Global health needs to change its game in the era of populism, perhaps the main global health disruptor of our times

This week, BMJ Opinion  started a really nice discussion on global health disruptors over the past decades (with also some reflection on the times awaiting us).

Thinking slightly along the same lines, it is clear that populism is one of the key global health disruptors of our times, if not “the” disruptor. Cas Mudde wrote recently in a Guardian piece, “How populism became the concept that defines our age” which is probably not far from the truth. Ours is, among others, the era of populism. In North ànd South, by the way. And it’s here to stay, at least for the coming decade or so.

My feeling is that global health hasn’t really (fully) adjusted to the populist era yet, still hoping somehow that the good old (MDG) times of support for global responses, global public goods, with almost unstoppable global health progress, world solidarity (at least in terms of high-level rhetoric),  support for the multilateral (though US-dominated) order, … will come back sooner rather than later. If that is to happen, however, the overall analysis of populism by global health (and development) has to change, in my opinion, including how to instrumentalize (and even capitalize on) part of the current wave of populism. Some aspects, that is.

Global health versus populism 

By and large, global health currently suffers from a focus on ‘rightwing populism’ (even if some global health scholars have zoomed in on populism in general, for example in IJHPM). That’s understandable, as even populism expert Mudde emphasizes leftwing populism hasn’t really taken off (and where it has, like in Latin America, things turned rather sour; in other places, it has been crushed). But maybe the fact that global health is still dominated to some extent by the US & the UK (where they have rather disastrous experiences with right-wing populism lately, to put it mildly ) also has something to do with it?

There’s a tendency in progressive, liberal circles (which include much of global health) to focus on all the dirty tricks (by Russian hackers, Cambridge Analytics, etc) used in the Brexit referendum & Trump’s narrow victory, while a more important question is asked far less: why was the election/referendum result so close in the first place?  Another vital question, for the many global health fans of a second referendum in the UK, is also not really taken into account: what would the rest of Europe (and especially ordinary citizens) think, if, once again, a second referendum is organized (as the first one didn’t actually lead to the “desired result”)? The EU doesn’t have a good track record in this regard, as you know. This can only further boost populism (or worse) in the rest of the EU, I think. (PS: Not that I wouldn’t like the UK to remain in the EU : ) )

Part of the reason, why the results were so close in the first place, of course, has to do with some of the root causes which have also led to left-wing populism (as it’s commonly labelled, even if some of their suggestions are probably just common (fair) sense) gaining  momentum in a number of countries, in polls or even in elections, certainly in the North: a deep unease with the current economic system and how it seems to favour the powerful and wealthy. Put differently, I just refuse to think that all Trump fans and Brexit fans are hard core racists or nativists. You just don’t hàve that many nativists & hard core racists in a country. You need to have some belief in humanity.

Other reasons why global health feels uncomfortable with populism, apart from the latter’s nasty tendency to nativism, xenophobia, … (in its right-wing form), are its post-truth and fake news streak, its difficulty with ‘evidence’, (cfr: the vaccines debate). All these are understandable, and global health should of course not give in on all of these.  Not an inch, even, with exception perhaps of trying to understand why many people have trouble to believe in science these days. Just think how the latest ‘Implant’ scandal might go down in some circles.

Towards a more nuanced global health take on populism (and the precariat, while we're at it)

Still, a more nuanced understanding of populism, and its root causes, in global health (power) circles, seems a must, if we are to make further global health progress in our messy SDG/planetary health era. I don’t think, for example, that it’s wise to talk about ‘an increase in the malign influence of nationalist, nativist, and populist movements’ (cf.r one of these BMJ blogs); that sounds too much like the Chinese government when it talks of the three evil forces of ‘extremism, terrorism and separatism’ in Xinjiang and elsewhere. It’s too easy.

There are parts of populism (and certainly of the right-wing form) that should indeed be strongly condemned, but there are other aspects of the current populist wave that global health should try to understand, and even try to work with. I find the debate somewhat linked to global health’s current (reluctant) stance versus “the precariat”, a now global group of people (a new ‘class’ in the eyes of some, Guy Standing of course in the first place) which it also hasn’t really thought through, yet (although a former colleague of mine has made a great effort,  recently (in Dutch, though)).  If the insecurity of the precariat is now increasingly a global phenomenon, global health has to up its game versus this new ‘class’. After all, this is the SDG era, presumably an era for the whole planet (not just for the South).

