The West may not have known it, but Putin's Russia was at war with it long before missiles rained down on Kyiv in 2022. It was not a conventional style of war. After the annexation of Crimea, Western analysts had scrambled to put a label on what seemed to be a new Russian way of war. “Hybrid war”, “grey-area war”, “full-spectrum war”, “asymmetric war”, the “Gerasimov doctrine” were just some of the terms devised. All these labels captured some of the truth, but none told the whole story. One way of thinking about the war ethos that gripped Putin's Kremlin after he returned to the presidency in 2012 is offered by seventeenth-century English political theorist, Thomas Hobbes. Hobbes described a condition of anarchy, which he called the “state of nature”, where people were forced to compete in a zero-sum struggle for survival. The result was a permanent war of all against all. This was not a state of permanent battle but rather a disposition. Each person distrusted every other; each believed the other posed a threat and presumed that increments of security could be bought only at the expense of others; and thus force was a latent possibility in every social interaction. What mattered most for Hobbes was this disposition, not the instruments used to conduct the war.

This image well describes how third-term Putin understood Russia's relationship with the West. He assumed the West was waging hybrid war against Russia, using its soft power, economic levers, clandestine force, and sometimes its military might to forcibly change regimes and extend its hegemonic reach. Since NATO could not risk direct war with Russia owing to its nuclear arsenal, it seemed to the Kremlin that the West had found a way around that by fostering “colour revolutions”, corroding and changing governments from within to pull them into its political orbit. The zero-sum mentality that characterized Soviet strategic thought during the Cold War told Russian leaders that the Western orientation of many formerly communist republics and the “colour revolutions” were the effects of Western hegemonic aggrandizement. Putin and his allies believed that as a great power with its own exceptional destiny, Russia was entitled to its “zone of privileged interest”, an imperial space it controlled. For Russian nationalists like Putin, nation and empire were not discrete entities.

This chapter looks at the remit of, and the activities engaged in by, different organizations and groups involved in global health. These include major world organizations (notably the World Health Organization and World Bank), constellations of public– private partnerships, non-governmental organizations and social movements. It also examines the role of philanthropy, asking whether it is more appropriate to speak of “philanthrocapitalism”.

Wrapped up in the geopolitics of health are issues of global health security: issues that have inevitably come to the fore during the Covid-19 pandemic but that emerged some years earlier when new strains of influenza were appearing and the earlier coronavirus infection (severe acute respiratory syndrome: SARS) appeared on the world scene. The second half of the chapter therefore explores what is meant by health security.

As the quote at the start of the chapter suggests, we need to examine the relative power of the different agencies involved in global health, and where power lies in determining who gets “secured”, how and where.

Governance

My focus here is on relations between the actors involved in global health – nation states and organizations of different types – and less on the governance within states or organizations. The latter matters greatly, of course. For example, there is a close relationship between maternal mortality rates among a set of 174 countries and indicators of their governance (government effectiveness, regulatory quality, rule of law, control of corruption, voice and accountability, and political stability and absence of violence – all indicators proposed by the World Bank) in those countries (Ruiz-Cantero et al. 2019). The stronger the governance, the lower the rate of maternal mortality.

As well as exploring the roles of nation states and major intergovernmental organizations, the governance of global health is seen as “stemming from a configuration of public private partnerships (PPPs) between governmental agencies and programs, NGOs and charitable foundations, including the omnipresent Bill & Melinda Gates Foundation and other “philanthrocapitalists” entwined with the neo-liberal order” (Lovell, Read & Lang 2019: 522). Each of these actors – and the relations between them – is discussed in this chapter.

In their introduction to health geographies, Brown et al. (2018) refer to “five cross-cutting critical themes” that thread throughout their chapters. In a book on global health it is inevitable that my own choice of cross-cutting themes overlaps with theirs, but the material I have covered leads me to suggest some alternatives (Table 10.1).

In this concluding chapter I want to use these themes to summarize what has been presented in earlier chapters.

