In this blog post, Kristof Decoster argues that the global health community should attack the consumerist American dream, now shared worldwide. The ultimate goal should be an ecological economy, instead of the now mainstream ‘inclusive green growth’ vision. Instead of a greenish version of the American dream, WHO and others should promote a truly sustainable lifestyle for the masses which respects planetary boundaries. This should be an explicit post-2015 global health goal, in addition to the promotion of UHC.
Universal Health Coverage has a number of things in common with ‘green growth’, it appears. Both ideas are obviously a huge improvement compared with the (dire) situation now in terms of respectively health equity and the global economy’s impact on the planet, are increasingly fancied (there’s a strong momentum for both), are set to play a major role in a post-MDG framework and both also seem acceptable to and endorsed by a large number of stakeholders. Some people think this is due to the fact that they are both rather encompassing “catch-all” terms, so that people and stakeholders can interpret them the way they want. I wonder instead whether they are ambitious enough to avoid a future world as depicted in a recent worrying WB report on global warming.
There are many good reasons for ‘green growth’, and it’s easy to see why international institutions and governments all over the world, especially in cash-strapped developed countries, welcome the idea. Green growth seems to guarantee both growth – good for jobs and public finances among others – and sustainability. The idea allows countries to be competitive (by investing in innovative green technologies) and sustainable at the same time!
UHC equally attracts the interest of ‘the powers that be’ nowadays in a fast changing geopolitical world, not the least because it’s also partly seen as a shrewd economic investment (for example in BRICs countries). UHC is in pole position to become the overall post-MDG goal in 2015. And just like green adjustment and restructuring of international and national economies could boost green growth, at least in the short term, UHC policy reforms and implementation would represent a major step forward for the health of people around the world in the short and medium term.
However, I have my doubts whether these two lofty aims are ambitious enough to avoid catastrophic climate change and more in general a virtually uninhabitable world by 2100. Inother words, short term health and economic gains still risk to be jeopardized in the long term, even if governments and multinationals worldwide immediately start implementing comprehensive green growth policies and business practices and implement UHC minded policy reforms. Most people who put their hopes in green growth still seem to believe, implicitly or explicitly, in Adam Smith’s invisible hand theory. If only the market could fully play, and people and companies would pay the real price (taking into account the ecological impact) for things, all will be fine. That’s a dangerous and naïve dream, and something we cannot afford anymore in the 21s century, I’m afraid. Green growth is an improvement, but isn’t enough. True, Adam Smith also emphasized regulation, but that part of his discourse is usually ignored, and I’m not sure green growth advocates won’t make the same mistake.
In the rest of this blog post, I just want to focus on health and the post-MDG framework.
Global health stakeholders in general and even UHC proponents so far refrain from challenging excessive consumerism and hedonism as societal values. I understand why, but it’s a major mistake nevertheless. Even if some people in the ‘UHC movement’ want to emphasize the social determinants of health (or even incorporate it in a broad UHC concept), I am not aware of any WHO report which would for example attack our dangerous “appetite for consumption” or argue in unambiguous terms in favour of less consumption. Margaret Chan might hint at it sometimes in speeches, but let’s face it, by and large the UHC cheerleaders do not challenge the American “middle class” dream, which has now become a world wide dream. It’s a dream of pathological consumption, we all know, “a world consuming epidemic of collective madness, rendered so normal by advertising and by the media”. Even with a more greenish and presumably more sustainable version of the American dream, currently increasingly in vogue, we’re still on a destructive road both for people and the planet. I think it is a huge risk to bet only on green growth, technological innovation (like cradle to cradle) and increased resource efficiency to avoid catastrophic climate change and arrive at a world that generally respects the planetary boundaries. Somehow we should make clear to humankind that we have to learn to limit our wants to some extent if we want to survive as a species. And yes, that includes Donald Trump and Paris Hilton.
