The argument lands twelve years after the Lancet-Oslo University Commission on Global Governance for Health concluded that the political origins of health inequity demanded institutional reform. In the view of lead author Ellen Beer of Karolinska Institutet and her colleagues, that reform has not materialised. Global governance frameworks for protecting health in conflict are still managed in silos, divided between humanitarian agencies, security councils and diplomatic fora, while routine public health governance rarely engages with the upstream political decisions that expose populations to violence, deprivation and displacement in the first place. The team contends that governance for health must explicitly govern the political, commercial, environmental and epistemic determinants of health at an institutional level, and that protecting life in conflict should become part of everyday public health discourse rather than an emergency afterthought.

The technical backbone of the argument rests on international humanitarian law, the body of rules codified in the 1949 Geneva Conventions and their additional protocols, which restricts the methods of warfare in order to protect civilians, health systems and the environment. Attacks on hospitals, restrictions on humanitarian aid and the destruction of civilian infrastructure mark, in the authors’ framing, the point at which political and commercial determinants of health produce their most system-destroying consequences. Political determinants, meaning the decisions of governments and armed actors, shape whether populations are exposed to violence. Commercial and regulatory decisions shape the circulation of resources, including weapons. When those decisions fail, the result is the collapse of the very systems that public health depends upon: supply chains, electricity, water treatment, cold chains for vaccines and the trained workforce that operates them.

The commercial dimension is where the authors draw their most provocative parallel. Public health has built binding regulation around other harmful industries, from tobacco marketing restrictions to conflict-of-interest safeguards that limit industry influence on policy, and has established norms requiring disclosure and management of tobacco industry links across publications, funding and employment. Yet outside international arms trade treaties, everyday policies governing institutional relationships with the arms sector are far less ubiquitous, despite the sector’s documented relationship to mortality, displacement and environmental harm. The authors ask a pointed question: if public health has decided that institutional entanglement with the tobacco industry must be disclosed and managed, should comparable norms not apply to institutional relationships with the arms industry? They argue that the arms sector, as a structural and upstream driver of violations of humanitarian law, warrants similar governance standards.

Environmental harm in conflict supplies some of the most durable evidence for the case. Armed conflict contaminates agricultural land, water systems and air, threatening health through chronic disease, malnutrition and intergenerational trauma. Attacks on water infrastructure contribute directly to cholera outbreaks, a mechanism epidemiologists understand well: destruction of treatment and distribution systems forces populations onto contaminated sources, and Vibrio cholerae follows. The carbon footprint of modern warfare is also enormous. Recent analyses cited by the authors estimate that carbon emissions from military operations can exceed the annual emissions of entire countries, folding war into the planetary health agenda alongside climate change and biodiversity loss.

The historical record shows how long these consequences can persist. The health effects of Agent Orange, the herbicide sprayed over Vietnam, remain measurable decades later, and unexploded ordnance still maims civilians in Laos and Cambodia. Such events prompted the international community to adopt Additional Protocol I, which prohibits methods of warfare intended or expected to cause widespread, long-term and severe damage to the natural environment, and later treaties such as the 2008 Convention on Cluster Munitions. But the authors stress a critical structural weakness: only signatory states are obliged to comply. Governing the environmental determinants of conflict through commercial and political routes, they argue, must therefore become a priority within planetary health rather than being left to treaty law alone.

There is also a distributional argument running through the piece. Failure to govern conflict-related determinants of health falls hardest on populations already structurally marginalised within health systems. Women, children, Indigenous peoples, gender-diverse people, older adults, people with chronic conditions and disabilities, and displaced people experience the most severe consequences of armed conflict and of violations of humanitarian law. Advocacy for the health of marginalised populations, the authors conclude, is therefore inseparable from advocacy for the evolution of governance itself. A public health field that documents inequity without engaging the political machinery that produces it, they suggest, is abdicating part of its mandate.

The team adds a decolonial critique to this structural analysis. Scholarship on decolonising global health has documented how power asymmetries persist in agenda-setting, funding allocation, authorship, representation and control over knowledge production, and in deciding which determinants and which commercial sectors get governed at all. The devaluation of local knowledge, lived experience and political analysis, the authors argue, constitutes a form of epistemic violence, and it helps enable selective recognition of humanitarian law violations. In conflict-affected settings, these asymmetries shape whose suffering is recognised, whose security is prioritised, which crises attract diplomacy and whose knowledge is considered authoritative in humanitarian research, advocacy and policy. Decolonising public health, on this reading, requires examining how coloniality persists through governance structures and determines who is protected.

