Health professionals for a safer, fairer & better world

The Lancet-UiO Commission on Global Governance For Health Commissioners should withdraw their recommendations and come up with better ones.

The Lancet Commission on Global Governance for Health – co-organised with the University of Oslo – was established to examine the political origins of health inequity, with a focus on ‘global governance’. It was a good idea: we need better and more democratic global governance and a form of ‘globalisation’ that is equitable and sustainable. And we need the global health community actively engaged in making change happen.

But after more than two years, the outcome of the Commission can be summed up as: excellent in intent; good with analysis; but poor on recommendations. Importantly, having identified the need for systemic and radical change, the Commission ended up with, what one commentator described as, the tame recommendations of “a talking shop and monitoring mechanism”.

I was disappointed; but also perplexed. How did the Commissioners (supported by a secretariat and team of researchers) end up with such poor recommendations – especially after so much good analysis had been conducted? Before addressing this question, it’s worth examining the gap between the Commission’s analysis and its recommendations.

Some Good Analysis…

The Commission does not shy away from its core purpose. It hones in on the undemocratic and unequal distribution of power as an underlying cause of health inequities and of deficiencies in global governance. It names self-interested actors with too much power; and it points to governments, communities and households with too little power. It also describes how the current form of globalisation has liberalised markets and promoted economic integration, but without the accompanying institutions required to uphold human rights, promote equity and protect society from market failures.

It highlights the growth in power of finance capital and trans-national corporations (TNCs) and the harmful effects of global and international trade and investment agreements that are formulated without even “a minimum level of transparency”. It describes the “complex system of global rules and regulations” that protects wealthy elites and cross-border flows of finance at the expense of democratic institutions and the public interest, and which enables finance-corporate actors to sue governments for compensation in secretive international arbitration processes in the event that laws or regulations passed to protect human or environmental health might impinge upon their profit margins.

In contrast to the easy cross-border flow of capital, commodities and profits, the Commission notes the lack of freedom for ordinary people to migrate in pursuit of a safe and secure life, and it deplores the plight of undocumented migrants who are denied essential health care in spite of international treaties that are supposed to guarantee universal rights and entitlements.

Another aspect of the current model of globalisation highlighted by the Commission is the expansion of privatisation and property rights, including through an intellectual property rights (IPR) regime that commoditises science and knowledge, creates perverse incentives in clinical research, and sustains large market failures and inefficiencies across the pharmaceutical sector. This regime – which works for the few but fails for the many – was designed by powerful corporate actors, globalised by the World Trade Organisation, and then deepened by bilateral and regional trade agreements.

Dysfunctional political and economic arrangements are also shown to underlie the growing prevalence of hunger and under-nutrition in a world that produces excess food. This is linked, among other things, to: unfair trade arrangements (especially the 1994 Agreement on Agriculture); predatory financial speculation and food-price volatility; unregulated land markets; agricultural production directed towards profit maximisation rather than the meeting of rights and basic needs; and the displacement of local food production in developing countries by food imports from subsidised producers in the USA and EU. At the same time, the Commission describes how the rising epidemic of obesity and diabetes due to the increasing consumption of unhealthy soft drinks and processed foods is related to the “penetration of food markets in middle-income countries by multinational food corporations” and the concentrated market power of globalised food retail chains.

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In its analysis of violence and conflict as “powerful and enduring threats” to health and wellbeing, the Commission similarly notes political and economic factors that increase the risk of war and armed violence. These include: high levels of unemployment; income inequality; economic instability; an unregulated small arms trade; and deficiencies in global governance (notably the “institutional stickiness” and “anachronistic” nature of the UN; the out-datedness of the Geneva Conventions; and the limitations currently placed on the International Criminal Court).

An absence of laws and regulations to promote public health is a prominent theme. But the Commission also notes that when appropriate laws and regulations do exist, states often lack the willingness or capacity to monitor and enforce compliance. Instead, elite, corporate and financial interests all too often subvert the capabilities and duties of democratic institutions to look after the general public interest; exploiting the gaps and deficiencies that exist within the international judicial system.

