The international health system implements strategies to achieve public health goals of a transnational nature. Drawing on the previous discussion, the mechanisms of international health reflect and foster interplay between social goals and institutions. The conventional international health system operates within a paradigm that national borders can stop diseases. National governments bear ultimate responsibility for public health in their territories, even though patterns of diseases and their determinants, as we increasingly understand, do not correlate with national boundaries.
Territorially organized national health policy, and the international health system based on it, originated with two key Western historical developments. First, quarantine played a central role in public health practices ever since Italian city-states. Second, the desire for healthy, flourishing populations during industrialization inspired government interest in public health promotion. Together, these factors cemented a system of inward-focused state-led public health, which accorded countries exclusive authority for their citizens’ health.
Further, the predominance of biomedicine in public health suppressed a multi-sectoral perspective that might highlight the ultimate weakness of state-centered health. The paradigm continued due to increasingly successful disease control from the 1800s until recently. Ironically, the international health system often further institutionalizes nationalized public health. Historically, the World Health Organization (WHO) contributed to the state-based nature of international health by “teaching” countries, especially newly independent ones, that “a national health policy was part and parcel of modernization” (Kickbusch 2000).
Today, the WHO, the World Bank and other international organizations provide some coordination and financing. However, around the world, domestic law, which regulates the importation of products, environmental quality and so forth, plays a significant role in shaping public health. In many countries, such regulations are woefully inadequate; nonetheless, each country remains largely at liberty to do as it wishes. As some specialists point out, while domestic law, international law and global governance all affect the formulation of public health policy and practice, domestic law predominates.
Thus, international health is somewhat of a misnomer. The dominant mode of cooperation entails incongruity between the spatialities of diseases, resources and political authority. This organization reflects two interconnected sets of values that have guided the system up to now. First, states are the primary organizing units in international society. Second, disease control is implemented largely within states. The more prominent the global health discourse becomes, the more problematic state-centered regimes become as well.
If the above values shift, and diseases, their determinants and effective responses become seen as transnational in nature, the international health system, as it has developed to date, faces two key spatial-political challenges. Kaul, Granberg and Stem (1999) term these challenges the jurisdictional gap and the incentive gapr The jurisdictional gap results from the discrepancy in governance authority between a globalized world containing transnational challenges and one divided into states responsible for their own policies, primarily focused on internal affairs.
The existing paradigm that diseases stop at borders fosters a lack of motivation to cooperate, or an incentive gap. While liberal theory posits that health policy organized by state allows each country to ensure its citizens’ interests as best it can, in reality it limits the cooperation necessary for addressing transnational issues. In the current system, health is not, in general, fully defined as a global public good (Kaul, Granberg, and Stern 1999).
One reason why public health is not fully developed as a global public good is because some diseases will not concern some countries due to lack of belief in vulnerability or lack of access to treatment (Zacher 1999b). International environmental problems clearly point to the problem created by addressing problems related to living in a biosphere after carving up the earth into distinct political distinctions.
Such issues, for example global warming, present formidable challenges for even the keenest international diplomacy. Nevertheless, the notion of “the commons,” (parts of the biosphere shared by all and owned by none), prominent in some environmental policy literature, makes such issues appear shared by all, even if they are not caused or resolved equally. Still harder to address are problems that affect all but arise in a place that is outside of the commons, namely within a particular political jurisdiction.
As Ruggie (1993) writes, “the really serious problem arose not in the commons, however, but right in the heart of the mutually exclusive state formations: no space was left within which to anchor even so basic a task as the conduct of diplomatic representation without fear of relentless disturbance, arbitrary interference, and severed lines of communication” (p. 164). These spatial-political challenges pose difficulties to policy responses that follow the growing sense of connection between “domestic” and “international” health.
The HIV pandemic is the most pressing health challenge that has appeared over the past two decades. The world community also faces all of the political, economic and social implications of globalization, including effects on nutrition, culture and health systems. It faces a drawn-out epidemiological transition from a disease burden shaped by infectious diseases and mortality to one shaped by chronic diseases and morbidity (although infectious diseases certainly persist).
It also faces an overall older population, based on decreasing birthrates and increasing lifespans (except in countries with the greatest number of deaths from AIDS). This fact, together with an increasingly urbanized population, means trends towards increased rates of diseases such as heart disease and diabetes will increase. Such diseases will pose increasing costs on already over-burdened health systems. These shifts render the heavy focus within international health on reproductive health and infectious diseases increasingly inappropriate.