Global Health Working Group Promotes Ebola Open Letter

Last week a Workshop was held at the Centre for Global Health Policy at the University of Sussex which brought together a number of scholars, primarily UK-based International Relations scholars, to discuss the current Ebola crisis and the international response to it.

From this workshop arose an open letter on what the field of International Relations offers in terms of learning the lessons from the Ebola response:

The Ebola outbreak in West Africa has brought to light some important issues and tensions in global health, ranging from the institutions that have been created to service the international community – such as the World Health Organization (WHO) – to the role of governments, politics and ideas in determining how, where and what health issues are addressed. Failings in the management of and response to the Ebola outbreak have sparked a debate about the efficacy of the system of global health governance. This is a necessary debate for the global health community to engage in. When the time comes, we believe that analysts of global health politics and international relations have several valuable insights to help ‘learn the lessons’ from the 2014 Ebola outbreak.

First, on institutional reform: The Ebola outbreak has been an exceptional event. It should not be assumed that lessons drawn from this single event can provide a template for redesigning the everyday workings and agenda of an institution such as the WHO. The WHO has certainly made mistakes in the Ebola response, and these need to be recognized and addressed. However, the efficacy of its Ebola response is not the only metric by which this institution should be judged, nor should Ebola be used politically as an opportunity to further undermine the WHO.

Second, on institutional innovation: We have observed recent calls for the creation of a new international ‘rapid response’ agency for health emergencies. Clearly in some cases rapid response is of the utmost importance, and enhanced rapid response coordination and capacity is needed. However, emphasising rapid response to the detriment of other solutions is problematic, inasmuch as the former is by its very nature ill-suited to building long-term solutions to deep-seated problems. The international community must also be careful that creatingsuch a body may be counterproductive, by shifting attention away from the important task of strengthening in-country health systems which are best-placed to be first line responders to health emergencies.

Third, on the relationship between global health governance and national health systems: Any investigation into institutional failings in the response to Ebola in 2014 must be cognizant of the wider system of global health governance that has dominated questions of African health reform since 2000. A knee-jerk “blame game” of “who did not do what when they should” will only provide a veneer of accountability. Instead, we need a systematic unravelling of why health systems were so poorly developed in Guinea, Liberia and Sierra Leone. Here, reflecting on the impact of the goal-oriented mentality underpinning the Millennium Development Goals agenda cannot be avoided. We must also consider the roles of the actors (state and non-state) that have supposedly been responsible for supporting these health systems, and what they could have done better. The results of such analyses could go some way to providing the basis for thinking about how to build a more sustainable model of global health governance.

Fourth, on the centrality of politics to all institutions: Attempting to separate politics from the technical workings of institutions is a useless exercise – and a potentially dangerous one. All global health institutions are engaged in the management of resources, expectations and the interests of a myriad of state and non-state actors. They have to engage in political brokering, negotiation, leadership and policy design and implementation. The idea that international institutions can or should be “apolitical” has only contributed to limiting their agency, whilst obscuring the real politicking that occurs within and between these institutions. ‘Politics’ is not the problem, and it must be part of the solution.

Fifth, on power and inequalities: Contrary to a much-repeated refrain, disease does know borders. These borders may be those that separate nation-states from one another, but they can also be cultural, racial, economic, or gendered. Access to information and adequate healthcare, as well as exposure to health risk, are not equally shared but rather are dependent on a multitude of local, national and international divisions – not least inequalities in power and wealth. These need to be acknowledged, understood and deconstructed if we are to finally make good on the promise of delivering ‘health for all’.

The recent Ebola outbreak in West Africa – the latest in a depressing series of outbreaks in this region in recent decades – has highlighted the extent to which global health policy has become reactive rather than proactive. A failure to take bold political action in addressing the concerns we have highlighted in this letter will mean that the global health community will remain ill-equipped to respond to future outbreaks, still less to prevent them occurring.

Should you or any of your colleagues wish to sign this open letter please email Sophie Harman (s.harman@qmul.ac.uk) by Midday UK time on Monday 8th December with: ‘Please add my name to the open letter, *name and *institution’.

Global Health Watch 4: Critique and Hope for a Healthier World

In this guest post, Ronald Labonté announces the release of Global Health Watch 4. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

globalhealthwatchToday marks the release of the 4th ‘Alternative Health Report’, widely seen as the critical voice for a more health equitable future. This fourth edition joins three previous ones released in 2005, 2008 and 2011; and readers new to the GHW and its family of reports should consider perusing these for their many still contemporary and important insights. All three earlier editions are available for free download from the Global Health Watch website (www.ghwatch.org), as will be the new 4th edition sometime in late February or early March 2015, by arrangement with its publisher, Zed Books.

Global Health Watch 4, like its predecessors, has been a collaborative effort by activists and academics from across the world, coordinated by the People’s Health Movement, Asociacion Latinoamericana de Medicina Social, Health Action International, Third World Network and Medact. All four editions of the reports are intended to provide health activists with the knowledge tools and mobilizing ideas to challenge the pathologies of a persisting neoliberal political economy. Indeed, unpacking that political economy has been a recurrent theme in all four editions, and the first section of the new report is build around a detailed account of the health crises of neoliberal globalization and the health damaging fiscal policies of austerity in Europe. Rather than see the financial crisis of 2008 and its subsequent ‘Great Recession’ as a regrettable ‘one-off’ of contemporary capitalism, these early chapters regard these recent events as extensions of a 40 year uncontrolled global experiment in neoliberal economic orthodoxy, an orthodoxy once described “as a belief that ‘the nastiest of men for the nastiest of motives will somehow work for the benefit of all’” (p. 12). There are signs of hope on offer, by way of evidence-informed policies that, if chosen, could steer the toxic ship of finance capital and rampaging inequalities around through re-regulation of global finance, rejection of austerity, increases in progressive national and global taxation, a clean break with the fossil fuel economy and continuous efforts to reclaim public discourse. There is some movement in all of these areas. Even austerity’s fiscal contractions, by no means restricted only to Europe, are increasingly under attack on both empirical and ethical grounds. But public health activists need to keep the pressure on.