Importantly, the Commission notes that civil society efforts to hold powerful global actors to account by monitoring and publishing their behaviours (e.g. the Publish What You Pay initiative focused on the energy and mining sectors) or to promote “socially responsible investment” are no substitute for legal and regulatory mechanisms that can enforce sanctions when international norms, laws and standards are violated. Similarly, initiatives aimed at mitigating the negative effects of the IPR regime (e.g. the creation of patent pools, corporate donation programmes and public-private product-development partnerships) are deemed to be insufficient.

Poor Recommendations …

The Commission makes a clear case for a redistribution of political and economic power: for the strengthening of real democracy, including more transparency and greater accountability of powerful actors at the global level, and for the reshaping of the rules and laws that shape our current form of globalisation. In short, it calls for systemic, radical and transformative change.

But having done this, it then loses its way and retreats to the safe and apolitical territory of ‘governance’ by proposing the establishment of two new global structures as its primary recommendation: a UN Multistakeholder Platform (to share and review information, influence norms and opinions, and make recommendations) and an Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health (to assess evidence and conduct research).

While both structures could provide some value in their own right, neither would redistribute power, nor alter the frame of existing laws, rules and systems. Furthermore, both would add to the already uncoordinated and crowded global governance landscape. Ironically, the Commission itself notes that a proliferation of international rule making, bodies and conferences has contributed to “regime complexity” and the blurring of obligations, responsibilities and lines of accountability.

A number of secondary recommendations are also made: make it mandatory for health equity impact assessments to be conducted by global institutions; create a regular forum for civil society organisations to present reports to the International Criminal Court on alleged violations by TNCs and other non-state actors; advocate more on the basis of existing human rights treaties; and promote the financing of global public goods through compulsory contributions made by all states according to ability to pay.

There is nothing bad about these recommendations. But some of them feel old and tired; and none of them are transformative. In fact the Commission admits that these secondary recommendations are not expected to root out the very causes of persistent health inequities” but merely “remedy the effects of the inequitable distribution of health”.

As a consequence, trade agreements and investment agreements are left untouched (which the Commission repeatedly notes as being too difficult to reform or amend). And nothing is said about banking reform, corporate tax enforcement, global finance regulation, or mechanisms to redistribute wealth and assets (including reclaiming from the ‘one percent’, that which should fall under public stewardship or ownership). In terms of addressing hunger and food scarcity, the mention of social protection schemes and greater investments to strengthen smallholder farmers are also ameliorative solutions rather than anything transformative or structural. In fact under the current system, investments that support smallholders often benefit private finance capital and big corporations through corporate capture and buy-outs.

Although the call for countries to make compulsory payments to finance global public goods would mark a significant change from the current system of voluntary contributions, even here, the actual benefits are marginal, and would do no more than to make ‘official aid’ a little more generous and predictable.

Why did this happen?

The gap between ‘analysis’ and ‘recommendations’ is startling. The identified need for transformative change is abandoned in favour of a set of marginal changes. It is as though having ‘spoken truth about power’, the Commission wasn’t prepared to ‘speak truth to power’ when it came to making recommendations. What can explain this?

One possible explanation is that the Commission was being pragmatic and strategic – proposing a set of moderate and unthreatening recommendations but which might promote transformative change later on. For example, the Commission might have imagined that a new multi-stakeholder forum and an independent scientific panel would bring about a social and political mobilisation that would then lead to transformative equitable and democratic change.

A second possible explanation is that having described the political causes of health inequity, the Commissioners lacked agreement or a shared vision on what an alternative form of globalisation and global governance would look like. It is possible that social, political and conceptual differences between individuals led to differences in opinion which led to the formulation of moderate, ‘lowest common denominator’ recommendations that were acceptable to all.

