Last week the elite of Global Health gathered in Bangkok for the Prince Mahidol Award Conference. This annual invite-only event attracts Global Health leaders from around the world, as well as practitioners and researchers from South East Asia. While previous years have covered infectious disease, UHC, equity (i.e. the usual), what was special about this year was the original theme, The Political Economy of NCDs, making it the first Global Health conference to address explicitly political economy – an exciting prospect.

Yet as the conference drew to a close I was overwhelmed with the same familiar feelings of frustration and hypocrisy that I have got used to at Global Health events. I know these sentiments are echoed by many friends and colleagues. My hope is that by publicly articulating my feelings (in more than 140 characters), we can begin to help transform our disappointment, frustration and anger even, into something more useful.

DISCLAIMER: I am hugely grateful to the ever-impressive PMAC Secretariat, and all those who worked so hard to make this conference a reality. This is not meant as a critique of anyone in Thailand involved. However, by design, PMAC delegates power to the Organizing Committee, made up of the co-hosts (see below), described by Margaret Chan during the conference as a “who’s who” in Global Health. This blog is not aimed at anyone in the PMAC Secretariat, but it is aimed at everyone in Global Health – and especially those associated with these organizations.

PMAC co-hosts: the “who’s who” of global health

The political economy of PMAC

Leading up to the event, over the last nine months I had the opportunity to participate in the organization of PMAC at various planning meetings. I soon realized that what I was observing in these meetings was a microcosm of Global Health. Around the table, representatives from all the big players; speaking freely, but also defending their institutional perspectives, and protecting their own Global Health ‘territory’.

As conversations digressed from the minor matters of the conference sessions, to the mega matters of how PHC and UHC are related, I saw that this opportunity was in fact a unique window into the political economy of Global Health: how the unbalanced distribution of power and resources play out, to amplify some perspectives over others, ultimately to shape the agenda and control outcomes.

Although in this case the outcomes were fairly benign – the structure and content of a conference – the discussions were fascinating and, while being under Chatham House rule, I cannot share details of who said what, I can share my critical reflections on what I saw and heard. Combined with my experience (and participant observation) at other Global Health fora, below I outline what I have learned about the political economy of NCDs, and of Global Health.

Civil society is being systematically disempowered

In political economy terms, the funding organizations civil society organizations (CSOs) rely on use their resources and material power to control what activities are and are not funded. To paraphrase the proverb, it is hard to bite the hand that feeds; especially when that hand has paid for your airline ticket and is feeding you a three course dinner at a five star hotel. While it is important to have a seat at the table, that table is not an even one and power asymmetries perpetuate. Voices are heard and respect is given, but it is a bitter sweet respect that leaves a sour taste in my mouth.

In the world of NCDs beyond PMAC, civil society are being steered towards certain actions over others. CSOs are being offered funding and partnerships that focus on treatment and access to services. For all organizations, funding to work on the prevention of NCDs is limited. Funding to work on the drivers of NCDs (including the commercial determinants) is even harder to come by. All these issues reflect broader challenges around partnerships that the SDG era presents in its opening of the floodgates to the private sector. 

The conflation of treatment and prevention may be problematic in tackling NCDs

Within Global Health, the issues around NCDs are being framed in terms of treatment solutions. Solutions that, for example, often involve public private partnerships to accelerate access to pharmaceutical products. This issue was evident in the UN General Assembly high level week (leading up to the 2018 High Level Meeting on NCDs), where only four out of over 50 Global Health side events mentioned prevention. Although in contrast, prevention was very clearly on the agenda at PMAC, the discussions soon returned to circular debates over engaging with “health harming” industries such as food and alcohol. This clip illustrates the situation at PMAC, where civil society (the People’s Health Movement and NCDFree) felt they had to interrupt the plenary to have their voice heard, to help support the brilliant panelist Kwanele Asante’s points. My analysis: if, as to quote Rhea Saksena, civil society are in “an abusive relationship with industry”, Global Health is an uncomfortable third wheel in this long-term relationship between Public Health and trans-national corporations.

The commercial determinants of health are at the top of everyone’s intellectual agenda – but action is not being funded

The most energized and well attended session at PMAC was the excellent People’s Health Movement-led session on the commercial determinants. Although the atmosphere was one of activism the audience contained a range of delegates, including from all those on the “who’s who” list.  Engagement with industry was THE issue of the conference. However, as illustrated in the plenary video clip, the discussions did not progress and likely only served to re-enforce pre-existing assumptions on both sides. While the importance of tackling the commercial determinants is widely agreed, as mentioned above this is not reflected in funding flows (articulated on Twitter by Professor Kelly Lee ). This highlights the challenges for Global Health actors to implement research and projects that may displease their donors; donors who are beholden to private capital flows that may well be invested in the products that public health evidence now shows to be so harmful. In other words, the political economy of Global Health in action.