Governance/security

Power, whether political or economic, is held by a wide range of actors – individual, organizational, state or international – with complex relations between different levels. Actors can include NGOs, government departments, private companies, landowners, and so on. All these, often networked together, dictate access to resources, including healthcare, that in turn shape health or its absence. The power contained within these networks may contribute to structural violence, as noted later. Yet states and international organizations alike can, as Farmer (2005: 142) has pointed out, be relatively powerless.

We saw in Chapter 3 that there is a debate among political geographers and international relations researchers as to the relative power exercised by the state and international bodies such as the WHO, notably in addressing infectious disease spread. The Global Health Security Index remains resolutely fixated on security from infectious disease. But countries in the Global North have their own, internal, issues of security.

Climate change is but one component of a set of wide-ranging human impacts on the environment, which also include urbanization, land use change and loss of biodiversity, deforestation, resource extraction on land and in the oceans, the growth of agribusiness, and conflict. It must therefore be borne in mind that climate change is part of a complex system of environmental disturbance and perturbation. The introductory quote by Merrill Singer makes it quite clear how embedded is the deeper structure of this complex system. The present chapter seeks to show how the climate crisis is also a health crisis.

There is abundant evidence of long-term climate change. For example, the United Kingdom's Meteorological Office reported in May 2022 that climate change has increased by 100-fold the chances of record-breaking heatwaves in northwest India and Pakistan; a heatwave (of more than 50°C) is projected to occur every three years (Met Office 2022). There was a fivefold increase in exposure to extreme heat events between 1980 and 2017 for the world's most populated cities, and current exposure to heatwave events is almost 15 billion person-days per year, with the greatest cumulative exposures occurring in southern Asia (7.19 billion), sub-Saharan Africa, and north Africa and the Middle East (Met Office 2022).

Any discussion of the impact of climate change on human health must begin with the monumental report from Working Group 2 of the Intergovernmental Panel on Climate Change (IPCC), which was delivered in February 2022 (IPCC 2022). At 3,675 pages this report is truly encyclopaedic, but the “Summary for policymakers” is an excellent starting point. My own focus is initially on impacts on vector-borne infectious disease (malaria and dengue), waterborne disease, nutritional deficiencies and food security. I then consider impacts on Indigenous groups before looking at the consequences for population displacement and migration. The latter, as with so much else on climate change, makes highly visible the “geographical connections” in this book title.

I noted in Chapter 1 that the essence of globalization lies in the various interconnections and interdependences across borders. These networked connections involve mobility, whether of goods, money, services, information or people. Such flows are the focus of this chapter and two of the next. In the present chapter the focus is on movements of people and the associated health impacts. Later chapters examine movements of materials – focusing less on the trade in goods and more on the flows of “bads” – and then infections.

In a very prescient observation ten years ago, Glick Schiller and Salazar (2013: 184) wrote that “the current global economic crisis seems to be accompanied by a normalisation – once again – of national borders and ethnic boundaries, even as the crisis itself reveals the degree to which the world is intricately networked and interdependent”. The connections afforded by globalization seem – after the Russian invasion of Ukraine, as well as Trumpian politics and Brexit – to be giving way to heightened nationalism. Despite these borders, desperate people will continue to seek safety and refuge by crossing them, dangerous as the journeys usually are and uncertain as to the welcome – or lack thereof – that awaits them. The welcome given to Ukrainian refugees in Greece contrasts with the appalling conditions in camps “housing” Afghan refugees on the island of Lesbos (Markham 2022).

A key theme in contemporary social science is that of “mobilities”. This is a vibrant multidisciplinary field that deals with the geographical mobility of humans, nonhumans and objects, as well as information, visual images and, crucially, capital (Sheller 2015). It reflects more than the mere act of movement or transport, looking also at the emotional work that goes into this as well as the physical infrastructure necessary to enable movement. A related concept is that of “motility” – the potential to move – which “captures the unequal distribution of power over mobility, mobility resources and access to space” (Stjernborg, Wretstrand & Tesfahuney 2015: 384).