Certainly, there is evidence of some ambiguity within the Commission’s report. For example, the Commission credits the global market system for having generated “ever greater flows of goods, people, money, information, ideas, and values” with the help of “privatisation, deregulation, and trade liberalisation”; and for having produced “unprecedented growth that has increased material prosperity for hundreds of millions of people and greatly improved their health and wellbeing.” It also notes how foreign direct investment “is widely regarded as an important vehicle to advance economic growth and development” and how TNCs also “yield enormous benefits by creating jobs, raising incomes, and driving technological advances”.

Both these claims contribute to a degree of ‘mixed messaging’ about globalisation and global governance. They also happen to be wrong. The trinity of privatisation, deregulation and trade liberalisation as currently structured, has done more to inhibit rather than encourage the generation and flow of knowledge, information and ideas (especially apparent in the pharmaceutical sector). Furthermore, it has hindered economic growth and development compared to other more pro-active approaches to socio-economic development. Similarly, there is no evidence that TNCs perform well in terms of job creation, raising incomes or driving technological advance (if anything, the evidence is negative).

‘Mixed messaging’ is also evident in the Commission’s discussion of the recent financial crisis and consequent austerity measures that governments have implemented. The focus was on how to respond to the financial crisis (i.e. whether counter-cyclical spending was better than austerity, and whether austerity could be implemented with less adverse health effects)but not on reforming and regulating the system of global finance, nor on how the vast amount of illegitimate and odious debt that has been piled onto governments and ordinary people could be annulled.

A third possible explanation is that members of the Commission were ‘censoring’ themselves – either consciously or sub-consciously. Promoting ‘transformative’ change that challenges power while seeking to redistribute resources equitably is discomforting and not without risks. One may want to avoid direct confrontation with power, and avert the risk of being labelled and then dismissed as an unrealistic or quixotic ‘radical’.

It is worth noting that the power and politics that shapes the global political economy also operates across the global health landscape. For example, TNCs are powerful and influential actors in global health who would positively welcome marginal changes in global governance (including the promotion of progressive norms, ideas and values), as long as trade and investment rules continue to be structured in their favour. And the Gates Foundation – a major source of funding for the global health community – is also a strong proponent of neoliberal globalisation and the prevailing undemocratic structures of global governance.

Importantly, the role of private philanthropy and official aid was not critically examined by the Commission, which instead praised the Gates Foundation by name and portrayed ‘global health’ and ‘aid’ as uniformly positive domains that counteract the negative effects emanating from ‘trade’, ‘national security’ and ‘finance’. The reality is more complex. While much aid and private philanthropy undoubtedly ‘saves lives’ and provides vital humanitarian assistance, their role in sustaining democratic deficits and disparities in power, and in shielding unfair trade and investment agreements and egregious market failures from reform was not even mentioned.

The Commission’s tendency to portray governments, civil society and corporate actors as separate and distinct actor groups that compete with each other for influence and power, also obscured the fact that power is organised horizontally across these three sectors. This links to another important contextual factor that was not examined by the Commission: the ‘public-private partnership’ paradigm which has come to virtually define global governance in the last two decades and which has enabled and legitimised the presence of powerful, undemocratic and self-interested actors at the heart of decision and rule-making structures and processes.

As I like to sometime say, the real occupy movement isn’t the one led by ordinary citizens on the streets and squares of towns and cities across the world: it is the occupation of governments, the UN complex and the media by the corporate sector and the wealthy. This occupation may also extend to universities and research institutions where changes to funding and management arrangements have shrunk the space for academic freedom and public-interest science.

Where is the Real Occupation?

Image by Michael Fleshman
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The suggestion that the Commission may have censored itself will not go down well. But this is less an issue about individuals and more about how power and the dominance of neo-liberal ideology in mainstream social and political discourse influences what is generally considered to be politically ‘feasible’ or ‘acceptable’, and how words like ‘radical’ and ‘transformative’ are defined and given meaning.

There may be other explanations for the gap between the Commission’s analysis and its recommendations. And I hope this blog will spark some frank but constructive debate. Even better would be for the Commission to withdraw its recommendations and come up with better ones. This will almost certainly not happen, but I have written to the Commissioners to ask them anyway.

