Dubai 2020 symposium theme contextualization from a (middle-aged) Northern point of view

Recently the Health Systems Global (HSG) program working group for the Dubai symposium reached out to various Thematic Working Groups to find out how the 2020  Dubai theme and sub-themes  are being interpreted, understood and linked to by the HPSR community in different contexts and geographies.  As you recall, the Dubai symposium will be themed ‘Re-imagining health systems for better health and social justice’.

Here I offer just a few quick remarks/humble suggestions from my point of view, mostly pertaining to sub-theme 1 (‘engaging political forces’) and 2 (‘engaging social, economic and environmental forces’).   

First a quick clarification on what I mean by ‘my point of view’: I’m a 46-year old man from a Northern country, fan of both Greta Thunberg & Michel Houellebecq  (I suspect I’m not the only one)  :)    Also, I don’t really qualify as a health policy & systems researcher, even if I am an HSG member and have been to all global symposia so far.  

Anyway.

·      In general, first of all I hope the Dubai symposium will manage to convey a proper ‘sense of urgency’, paying plenty of attention to the major tipping points  (ecological, political, social …) that are approaching fast now (if they’re not passed already), and their impact on health policies & systems. When it comes to climate change, it would thus be good to reframe the enormous challenge ahead in terms of ‘climate breakdown’ / ‘climate emergency’….  and probably make it clearer that this presents an existential threat to humanity (with the impact you can expect on global health progress of the past decades, health systems, ...).  As for politics & power, I think the UAE are rather well placed to understand how close certain nasty tipping points really are, at this moment in time – I just read an article this morning on the UAE partly withdrawing from the war in Yemen, among others because they’re getting worried that in case of a war between US (& Saudi Arabia) and Iran, the UAE could soon find itself in the line of fire.  

So some sort of (re-)framing, like ‘Re-imagining health systems before the world is going down altogether’ ( as an Indian friend of mine quipped ), might work wonders, to convey this sense of urgency :)  

·     Linked to the above, and more in general, I hope we won’t self-censor ourselves (too much) in Dubai. I’m not referring here to the social media constraints in the UAE (an issue in itself), rather to the analysis that more and more of us know, deep down, that this capitalist system has to go, and soon. If not, we’re on the road to hell. So I hope we can really discuss post-capitalism, post-growth, etc. (and invite relevant thinkers on these discourses & paradigms), and think through what this could imply for health systems & policies  ( PS: another good reason for these sorts of debates: the many links between capitalism/imperialism and the decoloniality debate in global health). Even if some of the Big Funders of the symposium aren’t very sympathetic towards this sort of ‘alternative’/’unrealistic’ thinking.   The same goes, by the way, for discussing as much as possible the root causes of migration, fragility, … instead of (only) assessing what health systems can and should do for the victims, so that nobody is ‘left behind’.   Only if we don’t self-censor, (i.e. making statements and using framing  palatable to some of the big funders of the symposium, also trying not to offend anybody ), we can truly re-imagine health systems for better health and social justice, instead of mitigating the worst excesses of an unfair and destructive system.

·     Still on engaging political forces & power, given the location, I think it’d be lovely to zoom in on patriarchy and its impact on 'Health for All'. You have probably come across some of the recent headlines on the UAE yourself.   I’m amongst those who believe SDG 5 is absolutely crucial in the whole SDG agenda.  Apart from that, I’ll refrain from engaging in this debate, as I usually get in trouble with my progressive/liberal female colleagues on some of these issues:)

·     I also wonder to what extent the “global health community” (with its seemingly never-ending love affair with ‘partnerships’) is still in sync with how the world is developing. Not just because increasingly it’s a fight “between oligarchy and the rest of us”, as Robert Reich put it, and so it seems high time to take sides, instead of ‘partnering’ with some actors. Or at the very least require them to pay proper taxes before they can ‘partner’.  And so,  ‘Winners take all’ (by Anand Giridharadas) should perhaps be required background reading material for symposium participants, and hopefully also inspire a strong paragraph in the “Dubai statement” afterwards, on philantrocapitalism, the Corporate Private Sector & their role in global health/health systems. While I will never deny the enormous merit of Bill Gates & his foundation, current fundraising for the Global Fund Replenishment (with the ridiculous goal of getting 1 billion from the private sector) is a case in point of how unfit global health fundraising has become for our day and age. It’s time to put ‘replenishment’ cases in starkly different terms: that billionaires & MNCs should contribute to tax, globally and nationally, the way they actually should, and not freeriding like, for example, Amazon has done in its 25 years of existence.   All over the world, people are fed up with this, both on the ‘left’ and ‘right’. For the ones among you who like ‘Beyond…’ mantras: in global health, it’s more than time to go ‘Beyond Philantrocapitalism’ :)     

·     As for the current “SDG health era”: there again,  it would be good if we acknowledged that the SDGs are not just ‘off track’, but instead, in spite of all the ongoing SDG-washing (by corporate and other sectors), going absolutely nowhere (see the just released civil society Spotlight report, which argues for not just a ‘software’ update but also a ‘hardware’ update (of governance & institutions at all levels)).  And that’s even making abstraction of the current ‘disabling’ (instead of enabling ) international environment (as Jens Martens has put it, accurately, in this Spotlight report), which, I admit, doesn't help much on the SDG 2030 journey. 