What elevates the piece beyond diagnosis is its proposed mechanism: health diplomacy. Once dismissed as soft power, health diplomacy has evolved, the authors write, into a practical instrument for managing crises, fostering trust and negotiating cooperative action under hostile conditions. It offers a channel for engaging the political determinants that lie upstream of humanitarian law violations, and a nominally neutral platform that can unblock traditional political channels by refocusing negotiations on shared health interests. Concrete applications include cross-border coordination on water and energy security, vector control and the protection of health systems in fragile contexts. Crucially, the authors frame health diplomacy as both a response tool and a preventive one: by reducing risk and building trust before crises escalate, it can support more resilient recovery pathways after them. Given its growing role in international security, they argue, public health governance actors need training in governance, negotiation and conflict-aware health policy so that a health lens can be integrated into international conflict dialogues and negotiations.

The authors close with a proposition that reframes the entire field. Violations of international humanitarian law, they argue, should be understood as failures in the governance of political, commercial, environmental and epistemic determinants of health, and preventing the disproportionate health and health-system impacts of conflict requires stronger governance of those determinants as part of broader global governance for health. That, in turn, requires confronting power asymmetries in agenda-setting, knowledge production and decision making. The message to the public health community is blunt: as one cited commentary puts it, public health has always been about politics informed by evidence, and its practitioners are agents of change working in the political arena. With attacks on health care at record levels and rising year on year, the authors argue that the era of treating war as someone else’s governance problem is over. The tools exist; what is missing, they contend, is the institutional will to connect them.

Subject of Research: Governance of the determinants of health in armed conflict, international humanitarian law violations, and health diplomacy

Article Title: The governance gap: Determinants of health, international humanitarian law violations, and the case for health diplomacy

Article References: Beer, E., Chen-Xu, J., Yuen, R., Planatscher, A., Gilmour, R., Ahmed, Z., Santamaria-Plaza, C., Zotti, N., Vasic, M., Hachem, M., Rosiello, F., & Shellah, D. (2026). The governance gap: Determinants of health, international humanitarian law violations, and the case for health diplomacy. PLOS Global Public Health, 6(10), e0007482. https://doi.org/10.1371/journal.pgph.0007482

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0007482

Keywords: global health governance, international humanitarian law, health diplomacy, attacks on health care, social determinants of health, armed conflict, planetary health, commercial determinants, decolonising global health, Geneva Conventions, health systems, PLOS Global Public Health

The study, published as a scoping review in the International Journal for Equity in Health, examined 286 documents published between 2008 and 2026. Following the PRISMA-ScR reporting guidelines, the researchers applied the Joanna Briggs Institute’s population, concept, and context framework to answer four questions: how the term “driver” is used globally and regionally, how it relates to the established concept of social determinants of health, what methodological strategies researchers deploy to study it, and where the glaring gaps in knowledge lie. The protocol was registered on the Open Science Framework, and the work was carried out as part of an effort to build a Health Equity Status Report for the Americas.

The headline finding is a conceptual one. The authors describe an evolution in the literature toward what they call Social Drivers of Equity in Health, a reframing that treats drivers not as passive background conditions but as operational engines of power. In other words, a driver is not simply a factor that correlates with poor health; it is a force that sets the social determinants of health in motion. This distinction matters because the social determinants framework, influential since the World Health Organization’s landmark commission on the subject, tends to describe the conditions in which people are born, grow, work, and age. Drivers, by contrast, imply agency and causation, the mechanisms that produce and reproduce those conditions in the first place.

The numbers reveal just how muddled the terminology remains. The review found that 36.4 percent of the analyzed literature uses “driver” and “determinant” interchangeably, treating them as synonyms despite their different analytical implications. Meanwhile, 38.5 percent of studies identify drivers as independent forces that put social determinants into motion, a more mechanistic reading. The remaining studies occupy various intermediate positions. This inconsistency, the authors argue, challenges theoretical coherence and makes it difficult to operationalize health equity in policy terms. If researchers cannot agree on what a driver is, they cannot agree on what should be driven, or by whom, or toward what end.

