The Political Determinants of Health Inequity - Another End of the World is Possible

In 2005, an alternative World Health Report was released by the People’s Health Movement (2005). It had a clear message. The crisis in global health is not a crisis of disease, it is a crisis of governance. At its core, health is deeply political. The 2014 The Lancet-UiO report was mainly concerned with the global political determinants of health which it defined as ‘the transnational norms, policies, and practices that arise from political interaction across all sectors that affect health.’ (Ottersen et. al., 2014) The commission’s recommendations aimed to inform the Post-2015 Sustainable Development Agenda. The report examined power disparities and dynamics across a range of seven policy areas that affect health and require improved global governance. It identified five dysfunctions of the global governance system that allow the adverse effects of the global political determinants of health to persist. Let’s have a brief look at the overall state of affairs for each of these seven policy areas before we assess whether the global governance for health functions has improved since then:

In 2005, an alternative World Health Report was released by the People’s Health Movement (2005). It had a clear message. The crisis in global health is not a crisis of disease, it is a crisis of governance. At its core, health is deeply political.

1. The financial crisis, austerity measures, and health. Ten years ago, the analysis focused on the impact of the US and European financial crisis. Nowadays, in the wake of the Covid-19 pandemic and a deepening financialization of the global economy, there is bleak picture. 143 countries are implementing policy measures that undermine the capacity of governments to provide education, healthcare, social protection and other public services. In effect, 85% of the world’s population will live in the grip of austerity measures by the end of 2023. In addition 60 countries are in debt distress. (Ortiz& Commons, 2022)
2. Knowledge, health, and intellectual property. Despite the strong call for ‘ending vaccine apartheid’ during the Covid-19 pandemic, and the temporary waiving of the intellectual property monopolies of Covid-19 countermeasures, the overall R&D ecosystem has changed surprisingly little. Vaccines should become common goods for health rather than profit-seeking market commodities. However, in 2021, excluding Covid-19 vaccines, just four pharmaceutical corporations (MSD, GSK, Sanofi and Pfizer) captured 73% of the global, oligopolistic vaccine market worth US$42 billion. (Torreele, 2023)
3. Investment treaties and health equity. The 2016 election of Donald Trump in the US led to the regional Transatlantic Trade and Investment Partnership (TTIP) and Trans-Pacific Partnership (TPP) treaty negotiations being cancelled. The Covid-19 pandemic, Ukrainian-Russian war and other crises have slowed down trade even further. An enduring public health concern has been that trade and its enforceable rules have long ceased being the means to achieve the goal of sustainable development. Instead, trade and investment liberalisation have become ends in themselves. The Covid-19 pandemic has put in plain sight the health risks and vaccine apartheid, associated with free trade agreement provisions. (McNamara et. al., 2022)
4. Food and health equity. Trade liberalisation and food commodities speculation were already identified in 2014 as key issues driving food insecurity and the double burden of malnutrition (under-& overnutrition). In 2023, the number of people facing, or being at risk of, acute food insecurity was 345 million spanning 79 countries, which is more than double the pre -pandemic levels in 2019. At the same time global inflation is rapidly rising, and food prices are volatile and relatively high. There is a need to re-enforce the key multilateral mandate of the Committee on World Food Security over a range of multi-stakeholder, often corporate friendly, initiatives. The aim is to arrive at a political agenda for food systems transformation that overcomes relationships of dependency and extractivism. (UN, 2023)
5. Conduct of transnational cooperations (TNCs) and health. An under-regulation of transnational companies, including through offshoring activities, the neglect of ecological, social and employment rights, as well as the siphoning-off of financial profits via tax havens from the peripheral to the core of the globalised capitalist economy, remains rampant. A 2021 study shows that Global North-listed TNCs are often engaged in violations of human rights and/or environmental rights. These, which mostly occur in developing countries and are often related to the extractives sector. (Ullah et.al. 2021) In 2013, a Treaty Alliance was founded following an UN Human Rights Council initiative towards a legally binding instrument to regulate transnational corporations. This Alliance has been organizing a broad mobilization with more than 1,000 civil society organizations and individuals since supporting its efforts. In 2023, international negotiations between UN member states are still ongoing, and not expected to conclude soon.
6. Irregular migration and health. Today, there are some 1 billion migrants globally, about 1 in 8 of the global population. These include 281 million international migrants and 82.4 million forcibly displaced (48 million internally displaced, 26.4 million refugees, 4.1 million asylum seekers).The UNHCR estimates that there are many millions of stateless people globally. The number of people on the move is expected to grow due to poverty, lack of security, lack of access to basic services, conflict, environmental degradation and disasters. Health is strongly related to the social determinants of health, including employment, income, education and housing. When not properly supported by appropriate intersectoral policies, migration can expose the most vulnerable socioeconomic groups to significant risks. (WHO, 2023a) It is likely that the EU+ will receive well-over a million asylum applications by the end of 2023. (EU, 2023) A spectre is now haunting Europe, with anti-migrant, anti-Islamic and Eurosceptic parties having gained considerable power in several EU member states.
7. Patterns of armed violence and effects on health. Armed violence within and between states has increased considerably since 2014. The outrageous Israeli-Palestinian conflict has led in 2023 already to about 20.000 casualties, at the time of writing, with over a million of people being displaced in the Gaza strip. With the global attention since 2022 mainly focused on the Russo-Ukrainian war, there is a neglect of many other (chronic) armed conflicts which include the drug wars in Mexico, the internal conflict in Myanmar, the insurgency in the Sahel, the Ethiopian internal wars, the massive displacement in the east of the Democratic Republic of Congo, civil war in Sudan, and many other places. In 2023 alone, there have been over 1200 attacks on health care facilities, and over 700 health workers have been killed, the majority in the occupied Palestinian Territories. (WHO, 2023) To be specific; this is not an era of peace, but a considerable part of humanity is affected by an era of armed wars. A perceived ‘stability’ in the core industrialized capitalist or imperialist countries should not distract from, and should be seen in direct relation with, an expansion of armed violence in periphery countries. Much of the militarisation and violence takes place in a context of neo-colonial imperialism, economic dependency and extractivism. (Brand & Wissen, 2021)

