We face a global context of rapidly increasing social inequalities, health inequities, and the expansion of excluded sectors of society. In this context, the integration of social rights and universal public goods into society, particularly health systems and policies, are central points of contention, shaping the very meaning and framework of the banners of social change and transformation versus regression and dispossession in the countries of the region. Inadequate access to healthcare, fragile care systems, continued dependence on science and technology, and limited access to medicines remain a collective problem of the 21st century, recognized as social determinants of unjust and preventable health-disease processes and the growing social inequalities that structure Latin America. Added to this are the increase in cross-border problems, epidemics, migration due to lack of employment and poor living conditions, socio-environmental disasters and emergencies caused by extreme weather events, unhealthy urbanization, extractive capitalism with its destruction of ecosystems and generation of new epidemiological crises, among other issues. In other words, Latin American countries still have deep debts and needs for answers to societies, in terms of rethinking the emphasis on collective health seen from a decolonial, intercultural and feminist South.

In this scenario, international health was and continues to be conditioned by a bias that Aníbal Quijano calls "coloniality of power and knowledge," through the economic and geopolitical interests of countries (self-defined as central or "developed") (Aragón, 2006). This implies making visible or invisible, depending on the case, social inequalities and their impact on global, regional, and national health inequities, on the impoverishment of public services in the Global South, on the unjust incidence of health and disease processes based on ethnicity, social class, and gender, and on the global determinants of collective health. It also includes vertical cooperation on diseases, without strengthening capacities and public sovereignty.

Thus, the central and overriding objective that allows us to understand the foundational bases of international health is the recurring theme of colonial geopolitics: the metropolis-periphery, North-South, and Center-Periphery relationships; knowledge and solutions in the North, problems and dependency in the South.  

To situate the object of study of this Working Group, it is necessary to understand that the genealogy of the contemporary world-system has two conceptual devices in the Health Sector that, due to their prominence and repetition, appear as disciplinary and structuring axes of the reflections, studies, agendas, policies, and actions in the health field in Latin America and the Caribbean: what we call the framework of the Pan American International Health (SPI) y global health liberal(SGI) (BASILE, G. 2018). 

That is, studying, investigating, problematizing, repoliticizing and acting on the dimensions of the international in the field of health, how the geopolitics of power and knowledge influences the regional health agenda and how health is inserted into international relations in the current world-system (Wallerstein, I. 1995) implies working on the intersectionalities of colonialism, capitalism and patriarchy on the field of collective health, and especially on International Health seen from the South.

One hypothesis assumed in this analysis is that by delving into the genealogy and historical and present-day development of international public health (Cueto, M. 2015)—expressed today as Pan-American—and its postmodern continuum of global health itself (Brown, Th. M; Cueto, M; and Fee, E. 2006), we are, in a way, immersed in the heart of colonial reason and relations, and their old-new languages ​​as conduits of reproduction and North-South power relations (Mignolo, W. 2016), which are also deeply rooted in the health field. These terms are not simply devices of two models for approaching and understanding the historical, conceptual, political, and methodological aspects of health and international affairs, or of what has occurred with biomedicine and public health in our region in recent centuries. Neither Pan American Health Organization (PAHO) nor liberal Global Health Organization (GHO) is a strictly geographical metaphor or simply an explanatory reference to health outside the borders of nation-states; rather, both were and are instruments of geopolitics that crystallize, represent, and reproduce global power bloc relations within the world system. In other words, both PAHO and GHO have become apparatuses for reproducing the power of the current world system, operating in the health sector.

In this sense, they managed to produce and shape Latin American and Caribbean health diplomacies, training generations of public health and biomedical professionals from universities and research centers as health training institutions to reproduce and administer their logics, agendas, and policies based on pre-packaged approaches that express their geopolitical priorities and interests of power and knowledge. We could assume that certain global actors in the current world-system have, for decades, constructed a set of symbolic, cultural, and political frameworks that, as “hegemonic“(GRAMSCI, A. 1978) reproduce totalizing narratives, managing to establish a set of ideas, beliefs, values, and interests that are internalized as supposed great “truths” of international public health and the novel concept of global health in Latin America and the Caribbean. Many of these reproductions impact not only at the epistemic level, but also public policy, the health institutions of the States—that is, the material reality of life and health in our Latin American and Caribbean societies today.” 

