Power as a ‘fuzzword”: We agree that applying theories of power can be critical to understanding health policymaking and implementation, as well as the social determinants of health and population health status. However, we are concerned by references to power as a general, catch all concept that is not easily mutable.  Power as a ‘fuzzword’ may not advance knowledge or promote change, whereas thorough applications of power as a lens may help us to identify the drivers of global health injustices ranging from health disparities to implementation failure. Moreover, we are anxious to move beyond explication of power dynamics to identify actionable strategies and tools that provide avenues for change. Are there particular ways of looking at power that make this easier?

Not enough reflexivity: Some in this group expressed discomfort with researchers assessing power as an external phenomenon that affected communities in other places, but not our own work. Researcher reflexivity is one approach to naming, acknowledging and addressing/accounting for certain types of power. However, just as we may uncritically engage power as a macro concept, we may insist rhetorically on the importance of reflexivity but fail to put it into practice in a robust way.  The dynamic of the outside researcher who fails to see his/her role in the political economy of health research can be more acute in the context of the neocolonial past (and present) of global health. Northern or otherwise elite voices are often louder, and while those with louder voices may advocate for more diversity and inclusion in global health, some might be unwilling to question or concede their own privilege and prestige. Key institutions can also neglect or muzzle honest engagement with both inter- and intra-organisational power dynamics.  UNAIDS, for example, was positively appraised for its gender-related policies, but it took an outside review to identify the extent and impact of patriarchal culture that existed within the organization despite these policies.

How does power shape ‘what’s in’ in global health? Lack of reflexivity influences our own research and global health agendas.  The dynamics researchers ignore are likely to be similarly absent from the agendas of national and global policy makers. This in turn undermines our ability to understand and address the very power dynamics shaping health disparities. Of course, there is ample rigorous, empathetic, community driven research on health policy and systems. Yet, there are also issues – so-called “big invisibles” – consequential in health systems – that remain underemphasized in global health. By way of example, SHAPES members mentioned corruption, disrespect and abuse in maternity care, access to safe abortion, informal payments for health care, and hospitals detaining patients because they are unable to pay, but doubtless more exist. Germane to people’s experiences, these issues are shaped at multiple levels of the system, including national politics and policies and global health governance, and are also deeply contextual. Moreover, these dynamics and relationships of power have taken shape over time. SHAPES members emphasized that it isn’t possible to fully understand their present iteration without reference to their historical underpinnings.

How do we ‘see’? Whether or not we acknowledge them, the persistence of these invisibles in global health is evidence of power. Moreover, failure to acknowledge such issues is a further  exercise of agenda-setting power – by researchers, policy makers and programmers. SHAPES members opined that intentions are key. In this context, conscious use of theories of power is important. Are we applying these theories just to our particular research topic and site, or to the ecology of global health governance that includes ourselves? Are we thinking of power as a political scientist may, as a top down system wherein individuals have limited decision space given political and economic structures? Do we also apply an anthropological lens so that we see how people at all levels apply and subvert mechanisms of power to suit their own needs? Or, do we think of power as Foucault did, as a pervasive system that regulates our language and behavior? And, what about the postcolonial underpinnings of these power theories – essentially western in origin, but used in the context of understanding LMICs? Our choice of approach has consequences for our research and for the global health agendas we create and inform.

These issues surfaced in our discussion of power and HPSR, but there are certainly others, and we welcome a robust discussion on those topics as well. Stay tuned as we try to tackle the practical issue of identifying approaches to studying power and health systems that facilitate both rich description and subsequent action.

The authors wrote this blog on behalf of SHAPES

1) The (lack of) emphasis on the ‘P’ – HSR seems to be predominantly focused on services, with a clear focus on policy implementation and evaluation, but less so on the development process underlying new policy, particularly issues of agenda setting and formulation, and the reasons for the entrenchment of existing policy. In the U.S. context, the latter types of studies – delving into issues of politics, interests and power – seem to be far more common in research from disciplines such as political science. I sense less of an incorporation of that kind of policy research in the HSR space, which is contrast to HPSR, where such studies have been actively encouraged (although still quite neglected). At AcademyHealth meetings, this inevitably results in many ‘elephants in the room’ – for example, the outsize role of lobbyists in shaping health care.

In my view, this is one of the fundamental differences between HSR and HPSR – the longer term vision in HPSR to delve deeper and understand how and why certain policies gain traction, in an effort to try to fundamentally reorient systems to become more equitable, rather than just retooling what exists. The U.S. health care system is notoriously complicated, and much of the AcademyHealth meeting felt as though we were focusing on band-aids to the problem, rather than trying to get at the heart of these issues. Those are understandably difficult conversations – even more so due to the intense politicization of health care in the U.S. – but is essential to a holistic understanding of health.

