Sociologists have much to contribute to the study of global health and development. Our discipline's fundamental concerns with power and inequality uniquely position us to leverage theoretical, conceptual, substantive, and empirical insights for the understanding of engines, outcomes, and processes of global health and development. This special issue highlights the diversity and depth of sociological engagements with the topics of global health and development. In this introduction to this special issue, I briefly outline how sociologists have approached the study of global health and development despite the fact that this is a nascent and not yet fully coalesced field. While medical sociologists and political sociologists have historically studied these topics, they have also marginalized them. Exciting sociological research is, however, underway. The challenge is in ensuring that scholarship on global health and development is in conversation across subfields in order to propel research on global health and development forward, both substantively and theoretically.
Sociologists have much to contribute to the study of global health and development. Our discipline's fundamental concern with issues of power and inequality renders us uniquely positioned to leverage theoretical, conceptual, substantive, and empirical insights for the understanding of engines, outcomes, and processes of global health and development. This special issue highlights the diversity and depth of sociological engagements with the topics of global health and development, ranging from individual-level analyses to examinations of national trajectories and global governance, and dealing with topics ranging from the politics of sexuality and global AIDS policies to gender and fresh-food consumption. While highlighting some recent research, this brief introduction is not intended to (and certainly does not) exhaust the wide variety of work being done by sociologists on global health and development, but to highlight the diversity of their approaches and entry points. It is also focused on American sociology, drawing on institutional information from the American Sociological Association (ASA).
While sociologists have long studied issues related to health and development, this appears to be a coalescent moment for a self-identified community of scholars working on global health and development within sociology. This moment is evident in the formation of a global health interest group within the ASA, sessions on global health within the same, and other sessions, symposia, and mini-conferences on the topic. The boundaries of this nascent community are fuzzy, with scholars doing work that most might consider squarely in the purview of global health and development but not identifying themselves or their work as such (identifying as political or medical sociologists, for example). The challenge, then, is bringing this otherwise disparate research into conversation. This is an especially exciting time for those engaged in research on global health and development, not least because of the timeliness of this topic amid national and international debates on health policy, concerns about epidemics and preparedness, and the proliferation of global funding for health.
The primary question surrounding this emergent field is, what counts as global health and development research within sociology? The boundaries, as mentioned, are fuzzy, and in many senses the question is one of framing. That is, global inputs to the research are not required. Work firmly under the purview of global health and development need not include all the world's countries, or exclude organizations without an international mandate. Nor is the process of doing work “over there,” in the global South, a necessary or sufficient condition to be counted as global health and development work. The “global” descriptor depends more on the research questions and the scope of analysis in terms of theoretical and conceptual concerns rather than the substantive or methodological approaches. Work on developed countries, both historical and contemporary, can and does engage with questions of global health and development. Similarly, work on global health and development shares a fundamental concern with how health is related to development. While for some scholars health is an indicator of development, for others it is conceptualized as an outcome of which development is a driver, while others complicate the causal relationship, noting that improvements in health outcomes may drive development, rather than functioning as its outcome. Development, then, can be viewed in economic terms (e.g., increases in GDP) or in social terms (e.g., a capabilities or social development approach), and as an individual, community, and/or national process or outcome.
SOCIOLOGICAL WORK ON GLOBAL HEALTH AND DEVELOPMENT: A DISJOINTED ENTERPRISE
There is a rich history in sociology of work that has been concerned with global health and development, much of it stemming from political sociology, with perhaps the most prominent strain of this work located in the welfare-state canon. Understanding the ways in which the state relates to welfare and health systems in particular has occupied political sociologists since at least T. H. Marshall's (1950) seminal work on social rights and citizenship. Historically, work on the welfare state has focused on Europe, and health has fallen comparatively out of the spotlight among political sociologists. Some of the classic work on health systems, which distinguishes between the Bismarckian and Bevedridgian approaches to health systems in the context of broader political economic concerns, reflects issues of the interface between national development and health in comparative perspective.
