Global Health Watch 6: In The Shadow Of The Pandemic 9781913441258, 9781913441265, 9781350320840, 9781913441241

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Praise for Global Health Watch 6 Global Health Watch 6 will assist readers to better understand the causes and consequences of the health crises now afflicting human and planetary health, from the COVID-19 pandemic to the climate emergency, deaths of despair, and rising health inequities. Even better, the book connects readers to the many organizations, movements, and individuals that are working to create a healthier, more equitable, and more sustainable world. —Nicholas Freudenberg, Distinguished Professor of Public Health, City University of New York School of Public Health, author At What Cost Modern Capitalism and the Future of Health (2021)

Global Health Watch 6 provides an extraordinary collection of evidence, perspectives and importantly a number of propositions to move reflection and activism on health  and well-being from exposure and complaint to justice-driven organization, challenge and action. With COVID-19 and ecological degradation reflecting and intensifying “the acquisitive inequities” of a neoliberal globalization, the GHW contributes analysis that merits debate within different regions and contexts for both self-determined and convergent action to build forward fairer. —Dr. Rene Loewenson, TARSC/ Equity Watch Cluster, EQUINET East and Southern Africa An essential guide to the many global and national forces that are threatening our health, our planet and our equity. While this analysis is frightening, the celebration of the power and force of progressive civil society like the People’s Health Movement is a call to collective action and to remaining hopeful. —Fran Baum, Professor of Health Equity, Stretton Institute, University of Adelaide, Australia

The Global Health Watch is a broad collaboration of public health experts, nongovernmental organizations, civil society activists, community groups, health workers and academics. It was initiated by the People’s Health Movement, Global Equity Gauge Alliance and Medact as a platform of resistance to neoliberal dominance in health.

GLOBAL HEALTH WATCH 6 IN THE SHADOW OF THE PANDEMIC

People’s Health Movement Medact Third World Network Health Poverty Action Medico International ALAMES Viva Salud Sama

BLOOMSBURY ACADEMIC Bloomsbury Publishing Plc 50 Bedford Square, London, WC1B 3DP, UK 1385 Broadway, New York, NY 10018, USA 29 Earlsfort Terrace, Dublin 2, Ireland BLOOMSBURY, BLOOMSBURY ACADEMIC and the Diana logo are trademarks of Bloomsbury Publishing Plc First published in Great Britain 2022 Copyright © People’s Health Movement, Medact, Third World Network, Health Poverty Action, Medico International, ALAMES, Viva Salud and Sama 2022 People’s Health Movement, Medact, Third World Network, Health Poverty Action, Medico International, ALAMES, Viva Salud and Sama have asserted their right under the Copyright, Designs and Patents Act, 1988, to be identified as Authors of this work. For legal purposes the Acknowledgments on pp. xviii–xix constitute an extension of this copyright page. Cover image © Dieter Telemans/Panos Pictures All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage or retrieval system, without prior permission in writing from the publishers. Bloomsbury Publishing Plc does not have any control over, or responsibility for, any third-party websites referred to or in this book. All internet addresses given in this book were correct at the time of going to press. The author and publisher regret any inconvenience caused if addresses have changed or sites have ceased to exist, but can accept no responsibility for any such changes. A catalogue record for this book is available from the British Library. A catalog record for this book is available from the Library of Congress. ISBN: HB: 978-1-9134-4125-8 PB: 978-1-9134-4126-5 ePDF: 978-1-9134-4124-1 eBook: 978-1-9134-4122-7 Typeset by Integra Software Services Pvt. Ltd. To find out more about our authors and books visit www.bloomsbury.com and sign up for our newsletters.

To Amit Sengupta

(1958–2018) Our dear comrade and friend, your death in 2018 has left a huge gap, but your writings and memorable actions will continue to guide and inspire us in the struggle to achieving social justice, equitable control on resources, and health for all! It is deserved recognition and moral necessity that this 6th edition of Global Health Watch (GHW) be dedicated to Amit Sengupta, our ex global associate coordinator of People’s Health Movement (2009–2018). Amit was the managing editor and coordinator of the 3rd, 4th, and 5th GHW editions and a part of the editorial team for the first two editions. Amit has been a visionary political leader, tireless health activist, and skilled strategist. He, in a masterly way, weaved and molded the direction of GHW with his vast knowledge of health and the broader health, pharma, political, and trade environment. Amit brought this political, organizational, and leadership capacity to the People’s Health Movement, mentoring and guiding those who needed it, often guiding direction while standing in the background, thereby allowing others to grow in capacity and confidence. When Amit made a statement, it was done so with solid fact and was unquestionable. His life was dedicated to social justice, politics, and the struggle of ensuring universal health (in its broadest sense) to all. In addition to his high work ethic and intellectual brilliance, Amit was a joy to work with, bringing his warmth, his wry sense of humor, contagious giggle, and commitment to a more equitable world into all he did.

To David Sanders

(1945–2019) David was one of the founding fathers and leading lights of the People’s Health Movement. He was a fierce critic of the impact of neoliberalism on the health of people and never hesitated to speak of this truth to those holding power. With a slight tilt of the head and a quixotic grin that would put the Cheshire Cat to shame, David would slowly rise from his chair to politely (or otherwise) and with deliberate cadence give some posturing plenary apologist a withering riposte. David was an accomplished researcher, academic, and mentor to many. He managed to bridge the often-divided worlds of academia and activism. He used his great intellect to pursue research in the service of health justice and made good use of his knowledge and academic achievements to bring light to the struggle for health for all. He continues to be an inspiration to health activists globally. Although it is with tremendous sadness that we mark his premature passing, we find some comfort in knowing that he spent the last day of his life pursuing his other great passion: fly-fishing in creeks dressed up in hip-waders and wearing his handtied fishhooks. Adieu, dear friend.

CONTENTS

List of Acronyms | ix List of Images, Figures, Boxes, and Tables | xiii Acknowledgments | xviii Introduction ������������������������������������������������������������������������������������������ 1 A1

From pre-pandemic pathologies to post-pandemic hopefulness������������ 17

A2

Gendered inequities during COVID-19 times: a view from the Global South ��������������������������������������������������������������������������������� 47

A3

From unethical growth to ethical degrowth: can capitalism be transformed? ��������������������������������������������������������������������������������������� 65

B1

The Universal Health Coverage/Primary Health Care divide ��������������� 83

B2

Global Health 2.0? Digital technologies, disruption, and power�����������105

B3

Healthcare and COVID-19: privatization by stealth���������������������������� 129

B4

Old/new politics of access to medicines���������������������������������������������� 147

B5

Transforming mental healthcare globally ��������������������������������������������173

C1

Austerity rerun �����������������������������������������������������������������������������������193

C2

Unequal labor markets meet a disequalizing pandemic �����������������������211

C3

Confronting the commercial determinants of health ���������������������������235

C4

Development model, extractivism, and environment: knitting resistances globally �����������������������������������������������������������������������������253

C5

Transforming food systems for healthy people and a healthy planet���� 275

C6

Conflict and health in the era of coronavirus�������������������������������������� 299

D1

WHO and the politics of pandemics ���������������������������������������������������317

D2 Shifting

playing fields: how new trade treaties govern governments �������������������������������������������������������������������������������������� 339

D3

The United Nations, global governance, and the toll of funding failures ���������������������������������������������������������������������������������������������� 369

D4 Watching

the international financial institutions: new rhetoric, old practice? ���������������������������������������������������������������������������������������391

viii   |  CONTENTS D5

The World Economic Forum’s Great Reset: corporate ambitions and the future of multilateralism in and beyond global health������������� 409



Conclusion: Building power in the struggle for health (justice): a call to health activists ���������������������������������������������������������������������� 429 List of Contributors | 443 Index | 447

ACRONYMS

ACT Access to COVID-19 Tools ACT-A Access to COVID-19 Tools Accelerator AI Artificial Intelligence ASEAN Association of Southeast Asian Nations ASHAs accredited social health activists BAT British American Tobacco BITs bilateral investment treaties BMGF Bill & Melinda Gates Foundation CDC Center for Disease Control and Prevention CDoH commercial determinants of health CETA Comprehensive Economic and Trade Agreement CFE Contingency Fund for Emergencies CFS (UN) Committee on World Food Security CHWs community health workers CIW Canada’s Index of Wellbeing COVAX COVID-19 Vaccines Global Access CPTPP Comprehensive and Progressive Transpacific Partnership Agreement CRPD United Nations Convention on the Rights of Persons with Disabilities CSEM Civil Society Engagement Mechanism CSM Civil Society and Indigenous Peoples Mechanism CSOs civil society organizations CSR Corporate Social Responsibility C-TAP COVID-19 Technology Access Pool DALYs Disability Adjusted Life Years DPKO Department of Peacekeeping Operations DRD domestic regulation disciplines DSSI Debt Service Suspension Initiative EPA Economic Partnership Agreements EPZs Export Production Zones ESA Eastern and Southern Africa ETAF Equitable Technology Access Framework EU European Union Eurodad European Network on Debt and Development EV electric vehicles

x   |  ACRONYMS

FCTC FDI FENSA FOPNL FTAs FTTs G20

G7 GATS GATT GBV GDP GHW GMHPN GND GNH GNI GPI GRI HCP HIA HICs HW ICD ICH ICSID ICU IFC IFIs IFPMA IHRs IIAs ILO IMF IOAC IP

Framework Convention on Tobacco Control foreign direct investment Framework for Engagement with Non-State Actors front-of-pack nutrition labeling free trade agreements Financial Transaction Taxes Group of 20 (Argentina, Australia, Brazil, Canada, China, France, Germany, India, Indonesia, Italy, Japan, Republic of Korea, Mexico, Russia, Saudi Arabia, South Africa, Turkey, the United Kingdom, the United States, and the European Union) Group of 7 (Canada, France, Germany, Italy, Japan, the United Kingdom, and the United States) General Agreement on Trade in Services General Agreement on Tariffs and Trade gender-based violence gross domestic product Global Health Watch Global Mental Health Peer Network Green New Deal Gross National Happiness gross national income Genuine Progress Indicator Global Redesign Initiative Human Capital Project health impact assessment high-income countries healthcare worker International Classification of Diseases International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use International Centre for Settlement of Investor Disputes Intensive Care Unit International Finance Corporation international financial institutions International Federation of Pharmaceutical Manufacturers Associations International Health Regulations international investment agreements International Labour Organization International Monetary Fund Independent Oversight and Advisory Committee for the WHO intellectual property