Put slightly differently: it’s probably relatively easy to go to Dubai with a story on climate-smart health systems, and link it with UHC. It’s probably far more difficult to say and argue we need a post-capitalist system sooner rather than later, or else UHC and Health for All will still be distant dreams in 2050 and beyond  ( plus get Bill Gates or USAID to fund this :)). The same goes for commercial determinants of health, STAX, access to medicines,  etc. :   let’s really take all these debates “beyond capitalism”.   Even if ‘thinking beyond capitalism’ might be a bit too early still.

As it’s more than necessary. Just this week, a new report thoroughly  debunked decoupling,   highlighting “the need for the rethinking of green growth policies and to complement efficiency with sufficiency”. Focusing on countries in the ‘North’, that sounded like this:  “Policy-makers have to acknowledge the fact that addressing environmental breakdown may require a direct downscaling of economic production and consumption in the wealthiest countries.”  So yes, let’s also not refrain from making clear what the “SDG agenda” entails for our countries in the North, including the very tricky political economy (& fairness) issues around this - as the yellow vests movement has proven.

But hey, I’m just a 46-year old bloke from the North. So I’ll be more than happy to read many other takes on how the symposium theme & subthemes are interpreted and understood elsewhere in the world, from different angles.  

On UHC & social contracts (fit for the 21st century)

I largely agree with Thomas Schwarz (MMI) ’s assessment of the “Key Asks from the UHC movement”    – it’s a strong and powerful document, and if a 7^th Ask is eventually added, in line with what Women in Global Health advocate for, it might even become stronger. However, as I was re-watching – online - the lovely session Moving Forward Together: Key Asks from the UHC Movement for the UN HLM at the Graduate Institute  (watch that gentle grin on Kickbusch’s face when Thomas almost wrecks the word ‘multi-stakeholder’ 😊), I started reflecting a bit more on some of the political economy (& causality) aspects around the notion of a social contract, certainly given the fact that UHC 2030 sees itself as a multi-stakeholder “We’re all in this Together” platform. 

The notion ‘social contract’ is mentioned in Key Ask 1 (“Ensure political leadership beyond health – Commit to achieve UHC for healthy lives and wellbeing for all at all stages, as a social contract”)) and I certainly agree with Thomas (and Kickbusch) that this notion of social contract is vital, and thus really good to have in the Key Asks.   

Broken social contracts

Nowadays, however, the starting point in this debate should perhaps be the following: in many countries, and certainly in the North, citizens have increasingly the feeling that earlier (post- WW II) social contracts are broken (or at least not in very good shape anymore). As a result, many – see Ask 2 – feel, ahum, ‘Left Behind’. Enter all the commotion in the streets and nastiness on social media, the yellow vests, populism and “political surprises” in a number of recent elections, certainly in richer countries.  

Against that backdrop, Ask 6 (Move Together: Establish multi-stakeholder mechanisms for engaging the whole of society for a healthier world)  feels a bit ambiguous, at least for me. As it’s precisely the private (corporate) sector (aka Big Business & Big Finance), that is considered a key culprit by many citizens in this breakdown of the social contract in our – until recently - neoliberal globalization era. Not the only culprit perhaps, but certainly a big one.  They are basically seen as having taking over 'the world as we know it'. You might say this is not very relevant for the ((L)MIC)countries the UHC movement is focusing on, but the SDG era is a universal agenda, and given globalization, we’re all in this together now, with often similar challenges (even if not to the same extent perhaps), and vested interests.

If UHC is first and foremost a political choice and political will key, as dr. Tedros and many others (rightly) stress, it will be absolutely essential  that the corporate sector does its part (or perhaps more accurately, starts doing its part again, in countries in the North), when it comes to building up a new social contract fit for the 21^st century. If that happens, it will become so much easier to ‘trust’ the private sector in a multi-stakeholder partnership like UHC 2030, as the WEF representative advocated for during the session.

For now, however, a pretty common perception among many ordinary citizens in the world is that Big corporations, Big Finance, Big Pharma, Big Soda, Big Tech, … don’t contribute much ( certainly not according to their ability, cfr. “the strongest shoulders”) to these social contracts in countries around the globe, and even shirk their responsibilities altogether in a number of cases. This is already the case now (see above), and many citizens fear this might get even worse in the (Fourth Industrial Revolution) future.

Instead of contributing to this social contract, many of these Big Fellas are thus considered ‘freeriders’ or worse, paying a low amount of taxation, preferring “going to the moon” over ensuring decent work conditions and salaries to employees (with many even planning further automation & robotization to get rid of workers altogether in the future, at least if they can get away with it), not to mention the enormous ecological havoc they cause in the process. Others try everything in order not to have to pay sin taxes (sugar, alcohol, tobacco, …) - or STAX, if you prefer that term. The financial sector (see the financial crisis) and Big Pharma are a story in their own right, when it comes to their role in the (disrupted) social contracts in recent years.