Some of the evidence for alternatives to the dominant global economy can be found in popular struggles in Latin America, and it is not accidental that GHW4 gives considerable space to many of the health systems and broader social innovations taking place in that region of the world. But as GHW4’s second section, drilling down on contemporary debates in health systems reform, not all bodes well. Despite the new emphasis being given to ‘Universal Health Coverage,’ public health systems in many parts of the world continue to be underfunded and under attack by private capital:

The fight for a just and equitable health system has to be part of the broader struggle for comprehensive rights and entitlements. To take this struggle forward, the dominant interpretation of UHC today – weakening public systems and the pursuit of private profit – needs to be understood and questioned (p.2).

From successful primary health care roll-outs in Brazil and promised tax-funded health insurance coverage in South Africa, to ongoing efforts to roll back the heavily privatized markets in countries such as Colombia and India, to the dismal efforts of the World Bank’s International Finance Corporation to incentivize private capital and actors to provide health care to Africa’s poorest, the struggle for equitable access to quality health care that is progressively financed continues to dominate health social movement efforts. As earlier GHWs, and the chapter on the TRIPS agreement in this 4th edition, warn, these activist efforts will continue to be challenged by the expansion of intellectual property and investors’ rights through new generation trade treaties, and ongoing efforts by transnational service industries to hive off more public sector services.

These trends are becoming most apparent in the important ‘beyond healthcare’ domains of public policy that govern social determinants of health:

  • social protection policy: high on the radar of international agencies but lacking the necessary commitments to changes in labour markets and taxation to make pre- and post-market incomes more equitable and social protection more extensive and sustainably funded
  • non-communicable diseases: where public health policies to reduce the commercial vectors of transmission may run afoul of trade and investment treaties
  • and the persisting devastation of extractive industries: with a particular nod to the role Canada has been playing as a safe tax regime for some of the most polluting mining transnationals in the world.
GHW4 Image A1.3 Demonstration in Bali in December 2013: demands to curb corporate power have grown (Benny Kuruvilla)

Unfortunately, as GHW4’s continuation of its ongoing ‘Watch’ on the World Health Organization finds, the world’s voice on global health is still muted on these and other issues by its financial woes and “is under continuing pressure to retreat to a purely technical role and to withdraw from any effective engagement with the political and economic dynamics that characterize the global health crisis” (p.5).

As with previous editions, GHW4 concludes with stories of resistance and struggle. Latin America again is prominent, evidence of the profound social and political changes that have characterized that region as a focal point of neoliberal opposition. But resistance is global. From India’s right to food movement to Australian Aboriginal controlled health services, GHW4’s final section illustrates that popular health struggles continue, community-controlled services work, and globally linked movements represent an ‘optimism of the will’ to counter the too-often experienced ‘pessimism of the intellect’ (with apologies to Gramsci). There is no pretense that these oppositional struggles will succeed. But what GHW4 represents, in its inception, development, writing, editing and production, and in the very content it creates, is a self-conscious effort to overcome the individualization of our social, political and economic lives that has been the thrust of the 40 year neoliberal project, through a deliberately collective endeavour to re-ignite the soul of solidarity.

The Scottish Referendum and Health Equity

In this guest post, Beth Thomas discusses what the Scottish Referendum means to her as a medical student and as a citizen of Scotland. Beth is currently a final year medical student at the University of Glasgow who has been working with Medsin UK for the past 5 years. She is currently the Scottish and Northern Irish Coordinator of Medsin UK and as such has been working on numerous campaigns including promoting health equity in Glasgow.

The referendum to decide whether the people of Scotland want independence from England is only days away, and everywhere you turn as a voter in Scotland you are faced by a barrage of information regarding the pros and cons of a yes or a no vote. And yet, whichever way we vote on the 18th of September, a fundamental truth remains; that this will be a pivotal moment in Scottish history. A moment when the government of Scotland, be it as an independent country or as a more devolved part of the United Kingdom, will have an opportunity to set an agenda to revolutionise the issues faced by Scots today. As a member of Medsin UK, as a medical student, and as a citizen of Scotland, I want that agenda to prioritise health equity.

The city of Glasgow is famous for many things; deep fried mars bars and football spring to mind for starters. But one thing that comes up time and time again when I introduce my place of study at international meetings: ‘isn’t that the place with the lowest life expectancy in the developed world?’.

We have the NHS, we have a strong welfare system and we are the largest city in Scotland, and yet some men born in Glasgow today can only expect to live to the age of 54. We have known about ‘the Glasgow effect’ for many years now, a study from 2003-2007 found that premature deaths in Glasgow were 30% higher than Liverpool and Manchester even though both of those English cities are home to populations who have comparable experiences of post industrialised Britain.

Since the publication of the Marmot report (‘fair society, healthy lives) in 2008 and ‘it’s not just deprivation’ in 2010, the Scottish government has begun to address the fundamental inequities in the social determinants of health which underpin the massive gap in life expectancy within the city. But these are not issues that can be addressed overnight, as Carol Tennahill, the director of the Glasgow centre for population health says, the long term nature of the changes ‘do not fit into a political agenda much shorter than that’.

The change in the political system of Scotland that is inevitable after this Scottish referendum gives an opportunity to cement the commitment to reducing health inequities in Scotland into longer term political vision. While the current governing Scottish National Party has been working to address these social issues, that is not a guarantee that future Scottish governments will do so.

It is here, that we as young people need to stand up and be counted. We need to make sure that politicians are aware that we do not want to belong to the city with the lowest life expectancy in the developed world, but the city that revolutionised the health of its people by addressing inequities in the social determinants of health. We are approaching one of the most important days in Scottish history; let’s not miss this opportunity to have our say.

http://www.gcph.co.uk/assets/0000/0801/GCPH_Briefing_Paper_25_for_web.pdf
http://www.who.int/bulletin/volumes/89/10/11-021011/en/
http://www.publichealthjrnl.com/article/S0033-3506(10)00033-8/abstract

This piece was originally posted on the Medsin blog

Global Trade and Health: Rana Plaza, One Year On

Last Thursday marked the one year anniversary of the Rana Plaza tragedy in Bangladesh, which left more than 1100 dead and many more injured. The disaster has been described as one of the worst industrial accidents in modern history.