ACRONYMS  |   xi

IPCC IPHA IPHU IPPF IPR(s) ISDS JIU LGBT LICs LMICs

Intergovernmental Panel on Climate Change international public health alert International People’s Health University International Planned Parenthood Federation intellectual property rights investor-state disputes settlement Joint Inspection Unit lesbian/gay/bisexual/transgender (people) low-income countries low- and middle-income countries; lower-middle-income countries MAI Multilateral Agreement on Investment MDGs Millennium Development Goals MEAs multilateral environmental agreements MFP Maximizing Finance for Development MMT Modern Monetary Theory MOU memorandum of understanding MSI Multistakeholder Integrity NAFTA North American Free Trade Agreement NCDs non-communicable diseases NGOs non-governmental organizations NHRC National Human Rights Commission (of India) NHS National Health Service NIEO New International Economic Order ODA official development assistance OECD Organization for Economic Cooperation and Development OEIGWG Open-Ended Intergovernmental Working Group OOP out-of-pocket OOPPs out-of-pocket payments PEF Pandemic Emergency Financing Facility PFHI Publicly Funded Health Insurance PHC Primary Health Care PHEIC public health emergency of international concern PHM People’s Health Movement PMI Philip Morris International PPE personal protective equipment PPPs public–private partnerships PTSD post-traumatic stress disorder QE quantitative easing QSE quality, safety, and efficacy (of medicines) R&D research and development RCEP Regional Comprehensive Economic Partnership SAPs structural adjustment programs

xii   |  ACRONYMS

SARS SDGs SDRs S-G SPF SPS SSA TBT TNCs TPNW TPP TRIPS

Severe Acute Respiratory Syndrome Sustainable Development Goals Special Drawing Rights Secretary-General Social Protection Floor Agreement on Sanitary and Phytosanitary Measures Sub-Saharan Africa Technical Barriers to Trade Agreement transnational corporations Treaty on the Prohibition of Nuclear Weapons Trans-Pacific Partnership Agreement (Agreement on) Trade-Related Aspects of Intellectual Property Rights UAEM Universities Allied for Essential Medicines UBI universal basic income UHC Universal Health Coverage UK United Kingdom UN United Nations UNCITRAL United Nations Conference on Trade and Investment Law UNCTAD United Nations Conference on Trade and Development UNECA United Nations Economic Commission for Africa UNESCO United Nations Educational, Scientific, and Cultural Organization UNGPs UN Guiding Principles UNHCR United Nations High Commissioner for Refugees UN-HLM UN High-Level Meeting UNHRC UN Human Rights Council UNICEF United Nations Children’s Fund USAID US Agency for International Development USMCA United States/Mexico/Canada (trade) Agreement VAT value-added tax WB World Bank WEF World Economic Forum WFP World Food Programme WHA World Health Assembly WHO World Health Organization WTO World Trade Organization

IMAGES, FIGURES, BOXES, AND TABLES

Images

Intro.1 Lockdown; while some had the privilege to work from home and earn millions, millions of others lost jobs. Some walked hundreds of miles to reach home without food or shelter������������������ 3 A1.1 “Home” (2020), a distant dream for India’s migrant laborers ��������� 28 A1.2 “Who sustains life?” (2020)��������������������������������������������������������������� 39 A2.1 A young woman wears the trademark green handkerchief of Argentina’s “green wave” movement ������������������������������������������������� 54 A2.2 Demands for accredited social health activists (ASHAs) in the form of a poster��������������������������������������������������������������������������������� 56 A3.1 Capitalism, the high price of healthy foods, and the hidden environmental cost������������������������������������������������������������������������������ 66 A3.2 Too much for some, too little for others; homeless person seeks shelter in front of overstocked store with a sale on its goods�������������������������������������������������������������������������������������������������� 73 B1.1 “Neoliberalism” (2020)���������������������������������������������������������������������� 97 B2.1 A sticker that reads “Big Data is watching you” ���������������������������� 106 B2.2 A sign on a wall in Nicaragua warning visitors about video surveillance ���������������������������������������������������������������������������������������110 B2.3 An umbrella protest in Hong Kong. Hong Kong’s famous umbrella protests were not simply about “branding” a populist movement. The umbrellas were used to prevent police and other surveillance devices from face recognition of protesters ���������112 B2.4 Data is the new oil. But for whom?��������������������������������������������������118 B4.1 Inequitable access to COVID-19 vaccines. �������������������������������������� 149 B4.2 Inequitable distribution of COVID-19 vaccines.��������������������������������152 B4.3 The Free the Vaccine Campaign Carnival March in London on July 27, 2020, supported by UAEM UK student activists ���������161 C2.1 “Attack on labour rights” ���������������������������������������������������������������� 217 C2.2 Over 2,500 years ago a message-courier ran scores of miles to proclaim Greek victory over the Persians, and then promptly died. Are gig workers our new marathon couriers?������������������������� 218 C2.3 “Quien sostiene la vida” / “Those who sustain life” (2020) ����������� 220 C2.4 A group of migrant agricultural workers petition for residency status in 2016 ���������������������������������������������������������������������������������� 226

xiv   |  IMAGES, FIGURES, BOXES, AND TABLES

C3.1 C3.2

C3.3 C3.4

C3.5 C4.1

C4.2 C5.1 C6.1 C6.2 C6.3 Concl.1 Concl.2 Concl.3

A young boy harvests tobacco on a farm near Sampang, East Java, Indonesia������������������������������������������������������������������������������� 237 A health food label from a Chilean product specifying that the product is “high in sugar … high in saturated fats … high in sodium … and high in calories” ����������������������������������������������� 239 Health Star Rating (Australia–New Zealand)�������������������������������� 244 A health promotion ad from Brazil that reads: “Soda has a simple formula. Syrup, water, gas, sugar, sugar, sugar, sugar, sugar, sugar and sugar” ����������������������������������������������������������������� 246 “Helping British Columbians access healthy food”����������������������� 248 PHM-Canada members bring messages from miningaffected communities in Ecuador to demonstrations against the Canadian transnational mining industry at PDAC, the largest mining conference in the world, held in Toronto, ON, Canada. March, 2020�������������������������������������������������������������������� 261 Barricade protest at the entrance of OceanaGold’s mining site in Nueva Vizcaya, Philippines�������������������������������������������������������� 264 Imagining a nutritious meal is the only way out for some����������� 281 “Militarization of quarantine/lockdown”���������������������������������������� 309 “Vaccine apartheid”������������������������������������������������������������������������310 “Funding on arms trade and health”���������������������������������������������311 White sheet action on April 7, 2021���������������������������������������������� 433 “Public healthcare for all”������������������������������������������������������������� 434 “Only Fighters Win” campaign poster������������������������������������������� 436

Figures

A1.1 A1.2 A1.3 A1.4 A1.5



A1.6 A1.7 B5.1 C1.1

C1.2

Neoliberalism’s three (or four) phases��������������������������������������������� 20 Increase in relative income by percentage of growth 1980–2016���� 22 Increase in absolute income in US Dollars 1980–2016 ������������������ 23 Doughnut Economics ���������������������������������������������������������������������� 24 Comparison of undepleted cumulative carbon dioxide (CO2) emissions by country for 1950 to 2000, versus the regional distribution of four climate-sensitive health effects (malaria, malnutrition, diarrhea, and inland flood-related fatalities)��������������� 25 Number of international migrants, by regions of origin and destination, 2020 ���������������������������������������������������������������������������� 27 Growth in untaxed global income 2002–2019 ������������������������������� 31 The elements of the EMPOWER platform����������������������������������� 186 Number of developing and high-income countries contracting public expenditure, expressed as a percentage of GDP, 2008–2025�������������������������������������������������������������������������������������� 194 Anti-austerity protests in 101 countries, 2006–2020 (in number of protests/year)���������������������������������������������������������������� 200

IMAGES, FIGURES, BOXES, AND TABLES  |  xv

C2.1 D2.1 D2.2 D3.1

Global profit and labor income share ��������������������������������������������213 Cumulative number of free trade agreements 1948–2020��������������341 The spaghetti bowl of free trade agreements �������������������������������� 342 Revenue by type of financing instrument funding the UN system������������������������������������������������������������������������������������� 370 D3.2 Types of financing instruments by year funding the UN system���371 D3.3 Revenue by financing instrument, by entity, funding the UN system��������������������������������������������������������������������������������������373 Boxes

A1.1 A1.2 A2.1 A2.2 A2.3 A3.1 A3.2 B1.1 B1.2 B1.3 B2.1 B2.2 B3.1 B3.2 B3.3 B4.1 B4.2 B4.3 B5.1 B5.2 B5.3

Income under neoliberalism – the elephant versus the hockey stick ������������������������������������������������������������������������������� 22 “Taxes are what we pay for a civilized society”������������������������������ 32 The struggle for women’s health and rights and the setbacks in the discourses and practices of the Brazilian government ���������� 50 The Argentine “green wave”������������������������������������������������������������ 53 Nurses’ health is unfairly affected during the COVID-19 pandemic: a look into the reasons why ������������������������������������������� 57 Gross domestic product or gross national happiness?��������������������� 69 The degrowth movement in Italy���������������������������������������������������� 74 Universal Health Coverage and the neglect of health workforce employment��������������������������������������������������������������������� 89 AB-PMJAY. The largest PPP in health initiated by the Indian Government��������������������������������������������������������������� 93 The future is public: cases of remunicipalization and deprivatization���������������������������������������������������������������������������������� 98 Digital surveillance��������������������������������������������������������������������������110 Activism in health data governance������������������������������������������������114 A particularly American failure ������������������������������������������������������133 Privatization of care homes contributes to high COVID-19 deaths among elderly in HICs��������������������������������������������������������138 Effects of the privatization of India’s health system on COVID-19 response �����������������������������������������������������������������������139 Colonial control: pharmaceuticals access in Palestine��������������������150 IP and barriers to access during the COVID-19 pandemic: the example of remdesivir ��������������������������������������������������������������157 Universities Allied for Essential Medicines UK: public return for public investment�����������������������������������������������������������������������159 Defining mental health problems ���������������������������������������������������174 The Global Mental Health Peer Network��������������������������������������178 Overcoming individual solutions for collective problems: a testimony from a community-oriented mental health service during the COVID-19 pandemic in Italy ���������������������������������������181

xvi   |  IMAGES, FIGURES, BOXES, AND TABLES

B5.4 B5.5 C1.1 C1.2 C1.3 C2.1 C2.2 C2.3 C2.4 C3.1 C3.2 C3.3 C5.1 C5.2 C5.3 C5.4 C5.5 C5.6 C6.1 C6.2 C6.3 D1.1 D1.2 D2.1 D2.2 D2.3 D2.4 D3.1 D3.2 D3.3 D3.4 D4.1 D5.1

