Global Health Governance Challenges

 Is the ‘Golden Era’ of Global Health Now Over? – The Ecological Global Health Perspective

Comment on “Global Health Governance Challenges 2016 – Are We Ready?”

Acknowledgement and Reflection on Themes in Kickbusch’s Editorial

Iona Kickbusch’s paper titled “Global Health Governance Challenges 2016: Are We Ready”(1) suggests that the year 2016 may have been the “turning point” for global health, the rise of new “political realities” and world uncertainties, that tested our governance and economic system(1). She hints at the “global power shift” manifesting, the evolution of “the rise of the rest” and changes in “the nature of multilateralism” and how these political factors, will shape the future of global health(1, 2). Kickbusch makes her points by discussing the letdown of our current development models on advancing health, eliminating inequalities, and serving our most disadvantaged populations(2). She speaks on the shortcomings of present global health governing methods and shares some enthusiasm for global health with current economic expansion in low-middle-income countries(2). The main overarching theme in Kickbusch’s editorial addresses the fluctuating context of global health, the potential for a new approach to global governance and the demand for new governing dynamics(1).

Kickbusch reflects on the year 2015 as a significant year in political agenda setting, with global health at the top of the agenda board. The year also faced global crisis and destabilization which challenged and questioned if the “post-World War II global organizational structures can handle the increasing insecurities the world faces”(1). The United Nations(UN) was critiqued on its ability to deliver during new emerging “political realities”, multifaceted risks and on its current global health governance methods(1). With the increase in displaced persons, refugee crisis and mass migration, Samantha Power, the United States delegate to the UN said the year 2015 revealed “with painful clarity that our existing systems, approaches and funding are inadequate”(1). This was the launch of tests and doubts on our current systems, as the threat of antimicrobial resistance on human, animal and environmental health increased, and the global crisis of non-communicable diseases set forth to destroy the health gains of the Millennium Development Goals(1). This impression of uncertainty and insecurity on institutional adequacy was further elevated after the Ebola outbreak(1). The World Health Organization(WHO) was brutally disparaged on its delayed response during the outbreak and member states questioned if the WHO can and should remain assigned to addressing global health security(1).

Kickbusch further elaborates on the possibility of a new approach to global governance(1). She questions to what extent can global conferences set priorities for global governance and concerns(1). Confronted with considerable global crises in 2015, a multilateralism approach was used, as major global conferences called for consensus on a way forward in international problem-solving(1). Substantial global health commitments like the Sustainable Development Goals and the Paris Agreement were agreed upon at key international conferences(1). Kickbusch rightfully points out that the current success of global health priority-setting is aimed at getting key health objectives on the agenda of major conventions and achieving binding agreements, accountability and funding commitments(1). The successes of global conferences deliver a strong message on multilateralism, however, the extent to which they set priorities for global governance may not be ideal for future concerns(1).

The multilateralism approach revealed that negotiations are challenging, and in a multipolar world where all members agree, is more difficult now than ever before. Multipolarity is predicted to breed more friction as countries toss and settle into a new stance of political and economic power, and the consensus in global negotiations will become increasingly strenuous to attain as this shift occurs(3).

In dissecting the call for new governing dynamics, Kickbusch explores Fareed Zakaria’s concept on “the rise of the rest”(1, 4). A witness of the shift in world politics as the distribution of economic, manufacturing, social and cultural power transition out of United States dominance/control(1, 4).  Multipolarity and the power shift, now open the involvement in global governance to a wider range of states, as more states gain geopolitical status, economic resources and international connectivity(1). This encourages flexible alliance development among states and now reflects on the dynamics of global governance(1). Kickbusch emphasizes the power shift of evolving economics, the restructuring of the global order of power, and the transition of United States as the sole superpower of the multipolar world(3). We need to gain insight on this new “political realities”, evolving economics, and move towards multipolarity, acknowledging the divide between our existing political mechanisms and new institutions evolving(3).