In the year since the accident, we have witnessed a number of initiatives aimed at providing compensation to the victims and preventing similar catastrophes from occurring in the future. As recent analyses and commentaries point out however, these efforts have been largely insufficient. Victims for instance, have thus far received little compensation despite promised assistance. The two agreements meant to hold corporations accountable for working conditions, fall short on a variety of fronts. And the market for cheap, fast-fashion continues to swell.

However, there is a particularly important issue which seems to have been largely neglected in these discussions: that garment production in Bangladesh, and its accompanying impacts on workers’ well-being, cannot be considered in isolation from the broader global trading regime within which it is situated.

Production in the textile and clothing sector is characterized by global commodity chains whereby suppliers around the world compete for contracts. This creates an imperative for suppliers to remain competitive by way of low labour costs and more flexible employment conditions. Poor working conditions in the sector are thus not unique to Bangladesh, or even less developed countries. This past December, seven workers were killed in a garment factory fire in Italy, where thousands of Chinese immigrants are reported to produce garments under conditions of squalor.

Employment in the sector is also extremely vulnerable to the type of economic shifts that are inherent to an increasingly interconnected world. In 2001, an economic recession combined with a change in US foreign policy diverted a significant amount of garment orders from Bangladesh to African and Caribbean nations. In a matter of months, almost 1,300 firms closed and 400,000 workers (mostly women) were left jobless. Job insecurity, in addition to poor working conditions, is thus a defining feature of employment in the sector.

Together these considerations suggest the need for a broader, global approach to ensuring the well-being of textile and clothing workers. Towards this end, some have suggested linking trade agreements to respect of international labour standards. However, others worry this might raise labour costs to the point that poor countries will lose a significant proportion of their employment.

It has also been suggested that “the struggle for labor standards needs to be broadened and made more inclusive by transforming itself into a struggle for a universal ‘‘social floor,’’” which would guarantee provision of basic needs to all citizens. This would not only ensure that workers are able to collectively organize without fear of losing their employment, but also provide a safety net for workers in times of economic downtowns.

At a minimum, addressing the well-being of textile and clothing workers requires recognitions of the links between global trade and labour markets, discussions of the ultimate objectives of trade policies, and more comprehensive and fine-tuned assessments of how trade interacts through international labour markets to influence health.

Canada and the post-2015 world: Part II

In this post, guest blogger Ronald Labonté concludes a two-part blog series about post-2015 development goals. Discussed are their relationship to health and specific steps Canada could take to encourage a healthy and progressive transition. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

Part I of this post commented on a number of global and intergovernmental initiatives to define new post-2015 development goals, specifically the sustainable development goals, the UN high level panel report and the health goals mooted by the World Health Organization. It also included brief analyses of the role Canada could play in each. Part II focuses more closely on Canada’s role, with some specific recommendations for a healthy and progressive stance we could be taking.

Aid, trade and health

Canada still lacks foreign policy coherence, in that we pursue trade and investment agreements that could compromise health equity globally, while committing to a charity model of international health aid. (We are far from alone in this regard.) More troubling is the trend to tie development assistance to the trade and economic interests of donor countries. The ‘trade not aid’ rhetoric has led to ever-larger sums of ODA being allocated to ‘aid for trade’. If Canada is to join in this chorus (which seems imminent with the transfer of its aid department to that of foreign affairs and trade) then the rules of trade treaties that we negotiate should clearly provide disproportionate benefits to poorer, aid-recipient countries. This is not presently the case. This lack of foreign policy coherence has salience both for UHC (where high-income countries with health financing and service industries are mobilizing to sweep the global low- and middle-income country field); and for control of noncommunicable diseases, where trade and investment treaties are posing risks to public health regulation (10).

Here, Canada could support growing public health advocacy to establish full health carve outs and strengthened health exceptions in trade treaties, starting with the detailed texts of the ‘agreed in principle’ Comprehensive Economic and Trade Agreement (CETA) with the EU, and the still to be completed 12-nation Trans Pacific Partnership Agreement (TPPA), the other major countries being the USA, Japan and Australia. There is growing support amongst some of the TPPA’s negotiating countries for a tobacco carve out in that treaty, such that no tobacco control policy could be challenged in a trade dispute. Such tobacco exceptionalism, while good for health as far as it goes, could nonetheless be problematic if we are also concerned with the global health risks posed by Big Food, Big Alcohol or Big Pharma. A more radical approach would be to ensure that such treaties include a provision requiring deference to WHO soft law (e.g. the Framework Convention on Tobacco Control) or World Health Assembly approved global actions plans (e.g. on noncommunicable diseases) whenever a public health policy or regulation is subject to a trade or investment dispute. Given Canada’s current obsession with striking trade and investment treaties with as many countries as possible – indeed, the only new foreign policy by our Conservative government commits to a ‘sea change in the way Canada’s diplomatic assets are deployed around the world’ such that all are ‘harnessed to support the commercial success by Canadian companies’ (11) – we are unlikely to lead this charge. At the same time, according to the leaked TPPA chapter on intellectual property rights, Canada has been opposing almost every effort by the USA to extend patent protection in that treaty beyond provisions in the WTO’s TRIPS Agreement (12). So there may be some room for a stronger global public health presence in Canadian trade policy.

 Aid for tax reforms instead?

Aid disbursements will be necessary for many low-income countries, especially in sub-Saharan Africa, since taxation reforms are still years away in being effectively developed. But aid is no substitute for domestic economic empowerment; and taxation is fundamental to that empowerment, and to responsible state building and the social contract between well-functioning states and their citizens. Thirty or more years of advice to or obligations on developing country governments by the IMF and World Bank to keep taxes low to attract foreign direct investment have done well for the investors, but poorly for most of the countries’ citizens.