Building the frontline workforce to deliver mental healthcare������� 186 The “5C” approach to integrating mental health in universal health coverage�����������������������������������������������������������������187 The failure of pension privatization reforms���������������������������������� 196 Anti-austerity protests�������������������������������������������������������������������� 200 The failure of hospital PPPs: the cases of Lesotho and Sweden�� 203 World Cup (of Shame) vs. the health of workers in Qatar �����������215 Associations of workers and former workers with occupational illness in Colombia���������������������������������������������������� 222 Temporary migrant agricultural workers���������������������������������������� 225 Basic income – a post-pandemic quick fix������������������������������������� 227 Front-of-pack nutrition labeling (FOPNL) ����������������������������������� 240 The Foundation for a Smoke-Free World ������������������������������������� 241 ACT Health Promotion advocacy work in Brazil ������������������������� 245 Women in the COVID-19 crisis ���������������������������������������������������� 281 False solutions to ending hunger and malnutrition and achieving sustainable food systems������������������������������������������������� 285 Agroecology and sustainable development programs in the dry land of Chile. Case study of the Pajal Community���������� 288 Agroecology and COVID-19���������������������������������������������������������� 288 Construction of the CSM’s vision document on Food Systems and Nutrition���������������������������������������������������������� 290 Building networks for food sovereignty: the University Chairs Network in Argentina and Paraguay���������������������������������������������� 292 The Treaty on the Prohibition of Nuclear Weapons�����������������������301 Islamophobia and genocide ����������������������������������������������������������� 307 Spending comparison: pandemic preparedness versus preparation for war��������������������������������������������������������������������������311 The ecology of zoonotic disease�����������������������������������������������������321 Philanthrocapitalism and the big pandemic binge������������������������� 324 Health implications of WTO plurilateral negotiations��������������������345 Trade treaties and women’s economic empowerment: a healthy gain or just more window dressing?���������������������������������� 349 Trade and the pandemic�����������������������������������������������������������������355 Public health activism���������������������������������������������������������������������361 “Development Decade” of the 1990s �������������������������������������������� 374 The contradictory SDGs���������������������������������������������������������������� 376 Appeal to individual giving ����������������������������������������������������������� 382 Selected list of UN human rights reports addressing the issue of unregulated economic growth���������������������������������������������������� 384 Pandemic bonds and the COVID-19 pandemic���������������������������� 396 A long history of struggle raises TNC impunity on the international agenda����������������������������������������������������������� 410

IMAGES, FIGURES, BOXES, AND TABLES  |  xvii

D5.2 D5.3

Private companies’ involvement in bilateral foreign aid ���������������� 414 The trajectory of TNCs and human rights at the UNHRC 1970–2014���������������������������������������������������������������� 417 D5.4 Building a UN Treaty on TNCs and Human Rights ������������������� 419 D5.5 The rise of stakeholder capitalism������������������������������������������������� 420 Concl.1 PHM global programs and the pandemic������������������������������������� 439 Tables

B3.1 B3.2

The seven main types of privatizations in healthcare systems��������130 Private hospital sector’s involvement for the treatment of COVID-19 patients��������������������������������������������������������������������������137 C4.1 Capitalism compared to Sumak Kawsay world view ���������������������255 D2.1 Recent free trade agreements �������������������������������������������������������� 342 Concl.1 Social movement practices of PHM, underlying principles, and strategic vision 2020–2025��������������������������������������������������������431

ACKNOWLEDGMENTS

This 6th edition of Global Health Watch is appearing a little later than planned. By mid-2019, chapter details were mapped out. By the end of the year detailed outlines had been developed, and contributors lined up. We expected Global Health Watch 6 to appear sometime in mid-2021. What we hadn’t expected was a long-predicted and routinely ignored global pandemic. To say that this put a hiccup in our careful plans is an understatement. For almost two years now we have lived “in the shadow of the pandemic” – the subtitle coined for this particular edition – and many will continue to reside in its deadly and disruptive shade for some time to come. Logically, then, COVID-19 figures prominently in Global Health Watch 6. At times it comes close to overwhelming the rest of our “alternative world health report,” but the pandemic is always approached from a vantage that locates its rise, impacts, and governance responses within a critical political economy of health framework. In doing so, we retain the structure of previous Global Health Watch volumes, beginning with a review of global political and economic policies affecting health before unpacking current debates of their health system impacts. We then look at several key social and environmental determinants of health, before turning to our “watching” of the global institutions whose governance and decision-making invariably “trickle down” to affect communities’ health, lives, and livelihoods and planetary well-being. One difference from earlier editions: we integrate narratives of resistance and social movement activism throughout our new volume, rather than group these in a closing section. We conclude with an editorial reflection on what these interwoven stories of hope and change mean for a progressive, post-pandemic health activism. As with all previous volumes, Global Health Watch 6 is the work of scores of volunteer contributors. Some, individually or as organized groups, authored chapters or one or more of their many boxes. Others served as chapter reviewers or added specific content advice as the Watch took shape. Our Indian political cartoonists are back, capturing the political contradictions that define much of the book’s content, sometimes with humor, other times with outrage. We thank all of these persons for their freely given labor to a project driven by care and commitment. In keeping with our almost two decades’ practice, individual authorship is not indicated and, instead, all who contributed to Global Health Watch 6 are listed at the end of this volume. We give special thanks to Pamela Bernal, for her efforts to edit and format all of the contributions, ensure copyright permissions are obtained, and apply her language skills for some

ACKNOWLEDGMENTS  |   xix

Spanish-to-English translations. In our role as co-editors of this volume, we have engaged extensively with contributors, striving to avoid repetition and retain consistency in content with the vision that has propelled all Watches, past and present. But we have also been mindful of retaining the voice, language, and sometimes the choice of terms made by different contributors. The global health movement of which all are a part has its founding beliefs (noted in the book’s Introduction), but it is also heterogeneous. Its diversity is a strength that we embrace. We also acknowledge our co-producing organizations: People’s Health Movement, Medact, Third World Network, Health Poverty Action, Medico International, ALAMES, Viva Salud, and Sama. We have enjoyed working with our new publisher, Bloomsbury Publishing, which took over Zed Books, our previous publisher. A special thanks goes to Olivia Dellow and Max Vickers for patience in receiving a book a little later than expected and for help in addressing our many queries concerning all the nit-picky requirements of getting a finished text ready for submission. We also acknowledge the reviewers of this book who were able to peruse its contents to the publisher’s satisfaction in record time. Finally, and with tremendous sadness, we have dedicated this edition to two of our comrades whose leadership in People’s Health Movement (PHM), and particularly past editions of Global Health Watch, is sorely missed: Amit Sengupta and David Sanders.

Chiara Bodini, Ronald Labonté (co-editors, Global Health Watch 6), on behalf of the editorial group: Peninah Khisa (PHM, Kenya), Elias Kondilis (PHM, Greece), Sarojini Nadimpally (PHM, India), Lauren Paremoer (PHM, South Africa/Senegal), Mauricio Torres (PHM, Colombia), David Woodward (UK).

xx 

INTRODUCTION

Twenty-one years ago, in 2000, some 1,500 health activists from 75 nations representing scores of civil society movements gathered for a People’s Health Assembly in Savar, Bangladesh, to mobilize a new global health movement to attain the aim written into the Constitution of the World Health Organization (WHO): “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” The Assembly drew up a People’s Charter for Health1 which named “inequality, poverty, exploitation, violence, and injustice” as the main drivers of ill health, and began a global advocacy campaign around the aspirational theme of “Health for All.” The Assembly also began the organizing process to create a Global Health Watch as a more critical and progressive companion to the (then annually issued) WHO World Health Reports. The first Watch appeared in 2005, beginning a critique of globalization’s failure to deliver its promised health and wealth benefits that remains a thread running through all subsequent editions. Watch 2 appeared in 2008, the same year the final report of the WHO’s ground-breaking Commission on the Social Determinants of Health (CSDH) was released and just before the world was plunged into the chaos of the Great Financial Crisis. By 2011, Watch 3 was able to delve into the immediate aftermath of that crisis, hopeful that leaders, buttressed by the findings of the CSDH and its rapid uptake by public health authorities worldwide, would give pause to consider the fundamental restructuring of the global economy needed after its public (government) rescue from near collapse. Unfortunately, as 2014’s Watch 4 lamented, there was a rapid return of a toxic neoliberal economic orthodoxy as the world’s political and economic elites failed to embrace the transformative implications of the global financial crisis. Even as neoliberalism was increasingly being exposed as a flawed ideology, politicians seemed unable to break from its policy nostrums while economic elites continued to extol it for the benefits it garnered them. The following year two historic agreements were reached with portents for a different version of the future: the Sustainable Development Goals (SDGs), universally applicable to all countries, and the Paris Agreement, committing to greenhouse gas emission targets to keep climate change temperatures within human livable boundaries. These formed the backdrop to 2017’s Watch 5, which expressed some optimism for a healthier future but remained wearingly critical of a persistent political and economic order that continued to undermine the structural conditions needed

2   |  Global Health Watch 6

to ensure an equitably healthy human population wholly dependent upon the ecological sustainability of a planet under threat. And so, we reach the present moment, with this 6th edition of Global Health Watch appearing at yet another critical global health juncture: the COVID-19 pandemic. More than any previous period in the Watches’ 15+ years of assessing the state of the world’s health, the pandemic has revealed the depth of global inequities in access to resources essential for health and the risk this poses to our future survival. Even as the rich world sees itself tentatively emerging from the pandemic’s shadow, much of the poorer world is unlikely to do so for another two or more years, or even much longer. As with all previous editions, the information and analyses in Watch 6 remain embedded in a vision of a world and a human society that is more just, more equal, more humane, and more respectful of our ecocentric responsibilities to all other living things that share our fragile home. As with all previous editions, it also begins with a section on “The global political and economic architecture,” building connections between global and national level politics and policies and what they mean for the world we envision. The Watch’s second section focuses on “Health systems,” drawing lessons for reforms made more urgent by the pandemic. The third section extends “Beyond healthcare” to address several critical social and environmental determinants of health, with policy implications that cut across multiple public and private sectors. The final “Watching” section critically appraises the state of global governance for health with a focus on several key institutions. We conclude this Watch with a rallying cry for health activists everywhere. We do not pretend that the tasks to achieve a health-equitable and sustainable world will be easy to accomplish, but the book highlights many leveraging points where activists might usefully engage. And there are signs that, the rise in autocratic repression notwithstanding, activists’ thirst for transformative change has not diminished. The global and political architecture

The pandemic has undoubtedly upheaved much of our global and political architecture, a point made obvious in many of the book’s chapters. Chapter A1 locates much of this upheaval in a continuation of three “existential” prepandemic trends: widening economic inequities, worsening ecological impacts, and growing movements of people seeking relief from poverty, conflict, climate change, or all three. COVID-19 made it impossible to ignore or dismiss the extent to which our recent history of neoliberal dominance placed so much of humanity in inequitable peril. The irony is that the ability of the rich world to publicly finance many of its pandemic-affected businesses (if big enough) and labor force (if highly skilled enough) created so much new money in the global financial space that those in a position to capitalize on it (the already billionaire class) grew hugely wealthier.

INTRODUCTION  |   3

Image INTRO.1  Lockdown; while some had the privilege to work from home and earn millions, millions of others lost jobs. Some walked hundreds of miles to reach home without food or shelter. Source: Sketch by Indranil for Global Health Watch 6.

For a brief period, a collapse in global supply chains slowed or shut down huge swathes of fossil-fueled industrialization, and the planet breathed some momentary relief. But this relief was very momentary, with 2021’s sixth Report of the Intergovernmental Panel on Climate Change warning us that we have only a few more years left to avoid a catastrophic tipping point. The policies dealing with the millions of the climate-imperiled, conflict-displaced, refugee-seeking, or poverty-fleeing populations are still failing to protect the most vulnerable. The chapter offers some signals of positive change. In the wake of high-income country (HIC) spending to hold their economies and societies together over the past two years, there is finally talk of national and global tax reform. The proposed minimum level of corporate global tax (15%) is too low, companies might still be able to dodge it, and most of the revenues will go to HICs. But it is a start. Movement on marginal income and wealth taxes, though, is desperately needed. Why should Amazon’s Jeff Bezos (like other billionaire uber-rich) be able to avoid paying almost any income tax (Kiel, Eisinger, and Ernsthausen 2021), and instead custom-build a half-billion-dollar yacht (Pendleton and Stone 2021)? Countries are tripping over each other in a rush to be “green,” and even if the green economy measures are limited and from a planetary ecosystem vantage deeply flawed, they nonetheless create change platforms that activists can seize upon. In our world of vaccine apartheid, however, any potential benefits from these initiatives will take some time to reach the dispossessed.