Moving forward …

A lot of the Commission’s analysis was good. But it didn’t go far enough. For this reason, the Lancet should also consider hosting a new Commission. It could be called a Commission on Power, Politics and Alternatives, and it would do three things.

First, it would deepen and broaden the analysis of politics and power conducted by the Lancet-UiO Commission. This would include: a) a better description of how power is structured and organised globally, and how it undermines democracy, equity and public health through the use of wealth, political influence, military force, laws, culture and ideology; b) a critical analysis of the role of aid and private philanthropy in global governance and the distribution of power; and c) an examination of the particular influence of the US corporate-military-government complex on global governance and the implications for the recent shifts towards a more multi-polar world order.

Second, it would work on proposals for an alternative development paradigm. We don’t just need better and fairer global governance; we also need a concept and vision of development which is ecological, sustainable and consistent with planetary health. Neoliberal globalisation isn’t working for the earth or most of the world. Only an alternative model would: a) construct development pathways that simultaneously address poverty and global warming; b) redistribute wealth and resources; c) ‘de-financialise’ the world economy and subjugate finance capital to greater social and democratic control; d) ‘de-globalise’ and ‘re-democratise’ economic and ecological policy; and e) break up monopoly power where it exists. These ingredients for an alternative model have received the attention of many serious scholars and thinkers: it’s time the global health community reaches out to such people.

Finally, it would develop the point made by the Lancet-UiO Commission about social movements “challenging undemocratic processes, or protesting against unfair policies”. Redistributing power or shifting paradigms cannot be limited to technocratic and intellectual interventions: social and civic action is required. But such action often provokes reactionary counter-measures which may be violent and oppressive. That is why it would be useful for a Commission to examine how the respected and privileged community of global health professionals can reach out to and stand by those social movements that are fighting for democracy, justice and survival on the frontline.

While this blog is written in my capacity as an academic at Queen Mary University London, Chair of the Board of Medact and a member of the Peoples Health Movement, the analysis, opinions and recommendations presented here can only be attributed to me as an individual. 

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Comments

Anne-Emanuelle Birn, Professor of Critical Development Studies and Global Health, University of Toronto                     7.5.14

Occupation: historian of public health/international health

As many others have noted, David McCoy has written a powerful and important critique of the recommendations of the Lancet-University of Oslo Commission: incisive, elegantly argued, and damning, all without faulting individuals on the Commission in an ad hominem fashion.

David’s analysis — also underscored by the responses of 2 Commission members thus far– shows that the Commission’s recommendations capitulate to what is perceived as doable, politically feasible, palatable,  “within reach,” “what can be done” etc.  Such premature capitulation, especially after the “excellent intent” of the Commission, is deeply disappointing and disempowering.

Battling the myriad injustices (including the health implications) of the current global health governance arrangements –arrangements which are embedded in the system of global capitalism–  is not a matter of a priori compromise, persuading those “open to persuasion”  or remedying  symptoms.   This is a profoundly political and long-haul struggle over power and its equitable distribution.  Progressive public health policymakers, scholars, practitioners, and activists can collectively play a key role in this struggle, both within and well beyond the health arena, but only if we have the persistence and imagination to work towards a radical transformation of the current world order.

NB: I was a co-author of one of the PHM background papers on extractive industries prepared for the Commission, but I had no involvement whatsoever with the Commission per se.

Sigrun Mogedal, Special Adviser, Member of the Lancet-University of Oslo Commission                                 04.05.2014      

Retired from Norwegian Ministry of Foreign Affairs, now associated with the Norwegian Knowledge Centre for the Health Services

As one of the Commissioners in the University of Oslo LancetCommission on Global Governance for Health, I note that we very much agree on the analysis of power and forces that drive and maintain inequity, including the illustrative examples presented by the Commission to follow the impact of these forces. We also agree that transformative change is critically important in order to achieve health equity and health security for all.

