and communicating severity, neglect, tractability and benefit in ways that appeal to political leaders' social values and concepts of reality.
Ideational portrayals alone are insufficient for issue ascendance and sustainability; they must be accompanied by institutions that create, negotiate, promote and sustain these portrayals.26
Traditionally, scholars have used the term "institution" in two ways.26 A concrete use is a specific organizational entity such as the Task Force for Child Survival and Development or World Health Organization. A broader interpretation, preferred by a developer of institutional analysis, is: "rules, norms, and strategies adopted by individuals operating within or across organizations".26 In the latter definition, the emphasis is on concepts that human beings share and use in repetitive situations. I believe the latter definition is preferable, but the two are connected in that organizations may serve to promote and solidify shared understandings. For example, the World Health Organization attempts to establish global rules and norms concerning what governments and individuals should do for better health.
Many global health issues are backed up by powerful institutions, understood in the organizational sense of the term. For instance, for several decades the Task Force for Child Survival and Development has coordinated global efforts to ensure political attention for the health of children.27 The Global Polio Eradication Initiative, linking the World Health Organization, Rotary International, the Centers for Disease Control and the United Nations Children's Fund (UNICEF), spearheads a global initiative to eradicate polio.23 HIV/AIDS is supported by a massive global architecture including: its own United Nations agency - UNAIDS; the US President's Emergency Plan for AIDS Relief (PEPFAR) - described as "the largest commitment ever by any nation for an international health initiative dedicated to a single disease";28 its own global financing source - the Global Fund to Fight AIDS, Tuberculosis and Malaria; and hundreds of civil society organizations.
These institutions mobilize resources, implement programmes and support research. But they do more than that. They create, sustain and negotiate portrayals of the issue. For instance, the global polio partnership has promoted polio eradication as a humanitarian crusade that will save the world's children from a scourge that has afflicted them for millennia. The late Jim Grant, the former leader of the Task Force for Child Survival and Development and head of UNICEF, effectively used these institutions to create frames for the issue of child survival that would generate the attention of political leaders.29 UNAIDS claims to be the "chief advocate for worldwide action against AIDS".30 Its former executive director, Peter Piot, has called for the need to "maintain the exceptionality of AIDS".24 He used UNAIDS to reframe the issue away from purely a public health concern to one that fundamentally affects the world's security and development prospects.20
The creation of strong global institutional arrangements with the capacity to create and negotiate issue portrayals is critical to an issue's sustainability prospects on the global health agenda. Where policy communities have struggled to create effective institutions, such as for malnutrition31 and pneumonia,32 political attention will be minimal until such structures are put in place. Where policy communities are in the process of developing institutions, such as for neglected tropical diseases33 and newborn survival,34 the prospects for attracting attention improve. Where policy communities have already established strong institutions, such as for HIV/AIDS and polio, the emergence and persistence of political attention is most likely.
Future research on the rise and fall of global health issues would do well to study the way policy communities develop ideas and build institutions. Specifically, we need to investigate the following questions:
How do global health policy communities form and why do some become powerful?
Why do some issue portrayals resonate with political elites while others do not?
Why do some global health policy communities manage to develop portrayals that resonate, while others fail to do so?
What are the characteristics of institutions that sustain effective issue portrayals? How do global policy communities come to build such institutions? What precipitates the collapse of these institutions?
What role do material factors such as mortality rates and the availability of cost-effective interventions play in issue ascendance in global health, and how do they interact with ideational factors? For instance, is there a minimal level of mortality burden or material evidence necessary in order for an issue to be taken seriously?
These are complex questions and I have not sought to answer them in this paper. Rather, I have taken a prior step: to propose that policy communities, ideas and institutions may be primary. A fully elaborated explanation grounded in these factors would require careful answers to these questions. If the explanation does stand up to empirical scrutiny, there would be clear implications for policy communities seeking to secure attention for their issues. First, they would need to consider framing systematically. Specifically, they would need to communicate clearly the nature of the problem and solutions, focusing on providing convincing evidence for the problem's severity and neglect, its tractability and the benefits that would accrue from surmounting it. They would need to consider carefully political leaders' concerns and interests in presenting their issue, rather than presuming, as so many policy communities do, that it is self-evident that their issue is important. They would need to select frames strategically, as some frames may be more attractive than others. For instance, policy communities may be more effective if, like the HIV/AIDS community, they make the case that their issue is not only a public health problem but a fundamental threat to human well-being, national security and/or economic development. Second, it would be to their advantage to build institutions devoted to their own issues, rather than to leave it to chance that existing global and national institutions are going to select their issues for attention. At the very least they should ensure that existing institutions have sections dedicated to their issues. Again, HIV/AIDS provides a prototype.
My primary intent in presenting this argument is to explain variance in issue attention, rather than to suggest what policy communities should do or what constitutes appropriate behaviour in global health advocacy. However, the rise and fall of global health issues certainly raise normative questions connected to long-standing vertical-horizontal debates in global health. As multiple global health policy communities compete for attention by developing ideas and building institutions for their own issues, are the poor well-served? Some observers of global health have expressed suspicions, pointing to the zero-sum nature of such competition for attention and resources. They argue for a more rational global health architecture that focuses on global public goods, considers material factors such as actual disease burdens in resource allocation decisions and is responsive to the preferences of national citizens.35 These concerns stand behind the emergence of several new initiatives to promote health aid harmonization, including the global campaign for the health Millennium Development Goals,36,37 and a call to turn away from issue-specific initiatives and towards an integrative approach that emphasizes strengthening health systems.38 On the other hand, other observers point out that competition may help generate new ideas and energy for addressing the health needs of the poor, and that focused initiatives are more likely to generate results, create accountability and produce political support.39 They also note that harmony may lead not to a rational global health architecture but to an authoritarian one: a few elite organizations colluding to dictate what is best for the health of poor people.40
I have proposed an explanation concerning why some global health issues attract and sustain attention while others remain neglected. It is grounded in a social constructionist paradigm and emphasizes the interaction between policy communities, ideas and institutions. It aims to deepen an existing framework that considered 11 factors, but that was not parsimonious or grounded theoretically. This explanation is simply a proposal, not a proven set of propositions, and demands critical scrutiny and empirical investigation. If accurate, the explanation has implications for our understanding of the role of strategic communication in public health. Far more than a sideline public health activity, it constitutes a core pursuit of global health policy communities.
Competing interests: None declared.
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(Submitted: 29 October 2008 - Revised version received: 2 March 2009 - Accepted: 3 March 2009)