Between nation and empire: how the state matters in global health

Abstract

The role of the state has been underplayed in scholarship on global health. Taking a historical view, this paper argues that state institutions, practices and ideologies have in fact been crucial to the realisation of contemporary global health governance and to its predecessor regimes. Drawing on state theory, work on governmentality, and Third World approaches to international law, it traces the origins of the 'health state' in late colonial developmentalism, which held out the prospect of conditional independence for the subjects of European empires. Progress in health was also a key goal for nationalist governments in the Global South, one which they sought to realise autonomously as part of a New International Economic Order. The defeat of that challenge to the dominance of the Global North in the 1980s led to the rise of 'global governance' in health. Far from rendering the state redundant, the latter was realised through the co-option and disciplining of institutions at national level. To that extent, the current order has an unmistakably imperial character, one which undercuts its declared cosmopolitan aspirations, as evidenced in the approach to vaccine distribution and travel bans during the Covid-19 pandemic.