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Int JJ Health
Health Policy
Policy Manag
Manag 2016,
2016, 5(2),
5(2), 117–119
117–119

http://ijhpm.com Commentary
Int J Health Policy Manag 2016, 5(10), 571–573 doi 10.15171/ijhpm.2016.79

Politics and Power in Global Health: The Constituting

Editorial Role
of Conflicts
Comment on “Navigating Between Stealth Advocacy and Unconscious Dogmatism: The
Comment on “Navigating Between Stealth Advocacy and Unconscious Dogmatism: The
Diabetes Dictating
Challenge Policy:
of Researching the Norms,An Editorial
Politics and Power Commemorating
of Global Health”
World Health
Clemet DayHeggen,
Askheim, Kristin 2016Eivind Engebretsen **

Amirhossein Takian1,2,3, Sara Kazempour-Ardebili4*

Abstract Article
Article History:
History:
In a recent article, Gorik Ooms has drawn attention to the normative underpinnings of the politics of
Abstract In a recent article, Gorik Ooms has drawn attention to the normative underpinnings of the politics of Received:
Received: 55 September
Article September
2015
History: 2015
global health. We claim that Ooms is indirectly submitting to a liberal conception of politics by framing Accepted: 13
Accepted: 13 October
October 2015
2015
The 21st century is an era of great challenge for humankind; we are combating terrorism, climate change, Received: 19 April 2016
the politics of global health as a question of individual morality. Drawing on the theoretical works of ePublished:
ePublished: 15
15 October
October 2015
2015
poverty, human rights issues and last but not least non-communicable diseases (NCDs). The burden of the latter Accepted: 11 June 2016
Chantal Mouffe, we introduce a conflictual concept of the political as an alternative to Ooms’ conception.
has become so large that it is being recognized by world leaders globally as an area that it is in need of much ePublished: 18 June 2016
Using controversies surrounding medical treatment of AIDS patients in developing countries as a case we
greater attention.
underlineInthe
light of this concern,
opportunity the World
for political changes,Health Organization
through (WHO) dedicated
political articulation of an issue,this
andyear’s World
collective
Health Day (held on April
mobilization based7,on
2016)
suchtoanraising international awareness on diabetes, the fastest growing NCD in
articulation. View
View Video
Video Summary
Summary
the world.Keywords:
This editorial is anHealth,
Global accountLiberal
of the Politics,
macro politics
ChantalinMouffe,
place forConflict,
fighting AIDS,
diabetes, both internationally
Antiretroviral (ARV)
and nationally.
Treatment
Keywords:Copyright:
World Health Day,
© 2016 by Diabetes, Health Policy,
Kerman University Non-communicable
of Medical Sciences Disease (NCD)
Copyright: Citation:
© 2016Askheim
by KermanC, Heggen K, Engebretsen
University of MedicalE.Sciences
Politics and power in global health: the constituting role of
conflicts: *Correspondence to:
Citation: Takian A, Comment on “Navigating
Kazempour-Ardebili between stealth
S. Diabetes advocacy
dictating policy:and unconscious
an editorial dogmatism: theworld
commemorating challenge
health *Correspondence
*Correspondence to:
to:
of researching the norms, health.” Int J Health Policy Manag. 2016;5(2):117– Sara Kazempour-Ardebili
day 2016. Int J Health Policy Manag.politics and power of global
2016;5(10):571–573. doi:10.15171/ijhpm.2016.79 Eivind
Eivind Engebretsen
Engebretsen
119. doi:10.15171/ijhpm.2015.188 Email: s.kazempour@endocrine.ac.ir
Email:
Email: eivind.engebretsen@medisin.uio.no
eivind.engebretsen@medisin.uio.no

