Ilona Kickbusch and Andrew Cassels introduce a collection of articles on global health disruptors
With global governance and global health at a turning point, it seems apt to use the occasion of the 10th anniversary of the Global Health Centre at the Graduate Institute to look back at global health disruptors of the past two decades and to look forward at what will shape global health in the future.
Looking back, it is evident that the links and interplay between sources of disruption are more important than individual factors taken in isolation. AIDS linked health to global security, resulting in a fundamental recalibration of development finance (from millions to billions). The demand for more resources was fuelled by activist civil society; it brought more organisational players into the picture, and thus required more multi-stakeholder approaches to governance and partnership. Success in tobacco control and access to medicines created an appetite for greater use of international agreements and treaties. Global health governance is—we realise—about understanding change in interconnected living systems.
We also see a clear disconnect between the first and second decade of this century. If the first decade reflected the optimism and innovation in global health after the end of the cold war, the financial crisis loomed large over the second. International financing for global health has so far remained relatively unscathed, but the political fallout from the crisis—in which solidarity and shared sovereignty no longer prevail—provides the backdrop for any analysis of the future. Failure to provide funding for preparedness for the next flu outbreak is one clear symptom. There will be more to come.
Looking ahead forces us to think about the institutions of global health governance. The key challenges—reducing the price of medicine, combating antimicrobial resistance, tackling the determinants of non-communicable diseases, the health of migrants, and the health effects of environmental degradation and climate change—are of concern to all countries. They are deeply interconnected and multisectoral. Where current institutions often fail is in persisting with purely technical solutions to solve political problems; relying on linear thinking in a world dominated by complex systems; and expecting elegant concepts to translate from PowerPoint presentations into reality. Some of the contributors to this collection argue for a new generation of governance institutions better equipped to handle complexity. Others put their faith in the transformation of existing entities combined with a focus on consolidation and coordination. However we view this choice, the key point is that it has to be made in the face of the most fundamental disruption yet faced by global health.
The turning point we refer to—captured in detail in Stephen Morrison’s piece about the decline of the postwar global order—is not related to one dominant event or health crisis. Rather it resembles an erosion, a growing feeling of uncertainty and threat in the face of a record number of problems; protracted humanitarian crises, substantial shifts in global power relations; and an increase in the malign influence of nationalist, nativist, and populist movements. The World Freedom Index finds that political rights and civil liberties around the world deteriorated to their lowest point in more than a decade in 2017.  A geopolitical shift is underway that challenges the norms, rules, and institutions of the postwar liberal international order—but it is not yet clear what will replace them.
Global health is beginning to experience the effect of a world that is more multipolar, less multilateralist, and more ideological. Support to international organisations and agreements can no longer be taken for granted, their value base is increasingly being questioned, financing mechanisms are no longer ensured, and political ideology increasingly trumps technical evidence.
Some argue that the concern is simply that the West is losing its power and that, as Kishore Mahbubani stresses repeatedly, it is a matter of perspective.  Developments such as China’s Belt and Road Initiative undoubtedly represent more opportunity than crisis. Similarly, one can argue that “2017 was probably the very best year in the long history of humanity.”  Never have so many people been able to move out of poverty; the global middle class is growing exponentially; more children reach the age of 5 years than ever before; the threat of hunger is receding for many; polio is nearly eradicated, and measles is not far behind; more countries give priority to ensuring that all their citizens have access to healthcare and medicines. South-South cooperation is booming, and it is to be hoped that Africa will at last be able to benefit from more investment rather than aid. At the same time, the results of the 2017 Global Burden of Disease study “shatter this comforting trend of gradual improvement and instead show plateauing death rates on a background of faltering and uneven progress, era defining epidemics, and dramatic health worker shortages.” [4 5]
The Organisation for Economic Cooperation and Development identifies 56 countries as fragile; by 2030 these countries are where about 80% of the world’s poor will live.  One in every 113 people on the planet is now a refugee—the number of people displaced by force has risen to a record 68.5 million in 2018. The Intergovernmental Panel on Climate Change has warned recently that we are reaching the point of no return for the impact of global warming.  We do not know the extent to which antimicrobial resistance will undermine medical progress. We are not yet sure whether advances in systems biology, genetic engineering, increases in computing power and informatics, and the development of materials science and nanotechnology will yield all the benefits that they promise.
Any one of these issues has the potential to be a disruptive force for global health, let alone all of them together. We are therefore at a turning point for two interconnected reasons. Firstly, these challenges are not yet fully accepted as being collective problems, requiring solidarity and a global response, as they are increasingly crowded out by short term domestic political concerns. Even with global agreement on the sustainable development goals, the willingness to invest in “others” and in global public goods is diminishing. Secondly, the UN and other multilateral institutions are currently ill prepared to deal with interconnected challenges and systemic breakdowns. The political environment for reform that will enable them to be more effective is lacking. These—and not viruses or diseases—are the threats that should keep us awake at night.
Ilona Kickbusch is director of Global Health Centre, Graduate Institute for International and Development Studies, Geneva, Switzerland.
Competing interests: None declared.
1 Abramowitz MJ. Democracy in crisis. Freedom in the World 2018. https://freedomhouse.org/report/freedom-world/freedom-world-2018
2 Mahbubani K. Has the West lost it? A provocation. Allen Lane, 2018.
3 Kristof N. Why 2017 was the best year in human history. New York Times 2018 Jan 6. https://www.nytimes.com/2018/01/06/opinion/sunday/2017-progress-illiteracy-poverty.html
4 Global Burden of Disease Study. 2017. http://www.healthdata.org/gbd.
5 The Lancet. GBD 2017: a fragile world. Lancet 2018;392:1683. PubMed
6 OECD. What are the key findings from contexts affected by fragility? States of Fragility. OECD Publishing, 2018.
7 Intergovernmental Panel on Climate Change. Global warming of 1.5°C. UNEP and WHO. 8 Oct 2018. http://www.ipcc.ch/report/sr15/