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This dispossession is also strongly gendered, as Chapter A2’s focus on the pandemic’s inequities describes. Gender has been a topic in almost every Watch, largely in connection to sexual and reproductive rights; this remains true with the present one. Chapter A2, however, is careful to expose the multiple and intersectional nature of gender discriminations and oppressions. The focus is on gendered pandemic inequalities in the Global South, particularly South Asia, with attention to how COVID-19 has disproportionately and negatively impacted women in their roles as healthcare, social, and domestic workers. It incorporates an analysis of the “shadow pandemic” of gender-based violence, extending this to a spectrum of gender identities beyond cisgender women to include trans, intersex, and non-binary persons, all of whom are more likely to be marginalized. It also recounts two narratives of activism on gender rights: feminist campaigns to resist the sharp turn right in Brazil with a strong emphasis on building mutual aid, and Argentina’s successful “green wave” campaign that led to legalization of voluntary abortion up to the 14th week of pregnancy. Facing stiff opposition to abortion reform from Argentina’s Catholic Church and evangelicals (amongst others) it was the persisting and mass mobilizing of “green wave” feminists that led to a successful “pro-choice” outcome that is sure to ripple across neighboring countries with more restrictive policies. The section ends with a return to some of the themes flagged in the first chapter. There are predictions of rebounding economic growth, reckoned by “chief economists” to be around 6% (Centre for the New Economy and Society 2021). Consumption is set to rise dramatically. While there is a lot of talk about a “green recovery,” there is little firm commitment to reducing overall ecological resource extractions. Chapter A3 tackles this head on with a look at the provocative concept of “degrowth” – a managed downscaling in aggregate human consumption by putting the Global North (and elites in the Global South) on a strict diet, essential to create consumption space in poorer countries where growth is needed to create healthier lives. Degrowth (what some prefer to call “fair growth”) will require a radical de-throning of capitalism’s intrinsic “consumptogenic” economic model, in which the mantra of “growth, growth, and growth” is based on the speed with which new things are produced and consumed, energy expended, and commodities tossed on the rubbish heap. There are, however, multiple alternatives to this model being played out at local scales, from alternatives to capitalism’s growth metrics to circular economies, and from labor market reforms to an emphasis and proper valuing of low resource-consuming “caring” work. As with the Indigenous concept of Buen Vivir (encountered in earlier Watches and in later chapters in this edition), efforts to transform an excessive and inequitably consuming world will almost certainly arise first in those local spaces where people live in close harmony with one another and with a respectful caring for all living things.

INTRODUCTION  |   5 Health systems

The five chapters in our second section narrow the scope of the book to the immediacy of health systems and the terrain of most health activists’ work. Every past Watch spent considerable time unpacking a host of issues related to the equitable provision of quality health services to all, invoking the AlmaAta principles and the clarion call of “health for all.” The very first Watch reminded us of the importance of the Alma-Ata principles, and what they meant for a Primary Health Care (PHC) approach. The public/private issue it underscored (and the risks inherent in healthcare commercialization) remains with us. Subsequent Watches parsed out different slices of these issues: the health of migrants, health system financing, the problematic rise of universal health coverage (UHC), new public management as “privatization by stealth,” and the role of opposition by certain states to a more state- (rather than market-)centered approach. Country experiences were frequently highlighted, often critically, but also with narratives of progressive change and struggle. Chapter B1 in this current edition builds on past Watches by providing a slice-in-time analysis of the global state of UHC/PHC debates that finds that UHC is everywhere and PHC has become stuck in the margins. Low- and middle-income countries (LMICs) are supposed to generate their own domestic financing (something the pandemic has since called into undisputed question), market rhetoric suffuses health systems reform, and the rising global policy discourse on engaging with the private health sector has investors’ cash registers ringing. There is nothing inherently wrong with the idea of UHC, the chapter points out, but its focus on financing and its agnosticism over any downside to increasing the role of private providers (but always with a backstop of state funding support) has led to less than impressive or health equitable UHC implementation. The health future must be public; but it is the activist public that needs to make it so. The importance of vigilance towards, and opposition against, the ongoing global tilt to privatization is starkly presented in Chapter B3, which locates healthcare privatization within the broader incursion of private financing and services delivery in most “public good” sectors. The chapter begins with recounting how earlier years of health system privatization (and associated shrinking of preventative public health budgets) left even some of the world’s richest countries ill-prepared for COVID-19. Chillingly, it illustrates how the pandemic quickly became a feast-day for private actors blessed with public financing to do anything from running quarantine hotels, special COVID-19 wards, and contact tracing apps or, if already operating in a country’s private care sector, benefiting from pandemic surcharges and/or generous government operating subsidies (the USA is a standout in this regard, but is far from alone). Public or not-for-profit healthcare facilities may not always have done well in coping with the pandemic, but they generally outperformed private

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facilities, especially those caring for older adults, COVID-19’s earliest and still hardest hit demographic. Despite the high public costs of coping with the pandemic, governments have little choice but to significantly strengthen their public healthcare systems. As Chapter A1 pointed out, there is more than enough global wealth to do so. It’s just tied up now in private hands satisfying no useful public purpose. Chapter B3 also briefly describes some of the innovations that arose in digital and information technologies as a result of the pandemic. This section’s Chapter 2, sandwiched between the two chapters focusing largely on health systems privatization, introduces a new Watch theme: a detailed exploration of the digitalization revolution that touches on most aspects of people’s lives, including their health. The “disruption” of digital technologies (from Big Data and Big Brother corporate or state surveillance, to apocalyptic or mundane biasing worries over the growth in Artificial Intelligence (AI)) holds both potential benefits and risks within health systems. Health technologies had been given only passing attention in past Watches, over cost, control, and confidentiality concerns or equitable access to new medical products. Chapter B2 is the first time a Watch probes deeply into how such tech is (or could soon be) reforming health systems. It acknowledges digital tech’s plausible benefits (more “personalized medicine,” improved health outcomes, reduced costs, better care quality, empowered “patients”) although finds a paucity of evidence for these, at least for now. It examines more critically their complex privacy downsides, from the rise of “surveillance capitalism” and Big Tech ownership and profiteering, to the risk of entrenching a deep global “digital divide.” It also details how the pandemic is incentivizing ever cozier relations between governments and the tech giants, as the latter see new healthcare market opportunities arising in COVID-19’s wake. This leads the chapter to caution on digital governance falling too far behind digital innovation, noting the challenge facing the “opensource” digital activist movements in their efforts to prevent corporations from laying monopoly claim to what should be regarded as a global public good, with justice at its core. This concern over monopoly rights lies at the heart of Chapter B4, and a return to one of the Watches’ most frequently featured health system challenge: the role of trade agreements’ protection of intellectual property rights in creating barriers in access to medicines. The chapter updates the parlous state of access (for low-income groups or countries, drug costs are still the biggest out-of-pocket healthcare expense) with the COVID-19 pandemic dramatically increasing inequities in drug (and especially vaccine) access. Not only did highincome countries scoop up vaccine supply in their advance market purchases, they did the same with most medical products (treatments, diagnostics). One of the root causes is the global intellectual property rights (IPR) regime first developed in the World Trade Organization’s (WTO’s) Agreement on TradeRelated Intellectual Property Rights (TRIPS) and then enhanced in bilateral

INTRODUCTION  |   7

and regional trade deals. The chapter reviews the tawdry tale of Big Pharma refusing to share their vaccine patents or technologies (despite much of the vaccine costs being publicly funded or guaranteed through governments’ advance purchase agreements) and the efforts of LMICs, led initially by South Africa and India, to push for a temporary waiver for key TRIPS rules to facilitate rapid vaccine scale-up. It took eight months of campaigning (October 2020 to May 2021) to initiate “text-based” negotiations for a waiver, whose scope and chance of success is still moot. Big Pharma remains opposed, the European Union does not believe the waiver is necessary, and the USA (whose agreement to consider a waiver in May 2021 sparked some forward movement) is restricting it to vaccines and to patents only (see Chapter B4). A TRIPS waiver will not in itself immediately resolve inequitable access to COVID-19 vaccines or health products, though it is a start; and there are other regulatory concerns in TRIPS and “TRIPS-Plus” intellectual property regimes. The waiver campaign has nonetheless provided health activists globally with a rallying moment and an advocacy platform with a potential to create more fundamental changes to ownership, control, and management of the “knowledge commons.” Meanwhile, vaccine supplies are still critically low as corporate profits from first-wave sales to HICs accumulate, the most public example of which is that of Pfizer. By its own acknowledgement to its shareholders Pfizer expects to generate $33 billion in vaccine sales this year, with profits of close to 30% (“high 20s”), say around $10 billion, not accounting for what it will earn from “booster” shots. The taxes Pfizer pays on its profits average only 5.8% due to its tax-avoiding practice of setting up hundreds of “letter-box” companies in tax haven nations. Under TRIPS treaty rules and current international tax laws, Pfizer can claim that it is only doing what it is allowed to (“Pfizer Using Dutch Letterbox Company to Avoid Taxes: Report” 2021). Moderna, which produces the other mRNA vaccine, is no better, with 2021 profits of between $8 and $10 billion on just $18.4 billion in sales. Profits will be held in one of two low-tax “tax havens”: the state of Delaware in the USA and Switzerland in the EU (Kiezebrink 2021). Whether or not this legally permissible behavior is ethically permissible is another matter. The section’s final Chapter B5 tackles an issue rising in pandemic importance: mental health. The psychosocial sequalae of COVID-19 are increasingly seen as one of its long-lasting health challenges, especially for younger people whose peak socializing years have been shuttered by lockdowns, school closures, and an uncertain future. Past Watches examined slices of the mental health challenges associated with social inequalities, the fallout of the 2008 financial crisis, and critiques of Western biomedicine’s tendency to treat any of its burgeoning list of “mental diseases” with drugs. This latter theme is picked up in the present chapter which, while acknowledging some of the benefits biomedicine brings to mental health, discusses the importance of primary prevention (dealing with the determinants of mental ill health at a systems level) and expanding the use of

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therapeutic alternatives to drugs and institutionalization, such as psychosocial interventions by frontline health workers and peer support networks. Strategies such as these have the potential to overcome the troubling paucity of mental health workers, another glaring deficit in the global health workforce described in Chapter B1 that strengthens Chapter A3’s argument for investing in a postpandemic recovery based upon a “care economy.” Beyond healthcare

