International Health Governance in the Era of Imperialist Globalisation
Dr. Omkar Mittal
The paper makes a link between the commercial interests of the transnational pharmaceutical companies, the charitable foundations like the Gates Foundation, the security concerns of the G-8 countries and their combined domination over the World Health Organisation to dictate new forms of global health governance through the Global Health Public-Private Partnerships. This is illustrated by the case story of the global polio eradication programme. It raises some issues for the revolutionary forces in the context of the newly emerging global social and health governance in the era of globalisation.
The process of western industrialisation and imperialism presented unforeseen opportunities for productivity and growth over the last couple of centuries. At the same time, the inevitable side-effects of industrialisation created tensions that had to be alleviated. The combination of the threat of political instability (revolution) and social reformist thinking led to the emergence of diverse institutional social policies at national and local levels in the two camps of imperialism – the NATO and the Warsaw Pact countries. The end of the cold war led to the closure of one of the internal crises and internal battles of the western imperialism. However, capitalism-imperialism being a world social order is perennially plagued with the crisis of under-development for the majority of the world’s population. The end of the cold war threw up new challenges for global governance in the social economic and social and health spheres.
At the present time we face a situation whereby some transnational corporations are financially bigger than many small southern countries. In the international arena, they have become major players and influential actors that make use of the fact that their conduct is essentially regulated on a national level. At the international level they lobby for rules and regulations that protect their patents, their investments and their market access. As a result of globalisation, the influence of the multinational corporations at the global level has increased enormously. This influence has stretched out into the social sphere and also in the international political ambits, like the UN-system. The consensus among the social scientists of the imperialist camp suggests that globalisation means a shrinking of time and space; an ever closer connection between economic and social actors and events in different parts of the world. From a revolutionary perspective, imperialist globalisation refers to the new phase of domination of the global capital led by the transnational corporations. From either perspective, in today’s world of globalisation, individual national societies cannot be understood in isolation from the processes occurring at the supranational level. National public policies and practices are always influenced by global factors. In order to define the rules of the game in their own interests, the transnational corporations are increasingly developing strategies for dominating the national and international institutions including those of the United Nations. These include the WHO, UNICEF, FAO, IMF, World Bank, WTO and many others.
Whereas within single countries, and even within the most advanced regional grouping of countries, the EU, there are established governance mechanisms and institutions for the formulation and execution of national and regional social policy, this is not the case for the world as a whole. The United Nations system was conceived in an era of inter-nationalisation (not globalisation) and is designed primarily to facilitate country-to-country co-operation. Alongside that have emerged the Bretton Woods organisations that are formally part of the UN system but actually, more often than not, in competition with it. In addition, there is a bewildering array of international civil society actors seeking to influence global policy. In order to redefine the roles of these institutions in the era of globalisation, the G-7-8 countries – USA, UK, France, Canada, Japan, Germany and Italy and Russia are preparing the new strategies for the global governance in their annual meetings and other forums. One of the key planks of this strategy was the UN reforms. Mr. Kofi Annan declared in the year 1995, the famous UN compact with the private sector and the originations like UNICEF and WHO started a new era of global health public private partnerships – GHPPP. It is very important to understand the functioning of these new institutions of global governance in order to make sense of some of the major public health and disease control initiatives in the developing countries today. It requires a complex multilateralist framework as its analytical starting point. Governments still play a major part, but so do trans-border civil society actors interacting with trans-border corporations and international organisations.
Globalisation and WHO
In 1993 the World Health Assembly called on WHO to mobilise and encourage the support of all partners in health development, including non-governmental organisations and institutions in the private sector, in the implementation of national health strategies for health for all. Subsequently the interaction with the commercial sector has broadened and deepened. WHO participates in a number of global public private partnerships. These collaborative relationships transcend the national boundaries and bring together at least two parties, a corporation (or industry association) and an intergovernmental organisation, in order to achieve a health creating goal on the basis of mutually agreed and an explicitly defined division of labour. Nearly 70 global partnerships have been identified. Some of these are: European Partnership Project on Tobacco Dependence; Global Alliance for TB Drug development; Global Alliance to eliminate Lymphatic Filariasis; Global Alliance to eliminate Leprosy; Global Alliance for Vaccines and Immunisation; Global Elimination of Blinding Trachoma; Global Fire Fighting Partnership; Global Partnership for Healthy Aging; Global Polio Eradication Initiative; Global School Health Initiative; Multilateral Initiative on Malaria; Medicines for Malaria Ventures; Partnership for Parasite Control; Roll Back Malaria; Stop TB Initiative; UNAIDS/Industry Drug Access Initiative;
In 1999 Kofi Annan said to the World Economic Forum that the UN once only dealt with governments but that by now he knew that peace and prosperity cannot be achieved without partnerships involving the business community. Also the director of the WHO, Gro Harlem Brundtland, has affirmed several times that today’s health problems are so vast and complex that tackling these problems requires the participation of all sectors, including the business sector. These statements reflect the recent trend of mushrooming of initiatives, especially in health, whereby UN institutions like WHO and Unicef collaborate with pharmaceutical companies and foundations such as the Bill and Melinda Gates Foundation. They tackle health problems like the vaccination of children, the lowering of prices of patented drugs, the development of new medicines and drugs for tropical diseases, etc. These so-called global public private initiatives allow the UN institutions to access financial resources they could not access before and provide the business sector with opportunities to influence health policies as they never could before. For example: one of the conditions of the industry in the Accelerating Access Initiative1 was that countries that wanted reduced prices for anti-retroviral medicines would not allow import or production of cheaper generic versions produced in Brazil or India. In addition the industries involved, which often are pharmaceutical companies, can and do use these initiatives to raise their public profile.