Somewhat late in the game, both the IMF and World Bank are now talking about the need for developing countries to substantially increase their taxation rates and improve their taxation systems (though still favouring regressive consumption over progressive income or corporate taxes). This is not to say that African countries have not been trying to comply, with their tax to GDP ratio in recent years rising to between 17 and 20 percent (13). But this rate is still too low to be adequate (the EU 15 countries average over 40 percent), and still inefficient and full of exemptions for imports, investors and transnational profits. As well, the continuing importance of tariffs as a form of taxation for some of these countries means that in any Canadian trade treaty involving developing countries, including those in South Asia where the tax to GDP is the lowest in the world, high tariff reductions should not be on the agenda until there is evidence of effective and transparent progressive tax systems in place. Why not aid for progressive taxation reforms, rather than (or at least in addition to) aid for trade?

Given that Canada has also become the Western world’s global mining giant thanks to the domestic tax breaks we give to mining companies, we also have a potential role to play in supporting developing countries (especially those in Africa and Latin America) in their efforts to increase their persistently low royalty rates, which were largely imposed during structural adjustment programs in the 1980s and 1990s.

We could also join with other countries in supporting innovations in global taxation. Why is Canada not supporting financial transaction taxes? Why haven’t we joined the very basic UNITAID airline tax? Why are we not doing more to close offshore financial centers, tax havens?

Canada could take an assertive role in the most recent G20 promise to develop a more transparent international tax identification system so that taxes are paid where production profits are earned, avoiding the toxic practice of transfer pricing through tax haven countries (14). In doing so it might also begin to stem the illicit capital flows, especially from Africa, which in the past 40 years has topped $1.4 trillion, more than all of the aid and debt cancellation funds that have gone to the continent, and much of it due to transnational corporate practices, and not simply criminality or corruption (15). There is a modicum of self-interest in this, as some estimates calculate that Canada is absorbing huge tax losses on the more than $160 billion in Canadian income parked mostly in offshore Caribbean branches of Canadian chartered banks (16).

Actions oriented towards such economic and taxation reforms by Canada would move us away from a charity model of intermittent, donor-driven aid to a structural model of global social solidarity and an equitable economic empowerment.

In sum, Canada in preparing for a post-2015 world could:

  • Continue but strengthen our commitments to maternal/child health
  • Promote our publicly-funded universal health system as an important model for expanding UHC
  • Ensure that health concerns (present and future) are fully protected in trade and investment treaties
  • Aid for trade – if trade treaties actually disproportionately benefit poorer people and countries
  • Aid for tax reform – to build the transparent and progressive tax systems developing countries need to build effective states and mobilize domestic revenues for health
  • Join and promote global systems of taxation to prevent tax evasion and illicit capital flight
  • Work with African and Latin American countries to improve their royalties on extractive industries, notably mining.

References

10.  Friel S., Gleeson D., Thow A-M., Labonté R., Stuckler D., Kay A. and Snowdown W. A new generation of trade policy: potential risks to diet-related health from the trans pacific partnership agreement.  Globalization and Health 2013, 9(46): 1-7.

11. See: Government of Canada, 2013. Global Markets Action Plan. http://www.international.gc.ca/global-markets-marches-mondiaux/

12. See: http://cips.uottawa.ca/canada-must-hold-firm-in-opposing-us-efforts-to-expand-intellectual-property-rights/

13. See: http://en.wikipedia.org/wiki/List_of_countries_by_tax_rates

14. See: http://www.bbc.co.uk/news/business-23994488

15. See: African Development Bank and Global Financial Integrity, 2013. Illicit financial flows and the problem of net resource transfers from Africa: 1980-2009. [pdf] Available at: http://www.gfintegrity.org/storage/gfip/documents/reports/AfricaNetResources/gfi_afdb_iffs_and_the_problem_of_net_resource_transfers_from_africa_1980-2009-web.pdf.

16.  See: http://www.taxfairness.ca

Provenance

Based on two plenary presentations at the 2013 Canadian Conference on Global Health, Ottawa, Canada, October 28-29.

Canada and the post-2015 world: Part I

In this post, guest blogger Ronald Labonté introduces a two-part blog series about post-2015 development goals. Discussed are their relationship to health and specific steps Canada could take to encourage a healthy and progressive transition. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

In 2000 the world committed to health and a paternalistic egalitarianism, as the Millennium Development Goals (MDGs) promised reductions in extreme poverty and hunger, and measurable progress in water and sanitation, education and a host of specific health targets. There was lots to criticize in the MDGs: lack of ambition in the targets (especially for poverty), failure to consider the already surging pandemic of noncommunicable diseases, lack of equity stratifiers for the targets, huge holes in the data used to measure progress, and a resounding silence on any of the economic and political systems that were fuelling global financial speculation, transnational corporate power and gross inequities in income and wealth. Still, the MDGs galvanized some important initiatives and have chocked up some successes.

As the 2015 clock on the MDGs ticks down, there’s been a flurry of intergovernmental, civil society and social mediated consultations on what the world’s nations should commit to next. If the 2000 MDGs were a bureaucratic exercise in synthesizing what states had already more or less agreed upon during the 1990s, the post-2015 has opened the floodgates to consultation processes to such an extent that one becomes either exhausted with keeping up with the opportunities to input, or cynical about why bothering to.

Bracketing an excess of cynicism to strike a balance between realism and defeatism, this two-part blog series offers a few reflections on the competing post-2015 goal streams and Canada’s potential role within them. The first post will reflect on sustainable development goals, the UN high-level panel, and health goals in the post-2015 context. The second post will discuss aid-for-trade and aid-for-taxation strategies, and summarize how Canada can prepare for the post-2015 world.

Sustainable Development Goals

No one outside of the US Tea Party any longer insists that climate change is a left-wing environmentalist plot. (Although it would be nice if there were more left-wing environmentalists at the political and economic levels where they are needed.) The problem with these goals, an output of the Rio+10 initiative, rests with the term itself, a throwback to the late 1980s Bruntland Commission (Our Common Future) (1) and the first wave of efforts to harness economic development to environmental sustainability. Back then Canada was a leader, jumping enthusiastically on the ‘roundtables on economy and environment’ governance ideal promoted by the Commission. I recall an environmental lawyer leaving one of such meeting, complaining that the business folks around the table ‘Just don’t get it!’ To which a senior government official gently chided, ‘Oh, but they do. You see, they got the noun and you got the adjective.’