In addressing the changing context of global health, Kickbusch touched on concerns of, if global health can solely rely on western donors. Programs like the UN program on HIV/AIDS and the Global Fund to fight AIDS were rolled out amidst a secure and highly devoted donor environment with minimal competition from other global concerns(1). However, as political attention to global health issues escalates the support from western donors to international health development and aid declines(1). So, what does this mean for the future of global health funding? The power shift has spurred a new global marketplace and the development of new economic institutions like the New Development bank BRICS(Brazil, Russia, India, China, South Africa)(1). The existing OECD (Organization for Economic Co-operation and Development) financial model of allocating states into donors or recipients is unappealing to new financial power as the model of “graduating” from recipient to donor is somewhat antiquated(1). Kickbusch illustrates a “diffusion of power” to more countries and new possibilities for “collective action”(3). So, while western donors may prioritize “national interests and foreign policy goals”, new economic institutions now offer new potential for global health aid(3).

Iona Kickbusch does a valuable service in describing the global health perspective and how the shift of power, a new marketplace and institutions, and a how a fresh approach to problem-solving will shape global health governance(1). She is correct in that the global “diffusion of power” warrants more thought on the link between “health security, social dislocation, financial crisis and the ecological crisis”(1). It is evident that we need to reassess our approaches to global health and attitudes towards the evolving “political and economic environment and ecological challenges”, to transition towards a more sustainable and equitable world(1). This commentary concentrates on the concept of ecological global health with the aim to expand on Kickbusch’s analysis, and add dimension from the context of the ‘golden era’ of global health.

Is the Golden Era of Global Health now over?

The ‘golden era’ of global health is recognized as the “success of policies shaped by multilateral processes, immense monetary aid and success of the actors in addressing infectious diseases”(5). Prior to that, global health was rarely involved in government, diplomacy or international cooperation. The ‘golden era’ is an idea used to explain the obvious changes in global health at the turn of the 20^th thru the 21^st century. Such as, the feature and high priority of global health in international conferences like the G8 and G20 summits and the influx of global funding from a range of resources into global health in the 2000’s, which steadily increased. Some scholars believe that the ‘golden era’ occurred from 2000 thru 2016, a few years after the global financial crisis, thus, the ‘golden era’ of global may now be over(5).

While there were some successful elements in this era, a significant flaw is apparent within its concept. There is an imbalance between global progress and the ecosystems, so while the 20^th – 21^st century development/ advancements have indeed improved global health, it has also undermined the ability to preserve life sustainably and has spawn negative health consequences(6). Today, these consequences endanger the health of both the people and the planet(1). China is a classic example of the correlation between economic growth and global health in the 21^st century(6). While China’s financial prosperity has elevated millions of its citizens out of poverty, we have also seen the emerging pattern of its wealth, and the extensive environmental damage (like air pollution, deforestation, desertification, biodiversity), environmental impact on public health (such as water contamination, soil pollution)(6) and the health risks on its population (i.e. the ‘cancer villages’).

China is an ideal case study on the rise of economic power at the expense of the environment. What made industrialization attainable in China was the use of high-pollutant coal for energy(6). China’s coal consumption over the decade was estimated at 2.3 billion tons annually(6), reaching 2.8 billion tons in the first three quarters of 2017(7) and consuming over 50 percent of the world’s coal today(6, 8). Given the introduction of coal as an energy source in the 1880’s, to the major shift and global transition to coal and oil as the prominent fossil energy source by the 1960’s(9), it comes to no surprise that the global economic development has been harming the planetary ecosystems and deteriorating the Earth’s climatic system(6).

Therefore, to refer to the turn of the 20^th – 21^st century as the ‘golden era’ of global health, is to speak of a sporadic, disconnected progression of improvement, incremental in impact, and shaped by visible effects/changes to the environment. Recognizing these contradictions and conflicts is not to say that the ‘golden era’ of global should be entirely dismissed(6), but rather what has been labelled as the ‘golden era’ might not have been so “golden” after all. As it was contingent upon the rise and inequity of wealth, unsustainable use of resources and the disregard of the adverse effects economic growth produced on the environment(6).

Ecological Global Health: the rationale

Several links between the environment, global health, social equity and human health have been described, and the underlining mechanisms behind these relationships have devised the concept of ecological global health(10). This concept of  “re-imagining public health in a way that acknowledges humans as part of the ecosystem, not separate from it, though not central to it”(10), and calls for the 21^st century to address the mismatch between “business-as-usual economic growth and healthy populations in healthy environments”(6). The risks we face in the 21^st century, are connected to the unintended and untended/neglected consequences of development and change, a sequence of effects on which we must now undertake(1). This means tackling the “combined impacts of rapid demographic, environmental, social, technological and other changes in our ways-of-living”(1). This concept of ecological global health is nothing new. In the 1980’s and 1990’s, several scholars, including Iona Kickbusch aimed to focus on how this concept could be adapted into sustainable development and health promotion(10, 11).