In short, Big Corporations & Big Finance are a big reason, if not thé reason, why social contracts are broken or at least under severe pressure in many countries in the North, among others via the pathway of underfinanced public goods & sectors. As for the South, there they are probably a big reason why social contracts never were established in the first place. But I’m not well placed to dwell on that.

People sense, all around the globe, that all this ‘People Planet Profit’ talk remains mostly empty talk, even in the SDG era, the only stakeholder to which multinationals really feel accountable are their shareholders. The economic system is seen as anything but fair, globally and nationally. In these kinds of circumstances, it will not exactly be a piece of cake to build up new social contracts.

To let UHC thus play its role, as the Key Asks advocate, as part of (building) an overall ‘social contract’ between citizens and the state, we’ll first and foremost have to get big companies contribute (again) their fair share to societies, via fair taxation, decent work & salaries, etc.    In the absence of that,  the whole idea is a non-starter, in my opinion, even a fata morgana.

How about the social contract with future generations?

A last (but equally important) comment: and how about the social contract with future generations? Although the Key Asks emphasize that we aim for a ‘healthier world’, there’s not much in them that talks about a social contract with future generations, in order to make sure that they are not ‘Left Behind’. Seems like a gap that needs addressing too, before the High-Level Meeting on UHC in September starts.  In the 21^st century, given our increasingly ecologically fragile world, a social contract between citizens who live now and the state no longer suffices.

To conclude: it would be good if UHC 2030 made it a bit clearer on what exactly it will take to get to such a ‘social contract’ via a strong UHC commitment. For example towards its ‘private sector constituency’ : )

A question for Dubai 2020

Lately, I’ve briefly visited Dubai and a few other places in the United Arab Emirates (UAE).  As reported elsewhere, I quite enjoyed the visit, much appreciated the very generous welcome by the local host of the next EV venture, and of course, just having a look in a new country (at least for me) is always a neat thing to do. So, in general, I think the next global HSR symposium in Dubai should be a great event, and I’m already looking forward to it. In many ways, Dubai is a very appealing and fitting location for a global HPSR symposium in 2020, also with a view on the current global health & HPSR challenges.

Still, after the visit I remained with one question, even if I know it's early days for "Dubai 2020".  The current draft of the symposium programme looks fairly ‘political’, and obviously, I find this more than appropriate, given our rather political times (see for example ‘Extinction rebellion’ (in the ongoing battle against climate change), the increasing polarization in many countries, after we saw TINA (“centre-right”) policies for too long, …), and the fact that health has always been (at least partly) political (and now even more than ever, some would argue). Still, I somewhat wonder how ‘cutting edge’ discussion on all these political issues will take place in Dubai, and especially how social media ‘coverage’ (including ‘noise’) of these (more political) symposium discussions will go. It’s a rather peculiar environment, certainly when it comes to social media. I certainly don't envy the job of the organizers & Communications people in this respect.

I’m sure the HSG Board has already deeply reflected on this issue, and there’ll likely be some recommendations and guidelines for symposium participants in the months to come, but I’m afraid at least some participants will have to thread a thin line between criticizing injustices in the world (including in “global health” itself) and “speaking truth to power” on the one hand, and breaking the laws of UAE and/or “not respecting” the local culture, on the other, certainly in the interconnected world we live in. At the same time, if we do manage to criticize some issues (within certain limits, obviously), that could push the UAE (and our own countries’ involvement in some issues) towards progress, and Leaving No One Behind in the medium term.  It will be about finding a good balance, is my sense, but that's easier said than done.

A few examples of possible controversies:

·     *    Patriarchy: although Dubai is fairly open for (and relaxed about) people from around the globe (including their various ways of clothing), and progress is gradually being made, patriarchy is (still) everywhere in the country. If that already bothers me ( a fairly average white male), I can only imagine how certain communities within the HPSR family will react. Two personal examples, for what they’re worth: I personally draw the line at niqabs, when it comes to clothing (anybody who sincerely believes that women should cover their face in public in the 21st century, when their husband is not doing the same, can try and come convince me), and also seeing the wisdom of invariably male rulers displayed on billboards isn’t exactly my idea of a political system fit for the 21^st century. I know both examples are potential minefields to wade into, and my opinion is certainly only one person’s opinion, no more - even a Western middle-aged male’s, which might disqualify me altogether from even having an opinion worth listening to on the first issue, I’m aware. But the strong patriarchy is an issue, nevertheless, I think, certainly in times where we think SDG5 (on gender equality) is crucial for the entire SDG agenda, and gender equity is rising on the global health agenda and in global health governance, for very good reasons by the way. How will we discuss this at the Dubai symposium, while also trying to respect local sensitivities and culture? I hope this doesn’t mean we’ll have to frame everything in politically correct “jargon” on social media.   

·      *   Migration & health:  we came across (many) taxi drivers who work 12 hours a day, day after day (and even one who worked 20 hours a day, 7/7 !). I totally understand they want to earn hard cash, and that they consider this a ‘win-win’ situation in most cases…  But still, one would like to discuss this full-on, within SDG 8 (‘decent work & economic growth’), while certainly also acknowledging some of the progress made in recent years (for example, quite a few of them had health insurance now). Again, if you discuss this in-depth during sessions, what will be the guidelines for social media?