We continue to live under the illusion that, with claims of a slowly greening economy, we can consume our way out of a problem of over-consumption. We can even invest our savings on the Dow Jones Sustainability Index, feeling better that our retirement returns derive from companies deemed to be operating in a ‘sustainable’ way. We just have to pretend that there is consensus on how to measure good corporate environmentalism so that we aren’t fooled by such as Pepsi-Cola’s claim that in India it is replacing more water than it takes to supply the sub-continent with its sugary beverages (2). As for our greening economy: Why should the USA use trade rules to challenge China’s heavy subsidization of its solar and wind turbine industries? Yes, it puts the US-based industries at a competitive disadvantage, but it drives up global prices and slows diffusion of possibly important climate change reducers. Why not exclude from trade rules subsidies on all new products that reduce the human environmental footprint, a race to the top rather than a slide to the bottom?

Canada scores very poorly on this account. Our exit from the Kyoto Accord in 2011 and our drive to become a fossil-fuel superpower have transformed Canada from a once-upon-a-time eco-leader (we were, after all, the birthplace of Greenpeace and home of the increasingly pessimistic David Suzuki) to one of the bottom-placing eco-destroyers. The potentially healthy challenge for Canada is that if the post-2015 goals achieve their mooted intent of applying to all countries, alongside the increasing anger of developing countries at the rich club reneging on its climate change commitments, we may be dragged back into accountable commitments to a greener future.

But the gravest challenge for a post-2015 sustainably developed future lies in the fallout of the Great Financial Crisis, which became the Great Recession and persists as the Great Austerity. Most domestic political attention has drifted back to conventional economics of spurring growth by re-energizing the real economy of production and consumption (jobs, jobs, jobs). This is saleable in the short-term, although the quality of new employment with respect to pay, benefits, security, and health and safety remain vexing complications under neoliberalism’s labour market ‘flexibilization’. But it grates against the reality that we cannot use conventional economics to grow incomes for a world of soon to be 9 billion producers and consumers (3). We don’t have enough of a planet to do so. Add to that our oft-proclaimed ‘time bomb’ – an aging population living longer, with demographers and politicians concerned with increasing the size of the active labour force (those aged 20 – 65 or 70) to sustain the social contract (health care, pensions and benefits) for the swelling cohort of elders. This continuous priming of the base of the demographic pyramid is simply an environmental ponzi scheme, one that only radical redistribution and economic regulation might prevent from imploding.

UN High Level Panel

The UN High Level Panel on the post-2015 goals (is there ever one called ‘low-level’?) came up with a number of useful suggestions that could partly forestall such a dystopian ponzi pyramid. These include a call for governments to regulate private finance, reform trade, crack down on illicit capital flows, stem transnational tax evasion, return stolen assets and promote sustainable patterns of production and consumption (4). Such recommendations are meatier than the Panel’s obligatory nudge to donor countries to honour their aid commitments. Been there, done that and, in Canada’s case, we don’t seem to care much. Despite our acknowledged if initially botched leadership on the ‘Muskoka Initiative’ for Maternal/Child Health, we are losing ground on our aid commitments, freezing the level of our disbursements, and restricting contributions to a smaller number of countries. Apart from issues of quantity, there are issues of quality. The 2012 Centre for Global Development’s Quality of ODA Index ranks Canada in the lower half of donors on efficiency and reducing the burdens or transaction costs of aid. We do better on fostering institutions, and are smack in the middle on transparency and learning; a middling assessment at best (5).

Returning to the Panel’s higher-level goals: Good as they are in intent, there is no operational guidance in the report. There is also too much emphasis on corporate social responsibility and partnerships between states and businesses to make global markets more just and equitable, rather than recognizing the pressing need for mandatory and enforceable market rules. It is in how we must move on the Panel’s goals that is of prime importance, which then requires an analysis of why we have these problems in the first place. As a People’s Health Movement commentary laments, none of the prevailing models for post-2015 priorities question, much less challenge, the prevailing paradigm of economic growth (6).

There is even the risk that the UN High Level Panel could reinforce some of the more egregious qualities of the prevailing paradigm. For one, it criticizes the core labour rights of the ILO-led initiative on social protection and ‘decent work’ (7) as too much of a ‘one size fits all.’ It calls, instead, for ‘good jobs’ and for ‘flexibly regulated labour markets’, an invitation to a continual reduction in labour’s power against that of capital. In sync with the World Bank and other economic development agencies, its poverty goal of ‘leave no one behind’ (commendable, depending on where one draws the poverty line) is based on the norm of ‘equality of opportunity.’ While the procedural justice inherent in this norm is important (all should be treated alike), in the game of economics it only becomes fair when all are alike when they start playing. This is patently not the case, not when fewer than 1500 people have more wealth than the combined populations of the continent of Africa and the sub-continent of India (8). Equality of opportunity only becomes fair when it is joined with a parallel commitment to equality of outcome – an ideal but measurable target – that relies on progressive tax/transfer programs within and between governments. Such a norm is unlikely to have much political traction in Canada at the moment, however, where reduced and regressive taxation have been the norm for the past decade or more. The same may be true for most of the austerity-addicted high-income countries and many of the recession-stuck middle-income ones.

What of health?

No one knows exactly how health goals in the post-2015 final list will be defined. Several of the goals from the sustainable development agenda and the high-level panel already deal with key health determinants, albeit imperfectly. The World Health Organization (WHO) is calling for completion of the 2000 health MDG’s unfinished agenda, and a ‘healthy life expectancy’ goal perhaps allowing some broader measurable target. But it seems most keen to bank on a post-2015 health goal of universal health coverage (UHC), a re-born concept still in search of consensus. The WHO defines it as “ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need” (a nod in the direction of the heady days of the Alma Ata Declaration on Primary Health Care), with services “of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship” (9). This sounds reasonable enough, but it ducks the contentious issue of the relationship between public and private sectors in health care financing and provision. With private insurers and providers eager to carve out a larger piece of the annual $6.5 trillion health care ‘market,’ the risk is that the costly chaos now passing for Obamacare in the USA will come to define the global default position.