The question for debate is how to get there. Our report can be read as combining a radical analysis with setting out incremental steps to reform, joining voices with the ongoing global consultations on sustainable development and “the world we want”. We may be too optimistic about this potential for change in intergovernmental collaboration, rule making and institutional UN reform. What you miss is a rejection of the current global order and the call for revolution. My position is that we will not see transformative change unless we use both these pathways.

You challenge recommendations that only respond to symptoms without dealing with root causes. I am tempted to use the experience we have as medical practitioners – we need to respond to symptoms with the diagnostics and treatment we have available, even where we are not able to get at the root cause of the disease. But it does not keep us away from seeking deeper and deeper understanding of the root causes of illness.

Our analysis took us as far as we were able to reach into the discussion of root causes – not to be exhaustive but to make the point that many decisions (or lack of decisions) which undermine health and maintain ill-health represent political choices that are far outside the domain of the health sector. At national level, yes. But also at global level. They are decisions of national governments, corporate sector and non state actors that have impact across borders and where global governance does not have the institutions, arenas and accountability mechanisms to take corrective and conducive action to safeguard peoples’ health.

You says there are too many structures and mechanisms related to health in the global space already. I believe we here speak about different things. There are many mechanisms concerned with health sector action and financing, and these could benefit from a more coherent and integrated institutional architecture. We know a number of reasons why it is hard to get there. We deliberately did not enter into this space, which we called governance of health. WHO reform is at the core of this discussion. Instead we were asked to examine forces outside the health sector and beyond the reach of the structures involved in governance of health. You may agree or disagree whether this was the right choice. But the distinction was a basic premise for the Commission, which is also explained in the report. I am not aware of global governance mechanisms that deal with the combination of cross-sectoral forces and actions that impact on health and hold actors accountable, which we addressed as governance for health. We speak about the political determinants of health as the transnational norms, policies and practices that arise from political interaction across all sectors that affect health – of which the WHO currently only is empowered to deal with a few. The UN General Assembly and ECOSOC seeks to respond when specific health related themes are placed on their agenda, such as recently ICPD+20 and now to come the High level session on NCDs. But experience demonstrate that, they have a hard time to integrate rights, trade, humanitarian affairs, peace and security in a way that represent a corrective and holds actors accountable . If you think that the institutions we have that are engaged in governance of health can be transformed to take on these challenges, let us know how.

We were pretty direct in our analysis and description of the five institutional dysfunctions affecting global governance for health. You do not respond to that, and only make the comment that any reform of these structures would carry along with it the same unequal power that currently plague global governance. I do not take that position. I believe that the UN is the best we have at the moment for global governance and that we need to do everything possible to overcome these dysfunctions. We definitely could have been smarter and stronger in setting out the recommendations and concrete reform options. There is not a lack of radical reform proposals on the table, including what has been presented as ideas for a new economic world order, and specific proposals for each institutions such as for IMF and the World Bank.

We chose another option, by showing steps that were seen to be within reach and which can pave the way for the kind of reform that can make global governance for health more inclusive, more transparent, more fair, better informed and more accountable – in line with what is also called for in the broad and participatory UN post2015 process for shaping the world we want, committed to globally sustainable development. This was intentional, and not to shy away from responsibility or in order to get group consensus.

We do not only need “good governance” in each nation. We need just international/global governance. This needs to be both claimed and built. This is where we can work together. It will not happen without strong movements around the world that show their anger and call for change. But it also will not happen without a critical mass of governments and institutions that pave the way for reform, building on the best of what we have and overcoming the barriers and dysfunctions through informed political choice and collaboration across actors. This is the case for working together, in mutual respect for the sincere search for options that can lead to the transformative change we need for health and for globally sustainable development.

Alison Katz                                                                                                                                                                                2014/05/1

The  critique of David Mc Coy in the Medact website is welcome.  I hope it will convince everyone that analysis is no longer required (and hasn’t been for a decade or more). I have two points, one on explicit political language and the other on what I see as a fatal flaw in the Oslo Lancet report.

