Inequality in global health expertise – and steps toward a pragmatic critique: Advantages of a comparative perspective

Luis Aue 
Visiting Researcher, Global Governance Research Unit,
Research Fellow, Research group Global Humanitarian Medicine, WZB Berlin Social Science Center
Research fellow, Research cluster Contestations of the Liberal Script (SCRIPTS), Free University Berlin

Synopsis: Luis Aue discusses the possibility of a more pragmatic critique of expertise. When we think in a comparative manner, he argues, ‘we start to understand that there are different ways in which politics and expertise can interact’. 

Keywords: Expertise, Global Health, Inequality, Politics of Expertise

Global health actors have become increasingly aware that health expertise is not a matter only for experts. What expertise “counts” is of the highest political salience. For example, expert advice is necessary for the WHO’s declaration of a health emergency of international concern; this declaration enables border closures. WHO guidelines are authoritative for best global medical practice – and agreed upon by expert committees. Expertise is highly political in global health as it determines the underlying course of action by organizations such as the WHO.

In response to the political importance of expertise, academic research has provided nuanced analyses of uses of expertise in and by International Organizations (IOs). This shows in academic research presented by authors of this blog: Christensen urges us to take a close look at how experts manage to influence politics and in how far they are being controlled or orchestrated by political actors. Louis and Martens demonstrate how expertise supports the depoliticization of issues by IOs. Such depoliticization allows a mission creep of IOs that claim special competencies for issues that are allegedly “technical” in nature. Furthermore, IOs strategically select experts and expertise to expand their mandate, as Littoz-Monnet has shown. Finally, Shaila has stressed the importance of how “international” experts translate their expertise to local conditions – and how they legitimize themselves in local sites.

Such research has shown the mechanisms of how expertise and politics interact. Contributing further to this agenda, I want to argue for a comparative perspective on the politics of expertise. A comparative perspective allows us to explore how expertise in fact supports global inequalities and allows us to move toward a pragmatic critique of expertise.

Before I explore these advantages, let me first sketch different possible dimensions of comparisons. On the one hand, we can compare temporal formations of expertise. In my work on the history of international health metrics, I compare analogue and digital measurement regimes and the way these have produced international health metrics. The analogue regime was built on national statistical infrastructures and supported by IOs like the WHO after the Second World War. It problematized international health politics as guiding nations along the development path of the global North. The regime limited participation to medical and statistical experts. In contrast, the digital regime —influential since the 1990s — is embedded into a private research institute: the Institute for Health Metrics and Evaluation (IHME). It has shaped the field of international health politics as continuously searching for neglected problems, extended participation to a large group of passive users of global health metrics and supported cost-effective interventions.

Besides such comparisons between sets of expertise that dominated different periods of time, one can also focus on the comparison of expertise that targets different socio-geographic spaces. In a current project on the policy history of diarrheal diseases, I explore differences between health expertise that has targeted the global South and health expertise for the global North. When focussing on the global South, international experts have constructed ‘magic-bullet’ policies, such as sachets with electrolytes against diarrheal diseases. In contrast, there has been a constant focus on infrastructural interventions such as water and sanitation infrastructure when experts target diarrheal diseases in the global North. Here, professionals continued to maintain and update interventions. In contrast, international magic bullets that focus on the global South quickly cycle in and out of attention in global health politics.

What are the advantages of such a comparative perspective? On the one hand, comparison between different sets of expertise makes visible how expertise contributes to inequalities. We can see how different expertise targets similar bodies. When we compare expertise for different socio-geographic spaces, it becomes visible that the global South has been targeted by a distinct form of ‘magic bullet’ expertise, that proposes quick fixes rather than durable solutions. The comparison between different ways of measuring health over time shows us how analogue regimes have especially forced Western notions of development on the globe. By contrast, recent digital measurement regimes allow for a continuous search of currently neglected diseases while favouring especially small-scale and cost-effective interventions.

On the other hand, comparative perspectives can lead toward a pragmatic critique of expertise. Scholarship on expertise debates whether the focus on the contingent and political nature of knowledge production supports post-truth politics. When we analyze how expertise gets shaped by political struggles, do we not contribute to current attacks against science? I believe that comparative approaches lead us to more pragmatic critical analyses of expertise. When we think in a comparative manner, the question is no longer whether expertise can uphold its claim for neutrality. Instead, we start to understand that there are different ways in which politics and expertise can interact. This enables a more nuanced choice of what politics of expertise we want to strive for – or how to combine different sets of expertise. For example, mainly highly-trained professionals used health metrics before the digital turn – but there were attempts by the WHO to train such professionals around the world. We should strive for such positive participation effects in the current digital regime of measuring health. Statistical literacy enables professionals to question the data beyond the shiny graphs and maps put out by digitalized health expertise. Comparative perspectives enable such learnings on how to redesign our global politics of expertise. During the current Covid-pandemic, the legitimacy of international health expertise has become strongly contested. In response, a comparative perspective provides us with insights how to reorganize and relegitimize international health expertise – for example, by enabling professionals all over the world to take part in international knowledge production.

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