CRITICAL INTERVENTIONS IN GLOBAL HEALTH: GOVERNMENTALITY,

RISK, AND ASSEMBLAGE

Tim Brown, Susan Craddock, and Alan Ingram

Accepted version of paper for Annals of the Association of American Geographers

ABSTRACT

The rise of the term global health reflects a concern to rethink the meaning of health in

the context of globalisation. As a field of practice, however, global health renders prob-

lems, populations and spaces visible and amenable to intervention in differentiated

ways. While some problems are considered to be global, others are not. Some are con-

sidered to be matters of global security, while others lack this designation and remain in

the realm of health or development. Attention is drawn to individual global health prob-

lems, while their broader structural dimensions are often obscured. We suggest that a

critical geographical approach to global health therefore entails reflexivity about the

processes by which problems are constituted and addressed as issues of global health

and identify three analytical approaches that offer complementary insights into them:

governmentality, risk and assemblage. We conclude by outlining some further issues for

critically reflexive geographies of global health.

INTRODUCTION

‘Health is global’, or so we are encouraged to think.1 The rise in prominence of the term

global health has gone hand in hand with a multitude of academic analyses, think tank

papers, policy initiatives, media reports, institutional innovations and political contro-

versies over the course of the last twenty years. The global health field has seen an in-

flux of new actors, including activist networks, high profile philanthropies and new

kinds of public-private partnerships, giving rise to a plethora of global health initiatives;

all of which has coincided with a doubling of donor aid for health over the course of the

last decade. This has triggered a rapid growth in academic global health centers and pro-

grammes, many of which recognize that global health now goes beyond biomedicine,

1 Here we borrow the title of a recent UK government report (HM Government 2008).

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epidemiology, public health and development to embrace matters of law, politics, his-

tory, economics, trade, diplomacy and security.

While geographers have long contributed to the understanding of health worldwide via

medical geography, epidemiology, public health and development studies, they are in-

creasingly turning a critical eye towards its political, economic, cultural and ethical di-

mensions, helping to shape a broader interdisciplinary field of critical global health

studies. An important part of this agenda is a critical rethink of how the global health

field itself shapes the way global health is imagined, understood and thus addressed. A

key concern here is the differentiated manner in which particular problems, populations

and spaces are rendered visible and amenable to intervention. While some problems

(like emerging infectious diseases or tobacco-related disease) are considered to be

‘global’, others are not. Some (like influenza, HIV/AIDS or biological weapons) are

designated as matters of global security, while others (such as maternal health, diarrheal

and other so-called ‘neglected’ diseases) remain in the realm of health or development.

Attention is often drawn to individual problems (like epidemics or other crises) or solu-

tions (such as vaccination or anti-retroviral therapy for HIV and AIDS), while the

broader structural dimensions and determinants of ill health, diminished life chances

and shortened lives (which derive from long term and wide scale political and economic

processes) are often obscured (cf. Brown and Moon 2011).

We suggest that a critical geographical approach can contribute further to the process of

revisioning global health by opening the processes whereby health is rendered global to

reflexive scrutiny. Building on recent interventions by geographers and others (Braun

2007; Ali and Keil 2008; Hinchliffe and Bingham 2008; Lakoff and Collier 2008;

Kearns and Reid-Henry 2009; Sparke 2009), we outline three analytical approaches that

offer complementary insights into these processes: governmentality, risk and

assemblage. Each is relevant, because it draws attention to how global health problems

and responses are not given, but enabled, imagined, and performed via particular

knowledges, rationalities, technologies, affects, and practices across a variety of sites,

spaces and relations.

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GLOBAL HEALTH GOVERNMENTALITY

A full account of today’s global health field would need to explore multiple

temporalities and spatialities, including imperial and colonial historical geographies; the

formation of the world economy and patterns of state formation in terms of their mutual

constitution with ecological and epidemiological processes; postcolonial

problematizations of the Third World as requiring developmental intervention; the

wreckage of post-communist transitions; and the emergence of disputes over neoliberal

globalization. It would also include a series of specific developments during the 1990s:

the formation of the concept of “emerging infectious diseases”; alarm at epidemics

spreading within and beyond the global South; efforts of policy entrepreneurs and

activists on health, human rights, development and peace issues; concern about

bioweapons stocks, infrastructures and expertise, and shifting concepts and practices of

security. It would trace too the emergence of an ecosystem of “global health

governance”, constituted by dozens of organizations and institutions concerned in some

way about global health issues. With the term governmentality, we signal additionally,

first, the reflexive implication of particular knowledges, rationalities and technologies in

the constitution of global health (Larner and Walters 2004; Elbe 2009; Nguyen 2009; de

Larrinaga and Doucet 2010; Ingram 2010). We wish to signal three further aspects of

global health governmentality in particular.

