In its analysis of violence and conflict as “powerful and enduring threats” to health and wellbeing, the Commission similarly notes political and economic factors that increase the risk of war and armed violence. These include: high levels of unemployment; income inequality; economic instability; an unregulated small arms trade; and deficiencies in global governance (notably the “institutional stickiness” and “anachronistic” nature of the UN; the out-datedness of the Geneva Conventions; and the limitations currently placed on the International Criminal Court).
An absence of laws and regulations to promote public health is a prominent theme. But the Commission also notes that when appropriate laws and regulations do exist, states often lack the willingness or capacity to monitor and enforce compliance. Instead, elite, corporate and financial interests all too often subvert the capabilities and duties of democratic institutions to look after the general public interest; exploiting the gaps and deficiencies that exist within the international judicial system.
Importantly, the Commission notes that civil society efforts to hold powerful global actors to account by monitoring and publishing their behaviours (e.g. the
Publish What You Pay initiative focused on the energy and mining sectors) or to promote
“socially responsible investment” are no substitute for legal and regulatory mechanisms that can enforce sanctions when international norms, laws and standards are violated. Similarly, initiatives aimed at mitigating the negative effects of the IPR regime (e.g. the creation of patent pools, corporate donation programmes and public-private product-development partnerships) are deemed to be insufficient.
Poor Recommendations …
The Commission makes a clear case for a redistribution of political and economic power: for the strengthening of real democracy, including more transparency and greater accountability of powerful actors at the global level, and for the reshaping of the rules and laws that shape our current form of globalisation. In short, it calls for systemic, radical and transformative change.
But having done this, it then loses its way and retreats to the safe and apolitical territory of ‘governance’ by proposing the establishment of two new global structures as its primary recommendation: a UN Multistakeholder Platform (to share and review information, influence norms and opinions, and make recommendations) and an Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health (to assess evidence and conduct research).
While both structures could provide some value in their own right, neither would redistribute power, nor alter the frame of existing laws, rules and systems. Furthermore, both would add to the already uncoordinated and crowded global governance landscape. Ironically, the Commission itself notes that a proliferation of international rule making, bodies and conferences has contributed to “regime complexity” and the blurring of obligations, responsibilities and lines of accountability.
A number of secondary recommendations are also made: make it mandatory for health equity impact assessments to be conducted by global institutions; create a regular forum for civil society organisations to present reports to the International Criminal Court on alleged violations by TNCs and other non-state actors; advocate more on the basis of existing human rights treaties; and promote the financing of global public goods through compulsory contributions made by all states according to ability to pay.
There is nothing bad about these recommendations. But some of them feel old and tired; and none of them are transformative. In fact the Commission admits that these secondary recommendations are not expected “to root out the very causes of persistent health inequities” but merely “remedy the effects of the inequitable distribution of health”.
As a consequence, trade agreements and investment agreements are left untouched (which the Commission repeatedly notes as being too difficult to reform or amend). And nothing is said about banking reform, corporate tax enforcement, global finance regulation, or mechanisms to redistribute wealth and assets (including reclaiming from the ‘one percent’, that which should fall under public stewardship or ownership). In terms of addressing hunger and food scarcity, the mention of social protection schemes and greater investments to strengthen smallholder farmers are also ameliorative solutions rather than anything transformative or structural. In fact under the current system, investments that support smallholders often benefit private finance capital and big corporations through corporate capture and buy-outs.
Although the call for countries to make compulsory payments to finance global public goods would mark a significant change from the current system of voluntary contributions, even here, the actual benefits are marginal, and would do no more than to make ‘official aid’ a little more generous and predictable.
Why did this happen?
The gap between ‘analysis’ and ‘recommendations’ is startling. The identified need for transformative change is abandoned in favour of a set of marginal changes. It is as though having ‘spoken truth about power’, the Commission wasn’t prepared to ‘speak truth to power’ when it came to making recommendations. What can explain this?