Brown and Taylor (2018) suggest that the study of health inequalities needs to be at the centre of geographical research on global health. It is therefore appropriate to begin an exploration of global health by describing, and explaining, the health inequality (more accurately, health inequity) that exists between and within different countries. “Health inequality” is invariably the term in common use, and so I follow that trend, although “health inequity” conveys more clearly that differences in health may be preventable – avoidable and unjust. The issue of who or what are responsible for avoidance – human agency, or wider structures of economy and politics – is still debated, although a critical geographical perspective suggests very much the latter. On this and other issues relating to health inequalities, the paper by Arcaya, Arcaya and Subramanian (2015) is valuable.

There is a vast literature on health inequalities in countries of the Global North, to which geographers have made key contributions, such as in the United States (McLafferty, Wang & Butler 2011), Canada (Shantz & Elliott 2021), the United Kingdom (Bambra 2016; Dorling 2013), New Zealand (Pearce, Tisch & Barnett 2008) and elsewhere. I do not intend to review these contributions, preferring to focus attention on some countries of the Global South. However, within some countries of the Global North there are marginalized groups to which I do want to give attention; in particular, as we see later, there are Indigenous populations occupying places that are as neglected as those who inhabit them.

The Global North literature on health inequalities tends to focus both on regional inequalities and, frequently, on more local – neighbourhood – variations. A classic distinction in this literature is between compositional and contextual effects (Gatrell & Elliott 2015: 82; Brown et al. 2018: ch. 8). In other words, is poor health in specific settings determined by the fact that poor people, with health-damaging behaviours, live there (the “composition” of a place) or by the fact that people live in places (“contexts”) that are environmentally or socio-economically deprived?

Geographies of health

Human geography is the study of human activity in relation to the places and environments that people inhabit, and health geography seeks to describe and explain how health (and wellbeing, and illness and disease, and the determinants of such) varies from place to place (Gatrell & Elliott 2015; Brown et al. 2018). Places can encompass diverse settings, including the home, workplace, neighbourhood, region and country. As a result, the subject matter spans a considerable range, such as the experiences of those living at home with chronic illness, how access to resources affects the wellbeing of those living in different neighbourhoods, and regional inequalities in morbidity and mortality. Most importantly, as I hope to show in this book, relations between (and within) different nation states; the flows of people, materials and infections, along with the historical, political and economic linkages between them, are – or should be – a focus of health geographers’ attention. Geography, as a distinct discipline, should be added to Koplan et al.'s disciplinary mix.

Approaches to the study of health geography are diverse, as revealed in Gatrell and Elliott (2015: ch. 2), the breadth of essays in the collection edited by Crooks, Andrews and Pearce (2018) and the critical introduction to the subject by Brown et al. (2018). Until the 1990s geographical enquiry that focused on illness and disease was labelled “medical geography” (Mayer 2010 has an excellent overview). Although some of that research looked at the distribution of morbidity (illness) and mortality in advanced economies, other research dealt with tropical diseases such as malaria. That tradition was called “disease ecology” (Learmonth 1988) – discussed more fully below – and it explored the ways in which the incidence of disease was associated with environmental conditions. Paralleling this was a rich tradition of mapping and analysing the distribution of mortality and morbidity (as well as the spread or diffusion of disease) that led to sophisticated visualizations and spatial analysis, often linked to the use of geographical information systems.

As clarified in the preface to this book, its subtitle, Geographical Connections, can be interpreted both in terms of the connections or flows that occur in geographic space and the relations between the environmental and social factors that shape disease incidence and unequal health. Two earlier chapters have dealt separately with the mobilities of populations and material goods, and I turn now to the spread – but also the incidence – of infectious disease. Of course, the movements of materials, people and pathogens are all interrelated.

