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 :)