In the face of numerous global health crisis, many solutions have been explored, including the promotion of “resilient systems” like the universal health coverage, as the next grand advancement in global health(1). However, Kickbusch is correct in that such approaches do not dive into assessing the “causes of the causes”, such as high inequity resulting from environmental stress on humans and the planet(1). Thus, we need a new conceptual approach to global health, targets and priority setting(1). The ecological perspective to global health argues that people and ecosystems are co-dependent, hence we can no longer dismiss the health of the ecosystems, nor embrace the fantasies of neoliberalism(12) but rather recognize the interface/boundary of health and wealth in new ways(1).

In 1989, Kickbusch proposed the following principles for ecological global health; “conviviality, equity, sustainability and global responsibility”(10, 11). So, although this concept has long been expressed as a perspective, it has rarely been conveyed systematically(12). However, that is crucial today, in remodelling civilizations, constructing policies, and informing economic choices(12). Ecological conceptual thinking has the capacity to tackle multifaceted dimensions (biological, social, cultural and material) of the human presence on Earth(12). Rayner and Lang, argues that the ecological perspective dominates other models as it “draws on complex science and system dynamics, introduces questions of non-linearity, acknowledges variation in scale, evolutionary mismatch and biological feedback, and addresses the emergent qualities of nature and human behaviour”(12). They explain that it encourages multi-actor and interdisciplinary engagement and promotes the role of social activism in changing and integrating global views on health and politics(12).

Overall, ecological perspective urges one to consider what is meant by progress especially in this era of global health, and questions if health is solely the absence of disease(12). It calls for a global effort in the well-being of humans and ecosystems(12) and promotes the goal of global in the 21^st century as “safeguarding both human health and the natural systems that underpin it”(13).

Global Health Power and Governance

In the comparison of conventional to ecological global health, Rayner suggests that ecological framework has origins from the Victorian era, a period when structural interventions encompassed policymaking and legislature and considered it a vital tool in public health action(10, 14).  So, why is it important to advocate for ecological global health governance now? There have been many dialogues around the possible pathways and governance dynamics needed to tackle global issues like climate change, ecosystem degradation, health and wealth inequality, NCDs, antimicrobial resistance, and the refugee crisis(12, 15). The world of policy is flooded with vast global challenges, that the current political methods seem unqualified and unable OR ill-equipped and incapable of addressing them, which invites either silence or action from policymakers(12).

The existing framework of our international partnerships, model of financial assistance, and investment in economic development, make it apparent that there is still a strong conviction in “harnessing the power of economic growth”, without acknowledging the environmental and social consequences that have resulted from it, certainly in the turn of the 20^th – 21^st century(15). There is a current atmosphere in global health governance that according to some scholars, questions the “legitimacy, ethical content and form of global leadership”(15). For instance, the world order and global governance may be viewed as a sovereign entity that is influenced by a fossil-fuel demanding ‘market-civilization’ and as a result, is slow in the inevitable energy revolution, as it would be followed by an inherent power shift(15). In this matter, Ronald Labonté poses the question, “How can we tame capitalism and the predatory market logic to support human equity and (now) a livable planet? Or, if it cannot be tamed, how might capitalism be transformed into something better fit for human social and ecological survival into a 21st century?”(15).

The need for a paradigm shift to resolve global health issues with rooted links to environmental health and the urgency for a reform is dependent on the reality that global health policies are shaped by political agendas, stakeholder interests, power dynamics, and the international networks of institutions and structures(15). In Jedediah Purdy’s analysis of the politics of the Anthropocene Era – a new age in which mankind has become the main driving force of planetary change –  he argues that “The only way to build a shared living space deliberately is through politics”(1, 16). In Naomi Klein’s lecture on the violence of “othering” in a warming world, she states that “climate crisis must be seen in the context of austerity and privatization, of colonialism and militarism, and of the various systems of othering needed to sustain them all. The connections and intersections between them are glaring, and yet so often resistance to them is highly compartmentalized”(15, 17). Anne-Marie Slaughter has proposed that the Paris Agreement could serve as a model for efficient/effective global governance in the 21^st century, calling it “a bold move toward public problem solving on a global scale”(1, 18).