DI
iabetes is a leading public health concern worldwide, a campaign that aims to increase awareness about the rising
andndespitea recent contribution to the ongoing debate about the
years of research and development on take the political as the primary level and the normative as
prevalence of diabetes and trigger a specific set of actions
role of power in global health, Gorik Ooms emphasizes secondary, or derived from the political?
diabetes care and prevention, it is still one of the for combating diabetes. The WHO has also launched its
the normative underpinnings of global health politics. That is what we will try to do here, by introducing an
fastest growing
He identifies conditions in theproblems:
three related world; according
(1) a lack oftoagreement
the first alternative
Global Diabetes Report onof this
conceptualization day, a document
the political and hence that free
World Health Organization (WHO) the number of people outlines not only the importance
us from the “false dilemma” Ooms also wants of battling diabetes, but
to escape.
among global health scholars about their normative premises,
living with diabetes has quadrupled since 1980
(2) a lack of agreement between global health scholars and and in 2014 also a framework for surveillance, prevention,
“Although constructivists have emphasized how underlying and effective
there were an estimated
policy-makers 422 million
regarding adults with
the normative premisesdiabetes in
underlying management
normative ofstructures the condition.constitute actors’ identities and
the world. 1
policy, Thisandis a(3)staggering
a lack ofstatistic;
willingness to better
amongput this to Diabetes
scholars is one
interests, theyofhave fourrarely
non-communicable
treated these normative diseasesstructures
(NCDs)
number clearly
into perspective, diabetes premises
state their normative can be addressed
and assumptions. as the This targeted in the as2011
themselves Political
defined Declaration
and infused on the
by power, Prevention
or emphasized
third most populated
confusion is for country
Ooms oneinofthe the world,
explanations after “why
Chinaglobal and how Control of NCDs
constitutive (the
effects alsoother three are of
are expressions cardiovascular
power.”22 This
and India.health’s
2
Thepolicy-makers
rise in worldwideare notdiabetes
implementing
prevalence the knowledge
has is thecancer,
disease, starting point for the political
and chronic theoristdiseases),
respiratory Chantal Mouffe,
which
mirroredgenerated
the rise in by overweight
global health’sand empirical
obesity, withscholars. ” He calls recognizes
a greater and her response
the needis tofordevelop an ontological multisectoral
population-wide, conception of
increase forin greater unity between
these conditions scholars
in low- andand between scholars interventions
middle-income the political,towhere prevent“the and
political belongs
reduce to ourInontological
NCDs. 2013, a
and policy-makers, concerning
countries. Unfortunately, the WHO Eastern Mediterranean
3 the underlying normative condition.
comprehensive ” 33
According
Global to
Monitoring Mouffe,
Frameworksociety wasis developed
instituted
Region, topremises
which and Irangreater
belongs openness
to, is nowwhentheitworld
comesleader to advocacy.
in
11
and through
adoptedconflict.
by the “[B]y
World‘the political’
Health I mean the
Assembly dimension
(WHA), whichof
We commend the effort 4to reinstate power and politics in antagonism which I take to be constitutive of human societies,
increasing diabetes prevalence. included nine voluntary targets to be reached by member states
global health and agree that “a purely empirical evidence-based while by ‘politics’ I mean the set of practices and institutions
But why is diabetes important? Because it is a lifelong 2025: a 25% reduction in mortality caused by cardiovascular
approach is a fiction,” and that such a view risks covering up through which an order is created, organizing human
condition,“thewith role ofnopolitics
established
and power.definite
” But bycure, has costly
contrasting this fiction disease, diabetes,
coexistence cancer,
in the contextandofchronic respiratory
conflictuality provided diseases,
by the
short- and long-term complications, can lead to premature 10%political.
reduction” An issue or a topic needs to be contested tophysical
33 in alcohol abuse, 10% reduction in become
with global health research “driven by crises, hot issues, and
death and thedisability.
concerns ofInorganized
other words,
interestitgroups,
is very” asexpensive.
a “path we are inactivity, political,30% andreduction in salt intake,
such a contestation concerns 30% reduction
public action and in
There are direct medical costs, which include
trying to move away from,” Ooms is submitting to a liberal expenditure smoking, 25% reduction in high blood pressure
creates a ‘we’ and ‘they’ form of collective identification. But or halt the
on prevention,
conception treatment and management
of politics of complications.
he implicitly criticizes the outcomes increase in high
the fixation bloodrelations
of social pressure (depending
is partial on national
and precarious, since
These encompass
of.11 A liberal outpatient, inpatient,
view of politics emergency
evades care, long-
the constituting role of circumstances),
antagonism is an halt
everthe risepossibility.
present in diabetes and obesity,
To politicize an issue
term care, medications
conflicts and medical
and reduces devices.
it to either There are economic
a rationalistic, also expansion
and be of able preventive
to mobilize cardiovascular
support, one needs treatment (including
to represent the
calculation,
indirect costs, whichorare anassociated
individual with
question
loss ofofmoral norms. This glycemic
productivity, world control)
in a conflictual
to at least manner
50% of “with opposed
eligible camps with
population and
premature is echoed
death and in Ooms whenand
disability he astates that “it
negative impactis noton possible
the to 80%which peopleofcan
availability identify.”basic
affordable
33
technologies and essential
discuss the politics of global health
countries’ gross domestic product (GDP). While calculation without discussing the Ooms uses the case
medicines for the treatment of the of “increasing international aid spending
aforementioned four
normative premises behind the politics.
of indirect health costs is difficult and quite complex, the ” 11
But what if we on 7AIDS treatment” to illustrate his point.1 He frames the
NCDs. The framework was accompanied by the WHO NCD
1