The first is the manner in which the global health field deals with problems of space.

Foucault’s (2007) discussion of how the management of population and circulation

comes to form the pre-eminent object and logic of modern government is particularly

suggestive when it comes to global health. As Braun (2007) argues, in the case of

biosecurity, what is apparent is an aspiration to govern the global biological which is

enabled by a variety of surveillance and monitoring technologies and institutional

arrangements. Furthermore, as Braun, Ali and Keil (2008) and Hinchliffe and Bingham

(2008) argue, the euclidean geography of the nation-state system, upon which global

health governance had been based, is ill-suited to the complex topologies of emerging

infections, where one thing can morph into another and distinctions between the inside

and the outside are blurred (see also Sarasin 2008). Efforts to secure the globe from

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emerging infections thus link cutting-edge surveillance, post-Westphalian sovereignty

and emergency alert-and-response (Fidler 2004; Elbe 2009).

Global health governmentality thus intersects with geopolitics in complex ways. Global

health security systems, which are largely grounded in and funded from within the

global North, reflect global North priorities and render sovereignty provisional, start to

look like a form of empire (see also King 2002; Weir and Mykhalovskiy 2006). But

things may be changing. Controversies over global health security (Aldis 2008) have

spurred the emergence of a discourse on ‘global health diplomacy’ (Kickbusch et al.

2007). While this marks a ‘rendering technical’ (Li 2007) and thus potentially a

depoliticization, it is evident that the emergence of global health diplomacy is also

linked with the increasingly assertive role being played within global governance by

countries like Brazil, India, South Africa, Indonesia and Thailand, especially when it

comes to issues such as intellectual property and access to medicines. What may be

required now is less a critique of empire than attention to the emerging contours of a

post-hegemonic global health agenda.

Second, to confine our discussion of global health to such high-profile ‘security’ issues,

however, is to replicate a selective focus. Global health as a field where the ‘will to

improve’ (Li 2007) is at work much more widely. We recognize the broad-ranging

nature of global health today, where governmental rationalities, technologies and

practices are deployed in relation not just to emerging infections, but the trade,

marketing and consumption of tobacco, to accidents and road safety, diet lifestyle and

nutrition and non-communicable diseases (Elbe 2010; Herrick 2009). There is much to

be gained, we suggest, from looking synthetically across such domains, to consider

through what kinds of technologies and tactics particular issues are problematized and

made visible, and how this relates to the production of particular kinds of spaces.

International responses to HIV/AIDS (Smith and Siplon 2006; Grebe 2008; Pisani

2008) and tobacco (World Bank 1999; WHO 2002) provide telling examples here,

where scaled up responses were leveraged upon efforts to characterize, quantify and

render visible particular problems, populations and spaces (see also Bowker and Starr

2000).

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Third, we problematize the articulation between governmentality and neoliberalism. To

put things starkly, the central concern is that the extension of infrastructures to manage

circulation and improve the health and well being of populations remains a thin

response to deep-rooted problems of structural violence and inequality that emerge from

global integration (Sparke 2009). Indeed, key global health commentators (Fidler 2008;

Schneider and Garrett 2009) have observed that the landmark global health initiatives

(like the international response to HIV/AIDS) of the 2000s have been narrowly focused,

short term and unsustainable. While recent interventions have attempted to force the

issues of disparities in human resources for health, the social determinants of health and

health systems development back onto the global health agenda, the relationship

between global health and the global economy is often only alluded to or addressed

indirectly. Furthermore, many of the new private actors in global health are heavily

invested in the current configuration of the global economy (Williams and Rushton

2011).

We suggest that these issues represent key points for investigation for critical

geographies of global health. Before considering how to develop this further, we turn to

risk as a key form of knowledge articulating global health practices.