2) Shared struggles of HSR and HPSR researchers – HSR and HPSR researchers seem to wrestle with similar issues – the desire to highlight community (but tellingly referred to as patients in the U.S. context) perspectives, underlying tensions between qualitative and quantitative methodologies, and challenges in integrating social science approaches. One common theme between last year and this year at AcademyHealth was the difficulties in developing constructive relationships between researchers and policymakers, something that has become more fraught with the Trump Administration. I had assumed that HSR researchers have an easier time accessing policymakers and disseminating findings given the dominance of government in funding HSR, but that assumption was proved wrong. Many of the issues brought up – need to use innovative methods for dissemination, challenges in engaging with the media, generating actionable messages, developing long-term engagement with policymakers and journalists, etc. – are themes that have come up repeatedly in the context of HPSR. I wonder if more can be done to share lessons across contexts, for example at the annual Dissemination and Implementation Symposium sponsored by AcademyHealth.

3) How ‘global health’ is perceived by the HSR field  – AcademyHealth has a small, but growing, focus on global health, and one can find posters, presentations and discussions on health services research outside the U.S. scattered throughout the conference. However, what’s more striking is how difficult it can be for stakeholders in the U.S. to draw lessons from other countries (even though international exchange has shaped the development of medicine in the U.S. for over two centuries). Few panels seemed to bring in lessons from other regions of the world, including other high-income countries with market-based systems. One reason for this might be that as the U.S. health care system becomes more byzantine, researchers, policymakers and practitioners gravitate to lessons from within the country – for example, at the state- and local-level – rather than countries where the political and socio-economic scenario is perceived to be too different to allow for meaningful learning and exchange. I would argue that such learning is in fact essential for benchmarking (not in the ranking sense of the word), and for introducing and testing new ideas and approaches.

I was also intrigued by how global health is perceived amongst HSR stakeholders. In one panel, someone noted that ‘We need to bring a global health mindset to U.S. domestic care  – lower cost, higher quality’. This comment says several things to me. One, due to the dominant role of technologically motivated global health organizations (including those based in Seattle), health in LMICs is increasingly being seen as a space for innovation – for trying out interventions that are in theory low cost and perceived to be more effective. However, there continues to be sharp criticism of these types of approaches. Two, introducing such a ‘mindset’ into the U.S. is a step in the right direction – but one wonders if this is a continuation of the band-aid approach discussed earlier. Finally, the panelist seemed to acknowledge that despite the major role of U.S. stakeholders in global health, HSR as a collective is still a bit isolated from international engagement and learning. As progressives (à la Bernie Sanders) embrace ‘Medicare for All’, it feels as though the U.S. will eventually reengage with Universal Health Coverage, and that could possibly an avenue for further exchange (we will however likely have to wait for the next Democratic administration for this to happen).

Definitions and understandings of the term ‘global health’ are evolving, and there is now a recognition that we need to see high-, medium- and low-income countries in relation to one another, and to also incorporate a focus on inequities within high-income countries, rather than the traditional dichotomy between high-income countries and low- and middle-income countries. It will be interesting to see how the Annual Research Meeting at AcademyHealth begins to reflect these changes in the coming years, and to see how the HSR community situates itself in relation to HPSR and other health stakeholders around the world.

This episode was remarkable for several reasons. First and foremost, there is the fact that this was an incredibly odd and surprising selection given Mugabe’s role in ruining his country’s once strong health system (strongly articulated in the PHM Zimbabwe statement on the appointment). Second, the decibel level of the outrage in the media and on Twitter appeared to be far louder than anything we have seen so far in global health. And third, the WHO reacted swiftly, within a matter of days, to rescind the controversial appointment.

Our focus here is not on the decision itself, which we agree was inappropriate, but with the global response, and what the response tells us about the power dynamics flowing through global health governance, serving as another example of the intense power that the Global North (still) has in shaping discourse in global health.

A key question in this entire episode is whether the outcome would have been different if we, hypothetically, replace Mugabe with a different authoritarian leader. Mugabe might have been an ‘easier’ target, given his advanced age and diminishing role in geopolitics. But had the decision to revoke Mugabe’s appointment been made with a more powerful, globally ‘relevant’ (from the perspective of high-income countries), authoritarian-style leader, would the criticism have been as vociferous? Possibly not. Several countries with leaders with questionable human rights records have played and do play key roles in global health diplomacy (examples here and here). Keeping in mind the ideas of social justice and fairness that the global health community is meant to espouse, this begs the question about what we consider ‘tolerable’ behavior from a political standpoint.