Just like the proletariat disrupted the system in the 19^th century, the precariat is already doing that in our times, as Paul Mason argued in a recent Guardian  contribution.  “At the most basic level – and this explains the rise of both the left and right opponents of neoliberalism – people understood that emotion, and with it feelings of identity, place, nation and class, could only reinsert itself into decision-making if the system were disrupted.”

And yes, the precariat can no doubt lead the world towards “paradise” or “hell”, as Standing argues in his book, but was that really any different in the 19^th and 20^th century for the proletariat?  The horrors of the 20^th century were not just their fault, I’d say…. And their (sometimes mob-style) pressure also led to public health (sanitation, …) progress in cities, and to a welfare system in many countries after the second world war.  Why would it be any different for the precariat, once they manage to organize themselves better? Moreover, who would dare to claim that our current elites don’t lead the world to hell, via a ruthless and unsustainable economic system?

For the moment, many in global health (power circles) still sound as if we’re still in the happy (ostensibly cosmopolitan) MDG era, focusing on the ‘most vulnerable and marginalized’, the ones “left behind”, … they hardly talk about this broader rage.

Take for example these Replenishments of global health stakeholders: their causes are lofty, and extremely necessary, no doubt about it, but how do you think these sorts of High-level events (where it certainly helps to get access if you are also a Davos “regular”) go down in the eyes of the global precariat? Do you think ordinary (struggling) people, say ‘les gilets jaunes’, think they’re on the side of elites, or of the common people, or even of the ‘most vulnerable’ they never stop talking about?  Same for Macron’s Planetary health summits, I have a hunch…. Perception matters. And I’m afraid this is, deep down, about a lot more than just perception.

Another global health (power) fixture seems to be its relentless focus on “innovation”, “cost-cutting to get more value for money”, inspired as it is by philantro-capitalism and consultancy companies like McKinsey et al. rather than, say, on ‘decent work’. Now ask yourself again: what do you think the precariat, working for the likes of Amazon, Deliveroo, Uber, … might think of all this?  And can you really blame them?

Final example: global development’s current focus on “leveraging” private sector money, “to get from billions to trillions”?  (as apparently we’ve given up on properly taxing them).  It’s good most of the precariat probably don’t know about it, as this ‘leveraging stuff’ sounds downright horrible as compared to fair and progressive taxation of the private sector & multinationals. Certainly when Oxfam reports are focusing every year on our extremely unequal wealth  (of which, I’m sure, ordinary citizens are very well aware nowadays).

Global health needs to change its political strategy/preference

Global health ‘power’ intrinsically favours centre politicians, or at least politicians they consider as ‘centre’ (say, Hillary Clinton). Unfortunately, or perhaps understandably, given the perfect storm we’re in, our times are no longer very friendly versus “centre politicians”. The centre is fading fast, and you get polarization on both sides. Politicians have to choose, pretty much like the rest of us, I guess, for a certain vision on the future. For the moment, it appears right-wing parties have the momentum, but all it takes is probably a few big countries where the dice are rolling the other way, to get perhaps a different global trend. As Mason argues, and I think this would be sound advice too for global health, it’s perhaps time to put our hopes on boosting alliances between centre-left and radical left (as is the case in Spain now). The radical left (labelled sometimes as ‘left populist”) is key in crafting a narrative of hope (for the precariat) and thinking out of the box towards another future. (I know: not every Corbyn opponent will agree with this assessment : ) )   Only then, after enough (big) countries have these sorts of alliances between centre-left & radical left in place, and ordinary citizens see the real progress in their own life, and fairer societies, the global wind might blow again in a more multilateral and solidarity-oriented direction. As for systems where you only have two parties (say the US), I’d argue global health should favour more radical left candidates for the more progressive party, rather than hoping for a more central figure, who could supposedly “bridge” things between the camps (say: Bloomberg). As I said, what might sound ‘rational’ (another word for ‘centre’), from the point of view of the current system, is perhaps not radical enough with a view on the system we urgently need in the 21^st century.

Instead, however, for the moment a key global health pundit is still putting his hopes on Macron, who is, let’s face it, very much a symbol of the neoliberal elite in the eyes of the precariat. Maybe that’s wrong, and maybe Macron will prove them wrong in the years to come (I certainly hope he’s smart enough to make this (necessary) switch). But for now, as things stand, it seems a highly risky strategy for global health to align with the likes of Macron, in spite of all the fancy words coming out of his mouth, also with a view on the enormous planetary health challenge that awaits us in the next decade to try to avoid further climate breakdown. A ‘just transition’, in which everybody is perceived to do his/her fair share, will be key, if that’s to be successful.  For the moment, the computer of most ordinary citizens, says ‘No’….  If they even have a computer.

