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Guddi Vijaya Rani Singh: Why the political origins of health inequity haven’t been tamed just yet

5 Mar, 14 | by BMJ

guddiLast week saw the release of the much vaunted “Political origins of health inequity” report by the Lancet-University of Oslo Commission on Global Governance for Health—an analysis of how policies and factors external to the health sector impact on health inequity, with appropriate recommendations.

The question for the public health community is: does this herald a true transformation in global health governance or merely reproduce its current impotence?

The report’s starting point is that given that health outcomes are determined as much by the circumstances in which people live as by their access to quality health services, there is a need to consider what can be done in other sectors that impinge on health. This marks an important shift away from biomedical fixes to global health problems, and as such, the commission promises a great deal.

The report focuses on the “political nature of global health,” reaffirming many of the points established by Michael Marmot, a member of this commission, in his social determinants of health approach. The key claim is that globalisation has promoted growth, but exacerbated inequality. The report talks of “an unjust global economic system that favours a very small elite with great wealth at the price of environmental and social degradation that negatively affects health equity.” To the extent that—until Davos at least—inequality was a dirty word at a supranational level, this report helps to make it part of mainstream discourse.

However, despite its length, the report makes some rather glaring omissions. We are told that the commission selected seven focus areas through a “process of informed deliberation.” What exactly informed the deliberation is not clear; how can they explain, for instance, why an obvious candidate such as climate change was neglected? This is an oversight that the people of Somerset would surely find hard to forgive.

The commission then goes on to offer two principal solutions to address the “systemic dysfunctions that impede the realization of global governance for health.” The first calls for establishing a UN Multistakeholder Platform. Given that the purpose of such an entity is purportedly to provide “space for diverse stakeholders to frame issues, set agendas, debate policy proposals that affect health and health equity, and propose solutions for concrete policy processes,” why is the World Health Organization given such a peripheral and miniscule role?

Far from bringing forth a revolution, the multistakeholder platform does little more than recreate the existing problem. And therein lies the rub. Global issues demand global solutions, not ones where the health community—represented by the WHO—helplessly wrings its hands at the fringes of a discussion led primarily by non-health and private interests. Why is the finance sector given the same voice as the public health community? The report notes that the finance sector and the trade sector cause ill health; now is not the time to listen to them, now is the time to change them.

Sadly, the commission’s second proposal offers little better. The suggested Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health “will call for, receive, assess, analyse, debate, and communicate multiple lines of independent evidence—across disciplines—and provide independent and transparent strategic information to the UN and other actors that affect global governance for health.” The similarities with the controversial Intergovernmental Panel on Climate Change is unsettling, and reminds us to ask: Can independence be secured in such a highly contested debate? Given the so-called balance of power in the proposed stakeholder model, who is to say that there won’t be strong influences from business, especially given that commercial interests are so explicitly represented?  If so, how effective can this “monitoring panel” be? And even if this were not to play out, what good is a watchdog nobody trusts?

With the Lancet-University of Oslo Commission on Global Governance for Health we must be careful of applauding merely another glossy report and ask whether it is feasible or practicable to set up new bodies of such complexity, and what they might achieve.

We have now perhaps come to expect anodyne recommendations from these so-called high-level panels. But is this really acceptable at a time when the world is facing the biggest challenges in human history? Economic justice and climate change will be the major determinants of health and wellbeing for decades to come. But this concept is not new. The report itself admits that many scholars have brought attention to the global and political nature of health and health equity. Another meeting of global health glitterati, convened at great expense, merely to come to the same conclusion that many in the global health community have known for years is disappointing.

It would have made more sense for the commission to demand specific changes in the policies of national governments—such as the City of London’s tax haven status in the UK, which literally steals hundreds of billions of dollars from the developing world each year, or to suggest reforms of the key international structures—such as the global tax secrecy network—whose governance and policies are supposedly being criticised. The commission’s principal recommendations—a talking shop and a monitoring mechanism—are disappointingly pedestrian for a report that calls for radical change to address the fundamental global inequities harming health.

Just because the issues are “complex and politically sensitive” does not excuse a response lacking in bite. Health inequalities and inequity are problems of power, and as such deserve powerful rejoinders. Anything less is feeble and—in today’s context of planetary crisis—morally indefensible.

Competing interests: I declare that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.