·     *    More tricky still, how about discussing the ‘causes of the causes’, the roots of some of the big migration waves, crises and ‘fragile & conflict affected settings’ in recent years? For example, hard to avoid weapons & weapons trade (including, clearly, Western countries’ own involvement in these) in this discussion, in, say, Syria, Yemen, …

·     *    Final example: global taxation. Just a personal example again: in a UHC era whereby countries agree, at least in rhetoric, more and more on the importance of public financing for health, last year I came across an article on how at least some Belgian companies seem “fairly happy” with the taxation rules in Dubai. Again, (global tax justice) progress might be on the horizon (at least if I believe the ‘glass half full’ person in me), but meanwhile, will we be able to really discuss this issue in-depth, including on social media?

These were just a few random examples, but I’m curious how HSG will handle all this next year. It will certainly be a difficult equilibrium to find.  But I’m confident we can pull it off, if we want. After all, at previous symposia (say, Cape Town, Vancouver, Liverpool, …) many of the local challenges also provided the backdrop for insightful and hardhitting discussions in various sessions at the symposium, including on social media.

Is global health truly “a lost cause”?

In recent weeks, several people dwelled on the question whether ‘global health has lost it’ (although not necessarily putting it in these terms). A very brief overview here, with some of my own comments & feedback added.

1.  In an Offline contribution from a few weeks ago, Lancet editor-in-chief Richard Horton started from Kishore Mahbubani’s book, “Has the West lost it?”, and then seemed to answer a similar question, “Has global health lost it?”, affirmatively.

I’m not a big fan of Mahbubani’s discourse, to be honest, it smacks a bit too much of geopolitical power shift thinking (while not seeming to question this “power” much), he’s a bit too fond of the “Singapore model” to my taste, and in general too close to Davos power corridors as well. I also have my doubts on the sustainability of assessments like “Paradoxically, while many western populations are losing confidence in their political systems, Asian levels of trust in government are increasing”. I’ll never forget the cynical grin on a Chinese friend’s face when we passed the “warped” shape of the CCTV building in Beijing, mumbling something like “a very neat symbol for the governance in my country’.

Nevertheless, it’s hard to argue with (most of) the conclusions Hortons draws for global health, based on his reading of Mahbubani’s book:

(quoted here in full)

“What does Mahbubani's analysis mean for global health? First, western global health elites must reappraise their history. They must reflect on, understand, and come to terms with their colonial legacies, the consequences of their wars, and the adverse effects of their political and economic dominance. Second, based on that historical reappraisal, western approaches to global health must be radically rethought. We should be preparing for a near future in which centres of economic, political, and people power will shift from the West to the Rest. Third, strong and effective multilateral institutions will become increasingly important for managing this new world. The West should be investing in multilateral health institutions, ensuring that their leadership and governance is truly international (which currently it is not). Fourth, the hegemony of the white Anglo-American male in global health must come to an end. Finally, global health initiatives, processes, and events must prioritise voices outside the traditionally dominant western elites. It is painful to be confronted with the truth about yourself. It is painful to give up power and privilege. But for all those working in global health, it's time we listened to Mahbubani. Because global health has indeed truly lost it.”

2.  When responding to the question ‘Has global health lost it’, Andrew Harmer nailed it, from another perspective, with a simple tweet:

“As long as it remains oblivious to the economic restructure required to avert #ClimateBreakdown, then yes. GDP cannot continue as the default measure of economic 'progress'!”

I had put my hopes on the planetary health paradigm to do exactly that, but for the time being, the “new paradigm” is not really living up to my expectations. The Planetary Health Alliance, for example, doesn’t really seem to seriously consider thinking “beyond capitalism”, even if our times truly and urgently need it.  Why that is the case probably requires a blog in itself.

3.  In an  IHP blog from some weeks ago, Rachel Thompson, after attending this year’s PMAC conference in Bangkok, dwelled on the political economy of global health.

In one particular paragraph, she put it like this:

“…Global Health – as a product of a certain time and place – cannot be taken out of the global political (and economic system) that created it. Public Health is here to stay, Global Health may not have the same longevity. …”

In short, she considers Global Health as part of the neoliberal global political economy, and says that as such, Global Health risks to get ‘left behind’ itself, as the times (and the fight for global justice) are changing.

Some more quotes:

“The global political economy is one dominated by the ideology of Neoliberalism, which places the individual and free-market at the centre. As I suggest above, Global Health is a product of the Neoliberal era (Public Health is not). … “

“…Once we understand Global Health as inseparable from Neoliberalism, we can begin to get to the root causes of why so much of the world are being “left behind” from global goals. To ignore its influence is to deceive ourselves and the people we are trying to serve….”

“Once we understand Global Health as part of a system that has increased global inequalities and inequities, it seems strange to expect it to do the opposite – to “reduce inequities” e.g. as part of Agenda 2030’s leave no one behind pledge. …”

Global Health is great for measuring things and improving health security; it is not necessarily the right place for people who want to tackle injustice, and change the world in the many ways it so urgently needs changing.

