Dr. Anne-Emanuelle Birn (BA, Harvard University; ScD, Johns Hopkins School of Public Health) is Professor of Critical Development Studies and Global Health at the University of Toronto. Her research explores the history and political economy of international/global health, particularly in Latin America. Her books include: Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico and Oxford University Press’s Textbook of Global Health (4th edition, 2017). She is a member of the Independent Panel on Global Governance for Health.
Q: World health is facing numerous challenges: The increasing Antibiotic resistance, NCDs like Type 2 diabetes are advancing, Health Care is increasingly unaffordable for many people. Who causes the damage? Who is to blame?
A: Even though it is difficult to pinpoint a single source for these problems, virtually all of them are connected in some way to the current world order, characterized by the neoliberal phase of capitalism. This means that powerful interests – transnational corporations (TNCs), venture philanthropies, wealthy elites and their political partners and intermediaries – have structured ever more elaborate “rules of the game” that benefit them, at the same time dodging regulation and transparent and accountable decisionmaking processes and opposing redistribution and social protections.
For example, the problem of diabetes is intimately connected to changing dietary patterns that have been encouraged by agribusiness, “Big Infant Food,” “Big Snack,” “Big Soda,” and other “Big Food” TNCs, in turn linked to mass-marketing of unhealthy products and displacement of small farmers and local food production. These developments have been enabled by shifting global trade and investment rules, which have forced open markets to TNCs, lessened or eliminated domestic rules and protections for smallholders and ordinary people. Meantime you have governments that have not responded to longtime citizen demands for clean and accessible water, in part responsible for the proliferation of unhealthy soft drinks as a drink of choice. On the other side you have Big Pharma (pharmaceutical TNCs) that see the opportunity to market medication to treat diabetes, for instance jumping on the bandwagon of a new “diagnosis” – pre-diabetes. So the routes to health damage are complex, but they are deeply linked to global capitalism.
Similar factors and forces have driven the return to reductionist, vertical disease initiatives in recent decades, instead of concerted investment in comprehensive, public, equitable health care systems that promote health rather than target diseases one by one without considering the context of (ill) health.
Q: Today the WHO is facing a loss of credibility. At stake are her independence, her legitimacy and her ability to continue to be the leading institution on Global Health. What are the root causes of the crisis?
A: Many people dismiss WHO for being bureaucratic. But all large institutions maintain rules, ideally to enhance transparency and accountability. WHO, as virtually any agency, could certainly become more nimble, yet its principal problems reside elsewhere. The weakening of WHO’s independence has accelerated since the1980s: with funding stagnation or cuts, health activities relegated to alternate institutions (first to other UN agencies including UNICEF, and, as of 1996, UNAIDS; then to public-private partnerships (PPPs), especially the Global Fund, Gavi, the Vaccine Alliance, and, more recently, “multi-stakeholder” initiatives. These lump all participants together, erasing key differences in the objectives and roles of organizations striving for health as a human right, and those ultimately pursuing their bottom line. Such multi-stakeholder arrangements are backed by the World Economic Forum, and even the UN, and they turn WHO into “just another partner” rather than an organization constitutionally charged with being the coordinating global authority for promoting health and for upholding health as a “fundamental right.”
Q: How can WHO regain the terrain it has lost? What should be the core of WHO work? How can WHO maintain its mandate in today's crowded Global Health Arena?
A: WHO could begin by resurrecting a system of fair and adequate dues that are not “earmarked” by donors to go to designated activities, but are instead subject to democratic decisionmaking processes and ongoing accountability to the wider public. As per its Constitution, WHO’s work ought to be centered on promoting human need – in terms of improvement in nutrition, housing, sanitation, work, and environmental conditions – as well as on regulating harmful commercial practices, all based on sound and disinterested science (only possible if WHO is fully funded). Effectiveness and success should be defined in terms of health equity. A crucial concern at present is the institutional conflict of interest faced by WHO, whereby its leadership — in the hopes of attracting more “innovative” funding and investment— seems to have given away its mandate to pursue health as a fundamental human right and has opened itself up to undemocratic private sector decisionmaking and control (via venture philanthropy and TNC interests).
Of course, accountable decisionmaking at WHO also depends on accountable national governments, and favoring health equity requires understanding and addressing the societal determinants of health and the role of public and universal health care systems therein.
Q: Bill & Melinda Gates didn't show up out of the blue. Which conditions and political decisions have paved the way for the influence of private philanthropists and investors?
A: The withholding of dues by the US government under the Reagan administration and a subsequent decades-long stagnation in member dues (net decrease in funding since the 1980s) has led to a dire budgetary situation. Enduring budgetary constraints and political pressures prevent WHO from effectively addressing key issues (such as the need to regulate harmful corporate practices) and have left a vacuum filled by private players, a shift that WHO appears to have willingly welcomed. The fact that almost 80% of WHO’s present budget is donor-earmarked (with the Gates Foundation the first or second donor in recent years) means that priorities and health approaches are determined in a highly undemocratic fashion and often promote and enrich private sector interests, such as via the stockpiling of unnecessary pharmaceuticals). The Gates Foundation, for example, has targeted its WHO funding to polio eradication, with approximately 20% of WHO’s budget going to this single activity in recent years. This is not a priority defined by the World Health Assembly but by the Gates Foundation.