That health is determined by much more than health systems has been long known, albeit a knowledge eclipsed by the dominance of Western biomedicine through much of the past century. The six chapters in this current Watch continue the series’ focus on what are commonly referred to as social determinants of health, but which can be described more critically as the hierarchic, gendered, racialized, and economically stratified systems of social oppression and marginalization that create inequitable health risks. Chapter C1 returns to an issue given considerable attention in Watch 4’s dissection of the austerity agenda, which globalized the fiscal yokes of earlier structural adjustment programs that the rich world had deemed essential for poorer nations to follow to preserve the liquidity of their own financial privileges. The pandemic’s economic fallout, like that of the 2008 financial crisis, appears set to orchestrate a repeat performance. Despite a change in rhetoric at the top (notably that of the International Monetary Fund), neoliberalism’s policy shibboleths still dominated the advice it proffered the world over (which LMICs dependent on lending assistance took as obligatory) as if the commitments made in 2015’s SDGs and Paris Agreement did not require a radical economic re-think. Civil society activism successfully challenged austerity’s cuts in several HICs, but this has not been the case in most LMICs despite the waves of anti-austerity protests on every continent. Having set the stage for the pandemic’s grossly inequitable health outcomes, austerity is now being reinvented as necessary fiscal prudence to reduce governments’ deep public debts created by COVID-19. As many as four of every five countries are in fiscal retreat, shrinking their public expenditures as a percentage of their already shrinking GDPs – even as third and fourth pandemic waves continue to buffet people’s lives and livelihoods. The chapter identifies important options to reverse this course similar to those noted in Chapter A1. Some of these are already commonplace in some countries, while newer ones are being sluggishly pursued, and all require a “more accommodating macroeconomic framework.” Whatever that framework might be, it must attend to the ecojustice (degrowth) agenda discussed at length in Chapter A3. It will also have to pay heed to global labor markets that continue to be in turmoil, with all but a small number of highly skilled (generally tech-based) workers still facing diminished earnings, insecure employment, loss of social security benefits, and an ever-smaller share of the world’s economic pie. Informal

INTRODUCTION  |   9

labor arrangements are nothing new, especially in the world’s LMICs whose employment opportunities (however exploitative) improved with globalization and outsourcing. But they are becoming the global default, with a “gig” economy powered by apps and labor platforms transforming increasing numbers of workers into “just-in-(part)time” laborers. Chapter C2 finds that COVID-19 is making a bad situation worse, even if some HICs that are reaching national vaccine herd immunity and rebooting their economies are seeing a reversal of their initial pandemic employment losses. Low-wage sector workers fared worst (no surprise there), as did part-timers and those working in high-risk sectors (agriculture, manufacturing, food services) and, as Chapter A2 documented, healthcare. The gendered aspect of pandemic recessionary disruptions has led some to call it a “shecession,” with women taking the hardest labor market hits and being less likely than men to return to employment. There has been no shortage of labor activism in response to both pre- and post-pandemic workplace health and social insecurities, with a healthy rise in unionization drives. But with labor markets likely to remain stressed by globalization’s undoing of the earlier era of a social contract between government, labor, and the market, more attention is being given to the concept of unconditional cash transfers: a universal, tax-funded basic income guaranteed as a citizen’s right. While neither a panacea nor a substitute for stronger labor regulations, such transfers bind more strongly the struggle for “decent work” with the drive to create “social protection floors” for all. One of the right-wing concerns with unconditional cash transfers is that the poor, with more money in their pockets, will just spend it unhealthily on ciggies, junk food, and alcohol. There is no evidence to support this association with such cash transfers, but the concern over the “commercial determinants of (ill) health” is warranted, as Chapter C3 documents. COVID-19 may have re-asserted our human susceptibilities to novel infections, but what WHO calls the “slow-motion disaster” of non-communicable diseases (NCDs) has not lost its enduring importance. Moreover, the “risk factors” for NCDs are every bit as transmissible as those for infectious disease, largely the result of the global diffusion of “unhealthy commodities” produced and marketed by commercial, capital-accumulating transnational corporations. The chapter reviews some of the well-known strategies deployed by the tobacco, obesogenic food, and alcohol industries to advance their interests (marketing, lobbying, litigation, and the smokescreen of corporate social responsibility), but updates these with a look at how the pandemic has created new digitized niche pockets for their purveyance. Enforceable trade and investment treaties remain potent barriers to activists’ efforts to reduce the spread of these “unhealthy commodities,” although there have been some successes in limiting their de-regulatory damages, primarily with respect to tobacco control measures. Despite extensive corporate opposition, and with the support of strong civil society mobilization and public health advocacy, more governments are also turning to labeling and taxation policies to restrain the consumption of health-harming products.

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Ultimately, and particularly regarding healthy food production and consumption, national and global governance must give greater attention to protecting the health of our environmental commons. Every past Watch has commented on the declining state of our planetary health and, with it, the future (indeed, already current) risks to our human health. Climate change, water loss, and extractive industries have all featured in past editions, and remain present throughout many of the chapters in this one. Extractives are the dominant topic in Chapter C4, a compelling weaving together of narratives from multiple countries and contributors who are part of the People’s Health Movement (PHM) Environment and Health circle. They take aim at the concept of development itself, and its reliance on endless extractions of so-called “natural resources,” a phenomenon accelerated by right-wing governments but no stranger to supposedly left-wing ones either. The chapter opens by contrasting capitalism’s development world view with that of Sumak Kawsay, the Indigenous philosophy of Ecuador, also known as Buen Vivir and common to the philosophy of many Latin American Indigenous peoples. Several of the chapter’s nine case studies concern mining, while others focus on water (and water rights), the gendered impacts of climate change, the toxic rise of agro-industry, and the ongoing struggles to defend Indigenous-inhabited, biodiverse regions of the planet against rapacious commercial and complicit government attacks. In highlighting the extent and intensity of activist opposition to extractivism’s inherent pathology, the chapter does not minimize the extent of damage still being fomented by extractivism’s “development” myth. But it is clear on the need to challenge it, and some of the means for doing so. A similar argument is advanced in Chapter C5, which brings together themes from the previous two: unhealthy (industrialized) foods, and the unsustainable extraction of planet’s ecological resources. The chapter’s argument is simple: the global food system is broken. It pollutes, consolidates control in a few oligopolies, and ravages the land needed for production, while failing to meet the world’s need for healthy and nutritious food. The chapter builds on previous Watches that explored the roots of malnutrition for some and overnutrition for others, the growth in food insecurity, the increased reliance on corporate technologies to compensate for malnourishing foods, and the need to protect communities’ right to food sovereignty. The chapter digs deep into the history of the dominant agro-industrial model, contrasting it with agroecological alternatives that have persisted despite the ongoing corporatization of agriculture. It finds considerable evidence of agroecology’s capacity to meet both human food needs and planetary sustainability, citing encouraging examples. COVID-19 has set back some of these initiatives: long shelf-life and packaged processed foods seemed safer than local food markets in a mobility-restricted, mask-wearing pandemic “new normal.” But mobilizing work to shape a transformation in global food systems continues to build through the Civil Society and Indigenous Peoples Mechanism (CSM) that is part of the UN Committee on World Food Security.

INTRODUCTION  |   11

A critical juncture in the short term will be the extent to which agroecology can prevent technical/corporate solutions and their underpinning economic interests from dominating global food governance. The section closes with Chapter C6, which sounds a somber note on the state of global conflict and the prospects for revitalizing the global peace movement. The wealth and resources consumed by what we once short-handed as the “military-industrial complex” become more absurd in a context of acute health and social need as the world tries to move past its pandemic crises. The chapter reminds us of the extent of health carnage perpetrated in two of the world’s worst conflict zones (Yemen and Syria), made worse by COVID-19, and how these proxy wars are underwritten by state and commercial interests in the arms trade. It describes how Islamophobia, partly under the cover of the pandemic, is seeding what many activists regard as genocides; and finds that too many countries are “weaponizing” COVID-19 in their responses, with autocracies seemingly set to challenge democracies in many of the world’s regions. But there is also praise for reform: the Treaty on the Prohibition of Nuclear Weapons which entered into force in January 2021, the rise in “peace from below” (the grassroots initiatives to build the conditions for peace and social cohesion), and the prominent role played by women in many of these efforts. Watching

The very idea of a Global Health Watch is to “watch” – to observe, study, analyze, and interrogate the global forces that give rise to the possibilities of health, through their effects on the social and environmental pathways to health, and their role in achieving greater (or lesser) equity in those possibilities. The themes running through this section can be summed up in two words (global governance) and the threat to its democratic accountability (the surging power of the world’s economic and corporate elites). In the absence of global government (outside of UN Security Council decisions that can be backed up by force), we have a multiplying plurality of multistakeholder governance platforms. Governments (elected or otherwise) sit around these collective decision-making tables, but they are gradually being outnumbered by private actors, the “philanthrocapitalist” uber-rich and the corporate sector, whose wealth and power our UN system of intergovernmental agencies is increasingly reliant upon. Chapter D1 sets the tone with its excoriating critique of WHO’s diminishing role as the world’s global health agency. This is not new and has been a feature in several Watches. But the situation worsens, with little of the WHO’s funding coming from “assessed contributions” over which, via the World Health Assembly (WHA), it has spending control. Its programmatic functions are now solidly dependent on a few wealthy countries and private wealthy donors which gives these donors privileged agenda-setting rights over those of the more representative WHA. WHO’s funding shortfalls also lie beneath some of its stumbling in the early months of the pandemic where, like its wealthier member

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states, the preparedness lessons of SARS and other threatening pandemics were not matched by protected finances should a new “public health emergency of international concern” (PHEIC) erupt. COVID-19’s global response, instead, fell to a public–private partnership (PPP), the Access to COVID-19 Tools Accelerator (ACT-A), in which WHO participates but does not lead. Created largely following the design and funding supplied by Bill Gates, it is a model that refuses to challenge corporate interests (primarily the IPR monopolies of Big Pharma discussed in Chapter B4) and that so far has failed to remedy the preventable tragedy of vaccine apartheid. Whether a post-pandemic look-back leads to another round of revisions to the International Health Regulations or to a spanking new pandemic treaty is moot; the need for WHO member states to proportionately increase their assessed contributions is not. The extent of WHO’s funding crisis is the more evident in 2020’s creation of its own Foundation, headed up by a former Big Pharma CEO, which is seeking corporate and private individual donations which return on investment would provide WHO with some new working capital. That this model instantiates WHO in the same global financialized system that has helped to create the surge in income and wealth inequities noted in Chapter A1 is an irony that has gone unnoted by most. The funding/global governance/privatization triad recurs in later section chapters. Chapter D2, however, casts its reproving gaze on a different facet of governance: the enforceable trade and investment rules that have shaped the global economy (and environmental commons) for at least the past quarter century. It focuses on shifts away from the multilateralism of the WTO to the trend to bilateral or regional trade agreements that, pretty much by definition, are WTO-plus. The new treaties it spends some time assessing for their new potential threats to public health are the CPTPP (the Comprehensive and Progressive Transpacific Partnership Agreement) and the USMCA (the US/ Mexico/Canada Agreement). Both tighten reins on policy measures governments might take that could inhibit trade, with new rules on how future regulations should be developed, including allowing or even mandating the involvement of corporate actors from other countries. Improving regulatory coherence across trading countries may not be a “bad” thing, but it depends on whether that coherence is based on health equity, labor rights, and environmental protection outcomes. Despite the inclusion of new labor and environment chapters in a few bilateral and regional agreements, these may prevent (or at least slow down) a “race to the bottom” but are hardly an empowering “reach for the top,” although the USMCA labor chapter does have some pro-worker potential, particularly for Mexican factory workers feeding the US-based industrial sector. The most troubling aspect of such treaties lies less in trade, and more in investment. International investment treaties have become one of the most predatory forms of financialized capitalism, with speculative investors, corporate law firms, and transnational companies holding governments (and the people they represent) hostage to vaguely worded treaty rules and secretive tribunal proceedings. The