I am making a plea to make use of political wisdom acquired over more than a century. And a start would be to use honest political language for really existing political processes and phenomena.   Not once yet, in this discussion has the word capitalism been mentioned and that is a feat in itself. Neoliberal dogma has made useful political terms into dirty words. Capitalism is not a dirty word. It is a dirty system.   I sincerely believe that if we want Health for All, we have got to use honest political language in order to explain political processes and systems and then take effective political action.

No wonder we cannot mobilize “the people”.  These discussions are unintelligible to most people but they don’t have to be. Curiously, when politics is explained truthfully, it is perfectly understandable for most of the population.

Example, Ireland, lost 9 million of 10 million in famine (1846, 47, 48) while ships full to the brim with wheat and oats sat in Cork harbor before setting off for England.  Today in the Horn of Africa, people starve and ships full to the brim sit in the harbours  . . . . . with food on its way to Europe.

Nothing has changed  . . . . not yet.  And in many ways it is worse. Ireland had to fight. What was it fighting? Capitalism and colonialism.

Real socialist parties in Geneva are leading a campaign to outlaw the murderous speculative trade that today is concentrated in our city. (Cargill and others). We can all do more in our own town or city to ensure food sovereignty (and thereby contribute significantly to Health for All) and to stop the diabolical exploitation of human and material resources in poorer countries than we can by contributing to Commissions whose political analyses are somewhat weaker than those presented a century ago. And make no mistake, speculation in cereals is capitalism. It is not some kind of spontaneously occurring phenomena, appearing independently of a political system.

1.      Global health governance and global governance for health cannot be separated. Doing so (as Oslo Lancet commission does) removes the central question from the debate

Global health governance (GHG) refers to governance of the global health system – defined as “the actors and institutions with the primary purpose of health”. Global governance for health (GGH), refers to “all governance areas that can affect health” (definitions used by the Lancet-University of Oslo Commission on Global Governance for Health.

The Commission’s report “does not focus on improving the governance of global health actors but rather looks at how global governance processes outside the health arena can work better for health and for the continued success of the global health actors”

GHG and GGH must be considered together for the following reasons. Not only is the relationship between these two kinds of global governance two-way but a discussion which separates the two, removes one of the central controversies from the debate, namely the scope of the leadership role of public health institutions and authorities in general, and of course the World Health Organization.

This particular global health actor is – until further notice – the peoples’ international health authority. As such, and as a knowledge and advocacy organization, the WHO itself is responsible for defining the scope of governance in relation to health, i.e., for identifying all the areas outside the health sector which affect health and for providing advice to Member States on how policy in these areas can promote and protect health.  This is the rationale of the WHO’s Commission on Social Determinants of Health which published its findings in 2008. Root causes of poor health – miserable living conditions resulting from poverty – had been progressively sidelined and then ignored in the thirty years since Alma Ata, in favour of the neoliberal approach exemplified by the Sachs Report in which health is conceived as an input to productivity, and illness as – by and large – the result of  irresponsible individual behavior.

It is because global governance processes outside the health arena have not taken into account the health impact of their activities, that this debate is taking place. The private sector has strenuously resisted measures for health, environmental and human rights protection in non-health sectors, because these would inevitably restrict their activities and profits. It is the reason for the right wing backlash which aborted the social justice project “Health for All” only two years after the declaration of Alma Ata. Social justice and human rights groups, on the other hand, have called for enforceable protection measures in non-health sectors for decades now. Furthermore, they support prioritization of health, the environment and human rights over trade and any other aspect of economic activity and as a logical consequence, they advocate for health governance institutions to exercise directing and coordinating authority in matters of health, over non-health sectors.

According to its constitution, WHO is the directing and coordinating authority in all health matters. That means health matters arising out of activities in non-health sectors. If anyone wants to change that, they must propose changing the constitution. We should be very clear on that.  Because very few of these “thinkers” promoting different versions of yet more global health fora are honest enough to say that that would imply changing WHO’s constitution. And they would likely encounter far more resistance if they did so.