The mushrooming of Public Private Initiatives at the global level is a very new phenomenon. Today more than 80 have been identified, all having their own goals, structures, ways of operation, funding mechanisms etc. The fundamental question is who decides in a partnership and who should decide? What is the desired governance structure? Another crucial issue is accountability. Most of these initiatives have autonomous secretariats and boards. At the same time, they are closely related to the UN system: in fact, the UN is part of these initiatives. In this way, situations are created that could put at risk the independence and legitimacy of the UN itself.
So far little information is available about the real benefits these initiatives have delivered for especially vulnerable and excluded populations, and for the strengthening of comprehensive health systems. The information that we do have is not very promising. Until now only a few thousand HIV/AIDS patients in Africa benefited from the drugs that have been made available through the Accelerating Access programme, while millions of people suffer from the disease. And it was the countries themselves that had to take care of transportation and distribution of the drugs, which meant that they had to divert funds and manpower from other health activities. The worst of it all was that the prices negotiated were even higher than the prices of generic drugs coming from India.
Public-private partnerships have elicited strenuous objections. The types of questions that have arisen include: are partnerships desirable, and under what circumstances, from a societal point of view? What are the appropriate criteria for selection of candidate companies, industries and activities, and how are such criteria developed? How can interactions be structured and monitored in order to avoid or deal with conflict of interest? How can partnership be made to function in accordance with principles of good governance?
In relation to WHO, critics believe that some of their fears are materialising. For example, it is charged that the independent setting of standards was jeopardised during the elaboration of guidelines for the management of hypertension because of the influence of a firm that stood to benefit from them. Similarly, is has been asserted that deliberations on breastfeeding were subject to ‘censorship’ because of consideration of the sensibilities of WHO’s new commercial constituencies. Others argue that WHO’s emphasis on the marginalised will be displaced as resource rich partnerships dictate organisational priorities and strategies. It has been suggested that WHO’s involvement in the Global Alliance for Vaccines and Immunisation has derailed its commitment to equity in relation to the goal of universal vaccination with traditional vaccines, as it joins its partners in bringing new vaccines to the relatively less hard to reach. Moreover for understandable reasons, partnerships sometimes focus, at least initially on countries and activities that offer a reasonable chance of success. Thus they usually concentrate on relatively affluent countries rather than on those that are very poor, and on drug donations and development instead of the more difficult challenges of capacity development for service delivery and research in low-income countries. Yet even relatively non-controversial initiatives such as donation programmes, may have considerable and unintended consequences linked, for example, with costs to recipients, sustainability and equity, which could damage WHO’s reputation by association.
It will be pertinent to point out in this context that WHO was never free from the influence of the extra-institutional interests. The larger part of its budget has always come from what is called ‘extra budgetary sources’ given by the developed countries and the World Bank to sponsor programmes of their own interests. The WHO bureaucracy had no freedom to allocate these resources and the use of these resources was governed by the contractual agreement with the respective agencies. Since the early eighties, the World Bank has emerged as a greater player than WHO in international health and WHO has been increasingly forced to play a second fiddle to it. Both UNICEF and WHO have been starved of the legitimate sources of funding and increasingly dependent on these extra budgetary resources for sustaining their large bureaucracies.
Globalisation, health and national security
The emergence of HIV/AIDS, SARS and diseases like tuberculosis and malaria are being perceived by the G-8 countries as a threat to their national security and are becoming part of their foreign policy concerns. In order to contain some of these threats, a Global Fund for AIDS, Tuberculosis and Malaria (GFATM) has been established by these countries to provide donations on a result oriented basis to the developing countries to contain these diseases on a war footing. The large pharmaceuticals and charities like the Bill and Melinda Gates Foundation are also on the governing board of this fund and WHO merely acts as a secretariat. The GFATM is one of the examples of the GHPPPs.
