Powerful concepts in global health Comment on “ Knowledge , moral claims and the exercise of power in global health ”

In this paper we emphasize the importance of questioning the global validity of significant concepts underpinning global health policy. This implies questioning the concept of global health as such and accepting that there is no global definition of the global. Further, we draw attention to ‘quality’ and ‘empowerment’ as examples of world-forming concepts. These concepts are exemplary for the gentle and quiet forms of power that underpin our reasoning within global health.

I n his recent editorial, Jeremy Shiffman (1) draws attention to the exercise of power in global health, and especially forms of power which are widespread but little analyzed and debated. He questions why some individuals and organizations become recognized as global health experts and under what circumstances their exertion of power is justifiable. He claims that while the World Bank is subject to constant criticism, we hesitate to recognize power inherent in a special issue promoting global health challenges launched by The Lancet. Likewise, the medical humanitarian organization Doctors without Borders, though increasingly influential, normally escapes the power radar. Shiffman argues the need to investigate how power operates in the global health field, and especially power which is perceived as legitimate "by virtue of [its] grounding in knowledge or humanitarian motives", or what he categorizes as normative and epistemic forms of power. We commend Shiffman for drawing attention to different forms of power and strongly support his efforts to examine how less apparent forms of power are exercised in global health. We also agree with Shiffman that the dynamics of power within global health are far more complex than moving power from the more powerful to the less powerful. We have argued elsewhere that liberal forms of power have become increasingly important within global governance of health (2). The "audit explosion" and systems of self-regulation have created new and indirect forms of governance. Governance has to a large extent become governance of self-governance. This is a form of power which does not only operate through knowledge and norms but through language and concepts, and often unconsciously. Furthermore, such powerful categories are not bound to specific institutions (be it the World Bank, The Lancet or Doctors without Borders) but circulate as a common way of reasoning among institutions and actors. Thus, we wish to expand Shiffman's power analysis by focusing on the power of concepts or what he briefly and somewhat vaguely describes as productive power. We see productive power as inherent in language in terms of unstable categories that lead us to create and express meaning about the world in specific ways. Language can never be totally commanded by a power-holder, it circulates between actors and is a channel for dominance. We will provide three examples of how conceptual power works within global health governance.

The idea of the global
The French philosopher Jean-Luc Nancy has argued that the concepts 'global' and 'globalization' are not neutral, though they are often considered as such. Nancy demonstrates how the concept of globalization does not only refer to supranational interdependency in terms of economic and technological exchange through which national sovereignty is weakened. The concept also denotes a norm, an ideology, a vision -a 'vision du monde' (3). 'Global' is not a fact but a category leading us to see how the world is and should be. To name an idea as global is to attribute universal legitimacy to the idea. This is always an imperialistic act because it excludes diversity and local differences. By adding 'global' to 'health' we presume that there is a universal health standard. Thus, global health does not only allude to supranational dependency within the health field but refers to a norm or vision for health with global ambitions. It implies a homogenization of a world view of health with someone in the role as Cosmotheros (world viewer). World Health Organization (WHO) is a symbol of this global vision setting norms and standards of health on behalf of the whole world. This transformation of the global from fact to norm is detrimental, according to Nancy, because it necessarily involves a limitation of possibilities. Nancy contrasts globalization with the French word 'mondialisation' , the former referring to a unified norm or vision while the

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latter signifies an infinite magnitude of views, an openness towards various possibilities. On this basis, he claims that the global -by imposing a unified vision -implies a termination of the world as a plurality of opinions and meanings: "It suffices to say that a worldview is indeed the end of the world of views, the latter being sucked up, absorbed and dissolved in one unified vision" (3). Furthermore, the global understood as a vision or value presupposes a rationality which is outside and above the world (a Cosmotheros) and from which "the global" might be objectively defined. There is a knowledge which is not of the world but superior and independent of it. Nancy's point is that the global can never be a neutral and objective concept because it is defined from within the world and not from without. Globalization is necessarily an expression of power because it relies on the false assumption of a neutral and superior rationality. According to Nancy, we need to question what we tend to presuppose: the universal validity of our own concept of the global. Our world is not the only world in the world. In our context, this means to be aware that our idea of global health can never be global. In the moment we think it is global it betrays itself, it becomes "unhealthy". This also implies questioning other concepts which are central to our worldview.

