Dissonance: Def. 1. n. A harsh, disagreeable combination of sounds; discord, 2.n. Lack of agreement, consistency, or harmony; conflict (The Free Dictionary). This is the sentiment that stayed with me after having participated in the 5th global conference on Health Systems Research in Liverpool and directly afterwards, the 10th World Health Summit in Berlin. This reflection was triggered by a recent tweet from Kate Raworth in which she referred to the rather conflicting messages for mankind coming from the latest IPCC report on the one hand, and the annual IMF/WB meetings in Bali on the other – “The history books will remember us as The Age of Dissonance, whose international institutions were simply unable to connect ecology and economy.” The (seductive) narrative of Leaving no one Behind, the discourses around accountability, and creation of more and more partnerships and sustainable innovations for global health are not in tune with recent (and increasingly common) events such as storm Leslie crashing into the Iberian peninsula or hurricane Michael devastating parts of Florida. The sustainable development discourse ignores the fact that the world economy is more vulnerable than ever, with worldwide debt now at $164 trillion, roughly equivalent to 225 per cent of global GDP, and up from a previous record of 213 per cent in 2009. The call to “Ensure healthy lives and the wellbeing of all people” (SDG 3) feels almost dishonest in the light of so many migrants fleeing violence and impoverishment from places as distant as Honduras and Syria, or being locked up in refugee camps in Nauru or Lesbos.
While it is encouraging to see that the academic and policy debate on health policy, systems and research is becoming less superficial and more thoughtful in its proclaimed aim to challenge power, politics and inequity, it is less clear whether the health systems global community itself has powerful agency, or whether the political actors it tries to engage in order to make change possible, are appropriate. During HSG2018 the onus was put on domestic finance, country processes and governance, at the same time, there was very little discussion around actual globalization and health policy pathways and politics that structurally limit or enable health systems to function. Issues like restrained policy and fiscal space in which to invest in health systems due to the effects of economic global straightjackets, the financialisaton of health care, capital flight and tax evasion were not explored or questioned. All in all, it is not so strange that HSG2018 did not delve into these issues, as the conference is financed by major global health actors & institutions, governments and philanthropy all of which adhere to the main SDG narrative of partnerships and convergence, rather than one of (global) discord and conflict.
Real power, money and politics were to be found at the World Health Summit in Berlin. After 10 years, the German capital has become a de facto core Global Health hub – if one did a social network analysis of key actors in Global Health, Berlin would no doubt have been a big red dot on the map, last week. The place felt like a beehive, with swarming bees everywhere and honey to be found! This development is remarkable as at its launch in 2009, the legitimacy of the WHS was seriously questioned, with Medico International saying “instead of creating a new body sponsored by the pharmaceutical industry, it would be better to strengthen the existing structures of the World Health Organization.” Yet for better or for worse, a WHO reform proposal (par. 87) to create a World Health Forum in Geneva was rejected by the World Health Assembly in 2011. Fast forward to 2018, when it is, in fact, the director general of the WHO, Dr. Tedros, who came to Germany to launch the multilateral Global Action Plan for health and wellbeing for all at the WHS, and present WHO’s investment case to funders (notably the Gates foundation, Germany and Norway). There is a certain wry irony in the fact that philanthropy shapes (to a large extent) the current global health agenda and it is also used as a resort to try “save” liberal multilateral health governance. Then again this is not new in history – we have seen the Rockefeller Foundation doing something similar before and after World War II.
However, the real dissonance in these global health fora comes from the fact that they neglect to address some of the crucial issues of our times and, indirectly, in this respect, continue to defend a politico-economic order that keeps preaching the (nowadays, “inclusive”, “sustainable”, … take your pick) economic growth gospel as a magic solution to improve health and development outcomes.
The latest International Panel on Climate Change (IPCC) report predicts that we can reduce emissions fast enough to keep under 1.5 degrees, but only if we’re willing to fundamentally change the logic of our economy. It calls for a scaling down of global material consumption by 20 percent, with rich countries leading the way. This approach requires that we evolve beyond the rigid constraints of capitalism, a system which clearly is not fit for purpose in the 21st century, with planetary health boundaries knocking increasingly at our door. Co-incidentally, the 50th anniversary summit of the Club of Rome also took place last week. In a new report to the club of Rome, called Come On! the authors call for a ‘new Enlightenment’, characterized by a vastly improved balance between human beings and nature, and between private consumption and public goods. This call for a circular economy is politically very uncomfortable, but urgent and by now more than overdue: the original Limits to Growth publication and recommendations from 50 years ago turn out, decades later, not to have been too far-fetched...
So, are enough of us, “humans of late capitalism”, able to connect the dots in Global Health? Will we be able to connect the dual aims of social and ecological justice? At the heart of this debate is a (global) political conflict around what is required to advance human wellbeing and planetary health. It is about Economic man vs. Humanity. It is time we bust the SDG myths of multi-stakeholder partnerships and of being “one happy family”, in order to ensure that “no one is left behind”, and instead focus on different narratives and collaborations of hope. As decent people we need to take serious and fair climate and economic action, as this is the best way to deal with living in conditions of crisis and violation, and fuel our spirit, conscience and society, in order to advance global health equity.
Health for All in the 21st century demands no less.
Footnote: having said all this, as global health researchers, we also need to tackle the cognitive dissonance within ourselves. I flew back and forth between Liverpool & Berlin last week. In this new era we have to adapt and organize in different ways, in order to reduce our carbon footprint considerably.