The emergence of a new coronavirus in late 2019/early 2020 has, as Cambridge geographer Matthew Gandy predicted in 2008, brought into the sharpest focus the impact of a new disease (Covid-19), and I consider here, briefly, the origins and wider determinants of the infection. I devote most of my attention to the differential impacts on (and within) nation states, particularly in the Global South, as well as inequities in how the disease has been managed through vaccination. Discussions of global vaccine availability and equity take us back to issues of global governance discussed in Chapter 4.

A key theme in the spread of the virus (SARS-CoV-2) that has transmitted Covid-19 relates to the networks of transmission through international movement, and I consider how changing patterns of air travel have enabled the spatial spread of infections – including newer strains of influenza. But I also consider other emerging and re-emerging infections, including an earlier coronavirus (SARS), as well as Ebola, for which mobilities across borders were less related to air travel but, rather, to road and track. The late Paul Farmer argued, in his last book, that the failure to deal with Ebola can in part be traced back to colonial exploitation and injustice. As he puts it, in west Africa “disease containment was a priority but care was not” (Farmer 2020). Much the same was true about Covid-19 in many parts of the world.

Earlier he was also careful (Farmer et al. 2013) to make the point that empirical research on disease requires not merely comparisons between countries but detailed data collection on local and regional variations in incidence.

My focus here is on the extraction and movement of materials that are either healthdamaging or whose transfer across geographic space results in potential harm. To that end, I concentrate on: mineral extraction; the transfer of waste, especially plastics; and arms transfers. These are linkages or commodity chains that all involve movement, including the extraction of materials from the ground, the transport of these and, ultimately, the disposal of waste products associated with extraction or with the residue of consumer products. Inevitably, those living near extraction or waste sites, or living alongside the routes along which materials are transported, incur environmental penalties or injustice (Box 6.1). Although many of these transfers can result in harm, in some cases there might be benefits; for example, the extraction of precious minerals may offer employment to those engaged in extraction and movement (although, as we see shortly, costs invariably outweigh benefits). Some may benefit, but others reap no rewards and incur harm.

Mineral extraction and global health

In Chapter 2 I explored some dimensions of health inequalities in Mozambique. Others are reflected in mining. Among the mining projects in Mozambique is the Montepuez open-pit ruby mine in Cabo Delgado, started by the major company Gemfields in 2011. Its impact on population health (along with that of other mines in sub-Saharan Africa) has been studied by Leuenberger et al. (2021). In focus group discussions, people reported their lives being threatened if they attempted to scavenge the mine tailings. Others reported ill health resulting from population mixing. For example, one person complained about the importation of diseases from those coming to work in the ruby mine: “Now these people from outside who come with their diseases come here and contaminate us without knowing the reason why the diseases are increasing more and more” (quoted in Leuenberger et al. 2021). The authors also report health effects linked to pollution and food insecurity. Despite attempts by the company to improve living and working conditions, the overall view on health was negative.

The previous chapter considered the impact that mineral extraction, waste mobilities and arms transfers are having on environmental quality as well as human health. These impacts are transmitted through the air and via water courses. The present chapter considers this pollution, and its consequences for human health, in much greater detail. However, although there is a truly vast literature on air pollution, water quality and their health impacts across the globe, attention here is focused primarily on how these impacts are felt unequally in different places, concentrating – as elsewhere in the book – on places in the Global South. Much of the literature on air and water pollution and health is epidemiological; although some of that research is touched on here, the emphasis is more on the political economy/ecology of air and water quality. Even though this is a generalization, it is invariably the case that those bearing the greatest burden of air pollution are also those in the poorest of households: a clear example of environmental injustice or inequity.

To give a brief indication of the scale of the problem, Fuller et al. (2022) suggest that pollution (of both air and water) is responsible for about 9 million deaths every year, an increase of 7 per cent since 2015 and more than 66 per cent since 2000. They write that “little real progress against pollution can be identified overall, particularly in the low-income and middle-income countries, where pollution is most severe” (Fuller et al. 2022: e535, emphasis added), and note that there are synergistic effects with climate change and loss of biodiversity. Air and water pollution are demonstrably planetary threats, with causes and impacts on human health cutting across national boundaries and therefore requiring international attention.