This is a debate in which Canada could aggressively insert its own comparatively positive experience with a universal, single-payer and mixed provider system. Canada’s national health insurance risk-pool and legislated public administration creates one of the fairest, most efficient and most accessible health care models on record (excepting Cuba). Sure, it has warts: wait-times, gaps in coverage, encroaching privatization. But compared to the American model, and to the dual public/private models dominating Latin America (which most countries in that region are trying to transform into a more public system), the warts on Canada’s system become mere cosmetic pimples.

References

1. Our Common Future, Report of the World Commission on Environment and Development, World Commission on Environment and Development, 1987. Published as Annex to General Assembly document A/42/427, Development and International Co-operation: Environment August 2, 1987.

2. See: http://www.indiaresource.org/news/2011/pepsipositivewater.html

3. Sustainable Development Commission, 2009. Prosperity without growth: the transition to a sustainable economy? London: UK Sustainable Development Commission.

4. High Level Panel on the Post-2015 Development Agenda, May, 2013. http://www.post2015hlp.org/wp-content/uploads/2013/05/UN-Report.pdf

5. See: http://www.cgdev.org/page/quality-oda-quoda

6. See:
http://www.phmovement.org/sites/www.phmovement.org/files/PHM%20statement%20submitted%20to%20the%20WHO.pdf

7. International Labour Organization (ILO), 2011. Social protection floor for a fair and inclusive globalization [online]. Report of the Advisory Group chaired by Michelle Bachelet convened by the ILO with the collaboration of the WHO. Geneva: ILO. Available from: http://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/—publ/documents/publication/wcms_165750.pdf

8. See my last blog: http://www.healthypolicies.com/2013/11/canadas-austerity-agenda-its-about-the-taxes/

9.  See: http://www.who.int/universal_health_coverage/en/

Provenance

Based on two plenary presentations at the 2013 Canadian Conference on Global Health, Ottawa, Canada, October 28-29.

 

 

Healthcare spending and health: looking beyond the money

LE

This graph was posted on the Atlantic last week and illustrates the striking relationship between healthcare spending and life expectancy.  There are many important and interesting aspects to this relationship, which has been documented for some time, but there is one aspect which is seldom discussed when the topic surfaces in mainstream media outlets.

One of the most discussed features of this relationship, and the one covered by Atlantic author Matthew O’Brien, is the isolated position of the US (in the top right area of the graph). O’Brien notes that ‘[Americans] spend much more than any other rich country, but [they] certainly don’t get more for it. [They] get less. [They] get about the same health outcomes, but don’t cover everybody like other rich countries do.’

With US life expectancy clearly positioned below 80 years, and other countries approaching levels closer to 85, I can’t agree with O’Brien that Americans ‘get about the same health outcomes’, but let’s leave that aside for now.

The obvious questions prompted here are why does healthcare cost so much in the US, and relatedly, how can this wasteful spending be eliminated? O’Brien points his finger at culprits like high doctors’ pay and patients’ opposition to having their coverage change.

A  more extensive debate on this relationship is happening on the blog, The Incidental Economist, which is the original source of the graph used in the Atlantic piece. Nonetheless, the bottom line of many of these conversations is likely to be some form of O’Briens conclusion:  [Americans] can’t afford [their] healthcare exceptionalism’.  With an extreme and growing number of Americans underinsured, unemployed and underfed, this conclusion is hard to deny.

But there is another important conversation to be had.

This conversation emerges when we look at the cluster of countries spending more than $2000 per capita on healthcare. Here the data begins to flatten out and after this point, spending on healthcare appears to buy little in terms of health improvement. This particular feature of the graph prompts different sorts of questions than those outlined above. Questions like: if healthcare spending is not buying health improvements then what  is responsible for better health; and why does the US lag so far behind in international health comparisons? The bottom line of conversations centred on these questions point to a different sort of American exceptionalism.

There are several, well-documented, reasons why healthcare does not produce health. These reasons derive from population health research and generally speaking, relate health to societal structures that govern the amount of inequality in a society. In this field of work, American exceptionalism is found in graphs like this one:

infant mortality

In this graph, the US (again, at the top right) is isolated for its extremely high level of income inequality and high level of infant deaths.

Despite the fact that there are now over 170 studies which show that health is worse in more unequal societies, even  journalists hired to cover health stories neglect to identify inequality as a crucial determinant of health.

The relationship between spending on healthcare and health illustrates the limited returns of exorbitant US spending, but it also demonstrates the limitations of medical care in producing health: a story whose time is beyond ripe.

Canada’s Austerity Agenda: It’s About the Taxes

Austerity policies pose major threats to the public’s health. In this guest post, Ronald Labonté argues that the austerity agenda in Canada stems not from a crisis in finances, but from a crisis in fair taxation. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

The American Jurist, Oliver Wendell Holmes, once wrote that taxes are the price we pay for civilization. By that account we are becoming less civilized with each new budget cycle. We are being told that we have a crisis of public debt and deficit. We do not. We have a crisis in fair taxation for the public goods that sustain health and civility, and a 40 year uncontrolled experiment in global neoliberalism and free market fundamentalism that has seen the starkest rise in income and wealth inequalities in over a century. Canada is just one of scores of national examples.

Canada began its downward taxation spiral in the 1980s. Marginal rates paid by the highest income earners dropped from 43% in 1988 to 29% in 2010. Corporate taxes fell from 49% in 2004 to just 27% in 2010 (Simms 2013). As taxes as a percent of Canadian GDP declined, so did public spending. Canada now ranks 24th of 34 OECD countries in our overall rate of taxation. Since 2006 and the Conservative government, we have lost over $220 billion in federal government tax cuts (Fanelli and Lefebvre 2012). The Great Financial Crisis of 2008, the result of profligate greed on the part of a handful of unregulated financial gamblers, and the trillions spent by governments on bank rescues and stimulus spending to buffer the subsequent Great Recession, have since become a pretext for: not more and fairer taxation, but more tax breaks and government cutbacks.