annual direct health costs associated with diabetes has been Global Action Plan, endorsed by the 66th World Health
estimatedInstitute
in a of
Institute ofrecent
Health meta-analysis
Health and
and Society, to of
Society, Faculty
Faculty ofbe US$825
Medicine,
Medicine, billionof
University
University Oslo, Assembly,
of Oslo, Oslo, Norwaywhich provides guidance on policies that help
Oslo, Norway
globally.5,6 achieve the ambitious targets set in the framework.8
All of this is a testament to the need for global action where NCDs, including diabetes, have also been recognized as a
diabetes is concerned. The importance of addressing the threat to sustainable development and thus, addressed in the
problem of diabetes has been emphasized by the WHO in 2030 Agenda for Sustainable Development, adopted by world
naming the 2016 World Health Day ‘Beat Diabetes.’ This is leaders at the 2015 United Nations Development Summit. The

Full list of authors’ affiliations is available at the end of the article.

Takian and Kazempour-Ardebili
Agenda includes 17 Sustainable Development Goals (SDGs),
the third of which addresses good health and well-being for
all. Among the objectives set for this goal, member states
have committed to ‘reduce premature mortality from NCDs
through prevention and treatment by one third by 2030,’ which
mirrors the first voluntary target set in the Global Monitoring
Framework for NCDs. By recognizing NCDs as an obstacle for
sustainable development and pledging to globally combat its
effects, world leaders have effectively raised the much needed
awareness of society as a whole towards the importance of
worldwide solidarity against NCDs.9
It is difficult to find a country that does not already have a
national diabetes plan, which underscores the enormity of
the global concern surrounding it. However, many nations
among those with lower incomes lack proper funding and
implementation of such plans and policies. The WHO Global
Action Plan for Prevention and Control of NCDs8 outlines
six specific objectives and recommends effective policies
for achieving those objectives and ultimately attaining
the NCD prevention and control targets set by the Global
Monitoring Framework. These objectives are: (1) to prioritize
(to a greater extent) NCD prevention and control in global,
regional, and national agendas and internationally agreed
development goals; (2) to strengthen the national capacity in
order to enhance national response for NCD prevention and
control; (3) to create, sustain and expand health-promoting
environments to reduce modifiable risk factors (namely
tobacco use, diet, physical activity and alcohol abuse); (4) to
strengthen and orient the health systems to address NCDs
through people-centered primary healthcare and universal
health coverage; (5) to promote high quality research and
development; and (6) to monitor trends and determinants
and evaluate progress. By adopting these policies and tailoring
them to their population’s needs, nations can move a step
closer to tackling NCDs, and among them diabetes.
As one of the countries in the Eastern Mediterranean Region,
the world’s fastest growing hub of diabetes, Iran is a country
of 78.8 million population with the second largest economy
in the Middle East (after Saudi Arabia), and an estimated
GDP of US$393.7 billion, categorizing it as an upper middle-
income country.10 The current life expectancy in Iran is 74
years, with 64 years healthy life expectancy.11 The greatest
burden of disease, as calculated by disability-adjusted life-
years (DALYs) is attributed to cardiovascular disease and
diabetes. NCDs in general are responsible for 76% of total
deaths in the country, with diabetes and cardiovascular
disease directly responsible for at least 48% of total deaths.11
A large portion of the deaths caused by diabetes may be
prevented by better control of the condition, which relies on
increasing awareness and compliance among the patients and
advocating self-care, areas in which many Iranian patients are
sorely lacking. The Iranian government has long recognized
the nation’s vulnerability to NCDs and numerous national