The political economy of pollution

The hypothesis of a pollution “haven” was introduced in the previous chapter with reference to waste, but is equally relevant in a discussion of air and water pollution. To recap, a haven effect means that firms in high-income countries seek to locate production offshore in low-and middle-income countries, where environmental standards may be weaker; any risk of pollution gets transferred abroad.

Although I am a geographer who has been interested in health issues for 40 years, my research has been almost exclusively focused on countries in the Global North, and even more exclusively on the United Kingdom. More specifically, it has embraced geographical epidemiology – the study of disease and illness in particular places – involving a mix of (usually) quantitative and (sometimes) qualitative methods.

The discipline of health geography, which Susan Elliott and I have sought to summarize in three editions of Geographies of Health (2015), has undergone various shifts in emphasis over the last 30 years or so. I have been led to write this present book in part because of the relative lack of research by geographers on global health. Much of the recent focus in health geography has been on topics that have (for example) explored the health and wellbeing of those living near green spaces and attractive walking environments. Yet, in many parts of the world, walking is less for pleasure and more for access to clean water or escape from violence. I hope here to have addressed key issues that affect those living and working outside Anglo-America and Europe; for sure, I have cast my net wide and have endeavoured to cite literature written by those living and working in regions other than my own.

The subject of global health demands an interdisciplinary perspective. The late Paul Farmer and his colleagues have cited anthropology, sociology, political economy and history as the key disciplines (Farmer et al. 2013). In this book I am adding geography to the mix, recognizing of course that it too draws theory and concepts from those and other disciplines. As Herrick and Reubi suggest in the introduction to their edited collection (2017b: x), “Geography has not yet carved out a disciplinary niche within the diffuse domain that constitutes global health”. I wish to help the inscription, which remains insufficiently “carved”: more than ten years have passed since Brown and Moon's (2012) important commentary on geography and global health, although the brief chapter by Brown and Taylor (2018) in Crooks, Andrews and Pearce's comprehensive Handbook of Health Geography offers a tantalizing taste of a research agenda and other chapters in that collection discuss global health concerns.

It is easy to imagine countries within the Global South as “hearths” of infectious disease, an imaginary that is enabled by graphic stories of Ebola in parts of west Africa. This chapter moves away from such tropes, by focusing initially on non-communicable diseases and the role played in these by markets for alcohol and tobacco. I then turn to matters of gender inequality, revealing how this too shapes health outcomes for women in the Global South.

There is a welcome, and growing, interest in inequality among Indigenous peoples, whether in the Global North or Global South, and this is considered next. The impact of the maltreatment of such peoples and the resulting trauma are felt sharply in particular places, and this trauma transmitted from generation to generation.

The previous chapter painted some broad-brush canvases of health in five countries but said little about the health of people living in particular places. The present chapter addresses some of the inequalities in urban areas. It then considers inequalities in mental health, with a particular focus on children, an area in which – alongside social determinants – exposure to violence is of major concern. Links between place and wellbeing have attracted considerable interest in recent years (witness the new journal Wellbeing, Space and Society), and the interest extends to places in the Global South.

There is a generally accepted view among those researching health inequalities in the Global North that access to health services plays only a minor role in determining these. Established technologies such as geographic information systems (GISs) can help monitor unequal access, while newer ones based on the use of mobile phones can also help. But the same “inverse care law” (those most in need get the poorest access) applies even in the Global South.

Geographies of inequalities in non-communicable diseases

As noted in Chapter 2, Sustainable Development Goal 3 seeks to “[e] nsure healthy lives and promote well-being for all at all ages”; within this, Target 4 aims to “reduce by, onethird, premature mortality from non-communicable diseases through prevention and treatment”.