For the time being, power in global health is thus doing the opposite of what it should do, as it’s still trying to get the ear of centre -right politicians. They’re for example very much framing things in terms of global health security, nowadays, as they feel the wind is blowing from the right. Unfortunately, that stance probably also further exacerbates the (harsh) anti-migration right-wing wind. Instead, global health should help push the (political) centre towards the left (instead of to the right, which happened over the past 10 years due to radical-right forces).   

On a tangential note, but not altogether different from the abovementioned assessment, global health seems at the same time rather ‘friendly’ (to put it diplomatically) versus authoritarian populists in the South  (think Modi).

To repeat, you can’t just push aside populism as a nasty movement, or hope it will just go away, with a few political victories in the US etc. It seems more than likely that it’s here to stay, at least for the coming decade and perhaps beyond. And so global health should try to analyze it clearly, and ride on the (more progressive) aspects of the rise of global populism, while distinctly refusing and rejecting the nasty part.

Perhaps one example: take the ‘commercial determinants of health’ debate. Obviously, some of the needed measures and regulation will not go down well with (many) populists, smacking off the ‘nanny state’ in their eyes. However, other aspects should be a relatively easy sell in our times, like tax justice (also for multinationals); decent work (McDonalds etc); … 

Populism & precariat require global health to make the switch to the SDG era. Urgently.

The precariat and global populism trend require global health to make the switch to the holistic SDG era, in both North and South, trying to connect all the dots (not just health related dots).  They have no choice, actually. Otherwise, the risk is that all gains made during the MDG era will have been in vain and might even be reversed, in a world more and more under ecological stress, with increasing security risks in many countries, or even downright war, …   Moreover, we will also need the (unwieldy) precariat to move towards the post-capitalist economic system we need. If not, sooner or later, we’ll all end up ‘left behind’…

PS: so while we’re waiting for that urgent global health switch to the SDG era, I hope some brilliant complexity thinker (I can think of a few colleagues…) thinks a bit through all the possible tipping points, when trying to channel some of the (often justified) anger of the precariat, while avoiding vicious feedback loops, as they will no doubt go on ‘disrupting the system’. A system, as most of us know by now, that is leading us towards hell. Just check the latest UNEP report : )

On making the switch to the planetary health era

In a previous blog I wrote the global health community should make the switch to the ‘planetary health’ era sooner rather than later.

I should probably qualify this statement a bit. Nobody should ever listen to me, I just make humble suggestions : )

More importantly, though, with that statement, I referred to  ‘planetary health’ the way Horton described it earlier this year in an Offline contribution, after attending the annual Planetary Health conference in Edinburgh ( see  Offline: Planetary health—worth everything )

As a reminder, it’s worth to provide here Horton’s related paragraph in full:

“…Planetary health—the health of human civilisations and the ecosystems on which they depend—has evolved into a capacious interdisciplinary inquiry. Yet it is neither capacious nor interdisciplinary enough. Planetary health, at least in its original conception, was not meant to be a recalibrated version of environmental health, as important as environmental health is to planetary health studies. Planetary health was intended as an inquiry into our total world. The unity of life and the forces that shape those lives. Our political systems and the headwinds those systems face. The failure of technocratic liberalism, along with the populism, xenophobia, racism, and nationalism left in its wake. The intensification of market capitalism and the state's desire to sweep away all obstacles to those markets. Power. The intimate and intricate effects of wealth on the institutions of society. The failure of social mobility to compensate for steep inequality. The decay of a tolerant, pluralistic, well informed public discourse. The importance of taking an intersectional perspective. Rule of law. Elites. The origins of war and the pursuit of peace. Problems of economics—and economists. The study of nations—their histories, geographies, ideas, and beliefs…. 

”

Defined in this way, i.e. ‘in its original conception’, ‘planetary health’ has the right feel for the challenges we face in this century.

(1) It certainly has the right sense of urgency – cfr Horton:  “There is our task: to see the thunderstorm ahead of us. Many have preferred to turn their heads away. It falls to planetary health to insist that we face the thunderstorm.”  

And (2) the paradigm aims to connect all the dots, going beyond silos, the way the SDG agenda is trying to do (while obviously, not going far enough, as it makes too many compromises with the current (growth focused) economic system). This is why I sometimes consider the ‘planetary health’ paradigm as an “SDG agenda on speed”: it involves a strong plea for a fair economic system, that works for all, within planetary health boundaries. Only such a system will have truly ‘global citizens’, as compared to the (few) ‘winners’ and (too many) ‘losers’ in this economic system.