The Gates Foundation has also had a heavy hand in the proliferation of global health-related PPPs, which have further displaced WHO. Most major PPPs were launched by the Gates Foundation or have received funding from it, such as Gavi and the Global Fund. Gavi, the Global Vaccine Alliance, promotes new second-order (often expensive, once countries lose their Gavi subsidy) vaccines to national immunization schedules instead of ensuring universal vaccination using existing effective vaccines; Gavi essentially underwrites already hugely profitable pharmaceutical corporations in the name of “saving children’s lives.”
To be sure, the Gates Foundation does not operate in a vacuum—multi-stakeholder partnerships have heightened the agenda-setting role of venture philanthropy and the private sector. Of course, this would be impossible if the major donor countries did not also jump on the philanthropy bandwagon.
Take Germany, for instance. Historically, Germany has been a relatively quiet player on the global health scene. Its bilateral agency, currently named the German Federal Ministry for Economic Cooperation and Development (BMZ), has been involved in similar development assistance approaches to other mid-level players like Canada: trade, sustainable development, etc. Yet Germany has been working increasingly with the private sector, including the Gates Foundation. A 2017 high-level Memorandum of Understanding between the Foundation and BMZ commits the two entities to work together to advance the UN’s 2030 Sustainable Development Goals (SDGs) through “revitaliz[ed]” global partnerships. The agreement gives the Gates Foundation access to BMZ’s large network of contacts and enables staff exchanges across the two organizations, undermining the BMZ’s democratic accountability to the German public. This coziness between the German government and the Gates Foundation is being entrenched through the German Ministry of Health’s new advisory board on global health, one of whom is from the Gates Foundation.
Here I think it is crucial that not only public-interest civil society, but also academics and politicians, start to play a much more active role in asking about the power structures and political entanglements shaping these global health initiatives. For example, how did the German government-Gates Foundation MOU come about in the first place? Who has helped shepherd and legitimize this and other such arrangements?
Q. Shouldn't we feel thankful that the Gates Foundation and other private actors support the WHO? What is wrong with their commitment?
Virtually all private donations have strings attached – that is, as mentioned earlier, they stipulate that their money go to particular activities and usually promote public-private hybrid approaches to these activities. The agendas of private actors thus increasingly shape public spending as well, even though private actors have no public accountability. Philanthropic donations in most countries are tax-free, meaning that the public subsidizes this spending without having a say in it. Even when private actors articulate a discourse of equity and human rights, they are often pushing a self-interested agenda. Most important is the influence of private actors in setting policies and priorities that (deliberately) do not address the fundamental problems of privatization, deregulation, and transfer of resources from the public to the private sector, which together are jeopardizing health. Ultimately this results in skewed power – favoring private agendas over the people’s health and well-being. Many people seem to be blind to this.
Q. 40 years back the member states of WHO committed themselves in the Alma Ata Declaration to Health as a Human Right and a Question of Equity, Equality and Participation. What remains today from this groundbreaking declaration?
A: People’s support for it and activists’ and professionals’ commitment to it. The Alma-Ata Declaration, with its advocacy of a New International Economic Order, remains, four decades later, the most widely supported statement of health justice.
But we must remain vigilant to cooptation. For example Alma-Ata’s <health for all> slogan has been appropriated by the current movement for Universal Health Coverage (UHC). Existing approaches to UHC, for instance, have not only left the door wide open for private profiteering, but do not address key issues of comprehensiveness and health equity. So it is not clear how UHC will fundamentally address poverty and ill health in the way that the Alma-Ata Declaration envisioned.
Q: What are the main challenges for a global health movement struggling for health as a human right?
A: The power of private interests. The lack of bona fide democracy and accountability in agenda setting for health. The very limited space for social movements and public-interest civil society to be part of global health decisionmaking.
Interview: Anne Jung, Global Health Adviser Medico international.
Some further readings:
- Birn, Anne-Emanuelle. “WHOse health agenda? 70 years of struggle over WHO's mandate,” The Lancet, 391, 10128: 1350-51. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30734-7/fulltext
Reposted: https://saudeglobal.org/2018/04/06/whose-health-agenda-70-years-of-struggle-over-whos-mandate-by-anne-emanuelle-birn/ - Birn, Anne-Emanuelle and Richter, Judith. “US Philanthrocapitalism and the Global Health Agenda: The Rockefeller and Gates Foundations, past and present,” in Howard Waitzkin and the Working Group for Health Beyond Capitalism, eds. Health Care Under the Knife: Moving Beyond Capitalism for Our Health, Monthly Review Press, 2018. https://monthlyreview.org/product/health_care_under_the_knife/
Also posted on: http://www.peah.it/2017/05/4019/ - Richter, J. (2015). "Time to debate WHO’s understanding of conflicts of interest." BMJ RR (22 October) http://www.bmj.com/content/348/bmj.g3351/rr.