This brings me to a tautology that I think is worth repeating:

Public Health and Global Health are not the same

Public Health being “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988; WHO). Global Health, here, being the self-identifying group of institutions, actors and individuals who work on issues that affect global public health (my own working definition). In NCDs, arguably more than for infectious disease, this distinction needs to be maintained. While in reality it may be hard to separate the two endeavors, conflating them conceptually is an issue. Both are political, however, Global Health – as a product of a certain time and place – cannot be taken out of the global political (and economic system) that created it. Public Health is here to stay, Global Health may not have the same longevity. 

Global Health is part of the neoliberal global political economy

The global political economy is one dominated by the ideology of Neoliberalism, which places the individual and free-market at the centre. As I suggest above, Global Health is a product of the Neoliberal era (Public Health is not). While changing the rules of the economy is clearly beyond the remit of both Global and Public Health, failing to situate our endeavors within this bigger context is a problem. Once we understand Global Health as inseparable from Neoliberalism, we can begin to get to the root causes of why so much of the world are being “left behind” from global goals. To ignore its influence is to deceive ourselves and the people we are trying to serve.

Once we understand Global Health as part of a system that has increased global inequalities and inequities, it seems strange to expect it to do the opposite – to “reduce inequities” e.g. as part of Agenda 2030’s leave no one behind pledge. This is the paradox at the heart of my frustrations with Global Health.

The appropriation of ‘political economy’ by Global Health actors could distract from understanding the political economy (and underlying issues of power) within Global Health

Finally, there is a danger that by holding a conference on political economy, by self-congratulating ourselves on seeking to address the issues of power and inequality in NCDs, a box is ticked and we move on. There is also a danger that the appropriation of the term by powerful players is a dangerous move. We need more political economy analysis of Global Health and its institutions. But who will fund it? Who will publish it?

The aim of PMAC was to: “identify major bottlenecks, root causes and propose solutions at national and global level to accelerate implementation of NCD prevention and control”.  While it certainly fulfilled the former objectives, unsurprisingly, solutions to root causes were not forthcoming. This raises the question: should an elite UN dominated Global Health conference be dabbling in political economy? I am not so sure.

Moving forward…

To conclude, I offer a few tentative suggestions for those who are also frustrated with the current status quo in Global Health.

1) Let’s leave Global Health to do its business: to protect us from pandemics, to fight infectious disease, to find the cure for cancer, to work towards Universal Health Coverage, to give us all the data it can generate.

2) Let’s leave the UN system to its work with member states, in safe-guarding norms, and aspiring to global goals.

3) In the meantime, let’s use the data Global Health generates more smartly – to show what is not happening as well as what is. And to use more political economy analysis to help show why.

4) Let’s dumb down the messages around NCDs, so that members of the public all over the world can understand the issues and causes of injustice. Let’s tell the stories behind numbers in ways that people can understand, communicated in forms they utilize (clue: not case studies!).

5) Finally, and most importantly, let’s be inspired by people like Thailand’s Dr Suwit, to be champions, to not give up on what we believe in (for me, gender equality, equity and social justice).

But let’s also be realistic: Global Health is great for measuring things and improving health security; it is not necessarily the right place for people who want to tackle injustice, and change the world in the many ways it so urgently needs changing.

*****************************

As we mark 100 years since up to 40 million people were killed by the influenza outbreak of 1918-19, it is daunting to acknowledge that, despite huge gains in health and medical technologies, the world remains ill-prepared for the next pandemic. For the 50% of the world’s population lacking access to essential health services these risks are amplified. As with other global challenges (most notably, climate change), ‘business as usual’ is no longer an option for those working in global health security. This is true for states, who have the responsibility to fulfil the right to health; for UN agencies mandated to support global goals like Universal Health Coverage; and for the plethora of state and non-state actors who are committed to deliver Agenda 2030, and its grand pledge to achieve equity by ‘leaving no one behind’.

The private sector – and the innovations it enables – is vital to the positive disruption of this global status quo that has left us all at risk from health threats. However, unlike governments and international organizations, private sector actors are not bound by legal or other frameworks to deliver products or services in a way that is equitable. While improved health security may be an outcome of innovation, current market logic does not prioritize based on global health needs; and however progressive a company may claim to be (e.g. in terms of delivering social impact), its ultimate purpose is to maximize return on investment.

