It’s almost Christmas and even if I’m not a Christian anymore (my relatives tell me I’m a fake Buddhist now ), I still kind of enjoy this time of the year. So it seems appropriate to come up with some reflections on the year to come for the world of global health. More in particular, even if I’m already middle-aged, my Christmas message is aimed at the young and emerging global health voices. But even if you’re a global health dinosaur or worse, you might want to read on.
In 2014 and beyond, I hope more and more young global health voices will put the mantra ‘Health in all policies’ into practice or at the very least demand it, loud and clear. It’s increasingly obvious that in the 21st century, this motto urgently needs to become reality. I have a hunch it will depend on Young Voices to make this happen and be blunt about a number of issues. That doesn’t imply they shouldn’t also, like the global health establishment, zoom in on more traditional global health concerns, disease burdens or debates, as these obviously remain key too. However, they should go beyond this.
Let’s offer some ideas to show you what I have in mind. Whether you fancy talk of ‘smart investments’ or rather ‘ensuring the right to health for all’, whether you want a ‘Global Social Contract’ to materialize in the near future or rather focus on value for money and ‘innovative financing’, it seems time for a global fight in other than health arenas. Arguably, some of the dinosaurs have been doing this for a while – we’re not reinventing the wheel here – but a new generation needs to pick up the baton and make it a more mainstream effort.
For a start, the global health community should not mince words anymore about the importance of fossil fuel divestment. At every global health and other big shot event, this issue should be firmly on the agenda. Think Davos for example (or other WEF fora in Doha, Dalian or anywhere else), or G8 and G20 summits. If global health spokespeople (like Gates, Frenk or Berkley) are invited to speak, they should open up the conversation beyond traditional global health items and concerns like the Global Fund, vaccines, NCDs, etc. and make it clear other areas have serious global health implications too. So let’s not just make this the ‘decade of vaccines’ or the ‘decade to finally turn around the fight against HIV’ and other ‘unfinished business’, but also the ‘decade of divestment’, Bill, Julio, Seth and others. David Cameron and others might not listen to David Price, David Sanders and other Ronald Labontés, but they might listen to Gates or Bloomberg. And even if they don’t, at least the world media will pay attention. However, Gates and co won’t do so, unless if thousands of young global health voices are pushing them in this direction.
The issue of fossil fuel divestment is, of course, linked to other issues, like the debate on ‘who gets to exploit the remaining oil and gas in the ground’. As you might know, ‘evidence’ says we have to leave at least two thirds in the ground if we want to avoid catastrophic climate change. I’d say it’s only fair if developing countries, for example in sub-Saharan Africa, get the bulk of this, as they still have to catch up with the rest of the world (who have used up far more fossil fuel resources so far) while making the transition to a more sustainable future. Also, and again, Gates and Bloomberg won’t say this, but developed countries need to embrace de-growth in the short term, as chances are ‘green growth’ won’t do. Speaking of ‘green growth’, if Jim Kim and others are really serious about the need to avoid catastrophic climate change, they’ll probably need to frame UHC in a different way as Kim and others keep saying UHC is “good for growth”. We need to get rid of this global health ‘cognitive dissonance’. But this can only happen if young global health voices start shouting this on conferences and events.
True, as Kim and others argue, some growth can be truly green growth, but you don’t need to be a rocket scientist to see that even a global economy based on green growth thinking (which is still far from the case, for the record) leads this planet to eco-destruction. Good to keep in mind, especially now that everybody wants policies to be ‘evidence-based’. So let the influential global health stakeholders like the Global Fund, Gates Foundation, Rockefeller, World Bank or Gavi not just talk about avoiding catastrophic health expenditure, but also about avoiding catastrophic climate change and actually doing what is necessary to avoid the worst case scenario. That would be ‘value for money’ in the long term, I believe. And yes, that will require talking about sustainable consumption & production patterns.