INTRODUCTION  |   13

latest: efforts underway, or planned, to sue governments fiscally challenged by their pandemic rescue packages for the public health measures they had to impose, since such measures may have interfered with the projected profitability of their investments. The chapter does note some windows of opportunity in health’s ability to influence trade and investment treaty negotiations, even if the underlying (and still largely neoliberal) economic rationale still prevails. The WTO is one small part of the global governance system, even if its dispute settlement rules make it one of the most powerful. The UN is a much larger network of intergovernmental organizations charged with a huge range of tasks, many, like the WHO, dealing with the social protection side of the economy/society teeter-totter. As Chapter D3 chronicles, this postwar network has been as severely underfunded as the WHO since the 1990s – the same decade that neoliberal economic orthodoxy had become so dominant that some heralded (albeit prematurely) an “end of history.” The chapter is particularly critical of UN efforts to play nice with transnational corporations in order to access their financial support. Playing nice translates into an unenforceable “global compact” that gives far more credence to the cult of “corporate social responsibility” (CSR) than evidence of CSR that merits any kudos. More positive developments, driven by continued civil society pressure, are efforts to create a binding treaty on transnational companies’ human rights obligations. Opposition to such a treaty from those it would govern is unsurprisingly fierce; but the pandemic might give it the nudge it needs to cross the negotiating finish line. But until there is a new “funding compact” to support the core functions of UN agencies (including that which oversees states’ compliance with human rights treaties) powerful economic self-interests will continue to infiltrate what is still the most enduring effort at peace-making global governance. Chapter D4 focuses on two global organizations whose governance has long been questioned: the World Bank (WB) and the International Monetary Fund (IMF). Concerns with the policies and practices of both were raised in earlier chapters. As D4 finds, the language of structural adjustment may have disappeared, but its basic premises have simply been re-packaged. The WB exchanges neoliberal tropes for the idea of “human capital,” in which at least the importance of investing in health and education are given post-SDG prominence, but less as ends in themselves and more as means to that perennial favorite: improved economic growth. Its human capital project is tied to its policies aimed at improving business opportunities and sits comfortably with its private sector lending arm, the International Finance Corporation, and its strategy of “building markets” and positioning private sector growth as a post-pandemic priority. The internal dynamics of the WB and IMF, however, are in some contradiction, as their combined 2020 meeting was replete with references to “investing in people.” The contradiction rests with where that investment is to come from: another round of social investment bonds (hopefully learning from the excessive capital generosity accorded by the failed pandemic bonds), more

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public–private partnerships, or, in the case of the IMF, more generous special drawing rights (SDRs) for LMICs (which countries can use as they see fit but not without IMF “policy advice … to ensure that countries do not postpone needed macroeconomic adjustment and reforms” (International Monetary Fund 2021))? Both institutions have released funds to LMIC governments to assist in coping with COVID-19, including the WB providing money to the COVAX vaccine initiative. Yet, disappointingly, the WB (or at least its US-appointed Director-General) is opposed to the TRIPS waiver. The IMF and WB both appear aware of the risk of widespread social rebellion and governmental collapse unless efforts to end the pandemic quickly and fairly are enacted. This becomes the more important when considering that, as HICs emerge first from the pandemic, their economic growth will be on a slow uptick while speculation in the real estate and financial markets continues inflating a massive bubble of historic size. The net outcome of both trends is a likely end or slow-down in the pandemic era of “cheap money,” the surge in COVID-19 relief measures, post-pandemic stimulus spending, and increased money supply via modern monetary theory. As Chapter A1 cautioned, rich countries that were able to afford these policies are poised now to increase interest rates to minimize downstream risks of inflation. Their tightening of monetary conditions is likely to trigger major debt crises in many LMICs which were already (again) debt-burdened pre-pandemic and now the more so. If such crises are met (again) with austerity measures, as seems likely, growing social unrest is likely to increase worldwide, along with the autocratic government responses. The section’s closing Chapter D5 presents a searing critique of what it calls our current era of corporate impunity. Some topics repeat from other chapters (notably a more in-depth look at negotiations for a binding treaty on transnational corporations and human rights, and a review of corporate malfeasance and community resistances since the 1990s) but its main argument is how the World Economic Forum’s (WEF) post-pandemic “Great Reset” is poised to anchor private capital and corporate rule within the heart of the UN system. Watch readers are likely quite familiar with the WEF, the annual gabfest of the corporate, financial, and (occasional) scholarly elite generally convened in Davos, Switzerland. WEF’s founder, Klaus Schwab, has for some years preached a gospel of multistakeholderism and what he terms “stakeholder capitalism,” in which corporations redefine their role away from maximizing shareholder value to one that (with echoes of CSR) recognizes their responsibilities to their workers, their customers, and their communities. Alas, past behavior does not bode well for such a “Reset” with activists more than a little worried that it becomes yet another fig leaf for a disequalizing business as usual. The immediate concern expressed in this chapter: its slow enfolding of the WEF within the UN governance structures, reinforcing the more disquieting overlapping of corporate/capital interests with the few more democratically accountable global systems of governance.

INTRODUCTION  |   15

This rather sober ending to the section gives pause for us to reflect in the final chapter on the potential for activist opposition and a truly transformative post-pandemic pivot. We are not sufficiently naïve or uncritically idealistic to ignore how, even pre-pandemic and now under the pandemic’s shadow, autocratic regimes are increasingly shutting down public protest. Democracy (especially in its Western liberal form) has never been a perfect system; and the rise of China globally under a state capitalist regime that makes no pretense of democracy creates a particular challenge for those civil society movements whose capacity to agitate, act, and advocate is at least somewhat protected by legal democratic norms. Whether we hold to Chapter A3’s “glocalized” idea of a degrowth post-pandemic future, where our social and environmental obligations to one another are enacted in a more human scale, or to a revitalized socialist vision of governance and government across multiple levels implied in chapters that span this edition, the need to continue to “speak truth to power” – indeed, to shout wisdom to the willfully unhearing – remains the force that feeds our activist animus. Doing so amidst the growing number of activism’s challenges is the topic of our concluding chapter, which emphasizes some of the lessons learned from two decades of PHM’s “Health for All” organizing and campaigning. It draws first from a reflective study of PHM’s work, a self-accountability to the many activists worldwide who advocate under its name and visionary aims. Involving scores of activists worldwide, the study synthesizes several principles drawn from practice and how these are mirrored in PHM’s planned future efforts. It recaps several of the pivotal examples of such principles in action that appear in chapters throughout this edition of the Watch. A key theme is that of convergence: “a coming-together of people, organizations, and movements who share similar concerns about health and are critical of the role of neoliberal globalization plays in sustaining health inequities.” There is no certainty that such a convergence will create the ecojust world that drives the efforts of most progressive social movements. But these efforts are as much ends in themselves as they are essential means to our healthier future; and this edition, as with all previous Watches, is a modest attempt to honor them. Finally, contributors have made efforts to keep their chapters as up-to-date as possible given a rapidly shifting global health landscape. Chapters were first completed in late June 2021, and most were updated in mid-September 2021. Although much of their content extends beyond immediate global health concerns, readers should bear in mind that some of the data or events described reflect information and analyses current to September 2021. Note 1  To access the People’s Charter for Health, visit https://phmovement.org/the-peoples-charterfor-health/.

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References Centre for the New Economy and Society. 2021. “Chief Economists Outlook June 2021.” Switzerland: World Economic Forum. Kiel, Paul, Jesse Eisinger, and Jeff Ernsthausen. 2021. “The Secret IRS Files: Trove of NeverBefore-Seen Records Reveal How the Wealthiest Avoid Income Tax.” ProPublica. June 8. https://www.propublica.org/article/ the-secret-irs-files-trove-of-never-beforeseen-records-reveal-how-the-wealthiestavoid-income-tax. Kiezebrink, Vincent. 2021. “Moderna’s Free Ride.” SOMO. July 13. https://www.somo.nl/ modernas-free-ride/. International Monetary Fund. 2021. “Questions and Answers on Special Drawing Rights

(SDRs).” IMF. August 23, 2021. https://www. imf.org/en/About/FAQ/special-drawingright. Pendleton, Devon, and Brad Stone. 2021. “Jeff Bezos’s New Superyacht Heralds Roaring Market for Big Boats.” Bloomberg Wealth. May 7. https://www.bloomberg.com/news/ features/2021-05-07/jeff-bezos-s-newsuperyacht-heralds-roaring-market-for-bigboats. “Pfizer Using Dutch Letterbox Company to Avoid Taxes: Report.” 2021. NL Times. May 11. https://nltimes.nl/2021/05/11/pfizerusing-dutch-letterbox-company-avoid-taxesreport.

A1  |  FROM PRE-PANDEMIC PATHOLOGIES TO POST-PANDEMIC HOPEFULNESS

Introduction

The last edition of Global Health Watch (GHW5) appeared in 2017, the same year Donald Trump assumed the US presidency. The world since has become more perilous. Radical right populism continued to rise. Autocratic leaders in most of the world’s regions stoked an “us/them” xenophobia while promoting a protectionist nativism. Regional conflicts and proxy wars worsened in the Middle East. The global economy remained sluggish despite growth in many low-income countries, notably in Africa, much of it debt-financed. Geopolitical power was in flux, from the slow withdrawal of the USA from multilateralism and the rapidly expanding influence of China to the diminishing normative authority of the United Nations and its many affiliated bodies. Civil society activist pushback against persisting inequities and ecological threats could be found almost everywhere. So could its increasingly forceful suppression. And then came SARS-CoV-2 and the arrival of COVID-19. There are few places not disrupted by a global pandemic long predicted and routinely ignored. COVID-19 has yet to become a “grim reaper” on the scale of past infectious outbreaks such as the 1918 flu pandemic, responsible for over 50 million deaths.1 But the high transmissibility of SARS-CoV-2, its initially unknown health effects, early findings of excess mortality amongst older people, and ill-equipped health facilities even in the world’s wealthiest nations quickly led to dramatic and novel “lockdowns” by most governments. National economies were thrown into disarray. The global economy, still struggling with the residue of the 2008 global financial crisis and reeling from geopolitical tensions, began a recessionary nosedive expected to worsen until late 2021. With unemployment rates surging, nationalist pretensions added fuel to rising right-wing populist politics (Labonté 2019). Trump-emboldened autocrats around the globe used the cover of COVID-19 to strengthen their holds on power, erode democratic norms, and suppress human rights (Repucci and Slipowitz 2020) (see Chapter C6). Public health became the daily news lead, drowning out almost every other concern through 2020. Although much of the world’s peoples tried to comply with the rigors of “flattening the curve,” sizable minorities embraced conspiracy theories, emboldened by a handful of political leaders whose own careers were built on fomenting distrust, discord, and deceit. By late 2020, COVID-19 fatigue was everywhere. The desire for a return to normalcy was palpable and, with vaccines now rolling out, apparently within