Beyond those political sociologists that seek to examine how political systems and states structure health systems and address health inequalities, other scholars note that health is not an outcome but rather a driver and indicator of social development itself. Recent research has reintroduced health as a primary concern of welfare-state research, noting that health expenditures are a large (and often growing) share of social expenditures (e.g., Noy 2017).
Medical sociologists have also studied health and development (Mabry 1971; Sigerist 1960). However, medical sociology has marginalized development and globalization: “the study of globalization in medical sociology has been slow to develop, but the topic is growing in importance with the increased realization that health and disease have global connections” (Cockerham and Cockerham 2010:21). Some medical sociologists have examined how social inequalities and social structures affect health, while others have focused on issues of biomedicalization and pharamaceuticalization. Health disparities have received, and continue to receive, extensive attention from sociologists. Theories of fundamental causes, the social determinants of health, and the relationship between economic inequality and health disparities have been particularly important in pushing scholars to consider how socioeconomic conditions, both within and across countries, shape health inequalities (Link and Phelan 1995; Phelan, Link and Tehranifar 2010). While this work on health disparities has focused on developed countries, and in particular the United States, there has been increasing concern with how health is treated and understood in developing countries. Nonetheless, despite notable recent developments, international and global health has been comparatively neglected. “The topics of globalization, internationalism in health care and social systems-level analysis appear to have been neglected by medical sociologists” (Seale 2008:693), with sociologists focusing on national settings rather than considering health and medicine as global systems (Beckfield and Krieger 2009; Bradby 2012; Pescosolido, McLeod, and Alegria 2000).
Beyond political sociologists working on questions of the welfare state and health systems, and medical sociologists engaged in understanding social disparities, other sociological subfields have engaged in research on global health and development. For example, sociologists have examined the medicalization of sexuality (e.g. Conrad 2007) which has bearing on our understandings of global health and development. Other sociologists have studied gender and its relationship to global health and development (e.g., Suh 2017). Sociologists studying aging and the life course have examined aging and health in global context, and investigated how development influences outcomes and trajectories (e.g., Koropeckyj-Cox and Call 2007). Immigration scholars have explored questions of migration and health as a transnational phenomenon and engaged with debates on global health and development (e.g., Sanderson 2010). Within population studies, sociologists and demographers have studied the relationship between health and development, often with a global approach (e.g., Goesling and Firebaugh 2004).
Structurally, the fact that sociologists who conduct research on global health and development are members of different specialties in sociology has meant that strands of this research remain separate and unengaged. Indeed, some sociologists who study issues that an observer may think are squarely in the domain of global health and development may not label their work as such; for example, those that study health in the context of welfare states may identify as political sociologists rather than global health and development scholars. We may expect that most scholars who conduct research on global health and development will self-identify and therefore be members, within the ASA, of the sections on the Sociology of Development and Medical Sociology, and perhaps Global and Transnational Sociology. That global health is not a distinct section, and because scholars engaging this area may come from different subspecialties and their own theoretical and substantive traditions, it is challenging for a community of scholars to cohere and develop an identity. The lack of such coherence makes it difficult to integrate the important insights not only from medical and development sociology but also from scholars that work primarily in other subfields (e.g., mental health, reproductive health, or political sociology) but whose work may also fall squarely within global health and development.
Figure 1 presents a sociogram of ASA sections, with the three sections most likely to contribute scholars interested in global health and development highlighted. The proximity of Sociology of Development and Global and Transnational Sociology in the graph space suggests that they are more similar in terms of shared members and those members’ other section memberships. Notably, they are rather far removed from the Medical Sociology section in this space. It is important to underscore again that scholars working on global health and development may be members of one or two or all three of these sections (or none of them), or others. However, these three sections are highlighted because at least scholars who identify themselves as working on issues of global health and development are likely to be members of at least one of these three sections.