This evolution between the tropics, coloniality, and the public illness of Pan-Americanism are the foundations of our Latin American public health. Some authors, such as Anne Emmanuel Birn, consider international health to be based on a tradition linked to the past of colonial powers from the 18th and 19th centuries. This is when they began to develop mechanisms to manage health in their colonies, driven by the concerns of the colonizers themselves (BIRN, AE. 2009). We could express this in two terms: the need for public health for the governance of colonial action, alongside sanitary hygiene and later tropical medicine, which strengthened the capacities of that coloniality. In general, Pan-American international health, known as international health (Godue, C. 1999), is defined as a field that analyzes the health situation of populations or the international community as a whole. It particularly focuses on issues related to diseases that transcend national borders and the role of nation-states. Although the field has become more complex decade after decade, addressing health challenges from a supranational perspective, prioritizing trade, security, and economic development.  

The accelerated relocation of liquid capital and the growing imbalance in the distribution of power, which worsened in the 80s and 90s, constructed what various authors have called “globalization,” which some, like Arturo Guillén, refer to as “neoliberal” (Breilh and Ylonka Muñoz 2009). This is associated with the intensification of economic and social processes that have severely affected the collective well-being of societies due to the inherent conditions that generate greater inequalities, a situation that persists to this day. The radical transformations produced by the slogans of the end of history (FUKUYAMA, F., 1992) and prophecies of the Washington Consensus (LECHINI, G. 2008) that many of the governments (DUARTE, M. 2002) and countries sacramentally accompanied during the decade of the 80s and 90s and that seek to recreate themselves currently in Latin America with the officious intervention of international organizations such as the IMF, World Bank and the IDB; They not only had direct consequences on the financialization (VILAS, A. 1994) of the economy, the commodification of life (BREIL. J, 2009), the destruction of rights and nature, the deepening of unhealthy and unequal living conditions (BREILH, J. 2009), the impact on economic and political sovereignty among other dimensions, but they also worked fervently on the construction of the birth of a new conceptualization: global health based on liberal rationality and neoclassical economics.

It is in this context, as described by Antonio Ugalde, that philanthropic foundations, pharmaceutical groups, and financial and trade organizations such as the World Bank (WB), IDB, OECD, WTO, and IMF became central actors in the global health agenda, especially in reforms to health policies and systems (Ugalde, A., & Homedes, N. 2007). As the development cycle declined in the Latin American region, Pan-American international health lost its centrality and global and regional power to a complex liberal political system where states lost their influence as actors and extra-health agents were incorporated into both the financing and the definition of the direction of health policies. Francisco Armada, Carlos Muntaner, and Vicente Navarro meticulously document the increasingly evident convergence of decisions by the World Health Organization (WHO), the World Bank, and transnational corporations (Armada F, Muntaner C, Navarro V. 2001). Philanthrocapitalism in health will also gain more prominence (BIRN, AE. 2018)

Thus, it is worth highlighting 3 central processes that are consolidated with the birth and apogee of liberal global health, which are defined not by their laudable pronouncements but by the global agendas, policies and actions that are operationalized especially on the countries of the South:

1. Regressive social reforms to the State and sectoral reforms to health systems of a neoliberal nature. The financialization of public goods, especially health services and coverage and social protections (e.g., pensions).

2. The subordination of public health to market demands, that is, the commodification of health and life and the residual role of the State. This was termed Essential Public Health Functions (EPHF), reflecting the convergence of complementary agendas between PAHO/WHO, the World Bank, and corporations. Pan-American health policy will adapt to its new role and the prevailing climate.

3. The consolidation as hegemonic actors of the medical-industrial-pharmaceutical-financial complex and transnational corporations (including so-called philanthrocapitalism) with public-private partnerships playing a structuring role in the new global agenda of world health.

From this analytical perspective, we begin with the premise that any discussion of the intellectual and political construction of Pan-American international health and its continuum of global health must address two simultaneous exercises: an internal critique of the hegemonic logics of the West regarding these concepts, and the formulation of interests and strategies of the Global South based on autonomy, geopolitics, emancipation, history, and culture. The first is a project of deconstruction and dismantling of the dominant field; the second, of construction and creation. These projects—the first functioning negatively and the second positively—appear contradictory, but it is necessary to carry out these respective tasks simultaneously.