plans, programs and policies have been implemented over the
years with little effect on reducing NCD burden. To effectively
overcome this burden, specific and clear policies are needed
not only to prevent diabetes, but also to optimize diabetic
patients’ control; this can be achieved by developing national
and local guidelines and auditing their use and misuse on
regular basis, as well as holding healthcare professionals
572 International Journal of Health Policy and Management, 2016, 5(10), 571–573
responsible when targets are not met.
Following the WHO’s call for global action against NCDs, an
Iranian National Committee for NCD Prevention and Control
was formed, chaired by the Minister of Health and Medical
Education (MoHME), and adopted by the Supreme Council
of Health and Food Security, which is a multidisciplinary
council including 3 vice-presidents and 10 ministers across
the government. The national committee is a policy-making,
regula­tory, scientific, and planning committee that has
subcommittees to perform its duties in all areas related to the
control of NCDs and risk factors; the committee is regarded
as a decision-making body of the MoHME with respect
to NCDs. This committee has produced the first National
Action Plan for the prevention and control of NCDs,12 which
includes the voluntary targets set by the Global Monitoring
Framework and goes a step further by adding 4 new targets
that are specific to national circumstances: zero trans fatty
acid in food products, 20% relative reduction in mortality due
to traffic injuries, 10% relative reduction in mortality due to
drug abuse, and 20% increase in access to treatment for mental
diseases. The Action Plan has also changed the targets for
reducing physical inactivity from 10% to 20% and expansion
of preventive cardiovascular treatment to at least 70% instead
of the WHO’s proposed 50% of eligible population.12
The Iranian National Action Plan for the Prevention and
Control of NCDs sets out ambitious targets and specific
recommendations for attaining those targets. Whether
implementing the program and its related policies will be
feasible and/or effective in the nation’s war against NCDs
remains to be seen. There are undoubtedly numerous
obstacles hindering the achievement of these targets, not
least of which is securing the required financial resources
needed in an era of resilient economy, as well as the need
for safeguarding peoples’ health and well-being in the post-
sanctions Iran, where further Westernization threatens to
increase the prevalence of NCD risk factors. Ambitious
targets, limited resources and rising risk factors; these entities
summarize the challenge of facing NCDs not only in Iran, but
in every developing nation around the globe. Therefore, how
Iran goes forward and what it achieves from adopting and
building on the United Nations Development Programme
(UNDP), WHA, and WHO agendas for tackling NCDs will
undoubtedly be of immense educational value not only to its
neighboring countries, but to the broader global community.
Ethical issues
Not applicable.
Competing interests
Authors declare that they have no competing interests.
Authors’ contributions
AT conceived the manuscript and contributed to content and revisions. SKA
contributed to writing, content, and revisions of the manuscript.
Authors’ affiliations
1
Department of Global Health and Public Policy, School of Public Health,
Tehran University of Medical Sciences, Tehran, Iran. 2Department of Health
Management and Economics, School of Public Health, Tehran University of
Medical Sciences, Tehran, Iran. 3College of Health and Life Sciences, Brunel
University London, Uxbridge, UK. 4Diabetes Research Center, Endocrinology
Takian and Kazempour-Ardebili

and Metabolism Research Institute, Tehran University of Medical Sciences, 2015;33(8):811-831. doi:10.1007/s40273-015-0268-9
Tehran, Iran. 7. World Health Organization (WHO). Monitoring framework and
targets for the prevention and control of NCDs: a comprehensive
global monitoring framework, including indicators, and a set of
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