To no one’s surprise, the Lancet-Oslo Commission did not withdraw its disappointing recommendations on global governance for health. In an earlier blog, I criticised the Commission’s failure to act on its own analysis of the impact of politics and power disparities on global health. It called for more research and evidence and another global multi-stakeholder talking shop; but it did not call for anything that would challenge the vested interests that block progressive change.

I suggested three possible explanations for the weak recommendations. One was that the commissioners actually believed that their recommendations were sound and strategic. The second was that the commissioners couldn’t agree on a more politically ambitious set of recommendations and settled on ones that were acceptable to all. The third was that the commissioners may have sub-consciously censored themselves in order to avoid appearing too radical or confrontational, especially in the eyes of those who wield power and influence.

Since publishing my blog, I’ve had private conversations with several commissioners and members of the secretariat, and a face-to-face meeting with Ole Petter Ottersen (Rector of the University of Oslo and Chair of the Commission). Two commissioners (Sigrun Mogedal and Desmond McNeil) posted public responses to my blog; and one wrote to me privately.

From these interactions, I learnt that there were indeed different and contested views amongst the commissioners. While some were unhappy with the final recommendations, others disliked the strong political analysis but were then appeased by the soft recommendations. I was told that the Harvard School of Public Health withdrew from its original intention to co-produce the Commission report because partly because of the strong political language of the report. I was also told that Julio Frenk (Dean of the Harvard School of Public Health and a commissioner) had argued against the use of words like ‘capitalism’ and ‘colonialism’ and pushed for moderate recommendations that would meet widespread multi-stakeholder consensus.

In their replies to my blog, Sigrun Mogedal and Desmond McNeil defended the recommendations. Although Sigrun admitted that “smarter and stronger” recommendations and more concrete proposals “for a new economic world order” could have been produced, she believed that the Commission had set out sound “incremental steps” for reform. Similarly, Desmond implied that having conducted a “rigorous analysis of the multiple political causes of the current inequitable situation”, the recommendations were designed for an audience who still needed some convincing and persuasion about the analysis. [See here for their comments in full]. A third commissioner explained in private: “we did not see how ‘unequal power’ would ‘go away’ from global governance in the near future, hence we came up with modest recommendations – and we admit they are insufficient”.

These justifications of the recommendations were, however, accompanied by recognition that political action was also required. For example, in seeing the need to reject the current global order, Sigrun called for a “revolution” and for “strong movements around the world to show their anger and call for change”. Desmond explained how the Commission’s report would complement the more overtly political analysis of the Peoples Health Movement and the actions of activist organisations. The third commissioner also recognised the need for popular mobilisation by saying that “real change will come only after the common people of powerful states will have understood that poor global governance for health is bad for their health as well, and when they will start building alliances with the common people of less powerful states.”

These comments are illuminating because they raise questions about the role and purpose of global health ‘commissions’ and ‘expert groups’. They suggest that the role and purpose of such actors are primarily to conduct analysis, provide evidence and participate in polite discussion with those who wield power and influence in high-level forums, meetings and conferences; while resisting harmful policies, challenging oppression, confronting power and rebelling against injustice are actions conducted by ‘activists’ and ‘social movements’, presumably at a distance from conference halls and meeting rooms in Seattle, Washington, New York, London, Geneva and other cities.

Thus, having called for radical and transformative change, it seems as though some commissioners are proposing a twin-track approach. The first track may be characterised as ‘participating in governance’ where one works with those who govern and wield power around a set of non-confrontational recommendations produced by experts; while the second track may be characterised as ‘engaging in social struggle’ where one confronts power and fights for justice and a redistribution of power. In this twin-track world, struggle doesn’t take place in the structures and spaces of global governance where decisions are made by ‘consensus’: global health experts avoid acting defiantly, but participate with strategic politeness, perhaps in recognition of the fact that one can’t challenge or de-legitimise those actors with whom one is simultaneously seeking to arrive at joint solutions.

The incorporation of elites, big business and private actors (including professionalised and corporatized NGOs) into major decision-making structures and processes under the guise of public-private partnerships is one of the defining features of globalisation. But together with trends in university funding and management that have weakened academic independence and critical public-interest scholarship, as well as public health policy approaches that privilege ameliorative and technological solutions over social and political change, it is also a feature that blocks the transformative and radical change called for by the Lancet-Oslo Commission. If so, the Commission’s recommendations ends up legitimising a blockage to social progress; and in doing so, distort the meaning of progressive transformative change.

Richard Horton, Chief Editor of the Lancet, asked what I would have recommended instead. My answer would include a set of ‘ready-made’ policy, legal and technocratic prescriptions which have been crafted by various other experts in the field of global economic governance such as the New Rules for Global Finance Coalition. However, I would also say that social and political change requires social and political action, which means mobilising communities and ordinary people. Furthermore, if we want change that is transformative and progressive, it means mobilising communities and people against powerful and vested interests. In this sense, there are no prescriptions. Actions need to be tailored to particular contexts and to different actors – including academics, technocrats and expert groups who can choose to support progressive social struggles in many different ways.

This does not mean that global health experts and public health professionals should abandon pragmatism, or dialogue and negotiation with those who wield power and influence. We should do what we can to mitigate the effects of socially unjust world by, for example, promoting access to health care or developing new technologies. We may even want to persuade multinational corporations to be more socially responsible or encourage the rich to be more charitable. But these are rarely steps that reduce power disparities or lead to progressive transformative change.

So perhaps the Harvard School of Public Health is correct to avoid ‘politics’ if it seeks to work through the anti-political structures and culture of the ‘partnership’ approach to global governance that is shaped by the rich and powerful. It would be a shame, however, if words like ‘capitalism’ and ‘colonialism’ are denied their academic and scientific meaning, and removed from any technical analysis of the current state of global health.

The Lancet-Oslo Commission has now established a scientific panel (as it recommended) that will look more deeply at the role of trade and investment agreements in shaping global health outcomes. This is a promising development. Few things are more important to global health (including our desperate need to prevent climate catastrophe) than rectifying the ethical and democratic deficits in the way that trade and investment laws and policies are fashioned. We should look expectantly towards the work of this panel and how it will apply evidence to social struggles for health equity that are taking place across the world.

More by David McCoy:

The social, political and ecological pathologies of the Ebola Crisis cannot be ignored

David McCoy

David McCoy

Professor of Global Public Health at Queen Mary's, University of London
David is a public health physician and academic, and former Director of Medact.

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