Consider another example playing out in real time – the World Bank’s women’s entrepreneurship fund, launched in partnership with the Trump Administration, (represented by Ivanka Trump). The incongruity of this alliance (captured beautifully in Bill Easterly’s tweets) is underscored by the fact that the head of this Administration has a particularly dismal history with women’s empowerment – an example of which is the number of sexual harassment charges that have been brought against him.

When it comes to powerful international actors with less than stellar track records on issues ranging from muzzling civil society, to cracking down on free speech, to promoting ethno-nationalism, there appears to be a recognition that partnerships with those countries are warranted for political reasons, increasingly so in today’s climate where multilateralism is in crisis. But such an argument did not seem to have much traction in the backlash against the Mugabe decision. For example, many articles in the US media for example focused on the loss of ‘goodwill’ for the WHO more broadly, particularly in light of the negative coverage the institution received during the Ebola epidemic. What is interesting is that such discussions about the reputation of these institutions become far more nuanced when Northern actors are deeply involved. To our knowledge, few are challenging the World Bank’s legitimacy in light of the Trump partnership.

The episode also highlights whether we are more willing to turn a blind eye when considering certain political figures as global role models, in a similar vein as the Goodwill Ambassador position. For example, it is well accepted that politicians from the Global North, many of whom have been deeply connected to war and conflict in other parts of the world, can leave office and go on to have a second life as architects of world peace and development ( e.g. Tony Blair and his role as UN envoy). Why does our bandwidth for forgiveness and acceptance extend in the case of elite Northern actors? One explanation is that the power that Northern leaders wield, and the way in which we as society are conditioned to view them, strongly shapes what is tolerated, and what is not.

Finally, the nature of the response in both the news coverage and on social media reflects the continued dominance of Northern voices in shaping global health debate and discussion. The US media coverage for example was largely decontextualized and stripped of any views from Zimbabwe or the broader region. Such context is an essential part of understanding this decision, as put forward in a recent piece by Simukai Chigudu. The news coverage and heated social media debate also neglects the longstanding discontent amongst LMICs with Northern dominated global governance ‘discourses’ e.g in diplomatic relations with the African Union. There is a tendency that countries and regions withdraw from multilateralism partly because of its ‘capture’ by high-income countries.

Beyond the media narrative, views on social media appeared to focus on dominant Northern voices – even if the outrage had much broader and deeper roots. This matters, because as social media becomes a platform for protest in the global health community, some views will gain traction and visibility over others, perhaps due to their geographic locations (eg. in certain democracies people feel more comfortable voicing their views on Twitter) or the power of these individuals relative to other stakeholders in global health. Therefore, we need to think about whether these platforms will mimic other fora, including academic journals, where voices from low and middle income countries do not receive the same amount of attention. Compared with other, arguably more fraught areas of international diplomacy – trade, nuclear security, climate change – global health remains, for a part, a relatively ‘safe’ diplomatic space where post-colonial viewpoints, including a considerable role for philanthropy, still play out (McCoy and Singh, 2014). Therefore, we need to closely engage with the evolution of this new territory of social media activism.

One positive lesson from this entire experience is that there is a role for the broader global health community to play in shaping the trajectory of global health policy, perhaps in a way that we have not seen in the past. But we need to also reflect upon and question our own agency, norms and values in taking these stances, and ask whether we are in some ways contributing to existing power structures in global health, or whether we are trying to strengthen the legitimacy of diverse and alternate discourses to ensure further meaningful change for health, equity and social justice.

The application of social sciences to health policy and systems is growing, but still in a somewhat nascent stage. Further, there appears to be a perceived overuse of certain theories or the under-utilization of others (theoretical understandings of power for example). These are valid points, but perhaps there are some additional questions that we need to ask.  Beyond calling for social science research, we must also consider why the social sciences have not been perhaps sufficiently integrated into HPSR.  At a recent symposium on global health policy and the role of power, Sara Bennett raised an important point – why exactly don’t we have more social science in health policy and systems research? What are some systemic and structural reasons that explain this disconnect? As crucial as the social sciences are to health policy and systems research, the underlying causes are critically important to understand and address. In my view, the disconnect seems to emerge from a series of interconnected issues – the nature of our training in public health, the accessibility of much social science theory, and the ways in which we build networks.