Desmond McNeill, Centre for Development and the Environment, University of Oslo                              2014/04/26

Member of the Lancet-University of Oslo Commission                                                                   

As commissioners I expect each one of us has a different reason for agreeing to put their name to the report, and I can answer only for myself. I do not see the recommendations as resulting either from compromise or self-censorship. If I can explain my thinking you may perhaps classify it as strategic, but, as you say, your three alternatives are not exhaustive.

Certainly I would like to ‘redistribute power at both the national and global levels’; but to me that is not a recommendation. The question is rather what can be done – and more specifically, in this case – what can the report of a commission such as this contribute? Redistribution of power will require action on a number of different fronts, by a number of different actors (of which the Peoples Health Movement will be an important one). The role of the commission, as I understand it, is rather different from that of the PHM and other activist organisations – but it can be, I believe, complementary. Our most important contribution, I think, is in presenting a rigorous analysis of the multiple political causes of the current inequitable situation; sufficiently rigorous, I hope, to persuade not so much those who are already more than convinced but rather those who are open to persuasion. But this in itself is not enough. It needs to be followed up by continued and still more focussed critical work on specific and topical issues; which is what the proposed panel will, I hope, achieve. You note in your blog,that in our report “trade agreements and investment agreements are left untouched”. As it happens, one of the first topics which has been suggested for analysis by the proposed panel is the Transatlantic Trade and Investment Partnership (TTIP), still under discussion and much in need of critical debate. The same is surely true of the proposed Trans-Pacific Partnership agreement.

I doubt whether this response will change your mind about the report, but I hope that it may enable us to work together effectively on following it up.

Best regards
Desmond McNeill

Richard David, MD, NICU Co-Director, Professor of Pediatrics                                                                   2014/04/25

The form of self-censorship most common in 21st century discourse on the topic of social inequities (health and other) is the complete removal of historical context. In particular, the role of an alternative vision of social organization called “socialism” that achieved remarkable population-wide changes in the social determinants of health, and in health indicators such as life expectancy, during the 20th century. That the countries that followed that path eventually returned to capitalism does not negate the sweeping changes that fundamental change in class power relations had on health for generations. I tried to introduce this missing element into the pubic discourse recently (Am J Public Health. 2014 Feb;104 Suppl 1:S8-S10. doi: 10.2105) but it didn’t seem to be noticed. It was probably “dismissed as an unrealistic or quixotic ‘radical'” perspective, as David McCoy would say.

Luiz Eduardo Fonseca, MD, FIOCRUZ Global Health Center Assistant                                                                     2014/04/24

David, very interesting points for reflection. I like what you say about the gap between analysis and recommendations of some important high level health institutions. I myself have questioned several times the use of “global governance” within the context of “global health” because I think the term “global” many times come to despolitize the context of govern and also the health sector, once the word “global” cannot take in account the mechanisms of power within the governs, it doesn’t take in account the level of representativeness of different groups. Go ahead!

Ronald Labonte, Professor, Academic Researcher                                                                                                     2014/04/24 