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rapid reach. At least for those in the wealthy “vaccine nationalist” countries that snapped up access to the first batch of vaccines for which others in the poorer nations will have to wait several years (see Chapter B4). Meanwhile, Biden’s election victory over Trump gave some relief to some Americans and to much of the rest of the world, but the USA continues to be a frighteningly divided and near-failed state. Geopolitical tensions with China are rising and unlikely to abate. As near-normalcy looms ever larger (the Omicron variant permitting), the bigger questions about what a post-pandemic normal should look like once more fueled a chorus of global voices. More numerous and intense than those that thought the 2008 financial crisis would put an end to neoliberal madness (it did not) and umbrellaed under a cornucopia of clever titles (a “Great Reset,” a “Global Reboot,” “Build Back Better,” to name just a few), there is widespread enthusiasm for a new set of policy playbooks. These compendia of ideas share many common themes, even if there is not yet (and likely never will be) deep consensus amongst them. There is also worry that, as with 2008’s reform agendas, these new policy recipes could devolve into stunted versions of the environmentally and economically just future that lie at the heart of most of the new playbooks. In 2008, governments’ immediate goal was to save the world’s economy from the unregulated greed of investment bankers and leveraged speculators, something the world’s richer countries did with surprising alacrity and a willingness to socialize enormous sums of private (corporate, financial, personal) debt. The post-COVID-19 task has a more universal and easily grasped urgency: mitigate a global health and economic crisis that some claimed was of civilization-ending potential (it wasn’t) and ensure plans to prevent future occurrences (which are almost certain). It is not surprising that much of the “rebuild” consensus centers on weaknesses in pandemic preparedness (there were many) and health system response capacities (crippled by years of underfunding and privatization in most countries). But the pandemic embodies risk, sickness, and death in a way that the health-negative sequelae of the 2008 financial crisis did not. We witnessed repeatedly that such risk and its consequences were, and remain, far from equitable. Diseases, infectious or otherwise, rarely are, but the sudden appearance of a novel virus with lethal impact quickly drew mass attention to how some people fared much worse than others in both health and economic terms: • • • • •

the poor, the elderly, the racialized the homeless or informally settled the undocumented or stateless migrants the precariously (under-)employed “essential” workers, healthcare or otherwise

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• women whose domestic care work mushroomed • those whose health was already compromised • and any of a number of other groups whose lives are characterized by social, economic, and political marginalization. These vulnerabilities are rarely singular, with the burden of any one marginalization compounded by the weight of multiple others. These vulnerabilities pre-dated the pandemic. Redressing their systemic causes is essential not only to ensure an end to the current pandemic or reduce the potential for new ones, but to create an “eco-just” social order capable of attending to the social and ecological crises only temporarily on COVID-19 hold. As UN Secretary-General António Guterres stated with striking clarity: COVID-19 has been likened to an X-ray, revealing fractures in the fragile skeleton of the societies we have built. It is exposing fallacies and falsehoods everywhere: The lie that free markets can deliver healthcare for all; the fiction that unpaid care work is not work; the delusion that we live in a post-racist world; the myth that we are all in the same boat. Because while we are all floating on the same sea, it’s clear that some are in superyachts while others are clinging to drifting debris. (Guterres 2020)

Our pre-pandemic pathologies

The 2019 book, Health Equity in a Globalizing Era, closed by summarizing what its authors considered to be humanity’s three interrelated existential crises: • Rising inequalities (wealth, income, resources) • Ecological collapse (climate change and more) • Migration (within and across borders) This trinity is termed “existential” because the first two, which drive the third, concern our very survival. They are not new issues, but their worsening metrics pre-pandemic are focusing more attention on them in conversations for our post-pandemic future.

1. Rampaging inequalities The health-negative impacts of poverty and inequality have been themes in every edition of Global Health Watch. In the very first edition (2005), the opening chapter began with the quote from the 2004 World Commission on the Social Dimensions of Globalization: “The current path of globalization must change. Too few share in its benefits. Too many have no voice in its design and no influence in its course” (Somavia 2004). Little has changed since that observation, except that it has moved from activist margins to a frequent (if only passing) lament by all but the most die-hard neoliberals.

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Every subsequent GHW edition located the rise in inequalities and their health-negative impacts as consequences of policy choices driven largely by the dictates of neoliberal globalization, an ideology that has dominated since at least the 1980s. GHW4, in particular, tracked the rise of neoliberalism through three phases (1.0 structural adjustment, 2.0 financialization, and 3.0 austerity), captured in Figure A1.1. More recently a 4.0 version has been mooted: that the rise of nationalist protectionism and radical right populism has not eliminated neoliberalism’s economic underpinnings, but merely emphasized their national (rather than global) entrenchment. Some have described this newest version of neoliberalism as “primordial,” resembling more the mercantilist capitalism of earlier centuries. Others describe it as “authoritarian” (as autocracies proliferate), or “mutant” (shape-shifting into something yet to be formed) (Callison and Manfredi 2019). Whatever we come to call it, the illusion that neoliberalism 1.0–3.0 was somehow a shared global enterprise is shattered by a more transparent version (4.0) in which the ability of national might to trump ethical or normative right is no longer glossed over but fulsomely embraced (Labonté 2019). And lest we think austerity has run its course, the post-pandemic fiscal hawks have governments’ trillion-dollar COVID-19 rescue packages in their sights as reason for new rounds of belt-tightening (see Chapter C1). One of neoliberal globalization’s vocal claims in the pre-pandemic era was the marked decline in both proportion and absolute numbers of people living below the World Bank’s measure of extreme poverty ($1.90/day).2 Most of this decline was accounted for by China and other South and East Asian countries. Sub-Saharan Africa (SSA) in 2020 had substantially more people in extreme poverty than it did in 1990; economic growth in that region failed to keep up with the rise in population, or to be shared equitably. Most recently, as GHW5 elaborated, the world’s countries in the Sustainable Development Goals committed to eliminating poverty “in all its forms” by 2030 with a focus on

Figure A1.1  Neoliberalism’s three (or four) phases. Source: Ronald Labonté using data from Labonté and Ruckert 2019.

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extreme poverty. Come January 1, 2030, however, even at pre-pandemic trends in global poverty reduction, half a billion people will wake up still extremely poor (Roser and Ortiz-Ospina 2013). Of poverty’s other measured forms: the United Nations Conference on Trade and Development (UNCTAD) estimates that a life expectancy of around 74 years, considered an ethical minimum (Edward 2006), would require around $5.50/day in consumption. Using that metric and pre-pandemic poverty trends, 90% of South Asia and SSA would wake up poor in 2030. That ethical consumption figure has more recently been revised to $7.40/day, a level at which 4.2 billion people would still be poor when 2030 dawns (Hickel 2016). These projections all pre-date the pandemic, which is only worsening matters. The World Bank reckons that lockdowns and a global recession could add up to 150 million more to the current 740 million still living in extreme poverty (Wadhwa and Barne 2019; Yonzan et al. 2020). Worst-case scenarios peg the pandemic increase at the $5.50/day poverty level at half a billion by the end of 2020 (Sumner, Ortiz-Juarez, and Hoy 2020). Longer-term forecasts are equally bleak, especially for those LMICs still unable to access vaccines scooped up by wealthy nations (see Chapter B4). The stark reality is that whatever modest gains in poverty reduction achieved in the past decades of neoliberal dominance are being rapidly undone. The tragedy of our poverty-reducing failures is that our neoliberal era (roughly since 1980) has seen the wealth of a tiny fraction of humanity reach stratospheric excess. In 2014, Oxfam calculated that the world’s 85 richest billionaires had as much wealth as the 3.5 billion poorest people. When it updated its estimates for 2019, just before the pandemic surged, the number of people with the same wealth as the poorer half of the human population had shrunk to a mere 26 (Lawson et al. 2019). There are quibbles with the methods Oxfam uses, but little disagreement that the wealth gap is growing and rapidly so (Matthews 2019). Even as COVID-19 reduced most people’s income or wealth, billionaires globally saw their portfolio riches rise by over $2.2 trillion (Meredith 2020). In the USA alone, its 650 billionaires saw their wealth climb from $2.95 trillion in early March 2020, to over $4 trillion by late November the same year (Manjoo 2020). And much of the $9 trillion pandemic-initiated government supports to individuals and businesses wound up in over-heated financial markets, allowing the world’s 2,700 billionaires to increase their wealth from $5 trillion (May 2020) to $13 trillion (May 2021) in just one year (Sharma 2021). We are now living in the most unequal world humanity has ever experienced, an unrepentant evil that transcends mere outrage.

2. A planet burning Images of a world in ecological peril have become so ubiquitous that they no longer disturb. Wildfires of unprecedented size and devastation. Storms of such intensity that they seem locked in a competition for title of worst of the

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Box A1.1: Income under neoliberalism – the elephant versus the hockey stick Cheerleaders for the poverty-reduction gains over our past 40 years of neoliberal economic dominance like to point to a model of global income growth where the bottom half didn’t do so badly. This “elephant hump” in income growth amongst the world’s poor (Figure A1.2) was largely the result of globalization’s outsourcing to low-wage countries and mirrored the resulting decline in income growth for the middle-class in high-income countries (HICs). Even so, the real take-off in income growth doesn’t start until we hit the rarefied.01% and.001% of the world’s uber-elites. Figure A1.2, however, measures only relative income growth over time. If you start with almost nothing and even if you grow at a faster pace than most everybody else, you still wind up with almost nothing (Hickel 2019).

Figure A1.2  Increase in relative income by percentage of growth 1980–2016. Source: Hickel 2019.

Figure A1.3 recalculates income growth over the same 40-year period using actual dollars and plots this alongside a slightly different graphing of relative income growth converting the sums into actual US dollars. In this modeling, most of the absolute gains in income, and the influence or political power that this provides, is almost a completely flat line, the shaft of the “hockey stick.” Once more, the income take-off only starts at the rarefied 1% and less bracket. Relative measures can hide a lot of inequities, which is why looking at absolute numbers is absolutely important.