I admit it sounds utopian, certainly given the way things are going currently on the planet, but in my opinion, planetary health defined like this, is the right (global) framing of the (interconnected) challenges we face now. (3) Planetary health along these lines would dare to ask the questions for a radically different economic system. Deep down, for me, planetary health is about finding the right balance between equity & a sustainable planet. With both emphasized to the same extent. That requires daring to think beyond capitalism, I think. Planetary health could ask these sorts of questions more than the related environmental health, EcoHealth, GeoHealth, OneHealth, .. in my opinion.

(4) Last but not least, ‘planetary health’ also best captures the sense ‘that we’re all in this together’  (California, as much as Delhi, the Sahel, …).  It conveys this, in my opinion, also better than “EcoHealth” et al. You could argue that 'global health' already does so, however there's a certain 'Northern dominated' feel about the latter term that is hard to get rid of.

The truth is, however, for the moment, Planetary health doesn’t really do all of this, or at least not nearly enough, even if it has the potential do so, as Horton rightly emphasizes.

When I look at the Planetary Health Alliance website, for example, there’s very little on asking for a radically different economic system, based on different (post-capitalist) values.  Very little on how neoliberal globalization has led to the current situation, on political determinants of the current global ‘perfect storm’,…. Maybe it’s because ‘Planetary Health’ (as conceived by Horton) feels too broad and encompassing for scientists – I agree it sounds a bit like a ‘Theory of Everything’ -, maybe because it smacks too much of attacking the status quo? The same goes for the website of the next Planetary Health meeting in Stanford. It’s hard to imagine that post-growth thinkers (like Tim Jackson, Jason Hickel, … and others) who dare to think of a truly different economic system, will get a prominent place there. I hope I’m wrong, though. For the time being, the ‘Planetary Health ‘community & the post-growth community are still fairly separate communities; the ‘green growth’ paradigm still seems much stronger within the Planetary Health community, than more radical proposals.

By way of a more concrete example of this claim, ask yourself the question: why is it that planetary health “champions” like Macron and Bloomberg are not trusted by many ordinary citizens (even if many very well understand that the planet is indeed in dire shape)? Because, like the ‘yellow jackets’ (gilets jaunes) in France now, they feel that it’ll always be common citizens having to cough up the most for green measures  (with some mitigating measures for the very poor, the standard recipe of Macron and other “structural reformers” like him), whereas the 1 % can continue to fly around the world, without being taxed much. 

Macron & Bloomberg want to ‘green’ the current economic system, instead of trying to think of a new system based on post-capitalist values. They admit equity is important, but Macron & Bloomberg will never find the right balance, I’m afraid. Chances are their ‘planetary health agenda’ will thus not be politically sustainable. From my point of view, it is thus a problem that they are currently seen as ‘planetary health champions’.

Planetary health, at least the way Horton conceives it, is not a “rebranding” of global health. It’s acknowledging that ‘global health’ can only have partial answers for the challenges the world currently faces, and that the values that (implicitly & explicitly) ruled much of global health for the past few decades will not lead to ‘Health for All’ in the 21^st century. In fact, quite the opposite seems true.     See some of the words Horton uses: ‘failure of technocratic liberalism; elites; …’     and then ask yourself whether many of our current global health leaders feel more confident talking to (and taking more into account) leaders of states (Macron), billionaires (Bloomberg, Gates), people from the financial industry, or instead to grassroots movements and people in the street.  

If Horton’s definition of ‘planetary health’ doesn’t become mainstream (and he’s certainly not winning for the moment, unfortunately…), then ‘planetary health’ will indeed turn out just another buzzword. And we might as well just forget about it.    

So the challenge seems clear: ‘planetary health’, if it is to have a future, should become ( a lot) more like what Horton had in mind. And then, once we agree on this, comes the even more difficult part: how do we get to a ‘planetary health(y)’ world?

Something in me says that we will need to look more at the likes of Ocasio-Cortez than to Macron & Bloomberg for this.

The wrong question?

Yesterday, Richard Horton started a discussion on Twitter with the following tweet: “A friend (male) of mine has just written to me saying that global health is such a “boy’s club.” It surely is. How do we change that?”

Lots of people weighed in, as you can imagine, many with valid suggestions.