One possible explanation is that the Commission was being pragmatic and strategic – proposing a set of moderate and unthreatening recommendations but which might promote transformative change later on. For example, the Commission might have imagined that a new multi-stakeholder forum and an independent scientific panel would bring about a social and political mobilisation that would then lead to transformative equitable and democratic change.
A second possible explanation is that having described the political causes of health inequity, the Commissioners lacked agreement or a shared vision on what an alternative form of globalisation and global governance would look like. It is possible that social, political and conceptual differences between individuals led to differences in opinion which led to the formulation of moderate, ‘lowest common denominator’ recommendations that were acceptable to all.
Certainly, there is evidence of some ambiguity within the Commission’s report. For example, the Commission credits the global market system for having generated “ever greater flows of goods, people, money, information, ideas, and values” with the help of “privatisation, deregulation, and trade liberalisation”; and for having produced “unprecedented growth that has increased material prosperity for hundreds of millions of people and greatly improved their health and wellbeing.” It also notes how foreign direct investment “is widely regarded as an important vehicle to advance economic growth and development” and how TNCs also “yield enormous benefits by creating jobs, raising incomes, and driving technological advances”.
Both these claims contribute to a degree of ‘mixed messaging’ about globalisation and global governance. They also happen to be wrong. The trinity of privatisation, deregulation and trade liberalisation as currently structured, has done more to inhibit rather than encourage the generation and flow of knowledge, information and ideas (especially apparent in the pharmaceutical sector). Furthermore, it has hindered economic growth and development compared to other more pro-active approaches to socio-economic development. Similarly, there is no evidence that TNCs perform well in terms of job creation, raising incomes or driving technological advance (if anything, the evidence is negative).
‘Mixed messaging’ is also evident in the Commission’s discussion of the recent financial crisis and consequent austerity measures that governments have implemented. The focus was on how to respond to the financial crisis (i.e. whether counter-cyclical spending was better than austerity, and whether austerity could be implemented with less adverse health effects), but not on reforming and regulating the system of global finance, nor on how the vast amount of illegitimate and odious debt that has been piled onto governments and ordinary people could be annulled.
A third possible explanation is that members of the Commission were ‘censoring’ themselves – either consciously or sub-consciously. Promoting ‘transformative’ change that challenges power while seeking to redistribute resources equitably is discomforting and not without risks. One may want to avoid direct confrontation with power, and avert the risk of being labelled and then dismissed as an unrealistic or quixotic ‘radical’.
It is worth noting that the power and politics that shapes the global political economy also operates across the global health landscape. For example, TNCs are powerful and influential actors in global health who would positively welcome marginal changes in global governance (including the promotion of progressive norms, ideas and values), as long as trade and investment rules continue to be structured in their favour. And the Gates Foundation – a major source of funding for the global health community – is also a strong proponent of neoliberal globalisation and the prevailing undemocratic structures of global governance.
Importantly, the role of private philanthropy and official aid was not critically examined by the Commission, which instead praised the Gates Foundation by name and portrayed ‘global health’ and ‘aid’ as uniformly positive domains that counteract the negative effects emanating from ‘trade’, ‘national security’ and ‘finance’. The reality is more complex. While much aid and private philanthropy undoubtedly ‘saves lives’ and provides vital humanitarian assistance, their role in sustaining democratic deficits and disparities in power, and in shielding unfair trade and investment agreements and egregious market failures from reform was not even mentioned.
The Commission’s tendency to portray governments, civil society and corporate actors as separate and distinct actor groups that compete with each other for influence and power, also obscured the fact that power is organised horizontally across these three sectors. This links to another important contextual factor that was not examined by the Commission: the ‘public-private partnership’ paradigm which has come to virtually define global governance in the last two decades and which has enabled and legitimised the presence of powerful, undemocratic and self-interested actors at the heart of decision and rule-making structures and processes.
As I like to sometime say, the real occupy movement isn’t the one led by ordinary citizens on the streets and squares of towns and cities across the world: it is the occupation of governments, the UN complex and the media by the corporate sector and the wealthy. This occupation may also extend to universities and research institutions where changes to funding and management arrangements have shrunk the space for academic freedom and public-interest science.