Immense powers have been bestowed on WHO in the era of globalisation. Under the WTO debate food safety has been a major issue and the WHO, enjoying the status of the scientific neutral world body, has a major say on this issue. Similarly during the SARS scare of the last year, WHO practically held China by the neck and all the travel was stopped till China followed the WHO directives and dictates on the control of the epidemic. The people of India would recall similar events in 1994 during the plague scare which is said to cause immense harm to its economy. We have been witness to a great interest in India on the issue of permanent membership of the UN Security Council. However surprisingly there is very little interest shown by the Indian security experts on the role of India and other developing countries in the WHO, which is now overseeing the health security concerns of the developed countries.
Global Polio Eradication Initiative (GPEI)
It will be important in the above context to discuss the polio eradication campaign in India at some length. Polio is a water-borne disease caused by an enteric virus. In a small percentage of children that it infects it causes paralytic illness which leave a residual paralyses in some of the cases. There are other non-polio enteric viruses that cause similar illnesses in children. Other enteric viruses like Hepatitis-A cause jaundice which affects very large numbers in the population. One of the enteric bacteria causes enteric fever which also affects large numbers of the population. All these water-borne diseases are caused by the water contamination and can be prevented by the supply of potable water and the promotion of sanitation and hygienic practices. It has always been the position of the proponents of polio eradication by the means of vaccine that the objectives of the provision of potable water and sanitation are not feasible for a country like India. After the eradication of smallpox in 1978, they have made an impassioned case for eradication of polio virus by the use of vaccine despite the facts that the efficacy of the vaccine has been questioned in tropical countries like India.
GPEI is an example of the new global health governance model. The polio eradication programme in India, as part of the global programme was launched in 1995. It promised the eradication of polio through national immunisation day approach called ‘pulse polio’, by the year 2000 and the certification of eradication by 2005. The target of eradication has now been postponed to the year 2004-07. Beginning from the year 1995, after nine years of national and international efforts it has finally dawned on practically everyone that the objective of eradication will not be achieved in 2004
The objectives of the programme when it was launched in 1994 were to eradicate polio virus, stop polio vaccination to save money, establish global surveillance for the polio virus and strengthen the health systems in the developing countries. Despite the failure in the eradication of the virus the WHO is now discussing the new post-eradication strategy for 2004-08 which include, introduce Intramuscular Polio vaccine instead of oral polio vaccine (to avoid the problem of VAPP – see below), laboratory containment of the polio virus, continue surveillance, use polio surveillance for more diseases and introduction of new vaccines in collaboration with GAVI (Global Alliance for Vaccine Initiative – a programme for the introduction of newer vaccines like hepatitis-B, largely funded by a donation from Bill Gates).
This global initiative is led by four main partners: WHO, UNICEF, Rotary International and Centre for Disease Control of the government of the USA. The other partners in this alliance are the donor development agencies of the G-8 nations, vaccine manufacturers and transnational companies like De-Beers. Bill and Melinda Gates Foundation is also one of the several contributors.
As per its constitutional mandate, WHO should play the role of a neutral technical adviser in the programme. However, in the India Polio Eradication Initiative, WHO has been directly responsible for setting up the laboratories and also supervising the entire programme through a network of Surveillance Medical Officers who are supervising the Chief Medical Officers in the districts. From the point of view of the health establishment in India, WHO is running this programme, as if it is some kind of supranational agency, having the authority over the national government. Agencies like UNICEF are the monopoly procurement agents for the polio vaccine. UNICEF is also the procurement agent for the social mobilisers at the district level. While acting as contractors, these agencies are also serving the role of providing the top policy advice on the continuation of the programme. There is no provision for the auditing of the accounts of these bodies by any of the national audit agencies. They provide an easy conduit to the national bureaucracy to bypass all the auditing requirements of Indian law and accountability to the national parliament and legislature.
The WHO and World Bank have made a clear admission that polio eradication is not an epidemiological priority for the developing countries and that the programme is to provide a small saving in vaccine delivery cost to the developed countries. For this reason, massive grants running into millions of dollars have been provided to the developing countries and WHO. However, India has been forced to borrow from the World Bank despite an impression being created that the entire programme is grant funded.
The polio virus is the cause of only a small percentage of childhood paralyses in the developing countries. In countries like India at least 25 percent cases of childhood paralyses are caused by non-polio enteric virus. Hence this is not a battle for the liberation of children from debilitating paralytic illness but a grand experiment of eradicating virus with vaccine.
The goal of eradication of the polio virus is a mirage, which understanding is accepted by several national and international experts today. We are pursuing this mirage in the hope of repeating the feat of smallpox eradication but there are several differences between the two viruses. One of these is that smallpox vaccination’s one inoculation provided one hundred percent immunity but in the case of polio oral vaccine there is not complete immunity even after several doses. The large majority of children getting polio paralyses are those who have received three or more doses of polio vaccine. Besides a significant number of children are also getting paralyzed due to the vaccine itself. This is known as vaccine associated polio paralyses (VAPP).