My own take on this: the situation is slowly improving, global health is becoming more diverse, to some reason due to the important work of Global Health 50/50 and Women (Leaders) in Global Health; other reasons are demographic and geopolitical changes in the global health world, and of course there’s the work on the ground by countless women, a clear majority (over 70 %).

However, the question is perhaps the wrong one.

“Global health”, for all its flaws, has been key in making progress in recent decades, first in the MDG health era, and now at the beginning of the SDG health era there are still hopes of a “Grand Convergence” by 2030. However, if that is to happen, chances are a ‘planetary health’ era will be required. ‘Global health’ can only go this far, versus the challenges the world faces in the 21^st century, that is increasingly becoming obvious.  Including perhaps when it comes to more (gender) diversity at the top.

There are many angles to look at this.

As many have pointed out already, there’s of course the challenge of climate change (& planetary boundaries in general), which makes it urgent to find a new (in my view, post-capitalist) global economic system. Deep down, much of “Global health” has its roots in (the values of) (neoliberal) capitalism, trying to capitalize on the merits of the current economic system (to get global health results), while trying to overcome ( or work around) its flaws (though not in a radical way). The World Bank (at least lately), Gates Foundation, GAVI, Global Fund, Bloomberg Philantropies,… have all done (and are still doing) great work and have great ‘global health’ impact via a business-style approach focused on ‘results’ and value for money.

The downside of this (comparatively low-cost) approach - as it shies away from systemic change - is becoming clear now, though. It’s not just that the world, even with a “green growth” approach (for example), probably won’t be able  to avoid catastrophic climate change, it also increasingly looks as if a world where many ‘global health’ (shortcut, though very important) achievements (lower child mortality etc) are being reached, might turn out politically unsustainable.

Thomas Bollyky hints at this, in his latest book “Plagues and the Paradox of Progress”.  “Recent reductions in infectious disease have not been accompanied by the same improvements in income, job opportunities, and governance that occurred with these changes in wealthier countries decades ago….”

While it’s obviously great that more and more people survive beyond early childhood, all around the globe, it’s also clear that if we don’t manage to let all these people contribute to society in a meaningful way, this is becoming a recipe for major political instability (or worse) - and this also around the globe. And that’s even making abstraction of the coming AI ( and industrial revolution 4.0) tsunami.

The rise of populism has at least partly to do with this (ask the Greeks & Italians), and it seems unlikely that Africa can escape this global trend, as demographic, employment and other challenges are far more huge over there. The pressure on African leaders, like elsewhere, will only increase.

In short, the current global economic system (focusing on ever more effectiveness & efficiency, with as little resources as possible, and whereby one is expected to compete with the whole planet, …), is not just a recipe for ecological but also for political disaster, as it’s increasingly being perceived as unfair by big parts of the population.  So the system has to go.

From that point of view, the challenge seems clear: we need to make the switch from ‘Global Health’ (steeped in an economic system that is no longer fit for this century) to ‘planetary health’. The latter requires a paradigm shift in values, division of labour, work-life balance, leadership … that we can only start to imagine.

But I’m convinced that the question Horton raised is connected to that, at least if the answer is to be positive. Let’s not forget that it’s only a certain type of men that reaches “the top” in the current economic system (including global health), and the same goes for many of the women currently reaching the top, the likes of Lagarde, May et al.   

Another indicator perhaps: in spite of all the good done in recent decades, “Global health” (at least “power” in global health) is still way too close to the 0.01 %. Many feel more comfortable in Davos than when meeting social movement leaders from the South.

I surely hope ‘planetary health’ will be different. To get there, “Planetary health” will need to find a balance between the (undeniable) good in the current economic system (a certain amount of meritocracy, striving for excellence & effectiveness & efficiency, competition, … are certainly needed, but they should only be ‘means’ to a fair and sustainable system), while doing something substantial about its flaws,  thus making sure that nobody has to feel like a ‘loser’ or precarious, via decent employment, or any other way to contribute meaningfully to society (as compared to taking on low-paid jobs desperately trying to make ends meet, as many do in this world)… ). I’m convinced that such an economic system will not lead to political “hiccups” like Donald Trump or Brexit. And hopefully, it’ll also allow a planet with 10+ billion people by the end of the century.

If that’s the case, ‘planetary health’ leadership will not be a ‘boy’s club’ anymore, I bet, but the very diverse club it ought be. In fact, we will all be planetary health leaders then, as we all have a stake in planetary health, broadly defined.

Global health cannot provide (all) the answers for this century, it’s time for planetary health.