Methodologically, the field shows both strengths and limitations. About a third of the reviewed documents, 33.3 percent, were primary quantitative studies, and 46 of them employed multivariate modeling designed to isolate structural effects from individual-level confounders. That is a technically demanding undertaking. Structural forces such as racism, class, and gender hierarchy are not measured directly; they must be inferred through proxies, interactions, and hierarchical models that account for people nested within neighborhoods, institutions, and nations. The fact that only a minority of studies attempt this rigor suggests that much of the literature remains descriptive, cataloging inequities rather than explaining the machinery that produces them.

When the authors turned to the regional picture, the results were striking. Within the Americas, structural racism appeared as the predominant engine of health inequity, cited in 80.0 percent of the relevant regional literature, followed closely by socioeconomic status at 79.3 percent. These findings align with a growing body of evidence showing that racialized populations across the hemisphere face systematically worse outcomes, from maternal mortality to chronic disease burden, even after accounting for income and education. The review’s framing treats these not as isolated risk factors but as relational dimensions of inequality that structure social positions, analyzed across the PROGRESS-Plus axes, a taxonomy covering place of residence, race and ethnicity, occupation, gender, religion, education, social capital, socioeconomic status, age, disability, and sexual orientation.

Perhaps the most forward-looking element of the analysis is its identification of emerging axes of inequality that traditional frameworks have been slow to capture. The PROGRESS-Plus analysis surfaced digital and commercial dimensions as novel mediators of geographic inequity. The digital dimension reflects the reality that access to broadband, telehealth, and health information increasingly determines who can participate in modern health systems, a divide laid bare during the COVID-19 pandemic. The commercial dimension points to the growing influence of industries, from ultra-processed food to tobacco and alcohol, whose products and marketing practices shape health far beyond the clinic. Both axes cut across geography, deepening divides between urban and rural populations and between wealthy and impoverished regions.

Beneath these findings lies what the authors call a significant research inequity. A staggering 79.3 percent of the regional evidence base is concentrated in the United States, leaving Latin America and the Caribbean substantially underrepresented. This is not a trivial bibliometric curiosity. The structural drivers of health inequity in a high-income federal democracy with a fragmented insurance system may differ profoundly from those in middle-income countries with universal health systems, large Indigenous populations, histories of colonial extraction, and high levels of informal employment. Policies built on a US-centric evidence base risk misdiagnosing the levers of change elsewhere in the hemisphere, perpetuating a form of epistemic dependency that mirrors the material inequities the field seeks to dismantle.

To resolve the tension between the term “driver” and established social determinants models, the authors propose a pragmatic compromise: a hierarchy of drivers organized along the familiar upstream, midstream, and downstream gradient. Upstream drivers would encompass the structural forces, legal frameworks, and institutional arrangements that shape the distribution of power and resources, with legal reforms and social protection systems identified as precise levers of intervention. Midstream drivers would cover the conditions of daily life in communities, schools, and workplaces, while downstream drivers would address individual-level factors. This layered architecture allows policymakers to locate where in the causal chain an intervention is aimed, and to recognize that downstream programs, however well designed, cannot compensate indefinitely for upstream forces that continuously regenerate inequity.

The review’s conclusions come with a caution. The term “driver,” for all its rhetorical energy, should be used carefully and only in articulation with robust theoretical frameworks, lest it become another vague buzzword in a field already crowded with them. Used well, the authors suggest, it can serve as an operational catalyst for structural intervention, translating the descriptive language of determinants into the action language of policy. The study itself models a degree of transparency worth noting: the authors disclose that they used an AI tool during data synthesis to refine driver categorizations and cluster theoretical frameworks, with all outputs critically reviewed and verified by the team. Funded by the Pan American Health Organization and the Robert Wood Johnson Foundation, the review arrives at a moment when governments across the hemisphere are grappling with post-pandemic reversals in life expectancy and widening gaps between the richest and poorest. Its central message is deceptively simple: to make health equity more than an aspiration, the hemisphere must first agree on what is actually doing the driving, and then reach for the levers, especially legal and social protections, that can change direction.

Subject of Research: Social drivers of health equity in the Americas

Article Title: Drivers of health equity in the Americas: a scoping review

Article References: Chapman, E., Araujo, M., Maylen, R.-B., Pardo, J. P., & Mujica, O. J. (2026). Drivers of health equity in the Americas: a scoping review. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03031-6

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03031-6

Keywords: health equity, social determinants of health, scoping review, structural racism, socioeconomic status, PROGRESS-Plus, Pan American Health Organization, Latin America and the Caribbean, health policy, digital divide, commercial determinants, public health