During the last 10 years the children have been administered several doses of the oral live polio vaccine in the national and sub-national rounds of pulse polio. The children born in the year 1997 in the states of UP and Bihar may have received 25-30 doses of polio vaccine by their fifth birthday, as against the previous wisdom of three doses under the routine immunisation programme. The star campaigner Amitabh Bachchan is trying to convince women through the national media, not to worry about the number of doses. Now the polio eradication is being re-linked to strengthening the routine immunisation under GAVI. This needs to be looked at from two angles – one, the original premise of WHO was that polio cannot be eradicated by routine immunisation and they have made a 180 degree turn after a decade of costly experiment. Secondly the strengthening of routine immunisation will be done under GAVI which is merely a cover for the introduction of newer costly vaccines in India.
The new objective of introductions of intramuscular vaccine in India will largely serve the interests of the pharmaceutical companies, as this vaccine is very expensive. Moreover there are no trials which prove the better efficacy of this vaccine in countries like India. The other major thrust of the new WHO strategy is to ensure the laboratory containment of the polio virus and extend the surveillance to other virological diseases. These objectives are directly linked to the perceived threats to the security of USA and other G-8 countries from newly emerging viruses and terrorist attack using the viral agents.
There are two kinds of public health – techno-centric and people centric. Polio immunisation has been used as an exercise for techno-centric public health to gain acceptance and legitimacy. It is manufacturing of consent for commoditised and marketised techno-centric approaches. However, mere technology cannot solve all health problems.
Issues for the consideration of the revolutionary forces in the developing countries
We live in an era where a heinous war has been unleashed by the USA and some of the other G-8 countries on Iraq and Afghanistan on the mere pretext of perceived threat to their national security from the terrorism and weapons of mass destruction. These weapons could be nuclear weapons, chemical weapons or bio-terrorism. In the case of America, the perceived threat has led to the reinstitution of smallpox vaccination in the armed forces and the public health personnel. The BBC has made a small documentary on the bio-terrorist attack using the smallpox virus. The real question to be posed is how real is the threat? Is it a threat from terrorists within the G-8 countries or from the terrorists from the developing countries? Or is it merely a ploy by the techno-industrial scientific and commercial establishment of the USA and G-8 countries to demand more and more budgets and become super-dinosaurs?
An academician would like to be very careful with his/her inferences and unless there is direct conclusive proof of an overt conspiracy to do harm, he would not like to call it a conspiracy. In case there are differences of opinion on the judgment and objective grounds, he would like to raise these issues and leave it there without trying to make any further inferences. This kind of attitude would be fairly legitimate in a purely scientific debate. However, we in the developing world are facing a situation where decisions are being made that are affecting the lives of billions of people. Ironically some of these decisions are being made with the overt intention to dispense some relief and crumbs to the downtrodden, without of course taking their own views and opinions and priorities into account. Seeing from the ground from their angle and perspective, and visualising that something terribly wrong is being imposed on them and it is being further intensified without any possibility of that minor good happening, it would be a legitimate political question to ask by them, whether there is any conspiracy or not?
Considering the similarities of interests between the national and international ruling forces, it is possible that the national political forces and civil services are either not concerned with these issues or they been easily bought over by the temptations of easy perks from these agencies to bother about these issues. However, if there is a demand from the ground, it will be difficult for the national governments to ignore these concerns, just as it has happened in the case of WTO. Therefore it should be the duty of the revolutionary forces to bring into the forefront the issues of global health and social governance to find common ground with national governments in the interests of the toiling masses.
Charity and philanthropy have been a key and welcome driving force behind most public-private partnerships. While helpful and catalytic, though, they are not a substitute for good and responsible government in the North and South. Even within a clear vision and mission, public-private partnerships cannot displace the responsibility of government to ensure and promote people's right to equitable access to health care, and to set the health agenda both nationally and globally. Public-private partnerships, their stakeholders and national citizens must insist that government and intergovernmental institutions fulfil their responsibilities in properly funding and directing need based R&D. Governments still have a duty to ensure that appropriate resources and capacity exist in independent national and intergovernmental institutions to set, drive, monitor and critically evaluate the national and global health agenda. This is a minimum requirement and goes far beyond the disease specific initiatives which typify most new public-private partnerships.
The author is a medical graduate by education. He has been a long time social activist and also a consultant with large number of NGOs and donor-development agencies. For more detailed discussion on these issues the author may be contacted on E-mail: O_Mittal@rediffmail.com
1. In the Accelerating Access Initiative 5 UN organisations and 5 pharmaceutical companies work together to lower the price of patented retrovirals. Price negotiations take place with individual countries and are secret.
Click here to return to the April 2005 index.