While I don’t fully agree with her – I don’t think Global Health is inseparable from Neoliberalism, although there’s indeed quite some overlap – it’s true that a big chunk of global health ‘power’ feels more comfortable with what I would call the ‘more progressive faces’ of neoliberalism, among others Macron and Bloomberg in this era, and Gates of course for almost 20 years now. Power in Global health is a lot less fond of the more radical language used by Sanders, Corbyn, AOC, Warren, …   

In general, Global Health also is a bit too close to the world’s leaders and their discourse (see the focus on the G7, G20, European leaders, Davos …), with of course the way ‘Replenishments’ are set up, as a key example. I wonder whether, for example, at the upcoming Global Fund replenishment, anything will be said about the yellow vests movement at all… to not ruin Macron’s “party”.  

4.  Global Health ‘power’ is certainly a lot less enchanted with the even more radical (and now increasingly violent) behavior and concerns of bottom-up movements like the yellow vests in France. Sometimes, global health even gives me the impression to be as baffled as Emmanuel Macron these days versus this movement of citizens (not unlike when Trump was elected or the Brexit vote turned out ‘odd’).

That brings me to another point where global health has failed in recent decades, and certainly since the global financial crisis. Global health has not paid enough attention to the broken social contracts in countries in the North between too many citizens and their government. With a retreating state, and more difficult access to public services, due to 30 years of neoliberalism, more and more people feel the system isn’t working for them (anymore).

Global health has not sufficiently paid attention, for a number of reasons (see also (3)), to the increasing number of citizens in the North who feel ‘left behind’, probably one being the fact that the field traditionally tends to focus on what ‘wealthy countries’ do in LMICs  (in spite of all the talk of transnational global global health challenges, and the “universal” SDG era). Perhaps global health was a bit too focused on ODA figures to notice what was happening inside Northern countries, in terms of rising within-country inequality? With all the polarization and even sheer hatred that comes with that, as we could, sadly, again see, on the streets of Paris, last Saturday.

5.  One of the more recent contributions doesn’t really frame things as bluntly as the others for global health, rather, it says Global health should focus in the future more on democratic governance. I’m talking here of course of the recent study in the Lancet by T Bollyky et al.   

Democratization seems to have all kinds of good impacts on public health, certainly on a number of NCDs. Presumably, as democracy comes with more attention for rights and accountability.

For the time being, I won’t dwell much on this very interesting study. Before I make up my mind on it, I’ll first await the no doubt many Letters in the Lancet to comment on it, in terms of the methodology but also the broader implications & messages : )

As for the methodology, I’m “in shock and awe” for this sort of thing, knowing all too well that the Dieleman’s of this world are way smarter than myself. My quantitative days are long gone (about 20 years in fact), not to mention my fast aging/pre-demented brain, but still, I vaguely remember this sort of research is always a bit tricky. For example, when it comes to constructing indexes, or in terms of ‘what do you compare with what?’

Also, what do national democracies (and even transitions) really “mean”, in this day and time, when at least a considerable chunk of the population feel their country is put in a ‘golden straitjacket’ (cfr. Rodrik); democratic transitions in the EU are probably quite different from ‘stand-alone’ democratic transitions;  and other ordinary citizens in "democracies", say the yellow vests, argue they can say pretty much anything in their country but that nobody (certainly not the elites) listen(s).  In any case, as I am not qualified, I hope the David Roodmans of this world will take a good look at the paper, and then share the good, bad & ugly in it, from a methodological point of view. 

As for one of the broader messages of the paper, I have my doubts, though.

I quote: “When enforced by free and fair elections, democracies are more likely than autocracies to lead to health gains for causes of mortality (eg, cardiovascular diseases and transport injuries) that have not been heavily targeted by foreign aid and require health-care delivery infrastructure. International health agencies and donors might increasingly need to consider the implications of regime type in their efforts to maximise health gains, particularly in the context of ageing populations and the growing burden of non-communicable diseases.”

Especially the part in bold I find tricky, certainly in a changed world. I’m more in favour of global health going wherever the needs are greatest, regardless of regime type, but then not shying away from saying a few ‘politically incorrect things’ whenever invited, whether it’s in Kagame’s Rwanda or Putin’s Russia.

Conclusion

My own take on the question ‘has global health lost it’ is, as you might have expected, a combination of most of the above. I don’t think it’s a lost cause, yet, but global health has to evolve in the SDG health & planetary health era, and urgently so. Otherwise, it will indeed – to paraphrase Christine Lagarde on the very much needed global tax reform, last week – soon become ‘out of date’.  

By way of thought experiment, if one would describe how “global health” works to Greta “I don’t do compromises” Thunberg, I guess she’d have rather harsh words for the field. But I will leave that task up to her compatriot Kent Buse : )

Having said that, there’s no denying that global health has done (and does) an enormous amount of good, just in terms of millions of lived saved, for example.

And already it’s changing, see for example – in the areas listed by Horton (need for more diverse voices) – the decoloniality debate, Women in Global Health, …   

Probably too slowly, though.