GLOBAL HEALTH, GLOBAL RISK

As noted, in order to understand global health, and to critically intervene in it, we need

to ask questions about the kinds of knowledges, technologies and tactics that are used to

render it visible or to make it doable (Kickbusch et al 2007). One possibility here would

be to focus on specific devices – such as the disability adjusted life year (DALY) – and

on the ways in which they are used to fix the geographical contours of global health and

around which specific assemblages are formed. However, a more extensive technology

associated with global health discourse is what Dean (1999) refers to as

“epidemiological risk”; it is upon this concept, which we suggest is an example of what

Foucault refers to as a dispositif (see Foucault 1980, 194-5), that we focus here. Before

doing so, we briefly discuss Beck’s original articulation of the risk society thesis in

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which risk is defined as a ‘systematic way of dealing with the hazards and insecurities’

that are the somewhat paradoxical result of scientific and technological advances

associated with late modernity (1992, 21).

Beck’s formulation contributed to the development of a new research paradigm in which

risk was elevated to the status of a key analytical rubric. This is apparent in analyses of

the heightened threats to health (and life) associated with globalization. As Brundtland

commented, there are ‘two critically important forces shaping the world we live in: the

revolution that is taking place in information and biotechnology, and the growing

momentum of globalization. Both of these forces carry with them immense potential for

good. But, as we are all aware, they carry risks’ (2001). Brundtland went on to highlight

the nature of these risks, noting that “[w]ith globalization, a single microbial sea washes

all of humankind’ and that there are ‘no health sanctuaries’”. She also pointed to the

growing recognition that it is not only infectious diseases that are spread with

globalization but heightened risks of heart disease, diabetes and cancer.

Brundtland’s general statements on the consequences of globalization can be associated

with the emergence of particular interventions; for example, the anti-tobacco campaign

mentioned above or others such as the global strategy against non-communicable

diseases and the Global Fund to Fight HIV/AIDS, malaria and TB. It is, then, important

that we acknowledge the centrality of risk to current understandings of global health

because ideas about its current and predicted future contours are in part shaped by this

particular analytical frame (Brown and Bell 2008). However, we would argue that it is

equally important that we recognize that this conceptualization, which, as Dean

suggests, assumes that ‘real riskiness has increased’ (1999, 182. Emphasis added), is not

the only approach that we might take. Beck himself acknowledges this in his recent re-

working of the risk society thesis. As he notes, ‘[r]isks are social constructions and

definitions based on corresponding relations of definition’ and, as such, are open to

dramatization, transformation and even denial (2008, 30. Emphasis in original).

It is at this juncture that we turn to readings that have been informed by Foucault’s work

on governmentality (e.g. Castel 1991; Dean 1999). When thought of in these terms, risk,

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and specifically here epidemiological risk, emerges not so much as an objective reality

of late modernity but as a dispositif. In making this connection, our goal is not to

undervalue the material realities that shape people’s lives and render them more or less

exposed to health-related hazards. Rather, it is to acknowledge that the ways in which

these realities are rendered visible, the ways in which they come to be known both now

and in the future, is to a great extent shaped by the ‘heterogenous ensemble’ of elements

that Foucault identifies as being a part of the apparatus of a dispositif (Foucault 1977;

see also Agamben 2009).

Clearly, then, we are referring here to a very different type of analytical frame than that

elaborated by Beck in his initial conceptualisation of the risk society thesis; and it is one

that demands a focus upon the constitution of things as risks and upon the material

consequences of this rendering within particular assemblages and in the context of

particular forms of rule. As Dean argues, it is possible, when using governmentality as

the lens through which to analyze risk, to “demonstrate that risk rationalities are not

only multiple but heterogeneous and that practices for the government of risk are

assembled from diverse elements and put together in different ways” (1999, 182). Two

points are crucial here. Firstly, that we recognize that epidemiological risk is central to

current conceptualizations of global health and that it represents the calculative basis

upon which the health status of a population is determined or rendered visible (Brown

and Bell 2008). Further, it is increasingly upon the basis of these factors of risk, what

Osborne refers to as ‘surrogate values’ (1997, 186), that public health interventions are

put into place.