Full disclosure: I met several times with the Lancet-Oslo Secretariat that prepared drafts of the report. I was not involved in the drafting the final version, or its recommendations. I agree with David McCoy’s assessment: pretty good analysis, reasonable typology of the pressing problems, nice to see identification of power as the driving force in inequities. But the recommendations are limp at best. The retreat to more data and monitoring is the default when we don’t want to actually name names or stake a claim for a different politics. And while a ‘talk shop’ is not inherently a bad idea, we have an already crowded and mandate overlapping set of global governance structures, many of them quite ineffectual. Rather than create a new one, how about reforming and strengthening existing ones? Or at least first assessing whether institutional stickiness precludes any hope of governance reform. In many ways the Commission’s recommendations are weaker than those of the WHO’s Commission on Social Determinants of Health. Where is the call for progressive taxation? (We would have no austerity if we actually had taxation at the rates we had 30 years ago. No huge wealth inequalities either.) Or for global taxation? And effective closure of tax havens (most of which are UK or US protectorates or former colonies, and a handful of European countries)? Even the IMF (or some voices within it) are calling for the same. Several scores of countries have stated nominal support for financial transaction taxes; and a number are already implementing very small ones (though not the global financial behemoths of the UK or US.). Where’s some meat about how to ensure existing and new trade and investment treaties embody strong public health exemptions? And the list could go on. While, true, these are actions rather than governance structures, surely laying out an agenda for action is part of what global governance for health should be doing. Especially when such an agenda is so well laid out in the body of the report. One of the problems with those of us who engage in global health debates from a pro-public health vantage is that we tend to nice, reasonable, diplomatic and generous in spirit to others. So we think that reasonable and evidence-informed conversation with the powerful elites should lead to nice, reasonable, diplomatic and generous compromise. Unfortunately, this history of confronting power, especially when it has become so grossly skewed, argues for mobilization and more than a dollop of righteous anger. Perhaps the Lancet-Oslo Commission needed an angry auxiliary to punch home its message more strongly?

Anuj Kapilashrami, Academic, Lecturer/PHM Member                                                                 2014/04/23 

David, thank you for a very interesting blog. I agree with the disconnect that you highlight between the comprehensive account of the crises of global governance and weak recommendations/ directions that are proposed. The Commission is not alone in demonstrating such ‘oversight’. There has been a series of recent calls for ‘radical and transformative’ action, which make due congnisance of the crises and deficits in global governance but end up proposing more institutions, ‘innovative’ practices and framework conventions/ solutions that reproduce the democratic deficit that they set out to critique and address.

I agree with the need for consolidating our knowledge on power, politics and alternatives but I do not believe another Commission is the best way to do so or will add any significant value. Knowledge of power and democratic deficits that are deepended by the operations of global health initiatives and philanthropies exists, albeit ignored or marginalised by the mainstream scholarly and policy debates on global health governance. So consultations and commissions will not generate new insights. There are however other forums – more democratic and people-centred initiatives- which should be given greater voice by journals such as the Lancet and prominence in academic/policy debates. It is true that the global forces of privatisation, neoliberal capitalism and trade liberalisation are not easy to tackle. However, there are encouraging examples of local initiatives and campaigns that are tackling these at different levels and scale. Some of these from UK were presented at the recently concluded 2nd UK wide People’s Health Assembly in Edinburgh. There are several others in other regions. While it is important to collate these examples it is also important to unpack the different components of an alternative vision of governance – in terms of structures, processes and production of knowledge that informs and sustains these.

I agree with the other recommendations but would like to add ‘research and academia’ to the list of institutions that need to reflect on the global concentration of power. Unfortunately, global governance and health systems research networks are becoming increasingly exclusive and elite (a recent call for a HSR conference in London costs £744 for attendance!). There is increasing nepotism in academic networks giving rise to unregulated and uncritical voices reinventing the wheel. We need to reject these! It is a shame that the resolve to ‘redistribute power and shift paradigms’ is not met with joined up thinking or action on platforms such as the People’s Health Assembly and movements. It is fora such as these that instill an optimism around an alternative vision of governance (and world order) that was shared by 100 participants who gathered in Edinburgh two weeks ago – recognised the urgency in “redesigning our political culture and our institutions, globally and nationally” and committed themselves to
i) Challenge the current ideology
ii) Recognise and build on current strengths:
iii) Build solidarity
iv) Develop national and regional action plans through community conversations [Specific recommendations and steps are outlined in the Call to Action]

Rashida Ferrand, Doctor/Academic, Senior Lecturer                                                                                                2014/04/23

Well done David-the only honest voice one has heard in a long time. How would you suggest we help?

Claudio Schuftan, MD, PHM Steering Commitee member                                                                                          2014/04/23

Well done David. This complements the letter to The Lancet sent by several of us in PHM. It was published this week and the Commission (very weakly) responded not really addressing our concerns.