Quality = quantity
In various studies of modern healthcare practice we have shown how the reform wave which is often referred to as New Public Management has created a new language, wherein several everyday concepts have been given new content. For instance, we explain how modern regulatory systems such as quality assurance, audits, evaluations and accreditation have altered the meaning of the word "quality" (4,5). Quality, as used in everyday language, is associated with a high degree of excellence. Global health policy has introduced different systems for ensuring and documenting quality. One consequence of this is an increase in bureaucracy; health personnel spend more and more time in front of the computer documenting treatment and care. The new procedures tend to be time consuming leading to a consequent reduction in time available for face to face encounters with patients (5). Another characteristic of New Public Management is the tendency to define quality based on minimum often quantifiable standards, possible to calculate. When quality refers to measureable indicators of a given standard there is a risk that both good and bad treatment quality are undetected. Quality comes to mean that which satisfies certain minimum standards: it signifies good enough, rather than excellence. Quality is transformed into a quantifiable concept. Based on this argument, one might question whether regulatory practices within global health have modified the concepts of quality in a way that makes it less significant to the end users. Another relevant question is whether a certain project with a high score according to quality standards is necessarily the best project? Are logical frameworks, quality indicators, and monitoring and reporting systems trustworthy signs of quality? Or might there be situations where quality assurance obscures bad quality because everything looks perfect on paper? There is a danger of turning quality into a technical and bureaucratic phenomenon which primarily satisfies the monitoring eye rather than individuals' healthcare needs.

The power of empowerment
During the last decades, there has been a strong focus on empowerment which means redistribution of power in favor of those who have less influence. There has been a distinct and strong linkage between empowerment and the ideology of social justice and civil rights. The concept has been linked to the political and radical left but has also been promoted by the political right. Increased cost-efficiency, competition, and user choice are perceived as instruments to economize scarce funding, while the needs of the users are allowed to clearly define the premises for the services provided to them (6). The concept has positive connotations, but a contradictory ideological foundation. People cannot "be empowered" by others; they can only empower themselves by acquiring more of power's different forms. The role of the external agent is to catalyze, facilitate or "accompany" the community in "acquiring power" (7). Empowerment has a clear application in the health and social services sector. This form of power intends to describe how strength and power are facilitated to the suffering and the vulnerable. Empowerment, in our opinion, does not imply the abrogation of power, but transforms the execution of power by the helpers into a more indirect form, whereby they catalyze and facilitate the acquisition of power by the user/community. But what about those who are unable or may be unwilling to be empowered? The question is whether the concept risks privileging those who have the capacity to gain control over their own life and health and excluding others as unworthy needy. A positively connoted concept such as empowerment harbours debatable and adverse effects of power when applied in the global health care context. The exercise of power is obscured, thereby also weakening the potential for criticism of empowerment.

Conclusion
We fully agree with Shiffman that we should draw attention to powerful individuals and organizations with substantial influence and power we usually take for granted as legitimate.
We argue the need to analyze and debate the power inherent in language and concepts which direct our understanding of the world and of global health. These forces of power are not restricted and controlled by certain actors but circulate among them. Concepts represent an omnipotent force within global health which empowers every actor but which is seldom considered a source of power on its own terms. In this paper we have emphasized the importance of questioning the global validity of the concepts underpinning modern global health policy. First and foremost, this implies questioning the concept of global health as such. We need to keep in mind that there is no global definition of the global. Secondly, this implies questioning central concepts constituting our understanding of the world. We have drawn attention to quality and empowerment as examples of world-forming concepts. These are not isolated cases but exemplary for the

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gentle and quiet forms of power that underpin our reasoning within global health.

Ethical issues
Not applicable.