This leads us to our second point. There is an acknowledgement in some critical

accounts of global health discourse that the risks to health and well being around which

global health assemblages cohere reflect the priorities of the global North rather than

those of the global South. Elbe provides an illustration of why this is important, when

he notes that interventions to secure populations against HIV/AIDS were justified when

they appeared to serve the national interests of those seeking security (those in the

global North) rather than those being secured against (those in the global South). It is,

however, not simply in relation to the risk posed by epidemics of infectious diseases that

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this question arises. As several commentators have acknowledged, despite recognizing

the threat posed by the globalizing of lifestyle diseases and especially the double burden

of disease that it poses to the world’s most vulnerable populations, questions have been

raised about the global commitment to tackle their causes (Beaglehole and Yach 2003;

Yach et al 2004; Marmot 2008).

This suggests that we cannot interpret risk in terms of simple dichotomies; there is more

than one at risk population in operation here and they are affected by risk in different

ways. This is an important point to acknowledge because risk is not a technology that

remains static. It is adapted to, or in Foucault’s terms fabricates, organises and plans, the

milieu within which it is operationalized and the specific problematic upon which it is

brought to bear. A second question is that while epidemiological risk renders visible a

particular present and future problematic (O’Malley 1996) there is a material as well as

subjective facet to this rendering process. Put differently, not only are some individuals

more prone to particular diseases or states of being, but the subjects of risk discourses

stake claims of identity, entitlement (biological citizenship) and voice on the basis of

their status (Rose 2007).

ASSEMBLING GLOBAL HEALTH

The discussion so far leaves open the question of the epistemologies through which we

might reflexively investigate, for example, the articulation between the constitution of

risk and the global political economy (Farmer 2005; Global Health Watch 2005; Sparke

2009). Our use of the concept of ‘assemblages’ is helpful here in highlighting the

various actors and forces coming together within the milieu of late 20th and early 21st

century global capitalism and shaping the regulatory structures, social practices, and

knowledge formations constituting global health. Our take on ‘assemblage’ is

purposefully syncretic, as we draw from a number of scholars who employ the concept

(explicitly or not) to elicit the ethical complexities of new technologies and the ‘regimes

of living’ they help determine (Ong and Collier 2005; Collier and Lakoff 2005),

highlight the productive frictions possible within the convergence of transnational,

grassroots, and institutional forces (Tsing 2005), or track the unpredictable movements

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within networks (Latour 2005). To varying degrees for these scholars, tracing the

interactions of highly diverse actors better elucidates the logic, contradictions, and

negotiations within global processes; it also brings visibility to the role of nonhuman

actors in changing the course of global practices. With few exceptions, however (cf

Nichter 2008), ‘assemblages’ as a theoretical framework has been applied to

examinations of environment, biosecurity, or technological deployment rather than in

the investigation of global health. Often, attention to how complex networks interact

also comes at the expense of retaining analytical sight of uneven power relations

making most global processes highly inequitable. We argue for a deployment of

assemblages that addresses these gaps.

Returning to the differential actions of technologies of risk, while the milieu of global

health is the globe itself, the spatial and political tensions between conditions of

vulnerability (to infectious disease, obesity, smoking, cancer etc), and the rendering of

securitization and governability take place within particular transnational circuits and

regional locations. One practice helping to obscure these relations is the way the

universal, as noted by Tsing (2005), has typically been produced within hegemonic

regimes valorizing western ideals and economies; it is a technique of obfuscation as it

works to suggest a commonality. Such hegemonic understandings of the universal or

global commonly underlie high-level policy reports on globalization and health, placing

in tension assumptions of universal practices of globalization with ascriptions of risk to

particular populations. This tension then leads to what Collier and Lakoff call the

‘emergency modality of intervention,’ (2008, 17), that is, quick fixes aimed at shoring

up, rather than extinguishing, risk.

An antidote to these problematic renderings is to look at the specificity of connections

as these reveal various interactions of multiple forces, technologies, agencies, actors and

power dynamics. As Ong and Collier suggest, assemblages are never “reducible to a

single logic,” and they do not “always involve new forms, but forms that are shifting, in

formation, or at stake” (Ong and Collier 2005,12). Every situation brings with it its own

different set of connections which are unpredictable both in their constitution as well as

their outcome (Tsing 2005), yet not every component of an assemblage plays an equally

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important role. Latour’s notion of the ‘intermediary’ versus the ‘mediator’ is helpful

here: the intermediary is “what transports meaning or force without transformation,”

while “mediators transform, translate, distort, and modify” (2005, 39).