PS: I learnt by now that Kent Buse is in fact Canadian, not Swedish. #allapologies :)

The Green New Deal is the battle of our age

It’s becoming increasingly clear that the ‘Green New Deal’ should be the rallying cry for global health & planetary health communities, at least if you haven’t given up on ‘Global Health’ as a force for the better in this world.

The Green New Deal is an agenda fit for the SDG health & planetary health eras. In fact, it’s probably the only agenda fit for our times in which humanity, as Owen Jones put it today in a Guardian op-ed, faces an existential risk, with the risk of overall systemic collapse fast becoming a mainstream topic in scientific journals & publications.

It’s an agenda that connects the dots, as Ann Pettifor already stressed, earlier this week.

“…The Green New Deal demands major structural (governmental and inter-governmental) changes (not just behavioural change) in our approach to the ecosystem. In addition, and as in the 1930s, such change to be driven by radical structural transformation of the finance sector, and the economy. It was developed on the understanding that finance, the economy and the ecosystem are all tightly bound together. Protecting and restoring the ecosystem to balance cannot be tackled effectively without transformation of the other sectors. Financing the transformation of the economy away from its dependence on fossil fuels cannot be achieved without a transformation of the finance sector.”

Owen Jones again: “The magic of the Green New Deal is it argues that confronting the environmental crises cannot be separated from social and economic justice: its other proposals include guaranteeing every American a job with decent wages and conditions, as well as high-quality healthcare, affordable housing and economic security.”   The same is true, at a global level.

It’ll be the Green New Deal, in the coming years and decades, or chaos and systemic collapse. That other ‘systemic agenda for the SDG era’, i.e. “going from billions to trillions’, with plutocrats, Big Finance and the global corporate sector still firmly in control, isn’t going very well, last time I checked. One of the main protagonists even left the Titanic.

Before you go away, feeling this is all too utopian, it’s good to keep in mind Rutger Bregman’s assesmment of our changing times last week, an accurate perception in my opinion, at least in the North:

“I’m 30 years old. I’ve been writing for seven or eight years now. And never before have I had such a strong feeling that the zeitgeist is really shifting and now you can talk about things that were simply not possible just a couple of years ago. It seems like the window of what is politically possible is just opening up, or that what they call the Overton window is shifting. Ideas, according to theory that originated with political scientist Joseph Overton, are seen as somehow acceptable to discuss at a certain creative time, and the real political challenge is to move the window….”

So yes, the replenishment of the Global Fund and other global health Funds is (very) important, given the number of lives at stake, but somehow, ‘Replenishments’ sound so MDG- (and dare I say, neoliberal era-like).  We live in different times now, and it’s time Global Health adjusts. I have a hunch that if we all, instead, rallied behind the Green New Deal, nationally and globally, Replenishments of Global Public Goods would almost overnight also become so much easier. And many more lives would be saved as a result.

I leave you with a nice quote. As a middle-aged person put it on Twitter, earlier this week: “When I grow up, I want to be like Greta Thunberg.”    I’m sure you know the feeling. We need to find back our inner Thunberg. We all had it, when we were young kids.

It’s time to bring her back.

The Global Fund: no longer a frontrunner in the SDG era (and what to do about it)

It’s been a while since the Global Fund was considered a splendid innovation allowing global health funding to go from millions to billions, at the start of the MDG era. So it’s sad (though perhaps not entirely surprising) to see that the Global Fund leadership doesn’t recognize times have changed.

I was reading Peter Sands’ case, this morning in a Stat  Op-Ed, in which he (rightly) claims the private sector should shoulder some of the responsibility for improving global health, but fails to draw the obvious conclusion.  

I understand his argument that the private sector can bring quite some expertise and resources, in a number of areas (and so global health would indeed be dumb not to make use of them).

On “SDG era / holistic global health thinking”     (see for example the rather “interesting” relationship of the GF with Big Alcohol – till recently? - and Big Soda), the Global Fund is certainly not a trailblazer anymore (as has been pointed out in detail by many, elsewhere), with superior service delivery expertise as one of the weak excuses used for these sorts of partnerships. Let’s hope that with time, the GF will become wiser in this area.

But here I’d like to focus on the fact that Sands fails to see the writing on the wall, in many countries, in terms of mobilizing resources. He still seems to think corporate “peanuts” will suffice: “  While in Davos, I called on private sector leaders to mobilize at least $1 billion (i.e. out of 14 Billion) of that target.” 

It’s worth quoting his final paragraph in full:

“…we also need private sector leadership in mobilizing financial resources. The Bill and Melinda Gates Foundation is by far the largest of the private foundations supporting the Global Fund, and (RED) has raised more than $600 million for its fight against AIDS in Africa. Business leaders should heed Bill Gates’ words that the foundation’s investments in global health funds (including Gavi, the Vaccine Alliance; the Global Fund; and the Global Polio Eradication Initiative; [Gates also added the GFF]) are “the best investments that Melinda and I have made in the past 20 years, and they are some of the best investments the world can make in the years ahead.” Gates said these investments have generated returns of 20 times the amount invested….”

So why, on earth, do Peter Sands (and also Bill Gates, for that matter) then not draw the obvious conclusion? That it’s high time, for (global health) public-private partnerships to mobilize a big part of the money via taxing of the private (and global finance) sector? Put differently, let’s take ‘partnerships' to the next level 😊.

