Political economy approaches are an increasingly popular framework in the Public Health and Biomedical Sciences scholarships. A quick search of major biomedical and public health databases, PubMed and Ovid, highlights over 2,000 and 1,200 papers, respectively, using ‘political economy’ in their title or abstract. Most of these papers that utilise political economy in some way, shape or form have been published since the start of the COVID-19 pandemic, which suggests that the crisis helped elucidate the centrality of political economy factors to matters of health and illness. This is, of course, a welcome development; the more that our colleagues in Biomedical and Public Health fields can integrate political economy analysis into their studies, the better it will be for us all.
The use of political economy frameworks has enriched the preventative, curative, and care processes of health practice, while adding to broader knowledge of the social and structural catalysts of disease pathogenesis. However, these accounts are sometimes afflicted by recurrent limitations, notable gaps, and missing pieces, which are often due to the broad manner by which much of the Health Science fields have deployed political economy analysis in their work, which may hinder their explanatory and analytical possibility. My latest paper in New Political Economy, titled ‘A Critical Political Economy of Syndemics: HIV in Ukraine amid War, Reform, and COVID-19’, seeks to engage with the new Health Science literatures that utilise political economy approaches. This paper highlights the broader gaps that are constraining this scholarship and attempts to demonstrate the merits of an alternative, critical political economy approach to questions of health and disease, summarised here. It is hoped that this blog and the paper itself can find some interest among Public Health and Biomedical science scholars and potentially spark a fruitful, critical engagement between these scholars and Political Economists; not only on the conceptualisation and application of Political Economy theory, but also on how we, together, can address critical health problems across our fields.
Political Economy on Life Support
The major starting point is that in the Health Sciences scholarship, where the utilisation of political economy analysis is in vogue, it is rarely explained how ‘political economy’ is conceptualised. Before this goes too much further, it must be pointed out that, of course, my points here are broad and paint this scholarship as homogenous, which it is not – however, there are general patterns one can notice upon a thorough review of this work. Indeed, if ‘political economy’ is explained in a typical Health Sciences paper, it is illustrated very narrowly. Typically, this literature separates the ‘political’ and ‘economic’ of Political Economy into dichotomous sectors, which are then populated by various sub-categories relating to health expenditures, political decision-making, regulatory factors, expert knowledge, or the vagaries of party politics and the like. These would then, typically, be fed into positivistic, causative models as variables, reflective of classical Political Economy approaches that orientate around atomistic interactions between separated categories.
With such a positivistic approach, however, the Health Sciences literature may not be as attentive in their political economy analysis as to how health effects are experienced, embodied and reproduced, and the position of such ‘variables’ within and through other social and structuring relations. In my paper, I highlight this problem through the orthodox approaches to HIV. Usually, those living with HIV are grouped into ‘exposure categories’ defined by individual behaviour that may be influenced by economic or political factors, which are then mobilised as sole explanatory variables for the incidence and prevalence of HIV, which guides an individualised public health strategy. The resultant biomedical response, focused as it is on behaviour, psychology, and other individual factors, however, often catalyses stigmatisation of, and violence towards, constructed groups, which makes it seem that only certain, ‘marginal’ people are at-risk of HIV – typically due to ‘aberrant’ sexual or drug-taking behaviours. These campaigns may miss the broader social and structural context in which transmission occurs and allows crucial causes to go unaddressed. This is not only an issue confined to HIV; in many public health reports one can find individual factors, such as health literacy, attitudes, and other behaviours, predominantly blamed for health crises. On the other hand, solely structural approaches to health are often overly deterministic and reductionist.
Political Economy, Know Thyself
In attempting to move past these tendencies towards categorisation and dichotomisation, my paper offers a relational view that ontologically privileges the interrelated connections between processes, people, and things that is also cognisant of the structuring totality. Conceiving of relations helps to understand how broader imperatives within a social totality, constructed by reciprocally-determining transformations, determine the possibilities of the individual, rather than ‘seeing’ an abstract society as only containing siloed individuals, things, and categories randomly interacting. A view of the totality thus helps understand how the social reality relates within a historically given context that has structuring relations, today being a historically-contextual capitalism (a c-word that is generally not uttered by the Health Sciences literature), which is also shaped by actors and other structures through reciprocal interactions with the state, community, and everyday struggles of people living with health and disease. For Health Science scholarship, critically engaging with ontologies and epistemologies of their work would be fruitful, to interrogate how, and what, we ‘know’.
My paper looks at HIV during war in Ukraine and argues that the prevalence and incidence of the condition is not just about biology, nor can it be explained by separated political or economic variables, but can only be understood through a relational, multi-scalar critical political economy framework that takes seriously the notion of a totality. The paper undertakes a historical narrative that reconstructs the chronology of people living with HIV in Ukraine from the collapse of the Soviet Union up to, and including, the Russian Invasion. Through this period, the piece analyses how multi-scalar, interrelated changes have impacted the ability to live with HIV, including the neoliberalisation of the Soviet state, the collapse in Ukraine’s national health funding, the take-over of health services by NGOs, the Global Financial Crisis, the violence of the War in Donbas, decentralisation restructuring, health reform, austerity, mass displacement, COVID-19, and Russia’s violent invasion. Indeed, the paper posits that the experience of those living with HIV during war is relationally determined by not only conflict, violence, and displacement, but also by broader restructuring of the capitalist totality that heralds reform at the state and local levels, such as decentralisation, health restructuring, austerity and state transformation. The interrelated effects and impacts of this multi-scalar political economy cannot be understood through cut-up, dichotomised and abstract, unrelated variables, but can only be seen with a relational view that seeks to reconstruct the actors, structures, and relations that impact the experience of those living with HIV.
The title of this blog recalls ‘Our America and Theirs’, a collection of Che Guevara’s speeches against Kennedy’s Alliance for Progress. The point of this stylised reuse is not to suggest that ‘their’ (Health Sciences scholarship) political economy is wrong or imperialist (though it is hegemonic), but to recall the almost forgotten history of these health sciences themselves, which is associated with Che. What my contribution seeks to amount to is a call for the Public Health and Biomedical Sciences scholarships to look not only at the critical Political Economy literature, but to be mindful of their own proud legacy of Social Medicine, which explicitly connected health analysis with a multi-scalar, relation, political economy that was determined by the totality.
For all of us working on the political economy of health, the lessons of Social Medicine still need to be learned.
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