A number of moves in recent years have helped establish a community of sociologists with interest in global health, for example the global health interest group within the ASA. The rapid growth of the Sociology of Development section since its inception in 2011 has also facilitated more dialogue for those scholars concerned with the linkages between development and health globally. Finally, recent annual meetings of the ASA have featured sessions on global health and development. For example, the 2017 annual meeting featured an invited thematic session entitled “Structure, Culture, and Health Inequality in International Perspective,” a regular session on Mortality and Morbidity entitled “Global Health Inequalities,” a Mental Health session on “Mental Health Research outside the United States,” and a Sociology of Development session on “Health and Inequality across the Globe.” All of these initiatives are promising and suggest the growing recognition of this important area of research within sociology.
SOCIOLOGICAL INSIGHTS ON GLOBAL HEALTH AND DEVELOPMENT
Contemporary research on global health and development within sociology (and this piece is focused primarily on American sociology) has yielded some important insights and findings. Its biggest strength, perhaps, is that it bridges theory, method, and concept from across different sociological subfields. First, as the articles in this issue demonstrate, we know increasingly more about power and inequality in global health. Partly, this power belongs to development banks and developed countries, wielding money, imposing conditions, and setting the global agenda in health. However, power is also manifest differently across community, national, and local contexts. Gender, race, ethnicity, sexuality, class, and disability status, among other identities and dimensions of difference, are rendered salient or important for health, both in terms of polity and interpersonally, in varied and important ways.
Second, we also know increasingly more about resistance and response. How do communities, people, and countries respond to the threats and realities of epidemics? How do they interact with global agents, donors, and lenders? And how do social movements frame their work in global health and development? This work is particularly welcome as it begins to address some areas we know little about despite their global importance: while the work within sociology on health systems has historically focused on developed countries, sociologists are beginning to ask how these theories and insights may (or may not) apply to other contexts. Research is beginning to reveal the limited but nonetheless useful ways in which classic theories of the welfare state and other social structures may be applied to developing-country contexts. Third, we are increasingly learning how social, cultural, political, and other factors affect not only what policy options are pursued to enhance human health and well-being globally, but also how these factors may pattern the relative success or failure of initiatives such as universal health care and maternal and child health programs.
Sociological work on global health has accomplished much, enriching our understanding of how states, people, communities, and regional and international organizations participate in health policies, outcomes, and inequalities. There remain several fruitful avenues for future research. More attention is warranted in examining global health governance, especially given the rise and financial power of newer organizations such as the Bill and Melinda Gates Foundation. Sociologists have much to contribute to these analyses, which have thus far been dominated by political scientists and international relations scholars. Another area ripe for research by sociologists, to complement public health research, is the impact of health systems on inequalities across different categories of difference—sexuality, ethnicity and race, class, gender, disability, geographic location—and in comparative perspective across countries and regions. Community-level and other meso-level analyses would also be welcome given the traditional focus (not only in global health and development, but across sociological research) on individuals and nation-states as the methodological and theoretical unit of analysis. As noted earlier, studies on global health need not consider the entire globe; rather, the orientation is a more conceptual one, considering health issues in the context of global health and development concerns, even at the individual and community levels.
Such studies would shed additional light on how community, neighborhood, and other intermediate contextual conditions may contribute to shaping inequalities and outcomes, and how policies are enacted and implemented across places. Methodologically, social network analysis may help push the field forward in mapping relationships in terms of financial and other resources flowing between countries and international organizations, and at the meso-level can provide additional information on organizations and individuals, and how ties and relationships may shape responses and outcomes in health. Comparative research can further enrich our understanding of how global recommendations may play out in national outcomes and policies, and how countries both within and across macro-regions may differentially respond to global health challenges.
The field is an exciting and growing one, as sociologists increasingly recognize that all policy is health policy, in that policies in education, defense, trade, environment, and other domains often have important, sometimes unanticipated and unintended, consequences for the health of people and nations. Coupled with the ways in which globalization is increasingly challenging conventional models and understandings of movement—people, illnesses, ideas, and their consequences—these issues serve as a call for sociologists to engage with the challenges of understanding these complex dynamics, to leverage our existing expertise and theories, and to continue to do research which sheds light on global health and development.