I heard Sands say, in response to a similar quote from Sania Nishtar, at the Davos session on ‘financial innovation for global health’ that ‘tax’ is “actually his favourite innovation”. Why not put this, explicitly, on the table then, also at global level (now, Sands & others mainly seem to consider tax key for domestic revenue mobilizing), for global corporations? As in: taxing the winners of globalization, and so let them really be ‘stakeholders’ in/towards a better future, and really “shoulder some of the responsibility for improving global health”.

A suggestion for the replenishment of the Big Global Health Funds (& then one more)

The same goes for Bill Gates. If, as he rightly states, replenishment of these Big Four Funds is very important to prevent  global health (outcomes) backsliding in the years to come, why not seize the current momentum in countries like the US (with AOC’s tax proposal) or many European countries, where many citizens understand damned well (and totally agree with) Oxfam’s  third key message in its annual Davos report,   to “End the under-taxation of rich individuals and corporations. Tax wealth and capital at fairer levels. Stop the race to the bottom on personal income and corporate taxes. Eliminate tax avoidance and evasion by corporates and the super-rich. Agree a new set of global rules and institutions to fundamentally redesign the tax system to make it fair, with developing countries having an equal seat at the table.’”

Jeffrey Sachs & others made an interesting suggestion in this regard, a few weeks ago, ahead of the Global Fund Replenishment – “hundreds of the super-rich could easily pledge $5 billion per year for the period 2020-2022”.  But it’s not going far enough (as he linked it to the Giving Pledge, and refrained from using the word ‘tax’, still a “toxic” term in Davos I understand). I also don’t understand why it should be limited to the GF replenishment only.

Why, instead, not explicitly, as part of the SDG 3 Global action plan, foresee taxing of multinationals ( or a similar proposal) as a way to (help) fund “the Big Four”? And of  course, WHO as well, no doubt the biggest global public health good of all?

It’s not rocket science. All global health leaders of big organizations actually believe in (more and progressive) taxing (and even Bill Gates does so, in his latest reincarnation).

The time seems certainly more than ripe. And trust me, if Global Health fails to do so in the years to come, it will suffer, funding wise and in terms of legitimacy. That would be a shame.  Conversely, global health (funding) could once again be an inspiration for other (SDG relevant) sectors.

How it needs to be worked out in detail, that’s something for (health) economists, tax experts (and lawyers), I’m not qualified 😊.

I suspect, though, that the current global health leadership is too close to Davos men & women to draw this – in my opinion, rather obvious – conclusion on “global health funding for the new SDG era”…    Let’s hope they prove me wrong in the years to come.  

Davos 2019: a Global Health 'Garden of Eden' no more, let alone a Planetary Health Garden of Eden

Hmm, what can I say about Davos that hasn’t been said already? Arguably, not much, after Anand Ghiridaradas has described  "MarketWorld" in extensive detail, and "Davos" is widely seen as "in decline".

Having said that, (too) many with power in global health still don’t seem to get it.   Indeed, as Stat puts it, “some of the biggest names in science and medicine are in the Swiss ski resort town of Davos this week to rub elbows with world leaders and one-percenters — and talk about the future of health care.”

So let’s try one more time.

Maybe you think I’m not very objective (and you would be right 😊), but my sense is that the annual meeting in Davos is by now fully delegitimized. Whereby in the past, western political leaders got away with the mantra ‘we need to go there to attract business to our country’, increasingly you’ll see political leaders make the same calculation as Macron - a smartass by all means - this year. Davos has become no less than “toxic” in the eyes of big parts of the population, certainly in the West.  

Moreover, Guy Standing probably has a point when he says that the ‘yellow vests’ movement is a sign that the precariat is (finally?) waking up as a class. If global (especially within-country) inequality is not dealt with substantially in the years to come, that trend will only increase. Standing already estimates the precariat in Western Europe at 40 %, and as he rightly mentions, even if that estimate is too high, many among what he calls the 'salariat' fear that their own children will be part of the 'precariat'. If these two classes were to ally, that could put a lot of pressure on political leaders in the years to come, and 'going to Davos' won't be a badge of honour anymore, to say the least.  Whether Klaus Schwab likes it or not, if political leaders stay more and more home (for good reason, in my opinion), that will jeopardize his lofty dream of a ‘multistakeholder’ platform “for the progress of the world”.

Yes,  the WEF talks all the time about inclusiveness and sustainability, and this year even more than ever before, but the ones who still believe that the Forum will be instrumental towards both key aims for the 21^st century, are probably an ‘endangered species’ themselves, anno 2019 :) 

Speaking of inclusiveness, for example: does anybody among you truly believe that ‘millennials are taking over Davos”, presumably because this year they are co-chairs?  If I were a millennial, wanting to change the world, the last place I’d want to be seen is Davos. Even if I were a 'Technology Pioneer' or 'Global Shaper'.   Instead, it’s mostly in countries that political fights for a more human and sustainable global economic system will need to be fought in the years to come, and the millenial generation is indeed taking the initiative in more countries, encouragingly.  