This is the post financial crisis austerity agenda being rolled out around the world, with between 80% and 90% of the global population now coming under its yoke (Ortiz and Cummins, 2013). Who pays austerity’s heaviest cost in poorer health and wellbeing? The poor, the rural, women, children and the ever growing number of the ‘precariat’ – those whose globalization’s ‘flexibilized’ labour markets offer lower pay, fewer benefits, less security and often only part-time or temporary jobs. Throw in the massive global youth unemployment bulge and we have a recipe for domestic and international conflict, some of which (the Arab spring, rural China, parts of Africa) has already emerged.

Cuts in tax and government spending are good for the economic elites of the world who have seen their fortunes soar since the Great Financial Crisis. Consider that the world’s 1,426 billionaires between them had as much wealth in 2012 as the combined populations of Africa (1 billion people) and India (1.27 billion people), an inequality ratio of 1.5 million to 1 (Forbes 2013). But tax and spending cuts are actually bad for the economy, especially when private investment is drying up and the ‘real economy’ of production and consumption is sluggish, if not sclerotic.

Indeed, public spending has a little known fiscal multiplier effect, which, in high-income countries such as Canada, ranges between 1.6 and 1.7. For every dollar in new government spending there is $1.60 to $1.70 in new economic growth. That is because government spending buys goods and services made by workers and employs civil servants who buy more goods and services. Private companies see things improving and start investing more of their hoarded cash. Some forms of government spending (in health, education, environmental protection, the things that matter in most peoples’ lives) have much higher fiscal multipliers. By contrast, as the Canadian economist Jim Stanford has calculated, for every dollar in new corporate tax cuts, only 10 cents is re-invested in the real economy that employs people (Stanford 2013). The rest goes to dividends, financial reserves or gambling in the still unregulated shadow banking world of derivatives and hedge funds – the highly leveraged ‘casino capitalism’ that brought us the Great Financial Crisis. So a win-win-win (public spending on things people value, healthier citizens and faster economic recovery) becomes a lose-lose-lose (more wealth for those who don’t need it, slower economic growth and new, toxic asset bubbles primed for another burst).

Another comparison: Based on OECD data, if Canada taxed at the average rate of the EU15 countries (40% of GDP), we would raise almost $160 billion more each year in revenue. If we spent on health and social programs at the EU 15 average rate of 30%, we would be pumping $208 billion more each year into the goods, services and income transfers that improve peoples’ health and wellbeing. None of these EU 15 countries are in structural deficit, and several have been outperforming Canada in narrowly measured economic terms for years.

To repeat: there is no fiscal crisis. There is a taxation crisis. We are not living with scarcity where everyone must tighten his or her belt. We are living in an era of egregious inequality where increasing amounts of global income are escaping the redistributive bite of the taxman, transfer-priced or squirreled away in the (still burgeoning) number of offshore financial centers (aka ‘tax havens’). Most of these are located within or under the protection of the world’s wealthiest countries, the same ones now hollowing out their tax-gutted welfare states.

Canada’s tax crisis is not exclusive. It can be found in most of the world’s countries, engaged in a revenue race to the bottom in order to attract or retain foreign investors. But over the short-term the austerity this leads to is bad for health and for the economy. Even the IMF is doing a deep re-think over the macroeconomic wisdom of its austerity mantra. Over the long-term the gap it widens between those few who too much and those many with too little imperils a peaceful global future. And without strong market regulations and progressively financed redistributive spending, relying on economic growth in ‘real economy’ of production and consumption to lift the world out of poverty will destroy our planetary life supports long before we come even close.

When are Canadian politicians (and those in most of the world’s countries) going to realize that the neoliberal emperor of free markets, low taxes and minimal government has no clothes?

References

Fanelli, Carlo and Priscillia Lefebvre. 2012. “The Ottawa and Gatineau Museum Workers’ Strike: Precarious Employment and the Public Sector Squeeze.” Alternate Routes: A Journal of Critical Social Research 23: 121-46.

Forbes. 2013. “Inside the Billionaires List: Facts and Figures.” Forbes. http://www.forbes.com/sites/luisakroll/2013/03/04/inside-the-2013-billionaires-list-facts-and-figures/

Ortiz, Isabel and Matthew Cummins. 2013. “The Age of Austerity: A Review of Public Expenditures and Adjustment Measures in 181 Countries.” Initiative for Policy Dialogue and the South Centre. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2260771.

Simms, David. 2013. “Canada Best Place in G8 to Pay Business Taxes.” Canadian Broadcasting Coporation. http://www.cbc.ca/news/business/taxes/canada-best-place-in-g8-to-pay-business-taxes-1.1380380.

Stanford, Jim. 2013. “The Failure of Corporate Tax Cuts to Stimulate Business Investment.” In The Great Revenue Robbery, ed. R. Swift. Ottawa: Canadians for Tax Fairness.

 

 

#StandingwithDNLee

Readers of Healthy Policies will know that inequities in health are very much rooted in inequities of power. Recent posts by Ted Schrecker have outlined how political trajectories shape landscapes of health disparities. A defining feature of these trajectories is that in addition to being determined by unequal distributions of power, they also perpetuate the social structures responsible for these distributions. Because shifts in power have hugely increased social inequalities, including health inequities, power politics are health politics.

In this post I want to draw attention to a recent event in the scientific community. Its links to population health are by no means immediate, but it is a recent and striking example of how power dynamics can play out even in the context of a reputable scientific outlet.

Here is the short version of the story:

Danielle N. Lee, PhD is a postdoctoral research associate at Oklahoma State University. She is an African-American biologist who writes on her Scientific American blog, ‘The Urban Scientist’, about diversity issues in the scientific community. Dr. Lee was asked if she’d be willing to write for free for biology-online.org, a partner of Scientific American. She politely declined with the following:

Thank you very much for your reply.
But I will have to decline your offer.
Have a great day.

The editor of Biology Online came back with this:

“Are you an urban scientist or an urban whore?”