Through research and events, The Centre on Global Health Security at Chatham House examines such issues. In 2017, the Centre hosted a conference on the role of the private sector in global health, looking at the opportunities, challenges, and tensions that arise when mixing commercial interests with public health ones, for example in Public Private Partnerships. Last week, the discussions continued, with a specific focus on harnessing the role of technology in global health security. For the first time, a wide range of practitioners, academics, policy makers, and developers from the private sector came together to explore how new technologies (medical and non-medical) are being utilized towards global health security. Representatives from international agencies including World Health Organization, Bill and Melinda Gates Foundation, United Nations Development Program, and the Global Fund, sat alongside innovators from a range of tech companies, who offered insights as to how their work could positively reinforce health security.

The conference heard about methods to keep vaccines cold in contexts without regular electricity; about how artificial intelligence (AI) can drive efficiency gains in healthcare and epidemic forecasting, and how empowering health workers through better data can improve patient care and stem the spread of disease outbreaks. But we also heard about the challenges and obstacles that are impeding progress. For example, there is often a disconnect between the developers’ perceptions of new technologies and those of the end users. This disconnect may result in a product or service being deployed to a country where there is no expertise for its maintenance; or an appliance being developed for the wrong voltage. How often do developers in the global north consider the very real problem of dust when designing for LIMCs? Does everyone actually have a smartphone? Even if they do, is there reliable electricity to charge it?

Panelists including Mariângela Batista Galvão Simão, WHO Assistant Director-General for Drug Access, Vaccines and Pharmaceuticals, discuss the importance of collaboration for innovation.

The conference also highlighted how existing inequities – for example, around access to connectivity and infrastructure – are being reproduced and amplified in the development and deployment of innovative tech. When it comes to R&D, ‘diseases of the poor’ like TB and cholera (and, until very recently, Ebola) are systematically neglected by private funding bodies, due to lack of commercial incentive. New ways of supplementing the market logic are thus needed to progress developments in global health security – for drugs, for diagnostics and for better data. AMR was highlighted as a ‘market failure’; a symptom of the shortcomings in the current system, but the impact of which will affect both rich and poor.

The current regulatory environment inhibits the adoption of existing technologies in the developing world. Key unanswered questions here include: how can incentives around risk-taking be reversed so that the benefits of scientific advances are not held back for years, or even decades? How can business be incentivised to pursue social as well as financial goals? How can technological innovation itself ultimately become a global public good, as asserted by Mariângela Batista Galvão Simão?

Big data holds big promises for global health security. For example, AI is enabling us to move from disease surveillance to ‘disease intelligence’. There is also great potential for healthcare workers to be empowered through their use of technology. By accessing real-time analytics of the data their work generates, those on the front line can make evidence-driven decisions without sacrificing time to centralised, ineffective or slow information systems. If this new technology is to be adopted, it must be tailored to the environments where it will be deployed and, to put it simply, users have to like using it.  On top of this, we must balance individual ethics and privacy concerns – as one speaker put it, “the right to be not counted” as part of general data ownership and management. How to share data efficiently, and ethically, will also be crucial.

But if one issue emerged most clearly throughout the conference, it was this: the optimistic spirit of the tech sector, and the potential of the technology itself, is in conflict with the world’s politics and power structures, and this conflict keeps those at the bottom end of the equation out of view. The politics of technology in global health security are a reflection of politics in general: the best new tech is concentrated in wealthy countries, and serves best the interests of the powerful.

We must not fall into “a critical app-ification” of solutions to global problems; there are no easy solutions or magic bullets when facing the entrenched social, economic and political issues that produce health inequity. The internet has not ended poverty, drones have not solved procurement problems in countries with poor infrastructure and blockchain technology has not ended corruption. As ever smarter phones, AI, blockchain, and other technologies become the norm, we must not forget that “technology will have the most impact for global health security when it reaches those with the most insecurity” (Rosamund Southgate, MSF). Technology that relies on a reliably functioning power supply or a robust public health system may only ever have limited impact in many contexts. Yet, it is in these contexts, where systems are weakest – where health security is weakest – that people have the most to gain from access to better technologies, whether existing or new.

If necessity is the mother of invention, how can we ensure those in most need gain most benefit from today’s inventions? This is the challenge for our time and make no mistake, your health security depends on it.