Over to sustainability (or dare we call it, ‘planetary health’), then.  I’m probably not the only one wondering why the Davos crowd would be listening attentively to David Attenborough’s wise words, when he pointed out this morning, “Growth is going to come to an end, either suddenly or in a controlled way’ – we need to get on with practical tasks.”   No, who really matters in Davos mainly listens to the IMF Global Outlook report (which came out the day before, setting the scene for the Forum), in which the global ‘growth’ percentage was wat really mattered. Yes, Christine Lagarde might call it ‘inclusive’ growth, or use some other politically correct term, but ‘growth’ is what still turns most of the Davos participants on. The “Globalization 4.0 era” is not different in that respect from the previous ones. Making the link with post-growth thinking is clearly beyond Schwab and fans. So no, I don’t expect much ‘planetary health’ progress to come out of Davos, as everything in terms of potentially useful initiatives kickstarted there, is somehow ‘overruled’ by the persistent overall (discourse) focus on growth. Unless, of course, you believe in the fairytale of green growth, Davos will not make the planet more sustainable. The many private jets at Zürich airport probably already gave you a clue in this respect.

Global health

So there’s not much to be done in Davos for the ‘planetary health ‘community  (although I hope Greta Thunberg proves me wrong), what about the ‘global health’ community?   While I appreciate the efforts from many who try to ensure global health financing (for example, for the “4 Big Funds”) for the coming years, I wish they’d make the link with tax justice much more explicitly. The latest Oxfam report (see their third key message this year) could be an obvious entry-point for that. And I’m sure the precariat would appreciate it, if for example the Global Fund and other global public goods got at least half of their funding from corporate Fat Cats (corporations & high net-worth individuals, enormously undertaxed according to the latest Oxfam report).  But I figure Sands, Gates et al didn't mean that, with ‘Financial innovation for Global Health’, the name of their session today….  ?

As for pandemics and global health security, “à la limite” i can understand why global health big shots want to go to Davos, to make that case towards political leaders & business people from multinationals, and get some ‘result’. See for example CEPI recently. But again, why not calling for a global wealth tax to help finance all these efforts ? 

On mental health then: I appreciate the efforts done by the  Wellcome Trust   and others to get this issue on this year’s agenda, as mental health should indeed become far more important on the global agenda. Two small remarks perhaps: (1) given that many WEF participants play key roles in sustaining this - by all means, insane - global economic system, maybe Davos is indeed an appropriate place to discuss ‘mental health’ 😊  (2) On the other hand, I’m more than a bit worried that this focus on ‘mental health’ in a place like Davos will mainly tick global business boxes if it leads to even more productivity. As in: “staff who feel well will also perform better for your company!”.   ( a bit the mental health equivalent of a global health “investment case”) I, for one, doubt whether big corporations truly care about the wellbeing of their staff (see Amazon and many other examples), and for the ones that do care, they probably don’t care much about the wellbeing of the many people who can’t find good jobs in the first place.  In short, I have some doubts about the relevance of the ‘mental health at the workplace’ agenda, if it’s not soundly linked to post-growth thinking (which also includes “decent jobs for all”, as far as I am concerned). I still dream about a world whereby everybody’s contribution, one way or another, would be appreciated in the economy and society (without all of us having to fit the harsh ‘efficiency’ laws of the global neoliberal economy).  But once again, I hope I’m proved wrong and that “The Duke” and others will make a real difference in Davos on mental health.

Davos Partners

Last but not least, I invite you all to have a look at Davos’ “Partners”. It’s quite an insightful list. 

Credit where it’s due, the WEF is quite transparent about it.

Quite a few of these Partners are actually led or owned by people on that notorious Oxfam list (the 26 billionaires owning as much as half of the world’s population). But there’s more.

Besides the Gates Foundation, the Wellcome Trust and the Rockefeller Foundatino, you also find there for example: Chevron; Lukoil; Shell, Saudi Aramco (Big Oil); Goldman Sachs  (global capitalism’s 'Darth Vader') ; Facebook, Google (surveillance capitalism), Deutsche Bank (crony capitalism); PepsiCo; the Coca cola company (Big Soda)); the Volkswagen Group (remind me again, Germans, what was wrong with these guys?).

Fortunately, we read, from the WEF’s info page:

“The World Economic Forum is an independent and impartial International Organization for Public-Private Cooperation. Its objective is to improve the state of the world. It does not promote any political, commercial or personal interests, nor does it use the names of its participants for promotional purposes. The Annual Meeting aims to be open and inclusive. Transparency and public inclusion are achieved through broad international media participation, televised sessions and webcasts, and through the Forum’s millions of followers social media. …”

For some reason, I trust the assessment of Nick Hanauer, entrepreneur and venture capitalist, more.  He says in the Foreword of the Oxfam report that if we don’t get this right, “eventually the pitchforks will come out”.

So here’s my humble advice to Seth, Peter, Katja and all the other global health bigwigs in Davos:  you might want to keep these ‘pitchforks’ in mind, when dealing with the current “powers that be” in Davos in order to get global health ‘results’ 😊.   And start thinking of a different 'Theory of Change' to make global & planetary health progress in the SDG era.