First, many people engaged in health policy and systems have been trained primarily in public health. Globally, public health training programs have evolved to adopt a somewhat formulaic approach – structured around biostatistics and epidemiology and oriented towards programs and applied research. Factor in the short length of time for these programs and the lack of cross-disciplinary teaching, and there simply isn’t the space or ability to adequately teach key social science concepts. Students therefore don’t have the opportunity to pursue training in a particular discipline, or have the breathing room to determine what their interests actually might be.

Second, accessing social science theory in the ‘real world’ is not easy. Exploring these resources often requires good access to a library and an online database, major challenges in most low- and middle-income countries, particularly for those working outside of academic institutions. Engaging with this literature also requires an extended period to sift through materials in attempt to figure out the right kind of social science theory or approach to apply. Such time is often built into doctoral research, but quite rare for other types of researchers facing fast deadlines or competing projects. Social science theory can sometimes feel opaque, and at least in my case, requires a long hard stare before comprehension kicks in. Since self-teaching is often necessary in our field, the combination of dense material and time limitations is a possible barrier.

Third and finally, there is the issue of disparate professional networks and obligations. Despite considerable progress on this front, academics are often incentivized to speak to and write for their ‘people’ (with of course many notable exceptions), limiting opportunities for cross-network learning. The broader health policy and systems research community particularly benefits from such cross-disciplinary fora, providing more exposure to new methods, concepts and theories. At a recent international studies conference, a theme that emerged in a global health session was the limited opportunities for social scientists to cross boundaries and present their work in trans-disciplinary fora. There are certainly many more cross-disciplinary fora now than in years past, particularly with international conferences, but such opportunities could be more widespread, certainly in LMIC settings.

These three barriers listed here can be addressed, but will require a concerted and coordinated effort, particularly from academics. The SHAPES community has recently been discussing possibilities of expanding the reach of the social sciences, for example, through accessible learning resources. Gagnon and a group of political scientists recently published an excellent commentary suggesting avenues for collaboration between their discipline and public health. Other ideas include expanding joint offerings in public health schools between public health and social sciences (more common for example in economics than in political science), and introducing more online courses for those already in the workforce. Finally, a more challenging endeavor will be to bridge divisions, real or artificial, between those squarely in their social science disciplines, and those in the health policy and systems research realm. Taking these steps could allow us to address those structural issues that underpin the lack of social sciences in health policy and systems, and enable us to ask different questions, and go deeper in our analysis and thinking.

These past two weeks have felt surreal, and horrifying, to many of us living in the United States and presumably for many around the world. A new day, a new executive order, a new enemy. The immigration ban is the most recent, and most appalling of his policy efforts. But, Trump’s far ranging, deeply conservative initiatives are going to have major impacts – from destabilizing international agreements, to silencing federal agencies of government, to building a wall with Mexico, to throwing his weight behind the anti-abortion movement, to politicizing the National Security Council. For anyone who suggested that Trump might soften once entering the office, think again. He is doing exactly what he said he promised he would. The enveloping xenophobia, misogyny, discrimination, inability to absorb criticism and dissent, and all around lack of decency, adds to the growing distaste. It’s safe to say that when the President of the United States eagerly takes on a beloved religious leader, such as the current Pope, we are in a new era where literally anything is possible.

If there is one glimmer of hope in this windfall of depressing news it is that progressives are not standing for it. The past several weeks have seen growing protests across the country – largely grassroots and driven by social media – that are fueling a burgeoning anti-Trump movement. For example, the women’s marches – the largest protest ever in American history – was largely about protecting and expanding women’s rights, but they also served as a conduit to protest a variety of concerns, ultimately converging on their intense dislike of this new President and his administration. This emerging resistance has fired up the left and the left-leaning, and within a span of days, emboldened Democrats to actively challenge the new Administration and congressional Republicans.

These protests have also sparked a wave of seemingly unabashed progressivism– and after participating in some of them –my sense is that this frustration and anger can coalesce, mature and strengthen into a movement that lasts well into this Administration and beyond. The divisions amongst progressives are real, but so is their unrelenting dislike for this Administration and everything it stands for. I would argue that through this process, groups on all sides and all generations will start to acknowledge, appreciate and begin to resolve some of their differences, leaving us in better shape than where we found ourselves in November 2016.