Then, of course, also linked to all this, is the need for global financial justice. Instead of being overjoyed when a global health actor gets some peanuts from a multinational or another winner of globalization (as in “the private sector is contributing now to the Global Fund, 30 million, hurray!”) let’s make explicit links between the difficulty of “replenishments” and the way the global financial sector is organized. So Sidibé, Dybul and others, if you’re really serious about the ‘end of HIV in this generation’, let’s start being frank about global financial justice and go beyond the usual fancy talk about ‘innovative financing’ or the need for a real ‘Partnership’ with countries in the global South. Do not just talk about the need for the accountability of recipients but also about the accountability of the North, multinationals, financial sector, tax havens etc. So called ‘mutual accountability’, a concept we all believe in, presumably, pertains to all of these. If you want to, be pleased when your own global health organization gets some peanuts from Walmart or another corporate actor, but also start talking about the need for global decent work and fair wages. It’s ok to cheer for Mandela’s legacy, but don’t ignore the Mandela’s of this day, the Edward Snowdens and other whistleblowers who do vital work in this age of information, social media but also secretive negotiations (for example when leaking negotiating briefs of insidious neoliberal trade agreements like TTIP) or the Arctic 30 protesters who take on vested interests, risking their own lives. Start talking about the need for trade unions in the retail and fast food sector in the US, and elsewhere. Start talking about the ‘economic terrorism’ of tax havens, and let your organization not just fund response to diseases but also white collar crime fighting units. And if they don’t, young voices should urge them to do so. If the pope can talk about these issues or about the immorality of neoliberal globalization, why not a big part of the global health establishment?
Let’s continue. I never thought I’d say this, but global health actually needs more economists, not just the usual bunch of health economists, but also an army of experts who know the financial sector inside out and believe in global justice. We don’t just need WHO or Global Fund watchers, but also watchers of the City, Wall Street and other financial centers in the world. In their own way, these are also ‘disease hotspots’. This is one of the key global health fights of this century, together with the fight for a more sustainable economic model. Every time some bank offers its clients so called ‘offshore services’ or actors like Starbucks & Apple don’t pay proper taxes, people somewhere in the world are dying. Economists also have to tackle the incentive structures of multinationals, Big Pharma, parts of the financial sector and even the mainstream media – as we know all these organisations and companies also count many people who are well-meaning but struggle with incentive structures based on the short term and making profit. To summarize: we need to start working with constructive corporate actors and help them when they try to make a transition to more long-term thinking, but ‘name and shame’ the others.
Then there is the post-MDG global health agenda. Let’s pretend for a moment that this post-MDG health agenda hasn’t really been decided yet by the 5 – 30 people who matter in global health. Then it would make sense to argue for a universal goal (like UHC or healthy life expectancy, while trying to make sure that UHC is not “interpreted/steered” in such a way/direction that all the PHM’s worst nightmares materialize) but it’s obvious flexibility also requires a few continent-or region-specific goals, like HIV for Sub-Saharan Africa, tackling dementia in the North, etc. And instead of pushing China to contribute to the Global Fund, far better would be going for a division of labour playing to the strengths of each actor – as in philanthropies focusing on innovation, China focusing on infrastructure, social housing in SSA, etc. China is still rolling out its own social protection system, so it’s kind of naïve to think the Chinese government can get away with huge support for the Global Fund, even in an “authoritarian” country.
Let’s also not forget that we need to lead by example. So why not having a session at the Health Systems Research symposium in Cape Town next year on the many global health “happy fliers”. Tim Evans, Richard Horton, Julio Frenk, … they’re all part of the 1 % of global citizens who fly the way ordinary citizens go to the local store. Instead of advocating for the right to health for all, they seem to believe in the right to fly. Let’s call a spade a spade, these people are all “eco-terrorists”, even if they reduce their carbon footprints with carbon offsets. How can you even pretend to care about global health if at the same time you destroy our very habitat? If we want our politicians to be ethical, why doesn’t this apply to us? It’s astonishing the CIA hasn’t taken them down yet, as they present a ‘clear and present’ danger to the world and future generations. In a way, a big part of the global health community, including some of my colleagues, behave as if the world is their very own Jurassic Park. I don’t want to single them out, as we’re all eco-terrorists, to some extent. I’ve just spent some weeks enjoying Cape Town’s “braai” (with huge quantities of meat)… but we have to start this discussion, otherwise we might as well relabel ‘global health’ and use a term that more aptly captures what we’re actually doing, while asking Michael O’Leary for funding.
Finally, the one billion dollar question: young global health voices will have to think of a way to engage their generations, who show up in their hundreds of thousands at festivals like Tomorrowland, and watch soaps in droves, but fail to take to the streets, at least for a prolonged time, and organize themselves. Many don’t believe in politics anymore. It won’t be enough if committed health activists take to the streets, who know the ins and outs of TTIP or other trade mechanisms with not so hidden agendas. Somehow these activists have to find a way to appeal to a whole new generation, even if many of these debates are complex and technical. So we need human rights lawyers and marketeers too to raise political awareness in a way that fits the 21st century. And global health storm troops, perhaps, like the Arctic 30 are doing for Greenpeace.
In conclusion, let me paraphrase JF Kennedy: “Don’t ask what your country can do for you, ask what you can do about your country (or any other governance level) to make this a fairer world”. Having said that, when doing this, try not to end like the former US president.