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 : )