The Paris Agreement’s creative tactic in integrating hard policy commitments with soft national targets, a method deemed as the (cre`me bruˆle ́e) by Jonathan Pickering et al, has the potential to encourage a flexible response to the changing climate conditions, with a stable structure to unlock progress in the global embrace on planetary health(19). The simple and essential message for policymaking practices is that human health and ecosystem health should be addressed within one unifying framework(12).

A Way Forward

We need to persist in our intent to progressively transform capitalism for the better while laterally, work towards moving beyond capitalism and into a new world order rooted in the preservation of the humanity and ecology(15). We should encourage alternative political and conceptual views to govern and welcome the shared obligation essential in governing societies, the environment in which they live in and the global risks they face(15). Ecological global health should be advocated for within global dialogues, policymaking processes, and among opposing parties, pushing for a better integration of civilization with the environment(12). Hence, the global health community should champion this argument in academic journals, global policy conventions, and actively contribute to collective campaigns to drive a real paradigm shift(15).

Reference:

1. Kickbusch I. Global Health Governance Challenges 2016 – Are We Ready? International Journal of Health Policy and Management. 2016;5(6):349-53.

2. Gill S, Benatar SR. History, Structure and Agency in Global Health Governance; Comment on “Global Health Governance Challenges 2016 – Are We Ready?”. International Journal of Health Policy and Management. 2017;6(4):237-41.

3. Lee K. Business as Usual: A Lack of Institutional Innovation in Global Health Governance Comment on “Global Health Governance Challenges 2016 – Are We Ready?”. Int J Health Policy Manag. 2016;6(3):165-8.

4. Zakaria F. The Rise Of The Rest2008. Available from: https://fareedzakaria.com/columns/2008/05/12/the-rise-of-the-rest.

5. Firliani A. End of golden era of global health governance: What it means for women. The Jakarta Post. 2018.

6. Lang T, Rayner G. Beyond the Golden Era of public health: charting a path from sanitarianism to ecological public health. Public Health. 2015;129(10):1369-82.

7. Ye Q, Lu J. China’s coal consumption has peaked Brookings  Insitution: Brookings  Insitution; 2018 [Available from: https://www.brookings.edu/2018/01/22/chinas-coal-consumption-has-peaked/.

8. World coal consumption, top 10 countries, 2017 Eniscuola Energy and Environment: Eniscuola Energy and Environment; 2018 [Available from: http://www.eniscuola.net/en/mediateca/world-coal-consumption-top-10-countries-2017/.

9. Fossil Energy Study Guide. Energy.Gov: https://www.energy.gov/sites/prod/files/Elem_Coal_Studyguide.pdf.

10. Bentley M. An ecological public health approach to understanding the relationships between sustainable urban environments, public health and social equity. Health Promotion International. 2014;29(3):528-37.

11. Kickbusch I. Approaches to an ecological base for public health. Health Promotion International. 1989;4(4):265-8.

12. Rayner G, Lang T. Ecological public health. Health of People, Places and Planet. 2012;617.

13. Whitmee S, Haines A, Beyrer C, Boltz F, Capon AG, Dias BFdS, et al. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health. The Lancet: The Rockefeller Foundation–Lancet Commission on planetary health; 2015.

14. Rayner G. Conventional and ecological public health. Public Health. 2009;123(9):587-91.

15. van de Pas R. Global Health in the Anthropocene: Moving Beyond Resilience and Capitalism Comment on “Health Promotion in an Age of Normative Equity and Rampant Inequality”. International journal of health policy and management. 2016;6(8):481-6.

16. Purdy J. After Nature: A Politics for the Anthropocene: Harvad University Press; 2015.

17. Klein N. ‘Let Them Drown: The Violence of Othering in a Warming World’. 2016.

18. Slaughter A-M. The Paris Approach to Global Governance. Project Syndicate. 2015 12/28/

2015 Dec 28.

19. Pickering J, McGee JS, Karlsson-Vinkhuyzen SI, Wenta J. Global Climate Governance Between Hard and Soft Law: Can the Paris Agreement’s ‘Crème Brûlée’ Approach Enhance Ecological Reflexivity? Journal of Environmental Law. 2018:eqy018-eqy.