Dr. Lee posted a thoughtful response to the Biology Online editor on her blog, which was then removed without warning by Scientific American. Mariette DiChristina, editor-in-chief for Scientific American, said in a Twitter post that“@sciam [Scientific American] is a publication for discovering science. The post was not appropriate for this area & was therefore removed”.

It is worth noting that other Scientific American bloggers have protested that standards about what they can write have never been made explicit by the organization. Indeed many have pointed at examples of their own writing which are unlikely to fall under the remit of ‘discovering science’.

Bloggers in the scientific community have been rallying to Dr. Lee’s defence.  I encourage those of us in the social sciences and concerned with the public’s health to do the same.

To stay up-to-date with this story, follow the Twitter hashtag #standingwithdnlee.

Changed priorities ahead? An anti-Thatcherite view of health and equity

As a follow-up to last week’s guest post, this week Ted Schrecker outlines the political trajectories which have not only shaped current landscapes of health disparities, but also continue to obstruct avenues towards achieving greater health equity. He challenges us to consider the prospects for national-level inroads and contemplates whether the future lies in more localized efforts. Ted is a Professor of Global Health Policy at Durham University.

Changed priorities ahead (1 of 1)It is now 34 years since Margaret Thatcher’s Conservatives came to power in the United Kingdom.  How time flies when you’re having fun.

The election of the Conservatives, and that of Ronald Reagan in the following year, transformed not only domestic politics in the two countries but also the global political landscape. The most direct and immediate global impact was the imposition of neoliberal orthodoxy on many low- and middle-income countries by the IMF and World Bank, in order to protect the interests of creditors, including many of the largest US banks, but this was only part of a longer-term recasting of political discourse.

The Thatcher-Reagan transition marked a break with postwar policies that led directly to today’s levels of economic inequality and their consequences for health.   Although forces of economic integration (globalisation) were already playing out within the economies of the high-income world, those forces were supported and in some cases driven by state actions and policy choices that could have been made differently.  For example, in the United States, although the pre-tax incomes of the one-percenters started growing rapidly as a share of all incomes in the early 1980s, research from Germany’s Institute for the Study of Labour shows that even before the economic crisis of 2008, tax cuts for the rich magnified the effects of market income inequality.  As pointed out in an excellent recent article on the history of neoliberalism:  “In the end, neoliberalism was very much a state-directed project, but the interests represented by these same states changed, as did the central actors defining policy.”

The Thatcher-Reagan transition also provided signals about the extent to which Anglo-American electorates would tolerate the undoing of postwar understandings of social citizenship.  Successor governments were quick to act on those signals.   Not Thatcher but the Labour government of Tony Blair introduced tuition fees for British university students and eliminated the 10p income tax rate.  Not Reagan but Democratic president Bill Clinton made good in 1996 on a campaign pledge to “end welfare as we know it,” playing to racist and sexist stereotypes while expanding the low-wage female workforce whose precarious living and working conditions were eloquently described a few years later by journalist Barbara Ehrenreich.

Both Blair and Clinton were rewarded with stratospheric wealth after leaving public office; there may or may not be a connection.

Fast-forwarding through the effects of the financial crisis and subsequent recession, which are now familiar, it should now be evident that public finance is a public health issue.  (More about this in my next posting.)  “Changed priorities” – the phrase taken from a road sign in my neighbourhood – are essential if health disparities are to be reduced.

What are the prospects?  One possibility is that finance capital, transnational corporations and wealthy households are too powerful domestically, or too mobile, to leave governments with much room to manoeuvre.  Globalisation has doubtless reduced the policy space available, but it is difficult to see that (for example) a mansion tax and a return to the 50p tax rate would lead to an economic implosion.  Perhaps more important is the possibility that an electorally decisive plurality of the population now share Thatcherite worldviews and allegiances, even if the rest of us do not. (Does anyone else find the normalisation of “climbing the property ladder” – the expression and the activity – as objectionable as I do?)

This is partly a generational effect.  Alex Himelfarb, who retired as Canada’s most senior public servant, recently wrote: “North Americans under 40 have never really known anything other than neo-liberal politics and governments that seem to be backing away, so many will understandably see small government and low taxes as the only option.”  On this side of the Atlantic, such diffusion of neoliberal norms appears to be what Johan Mackenbach had in mind when he wrote in 2010: “[I]t is unlikely that a majority of the English electorate would have supported the substantial redistribution of income and wealth that would have been necessary” to avoid the persistence and growth of health disparities during 13 years of Labour government.

Mackenbach’s reference to a majority reflects a widespread misunderstanding of electoral arithmetic and institutions; only under extraordinary conditions is support from a majority of any electorate needed for the success and survival of a policy, or a government.  If we substitute a more accurate term, he may well be correct.  Thomas Mulcair, the leader of Canada’s centre-left New Democratic Party (NDP), appeared to adopt Mackenbach’s view when he rebuked a byelection candidate who has called for higher taxes on the rich by saying that “no increases in personal taxes will be in any way shape or form part of our political offer in 2015.” (Canadians, like British voters, head to the polls in 2015.)  Since the NDP marks the leftward end of Canada’s political spectrum, hopes for ending a retreat from redistributive policy that has been well documented by Canada’s national statistical agency and the OECD are now a dead issue for the near future.  Dead as well, as a consequence, are prospects for tackling health inequity in Canada through national-level initiatives.

Marketing private health insurance in London 2011

Mackenbach has identified the core political question about the prospects for reducing health equity by acting on social determinants of health.  Five years ago, the WHO Commission on Social Determinants of Health articulated the aspiration of closing the health disparities gap in a generation.  The policies of the Coalition threaten to widen the gap, for example by imposing spending cuts that will disproportionately affect England’s disadvantaged regions while debilitating the National Health Service. If changed priorities are not ahead, then the best that we can probably hope for in jurisdictions like Canada and England is that ambitious localised interventions will reduce the speed at which the health gap grows.

A note to readers:  Unfortunately, a couple of sources cited in this posting may be protected by paywalls.  If you have difficulty accessing them, please contact me at tschrecker@gmail.com and I will try to arrange access.