Influenza vaccines are a good illustration of how a focus on assemblage elucidates

aspects of “global health”. During the H1N1 pandemic, egg shortages thwarted rapid

development of vaccine serum, forcing questions concerning why laboratories were still

dependent on outdated technologies when new genetically-based methods are known to

be quicker. The answer in part lay in high liability risks and low profits, generating little

incentive for pharmaceutical companies to develop new technologies. The areas of the

world most at risk of inadequate vaccine supplies, however, are those who lack legal

capacity to negotiate contracts with, or afford sizeable fees to, the few pharmaceutical

companies producing flu vaccines – fees governed in large part by global regulatory

mechanisms such as the WTO’s Trade Related Aspects of Intellectual Property, or

TRIPS. Within the context of regulatory regimes, legal negotiations, scientific

parameters, pathogenic viscissitudes, and national financial capabilities, influenza

vaccines become mediators changing the biopolitical terrain of influenza prevention and

– in the event of a more virulent outbreak – survival. As many have noted (cf especially

Hinchliffe and Bingham 2008) techniques of security actually end up rendering some

populations more vulnerable, thereby ironically diminishing the efficacy of those

techniques no matter how robust. Yet these formations are in constant tension as well as

emergence, as countries contest the terms of TRIPS, new organizations arise to respond

to inequitable distribution, and philanthropic agencies underwrite the costs of better

vaccine technologies.

Thus embedded within the narratives as well as practices of intervention and security,

yet belied in the declarations of universal vulnerability, is the fact that some people are

profoundly more likely to be at risk of disease than others (Brown 2010). In other

words, it is important to look not only at the ways in which practices of governability

and security shape understandings of risk and their spatial contours: equally trenchant is

the recognition that these practices are a part of the broader network of global economic

practices actually creating patterns of risk and disease burden.

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CONCLUSION

The field of global health has emerged in large part as a response to the increased

mobilities of populations, commodities, and pathogens associated with late 20th and

early 21st century globalization, yet the particular financial, regulatory, economic and

political structures determining these movements and the risks that result often remain

in the margins of dominant global health imaginaries. A focus on mobilities but not the

interrelations of their determinants produces consequently a turn toward securing

countries and populations against a constant state of risk ‘emergence’ (Cooper 2006).

While Cooper focuses on the biological, we extend the analysis to include such risks as

the global spread of obesity, cancer, or deaths from road accidents, as well as on the

techniques utilized to secure against them. Too often, though, the technologies

mobilized by governments, or even pharmaceutical companies, contain risk by

‘conducting conduct.’ Containment is simultaneously about making particular risks

visible through increasingly robust technologies of surveillance, which in turn produce

definitions of vulnerable populations and their socio-geographic loci of intervention.

What these techniques are, how they operate, and the geopolitical terrain informing

them constitute a field of inquiry requiring more attention from geographers.

Furthermore, these same technologies obfuscate as much as they elucidate. Though

health risks are made visible through ever-more sophisticated scientific,

communications, and biotechnological capabilities, these cannot be construed as neutral.

Not only are some issues made visible through practices of security and medical

discourse (AIDS, SARS, H1N1) while others are not (vitamin deficiency, domestic

violence), vulnerable populations are themselves redefined in sometimes problematic

ways through the production of statistics or the mapping of epidemiology onto

geopolitical and historical understandings of behavior. Further, at risk populations are

themselves not entirely absent from this rendering process. As Rose has indicated,

human beings are increasingly coming to understand themselves in somatic terms and as

such play a crucial role in the framing both of themselves and the issues that affect them

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as global health concerns. Going beyond such fixes requires critical contextualization of

the kind that we have begun to outline here.

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Correspondence: School of Geography, Queen Mary University of London, Mile End

Road, London E1 4NS, UK, e-mail: tim.brown@qmul.ac.uk (Brown); Institute for

Global Studies and the Department of Gender, Women, and Sexuality Studies,

University of Minnesota, 425 Ford Hall, 224 Church Street SE, Minneapolis, MN,

USA, e-mail: craddock@umn.edu (Craddock); Department of Geography, University

College London, Pearson Building, Gower Street, London, WC1E 6BT, UK, e-mail:

a.ingram@ucl.ac.uk (Ingram).

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