Much has been written about the handwringing amongst liberals for not broadening and expanding their message of economic inequality. The Bernie-Hillary fight for the Democratic Party nomination exposed the growing divide between the neo-liberal and more progressive factions of the party. Some were perhaps not willing or able to reconcile their own ideologies with what they believed as a political inevitability – an incremental, not sudden, climb towards more left-leaning values – universal health coverage, for example. But any reservations about moving too quickly to the left seem to have dissipated in these distressing ten days of Trump’s Executive Actions. For every callous and cruel stance that Trump takes, this new movement seems to value the exact opposite – tolerance and compassion. People from all ages and all backgrounds are acting out about the authoritarian turn of events, something profoundly ‘un-American’ in the eyes of many (although this country has a history with this sort of behavior). And further, people are becoming more unapologetic about their left-leaning views – something that has not always been in fashion in the U.S. I’ve noticed that these protests are driven by a liberating sense of nothing left to lose – since the worst has come to pass, why not leave it all on the field? That combination of progressivism and fearlessness might in fact be what helps the Democrats slowly undo the damage of the past few years, lose their ‘elite’ sheen, and begin working towards some of the more socially oriented policies that Obama tried, and due to merciless opposition from the right, failed to implement.

Some of this sounds like a fairytale – perhaps it might never come to pass. Trump has been remarkably adept at speaking to his base, and by all accounts, they are on board with his decisions. But, what we are seeing now is their support for Trump’s discriminatory initiatives beyond his economic argument – the immigration ban for example – is dialing down the sympathy that some on the left might have had for their perspectives. The conservative movement might have been better organized in rallying their base, but the other side now has the stomach to fight back. It now comes down to which side will raise their voice the loudest. My money is on the side without the albatross of Trump around its neck.

But, reminders of our new world order are never far. While skimming the news during a session break, I came across this piece on Trump’s potential cabinet picks in the New York Times.

It says something about the state of the world, when on the one hand, you have incredibly well-intentioned, capable and smart citizens of high-income countries discussing the important role of donor agencies in promoting national-level accountability, while on the other hand, the leading choices for the Secretary of Health and Human Services in the United States have variously denied climate change and evolution, supported concealed carry of fire arms, believe that homosexuality is abhorrent, restricted abortion services, and limited the expansion of pro-poor Medicaid. As an American citizen, there is a certain hollowness that one feels knowing that despite all our efforts to instill empowering values in our work, we are often woefully inadequate in finding it in our own political systems.

Many of us in global health carry multiple identities (citizenship, ethnicities, you name it). My own identity is complicated – an American citizen, raised in India, studying at Johns Hopkins, and researching health policy and systems in the Indian context. One of America’s strengths has been its ability to absorb people like me into its urban centers with relative ease, providing a safe and vibrant multi-cultural base for – in my case – work on health issues in low- and middle-income countries. The need to look ‘inward’ never felt quite as urgent as the problems in more disadvantaged places, nor was our orientation towards global health at the expense of domestic issues deeply challenged.

However, in the age of Trump, Brexit and other nationalist movements, that feeling of ease is out the window, as beautifully put by Jonathan Glennie in his op-ed today. The utter shock that many of us felt following the election is a signal that we do not know our immediate environs. Or at least we don’t know it well enough. The sexism, racism and discrimination is real, but so is the fact that as elites, we perpetuate islands of freedom, security and liberal thinking within a sea of more complicated and often conservative thought. I’ve always taken the notion that international work has its own unique promises and challenges, and should be given a space of its own to function. But given the direction of our national politics, it seems a bit artificial to fully detach from our association with a Trump-led America that denounces science, promotes guns, and disrespects women, and to continue with business as usual. The same goes, by and large, for my colleagues in Europe, even if Trump probably “trumps” the current crop of European xenophobic and populist leaders. More accurately, perhaps, it is not possible anymore to continue with business as usual, even if we wanted to.

But, what comes next? Do we start to integrate more domestic activism in our public health training? Do we actively encourage domestic research alongside international projects? Do we abandon our existing careers and move to so-called red states to win ‘hearts and minds’? Would any of this really make a difference? The vagueness and confusion of the aftermath is frightening.

So while I am here at HSG 2016, I seek a little bit of clarity. I understand the argument that a post-Trump world may not be the apocalypse, but based on his leadership appointments, it’s not going to be Bush 2.0 either. So we would be well-served to think about this differently. The world is filled with kind, thoughtful and brave people, and my cohort of EV 2016s are living proof of that. From them, and from others at the conference, I hope to learn how we as Americans can become more active and alert in our politics, become willing to work within our context, and to continue to work passionately and collaboratively on health, empowerment and social justice in other parts of the world.