The articles in this special issue provide examples of the wide-ranging and innovative work, across theoretical, substantive, and methodological approaches, that sociologists are doing at the frontier of research on global health and development. In doing so, they represent not only the important work being done but also the promise of sociological treatments of global health and development concerns. This work stands to enrich existing subfields, such as the sociology of development, but also to highlight the importance of global health as an area of study, which can and should be informed by existing insights from the sociology of development, organizational theories, and studies of sexuality, to name a few, as the papers in this issue demonstrate. The research presented in this issue also showcases the unique opportunity that global health and development provides to push forward sociological understandings of political and policy processes, individual outcomes, and global governance in other subfields and more generally, to name a few areas.
The issue begins with a literature review by Harris and White, who review contributions to a sociology of global health, including and going beyond the connection between global health and development. They discuss three main streams in the sociology of global health: the first focused on macro-level research, the second on social structure and health across levels and units of analysis, and a third that takes as its subject social movements and organizations that play an important role in the organization and production of health and healthcare. This final area offers an important corrective to existing sociological contributions, as it takes account of nonstate actors that play a critical role in the health domain in large parts of the world, including NGOs, donors, and international organizations.
Sommer, Shandra, Restivo, and Reed offer a macro-level study that examines how the African Development Bank affects maternal mortality in sub-Saharan Africa, drawing on data from 33 countries over 20 years. They argue that the bank engages in “organized hypocrisy,” with differential outcomes associated with different lending instruments: structural adjustment loans correspond to increases in maternal mortality, while health loans correspond to reduced maternal mortality. This paper highlights the utility of theories from other domains (e.g., organizational theory) for understanding the emergent patterns and effects of global and regional governance institutions in health.
Jafflin examines how the World Health Organization's immunization program was implemented in Malawi and Cameroon in the 1970s and beyond. She argues that the poor performance and comparative failure of this program in Cameroon was due to insensitivity to local conditions and historical legacies. In Malawi, on the other hand, global imperatives dovetailed with local practices to enable the program's success. This article highlights not only the importance of comparative research but also how global objectives play out in national outcomes, and what national conditions facilitate successes and failures in global health programs.
Angotti, McKay, and Robinson explore the consequences for LGBT populations of the HIV/AIDS policy responses in Malawi and Senegal. In particular, they argue that the inclusion of men who have sex with men (MSM) in global HIV/AIDS response efforts had some important and often unintended consequences for LGBT populations in these countries. In particular, while these efforts provided new urgency and sources of support for nascent LGBT- and MSM-identified groups to organize around sexual identities and address HIV prevention in their communities, this new visibility also contributed to political backlash against LGBT Malawians and Senegalese, and access to funds to respond to HIV/AIDS was sometimes conditioned on a lack of LGBT advocacy. This piece highlights the importance of domestic conditions, but also the ways in which global health efforts may have far-reaching and sometimes unintended consequences in the political marginalization and oppression of particular groups.
VanHeuvelen and VanHeuvelen examine how gender and national economic development pattern healthy eating behaviors, and how these in turn predict health outcomes in 31 middle- and high-income countries in 2011. They find that economic development increases women's consumption of fresh fruits and vegetables. They also find that in less economically developed countries women report lower health than men but that this is limited to those who do not report healthy food consumption. In contrast, in more economically developed countries women report better health than men, but this is restricted to those consuming healthy foods. These findings underscore that gender operates differently across national contexts and interacts both with national economic development as context and with individual health behaviors such as fresh fruit and vegetable consumption to influence individuals’ self-reported health. Taken together, the articles in this special issue provide important, distinctly sociological treatments of issues central to our understanding of global health and development, highlighting the promise and diversity of research in this area.