The global health community – or at least the more influential actors within the community – are very much in favour of ‘sustainable development’, it’s true. Unfortunately, they subscribe to the “mainstream version” of it. So they tend to agree with Jim Kim when he argues in favour of ‘inclusive green growth’ as the low carbon way forward. As I mentioned, I wonder whether such a world is indeed as sustainable as international institutions and governments worldwide proclaim and would let us believe. Instead, I think 21st century human civilization should start from the concept of an ‘ecological economy’ or respect for planetary boundaries and tresholds, and adjust the economy and people’s wants accordingly. The ecosystem and biosphere should come first, only then comes the economy. Not vice versa. No more trust in the “invisible hand”. Along these lines, a recent report by Alex Evans argues for example for an IPCC-style comprehensive global institutional mechanism for monitoring the nine planetary boundaries.
Many people in the global health community don’t share this idea, because green growth is indeed a very attractive concept, but perhaps also because the private sector or influential donor countries have quite some leverage over their institution or organization. Some public health people, like the emerging Ecohealth community, think otherwise, but they are still fairly marginal, although gaining strength. I think it would be a huge boost for the latter camp, if a reputed institution like WHO, in addition to promoting the incorporation of UHC in the post-MDG framework, started expressing serious doubts about ‘green growth’ as the only (and sufficient) way forward to reach a sustainable world. (not sure whether it would make WHO more sustainable, though)
But if the WHO is serious about UHC – defined by them as “securing access to adequate healthcare for all at an affordable price” – not just in 2020 or 2025, but also in 2050 or 2080, in my opinion it should push for an additional global health goal in the post-MDG framework. This goal could be framed as an NCD related goal, perhaps, initially, but the wider benefit is for the planet as a whole that sustains human life. The goal would focus on developed countries first, being long-term “consumption addicts”. They need to set the example. Middle classes (and obviously also the upper classes whose lifestyle often ‘inspires’ middle classes) need to make a rapid transition towards a more humble lifestyle characterized by less consumption, and definitely by less consumption that harms our planet. Flying with budget airlines like Ryanair, eating meat every day, all-you-can-eat buffet restaurants, buying stuff from10.000 miles away without even thinking about it, …. should all become far less ‘normal’ than they are now. Only then, upper and middle classes in BRICS and developing countries might follow. The West is no longer a role model in many respects, but in this vital respect it needs to be.
Let’s make one thing clear though. When I emphasize a more holistic “ecological economy”, I don’t want to rule out the market. Obviously clever market mechanisms (like a carbon tax) can and should be used, as well as innovative public-private partnerships (like GAVI), if they turn out the best way to reach objectives of sustainability and social justice and if they are required to price externalities properly. But the global and national markets should be firmly regulated and kept in check so that we don’t cross planetary tresholds.
The global health community should be among the set of progressive actors who argue that the only future for humankind lies in a holistic ecological economy. TINA, if you want, in this new millennium. So WHO and other UHC proponents should fiercely challenge current ‘mainstream’ sustainable development thinking, built as it is solely around ‘green growth’, and argue it needs to be complemented by a fundamental different mindset, values and behaviour. Starting from now, I would say. If Bill Gates and others don’t agree, that’s too bad.
That might not be a popular message in these times of hedonism and excessive individualism – people will be quick to say this sounds ‘authoritarian’ or ‘nanny-style’, a label public health people always want to avoid, even in better times than these. But I’m afraid it’s the price we have to pay in a world inhabited by 7 + billion people who all want the American dream. Worse, many even want the life of Posh Spice. If we also want our children and grandchildren to enjoy UHC, somebody should start saying that’s just not possible. The invisible hand was always a dream, but in the new millennium it risks to create an ecological and social nightmare. And anyway, we already live in an authoritarian world, driven by the financial industry, neoliberal dogma and multinationals. Better to go for a different sort of ‘authoritarian’ world then, more people-and planet centred.
No doubt this is a politically naïve idea, when considering the current global health architecture and more in general our world dominated by finance, rating agencies and multinationals. But naïve ideas aren’t necessarily wrong.