To be specific; this is not an era of peace, but a considerable part of humanity is affected by an era of armed wars. A perceived ‘stability’ in the core industrialized capitalist or imperialist countries should not distract from, and should be seen in direct relation with, an expansion of armed violence in periphery countries.

Interestingly, The Lancet – UiO commission decided back then not to deal with the new threats to health that arise with environmental degradation, climate change, unprecedented urbanisation. Nor did it want to engage with the benefits and risks of rapidly developing digital technologies. (Ottersen et. al., 2014) This consideration builds on the original report by the WHO commission on the social determinants of health from 2008, that also had limited attention to the ecological aspects of health inequity. This indicates to a sort of ‘rift’, that is a kind of disciplinary gap between the Global -and Public health communities on one side, and the One- and Planetary Health communities on the other side.

Karl Marx’s theory of the ‘Metabolic Rift’ is useful here. To enable human labour, some kind of metabolic exchange between the social and the natural is inevitable under all forms of social and economic relations. What is unique about capitalism, in Marx’ view, is the rift it creates between human and natural systems, undermining the conditions for human and nonhuman flourishing. (Van de Pas, 2023) Many of the policy discourses in global and planetary health take place in a rather technocratic, fragmented and siloed manner, hereby negating structural, political and economic powers, normative drivers and actors that are often capitalist, colonial and patriarchal in nature. (Van Woerden et. al., 2023)

This is then also the main critique of the original Lancet-UiO report. The 5 dysfunctions it describes are mainly focused on the need for (global) institutional reforms, but as such remains virtually silent on the neoliberal drivers and (state and non-state) power inequities that underlie the several crises as described above. There is also very little on the consumptogenic nature, and capitalist relations of production (offshoring of pollution, exploitation, labour-related abuse) of OECD countries addressed in the report. These patterns are by now known as ‘Capitalogenic disease’. (Singh& Hickel, 2023) The global governance for health reforms propose to counter health inequities have, largely, not occurred and we see a deepening gridlock of international cooperation at the multilateral level when it comes to matters of human rights and social justice. (Hale &Held, 2018) The political world order shifts rapidly and the Western imperial hegemony, also known as the Pax Americana, comes to an end. Global health policy needs to reflect this shift and it requires scholars, activists, policymakers to study and propose alternative pathways and political models.

This is then also the main critique of the original Lancet-UiO report. The 5 dysfunctions it describes are mainly focused on the need for (global) institutional reforms, but as such remains virtually silent on the neoliberal drivers and (state and non-state) power inequities that underlie the several crises as described above.

One such pathway follows Postgrowth theory. This builds on ecological economy arguments that there are a finite physical (material and energey) limits to growth, and that there needs to be some form of a democratic Degrowth trajectory in high-income countries to still enable space for economic development on the periphery. Althoug it is being heatedly debated in political-ecology circles, the Postgrowth argument (‘Sufficiency, Do No Harm First’) is mainly absent from global health policy debates, where the ‘investment case’ and ‘value for money’ discourse remains dominant. (Van Woerden et. al., 2023) One could see such a Postgrowth approach as arguing for the ‘Double Objective of Democratic Ecosocialism’, basically focusing on an internationalist social and ecological transformation that is just, inclusive, intersectional and decolonial in principle.

But none of this will happen on its own. It will require a major political struggle against those who benefit so prodigiously from the status quo. This is not a time for mild reformism, tweaking around the edges of a failing system. This is a time for revolutionary change. (Hickel, 2023)

​One such a pathway follows Postgrowth theory. This builds on ecological economy arguments that there is a finite physical (material and energetic) limits to growth, and that there needs to be some form of democratic Degrowth trajectory in high-income countries as to still enable space for economic development in the periphery.

References

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