Guddi Vijaya Rani Singh is a doctor training in paediatrics in London. She also has a masters in public health from Harvard University and has worked for the World Health Organization (WHO). She is passionate about social justice, human rights, and challenging barriers to access to health. Most recently, she has worked with 38 Degrees and openDemocracy on the Save the NHS Campaign, and is now working with Medact to set up the People’s Health Movement UK.

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  • http://www.uio.no/english/ Desmond McNeill

    As a Commission member I am certainly surprised to be described as one of the ‘global health glitterati’, but pleased to see that the report has stimulated debate. As other commentators you seem to fully support our intention (‘an important shift away from
    biomedical fixes to global health problems’) and commend us for helping to make the ‘dirty word’ inequality ‘part of mainstream discourse’. Your critical comments relate primarily to the proposals for follow up, so I will try and respond to those – in a personal capacity.

    You criticise the proposal for a UN Multistakeholder Platform on the grounds that the World Health Organization is given such a peripheral and miniscule role. The report is in fact not very specific about the extent of WHOs proposed role in such a platform (the sizes of the circles in the diagram do not reflect any recommended
    ‘voting power’, even in the unlikely event that such a platform would take a vote). The question, which you rightly raise, is ‘how to best engage with non-Health sectors, such as finance and trade’. Your
    answer is ‘now is not the time to listen to them, now is the time to change them’. That is indeed what we want to do, but engaging with non-health sectors does not just mean talking to them’ (presumably meaning powerful interests) but talking also to others who are well-informed about issues of trade and finance.

    There is certainly a need for change, and we hope that our second proposal – for an Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health – will be positive in this respect. Here I think you misunderstand: it is not envisaged as a body in which commercial interests will be represented at all, but rather a scientific (in the sense of academic) panel, whose legitimacy derives from its independence and the quality of the evidence offered in its reports.

    I agree that “just because the issues are ‘complex and politically sensitive’ does not excuse a response lacking in bite”; and your assertion that ‘health inequalities and inequity are problems of power, and as such deserve powerful rejoinders’ is in fact a central
    claim of the report. I believe, however, that the two proposals you criticise should be seen as only a part of the Commission’s response. A major contribution, I hope, is that unlike very many such commissions we have been very explicit about the power dimension of the problem.

    Desmond McNeill, SUM,
    University of Oslo, Norway

  • http://www.uio.no/english/ Desmond McNeill

    As a Commission member I am certainly surprised to be described as one of the ‘global health glitterati’, but pleased to see that the report has stimulated debate. As other commentators you seem to fully support our intention (‘an important shift away from biomedical fixes to global health problems’) and commend us for helping to make the ‘dirty word’ inequality ‘part of mainstream discourse’. Your Critical comments relate primarily to the proposals for follow up, so I will try and respond to those – in a personal capacity.

    You criticise the proposal for a UN Multistakeholder Platform on the grounds that the World Health Organization is given such a peripheral and miniscule role. The report is in fact not very specific about the extent of WHOs proposed role in such a platform (the sizes of the circles in the diagram do not reflect any recommended ‘voting power’, even in the unlikely event that such a platform
    would take a vote). The question, which you rightly raise, is ‘how to best engage with non-health sectors, such as finance and trade’. Your answer is ‘now is not the time to listen to them, now is the time to change them’. That is indeed what we want to do, but engaging with non-health sectors does not just mean talking to ‘them’ (presumably meaning powerful interests) but talking also to others who are well-informed about issues of trade and finance.

    There is certainly a need for change, and we hope that our second proposal – for an Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health – will be positive in this respect. Here I think you misunderstand: it is not envisaged as a body in which commercial interests will be represented at all, but rather a scientific (in the sense of academic) panel, whose egitimacy derives from its independence and the quality of the evidence offered in its reports.

    I agree that “just because the issues are ‘complex and politically sensitive’ does not excuse a response lacking in bite”; and your assertion that ‘health inequalities and inequity are problems of power, and as such deserve powerful rejoinders’ is in fact a
    central claim of the report. I believe, however, that the two proposals you criticise should be seen as only a part of the Commission’s response. A major contribution, I hope, is that unlike very many such commissions we have been very explicit about the power dimension of the problem.

    Desmond McNeill, SUM,
    University of Oslo, Norway

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