The thesis put forward and developed within the critical perspective of the CLACSO International Health Working Group lies in characterizing Pan-Americanism and liberal global health as mechanisms for reproducing the geopolitics of power of the world-system in its various stages and cycles of global capitalism: colonial, industrial, and liquid-financial. This world-system is profoundly asymmetrical, predatory, exclusionary, and reproduces the coloniality of Center-Periphery (PRECIADO, J. 2008), with a dehumanizing acceleration that leaves increasingly less space for health and life. This generates health dependency, reproduces North-South geopolitics, and establishes public health policies based on their Westernization, commodification, and transfer of development theory. In other words, they constructed a periodization of health based on the thinking, interests, and policies of the Global North. Therefore, attention should not be paid so much to their theories, periodizations, and pronouncements, but rather to what they do: their agendas, policies, actions, interests, and impacts.

From this location of the topic and problem, this GT assumes the idea that a first exercise of deconstruction is essential, which implies outlining a primary methodological objective in the need for decolonization of international health towards a South South geopolitics, a decolonial and emancipatory turn based on the reconstruction of regional health sovereignty.

South-South International Health (SSIH) and Health Sovereignty constitute a new interdisciplinary field of knowledge, research, and public policy action grounded in a South-South and decolonial epistemology and geopolitics (BASILE, G. 2018). It not only addresses issues related to collective health, illness, and the care of populations, as well as systems and policies beyond national borders, but also studies and acts upon the global determinants, dynamics, and agendas that the Global North establishes and that the current world system reproduces in our health policies, systems, and agendas. Eurocentrism, in its variants of "Pan-Americanism of international health" and postmodern liberal "global health" (BIRN, AE. 2009), represents two variations of the same logic of dependency and worldview of the contemporary world system. Thus, the need to study international issues and health from a Southern perspective is not without epistemological and geopolitical disputes. In recent decades a new directionality has developed called SISS whose central objective is to promote a decolonial turn (MALDONADO-TORRES, N.2008) and the construction of health sovereignty in Latin America and the Caribbean.

Since 2016, the CLACSO Working Group has been examining the field of Health Security Systems (HSS) in our region, the foundations of the decolonial turn and health sovereignty, global actors and health policies, comparative health systems, international epidemiology, migration, health emergencies and disasters, geopolitics, and the health cooperation system in the 21st century. It investigates different theoretical and methodological frameworks and epistemologically discusses dominant and alternative hegemonic concepts.

This proposal was developed by the CLACSO Working Group on International Health and Health Sovereignty, fostering synergies and cooperation networks to produce Latin American knowledge and critical thinking on collective health. It stems from the need to create a new platform for training, study, research, and thought in the field of international affairs and health from a Southern perspective. It assumes, first and foremost, the integration and framework of social sciences applied to health, the development of critical health theory embodied in the paradigm of Social Medicine and Collective Health (Granda, E. 2008), and its implications and tensions with hegemonic clinical biomedicine (Menéndez, E. 2005).

We consider SISS as a field of knowledge, governance management and geopolitical action, which in addition to studying and working on the dimensions for the deconstruction of the dominant matrix, is also essential to base approaches of an epistemological search from the South with the objective of producing a new framework between emancipation, autonomy and sovereignty in the health field towards the development of South-South International Health (SISS).

The SISS's founding objective is to promote the construction of health sovereignty and a decolonial shift for Latin America and the Caribbean. It seeks to provide an explanatory framework that prompts reflection and questions: how can we identify what the field of health in Latin America and the Caribbean needs to be decolonized from? This implies asking: What is the colonial problem in Pan-American international health and liberal global health? These questions were largely addressed and studied in the first stage of the CLACSO Working Group from 2016 to 2019. In the second stage, we will delve deeper into the theoretical and methodological framework of the SISS proposal, expand regional and international networks, promote dissemination and outreach, and consolidate CLACSO as a key player in the field of health at the regional level.

To carry out this exercise of deconstruction and analysis as well as theoretical-methodological construction, South-South International Health seeks to base its theses on 3 indispensable counter-hegemonic dimensions that help to think about and problematize new foundational bases of an emancipatory health geopolitics:

1. The first dimension: The coloniality of power and knowledge applied to the health field as the first constitutive element (QUIJANO, A. 1999).

2. The second dimension is the theorization of development (GUDYNAS, E. 2011) and its reproductive character of health dependency.

3. The final dimension of analysis will be North-South geopolitics and the production of health diplomacies trained for their management, reproduction and administration.

The Working Group's proposal argues that it is essential to address these three dimensions from a national/regional perspective to develop a different conceptual framework and public policy design approach that considers the challenges that transcend national borders and affect health in the Global South. This is a key epistemic debate, as it reflects current tensions surrounding health: whether it is understood as a public good, a universal human and social right, or as an individual service and a private commodity for profit.

Thus, this Working Group proposes to contribute to and develop research-action capacities of national and regional scope, of a comparative nature, and to contribute to the formation of study and cooperation networks in research, training and dissemination in South-South international health in order to foster dialogue between researchers, study centers, universities, social movements and civil society organizations, as well as with national, regional and international public managers.

Since the mid-80s, multiple attempts have been made to conceptualize international health in Latin America and the Caribbean, seeking to dismantle the ethnocentrism of core countries that view global health problems from their own perspective, their own interests, and their own approaches, analyses, and conceptual-methodological responses. As the pioneering Dr. María Isabel Rodríguez (MINSAL, 2010), former Minister of Health of El Salvador and founder of the Edmundo Granda International Health Program, once defined it, “the health of others insofar as it affects us”The connections with Latin American social medicine and collective health are undeniable, and the fundamental bases of critical thinking in health are nourished by these social medical productions and authors (Paim, JS, & Almeida Filho, NMD 1999).

QWhat are the implications of reinterpreting this field, and is it necessary to develop a conceptualization of South-South International Health? The challenge is to embrace the decolonization of knowledge in the study, geopolitical action, and public health policies at the regional and international levels.

Assuming the foundations of Latin American critical thought with the proposal of the epistemologies of the South (De Sousa Santos, B., & Meneses, MP 2014) is to start from a position in the geopolitical South. Boaventura de Sousa Santos defines it as "the search for knowledge and criteria for the validity of knowledge that give visibility and credibility to the cognitive practices of the classes, peoples, and social groups that have been historically victimized," or, as he would say, "from the oppressed" of the South. In practice, this means to build a new epistemology of International Health from the SouthA new epistemology of the world represented in a view of health from the South.

The 5 structuring principles in an approach to South-South International Health:

1. Health Sovereignty. complementing Dependency theory to the challenges of the 21st century and Helio Jaguaribe's autonomy theory (JAGUARIBE, H. 2009)We will define it as follows: seeking maximum decision-making capacity within the prevailing global context and counteracting the hegemonic logics of the SIP and SGI is perhaps a fundamental premise that allows for a genuine capacity to formulate emancipatory policies, goals, and strategies based on our own actors and decisions. We call this Health Sovereignty.

2. Decoloniality / Decolonial turn. As detailed in the section by Maldonado Torres, Arturo Escobar, and Chantra Mohanty, the revitalization of a change in the coordinates of emancipatory thought from which the liberal modernity of the Center is conceived and its structures and reproductions are subverted.

3. Interculturality. If the epidemiological situations of our populations are unique, if the health-disease process is a historically constructed and determined phenomenon in each society, if the very concept of disease is dependent on sociocultural construction, why do our health models, services, and systems continue to be, in many ways, almost copied and standardized? Interculturality should be understood not merely as an instrumental measure of communication, language, or asymmetrical multiculturalism of beliefs, but from a political dimension where interculturality implies de-Westernization, an ecology of knowledge, and a distribution of power.

4. South South. It involves thinking and acting as an epistemological subject of the geopolitical South. Geopolitical orientation, cartography, and counter-hegemonic praxis from a Gramscian perspective.

5. Horizontality: It has connections with intercultural dialogue and the ecology of knowledges. It is not only about non-asymmetrical relationships between people, groups, and/or collective representations. It is especially about The principle that enshrines the limitation of hierarchical, conditioning, asymmetrical relationships, understanding that the perspectives assumed in the SISS should be based on the recognition of the Other, reciprocity, cooperation between equals and solidarity association.