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Figure A1.3  Increase in absolute income in US Dollars 1980–2016. Source: Hickel 2019.

century. Heatwaves soon to make many parts of the Middle East and South Asia uninhabitable. Ice shelfs threatening the imminent sea-level rise long anticipated. And, still, the fossil fuels burn. The forests are felled. The oceans overfished and plasticized. The jungles leveled for beef and soya. Freshwater lakes becoming desert ponds. It is the stuff of nightmares, of a toxic consumption driven primarily by the few (the same few topping our evil inequality) but at the cost of the many. Ironically, global health (at least as measured by average life expectancies) continues its ongoing if inequitably distributed improvement, albeit now stopped short by the pandemic.3 But as the Rockefeller Foundation– Lancet Commission on Planetary Health cautioned, this is only because “we have been mortgaging the health of future generations to realise … gains in the present” (Whitmee et al. 2015, 1973). Pre-pandemic media fell in thrall with Greta Thunberg and the school strikes for climate. Extinction Rebellion became the environmental equivalent of 2008’s Occupy Movement. Green political parties in many countries gained more electoral seats. Climate change politics assumed activism priority, but climate change is not the only ecological crisis we face. In 2017, the economist Kate Raworth published a popular book in which she summarized evidence of where our environment was being ravaged as our social commons were being pillaged. She called it Doughnut Economics, because it lent itself to a simple diagram where an outer ring of ecology enclosed an inner ring of society (Figure A1.4). In almost every ecosystem domain we are over-shooting

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or poised to cross planetary boundaries into a world that may support (some) life, but likely not ours. We are in the midst of a sixth mass species extinction and fertilizing our way into eutrophic lakes and oceanic dead zones. But the most immediate and potentially irremediable crisis is climate change. We may not yet have passed the tipping point, but according to the August 2021 report from the Intergovernmental Panel on Climate Change (IPCC) we are extremely close to doing so (IPCC 2021), causing the UN Secretary-General to describe the report’s conclusions as a “code red for humanity” (Chestney and Januta 2021). Most (some say all) fossil fuels currently in the ground must stay there, along with an immediate end to new fossil fuel exploration, development, and the $5.2 trillion annually in government subsidies to the industry, if we are to reach 2050 within the 1.5 degree increase governments committed to in the Paris Accord. Unless we do this immediately, we may reach that agreed limit as early as 2024 (World Meteorological Organization 2020). Despite Big Oil first acknowledging its role in creating climate change over 40 years ago, and despite the Paris Accord requiring a 45% reduction in emissions by 2030, the forecast is that the top 50 oil companies are on track to increase their emissions by 35% over the next decade.

Figure A1.4  Doughnut Economics. Source: Reproduced with permission from Kate Raworth; Raworth 2017. Licensed under CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0/

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The proximal health impact of those emissions is deaths from air pollution, which the World Health Organization (WHO) estimates numbered 9 million people in 2015. Over 90% of these deaths occur in low- and middle-income countries (LMICs). The inequities in this disease burden are striking. Figure A1.5 shows two density-equalizing cartogram maps that compare the global CO2 emitters (1950–2000) with the aggregate mortality rates for four climate-sensitive health impacts: malaria, diarrhea, malnutrition, and flooding. The wealthier over-consuming North is quite literally killing the poorer under-consuming South. The richest 1% of us emit twice the CO2 as the poorest 50% of the planet’s entire population. There is a COVID-19 connection as well. In India air pollution combines with high levels of poverty, malnutrition, and respiratory disease to cause surprisingly high rates of COVID-19 mortality in infants, young children, and youth. The point about our globally inequitable levels of consumption is a critical one and attests to capitalism’s fundamental contradiction (neoliberal or otherwise): that our economic growth imperative is also the consumption imperative.

Figure A1.5  Comparison of undepleted cumulative carbon dioxide (CO2) emissions by country for 1950 to 2000, versus the regional distribution of four climate-sensitive health effects (malaria, malnutrition, diarrhea, and inland flood-related fatalities). Source: Reproduced with permission from Jonathan A. Patz; Jonathan A. Patz, Holly K. Gibbs, Jonathan A. Foley, Jamesine V. Rodgers, Kirk R. Smith, “Climate Change and Global Health: Quantifying a Growing Ethical Crisis,” EcoHealth 4 (2007): 397–405. doi: 10.1007/s10393-007-0141-1

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As a marketing consultant cheerfully noted in a 1955 article, “our enormously productive economy demands that we make consumption our way of life” such that things are “consumed, burned up, worn out, replaced, and discarded at an ever increasing pace” (Lebow 1955). This revealing maxim was written in the early years of les trentes glorieuses (the three glorious decades), the 1945–1975 postwar period of rapid economic growth, progressive taxation, strong unionization, new social protection programs, sharp declines in income inequalities, and the rise of modern feminism and a host of progressive social movements. At least in high-income countries. What we then called “developing countries” pursued their own paths of de-colonization and efforts to create a “new international economic order,” playing off the Cold War and its competing discourses of individual civil and political rights of the market, on the one hand, and the collective economic and social obligations of the state, on the other. This era came to a shuddering stop when the rise of conservative governments in the world’s (then) economic powerhouses (UK, USA, Germany) combined with a period of “stagflation” (high inflation and low growth), which monetary theory claimed could only be controlled by sharply raising interest rates to reduce the money supply. The result: the developing world debt crisis and the advent of neoliberal triumphalism. For the disaffected middle classes in HICs, and for many orthodox economists, the three glorious postwar decades of high productivity and equally high consumption is the economy for which there is a nostalgic wish to return. It suffuses the pandemic recovery mantras of most governments, where economic stimulus packages (on which more, shortly) are primarily efforts to increase demand in order to increase production, rebooting the production and consumption economy as quickly as possible. But this economic thinking is largely mythical. Far more capital (profit) is accumulated through financialized instruments and speculation than from what people make or buy (Bello 2020). It is also environmental genocide.

3. People moving (or trying to) Migration is not new, but its scale today is unprecedented: one in seven persons is now a migrant (World Health Organization 2017) with more people on the move, in both absolute and relative numbers, than at any prior time in history. Much of this population movement is national, a migratory flow from rural agriculture to urban manufacturing that began with European industrialization in the nineteenth century, and which is occurring now across LMICs on a greatly truncated time scale. Pre-pandemic, over one billion people were counted as migrants, almost 260 million of whom were crossing international borders (United Nations 2017). The late sociologist, Zygmunt Bauman, in a 1998 book critiquing contemporary globalization, noted how the world was increasingly dividing into two classes: tourists, those with the money and status (and requisite visas) to move

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through the world with no rooted obligation to place or place-bound people, at least until COVID-19 temporarily grounded many of them, and vagabonds, those less privileged hundreds of millions whose migrations to escape conflict, poverty, drought, or simply to pursue the image of a better life in a wealthier country are increasingly unwelcome. Some countries cautiously accept refugee claimants and asylum seekers. But over 65 nations are busily building walls to keep out the vagabonds, those 66 million international migrants whose flights from their homelands are considered to be “forced” by immiseration, drought, conflict, or all three. Tens of millions more become internally displaced, housed in massive refugee camps located in LMICs that lack the resources to provide for them. These camps are a locked-in perfect storm for pandemic spread: crowded conditions, limited water or sanitation facilities, and no ability to care for COVID-19 cases that might require intensive care. With wealthier donor countries now trimming foreign aid budgets to cope with their own domestic pandemic bailouts or recoveries, cuts to food aid are leading to extreme hunger for hundreds of thousands of those running from the shark’s mouth, only to become trapped within refugee camps (United Nations World Food Programme 2020). Some countries treated migrants generously in their pandemic policies, most often by extending healthcare access to all migrants including those considered “irregular.” Several countries removed eligibility barriers to unemployment benefits or offered direct income support to affected workers, improving living conditions for at least some migrant workers (OECD 2020). Portugal went so far as to extend full citizenship rights to asylum seekers (OECD 2020). But with few exceptions, the foreign-born in HICs experienced greater unemployment partly because their jobs prevented them from being able to work from home. Those still working often did so in low-paying jobs under conditions placing

Figure A1.6  Number of international migrants, by regions of origin and destination, 2020. Source: United Nations Department of Economic and Social Affairs, Population Division (2020). International Migration 2020 Highlights (ST/ESA/SER.A/452).

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them at greater COVID-19 risk (e.g., personal care workers, farmworkers, food factory workers). The pandemic also provided a pretext for pre-pandemic xenophobia to thrive. In many European countries, prejudice against the Roma population and communities increased rapidly. Several Roma encampments and suburbs were forcibly quarantined with no one able to leave their areas except for a proven medical emergency (Kingsley and Dzhambazova 2020). Imperiling conditions also faced the hundreds of thousands of African and Asian migrant female domestic workers in the Middle East. COVID-19 caused some to lose their jobs with nowhere to go or means to return home, and others to be forcibly detained indoors by their labor agencies or compelled to remain and work 24/7 indoors with their employers (Hubbard and Donovan 2020). Overall, 70%–80% of all new COVID-19 cases in the Gulf states are in migrant workers. Modi’s Hindu nationalist government in India, in turn, used the cover of COVID-19 to remove rights for the minority Muslim population. It also led to at least 1,000 migrant workers dying in their forced march from the cities to the villages, a failed early

Image A1.1  “Home” (2020), a distant dream for India’s migrant laborers. Source: Vikas Thakur, Tricontinental: Institute for Social Research, Delhi, India.

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effort to lockdown COVID-19 risk in India’s cities that only resulted in spreading across rural areas (Rupasinghe 2020) and contributed to India having one of the world’s highest number of cases and deaths by mid-2021. Our post-pandemic policies

The French word, politique, is revealing; it means both politics and policy and can bend to imply ideology and strategy. Policies are choices, choices are political, and politics is both ideological and strategic. When we consider postpandemic policies we are drawn inevitably into the web (some might call it “complex systems”) of power and privilege. Since the gradual transition from feudalism to capitalism only two meta-policy measures have successfully blunted the acquisitive inequities built into market systems: when more of the share of productive wealth created goes to labor (workers) than to capital (investors); and when governments intervene through taxation measures to redistribute postmarket productive wealth. Both meta-policies have suffered under the neoliberal yoke, and both are central to post-pandemic narratives.

1. Labor’s declining share of wealth The share of global economic product going to labor has dropped precipitously since 1980 with ever larger shares going to capital (UNCTAD 2013). Several factors figure in this decline: reduced unionization, outsourcing, technology, deregulation, and, in many countries, a de-coupling of the historic correlation between increased productivity and wage growth. Companies could now produce more in less time with fewer workers. The subsequent wage stagnation for many in HICs led to increased debt-financed consumption. In a more fundamental way neoliberalism altered the way in which capital accumulation occurred. Banking deregulation and the power of computer technologies led to the creation of novel and opaque “derivatives,” such that speculative finance, rather than the “real” economy of production and consumption, has become the main driver of capitalist economies (Bello 2020). The 2008 financial crisis paused briefly, but did not stop, this financialization dynamic. The frenzied rise of stock markets during the pandemic, one reason for the licit but amoral gains of global billionaires even as the employment-creating economy of production and consumption plunged into recession, is one measure of this. The pro-labor policies we could (and at least carefully should) pursue, such as increased labor rights and unionization, repeal of legislation reducing collective bargaining, and creation of transnational unions across global supply chains, are unlikely to reset capitalism to its pre-neoliberal, pre-financialized “real” economy mode. The shift away from labor to capital-intensive automation follows every recession but is more likely post-COVID-19 given that episodic lockdowns affecting human labor will continue until global vaccine-initiated herd immunity or endemicity occurs (Blit 2020). By then, the pandemic’s disruptive shifts in the economy may well be path-dependently cemented in place. And all this before the future impacts of artificial intelligence (AI) are considered.

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Unsurprisingly, then, the pandemic has renewed policy attention for Universal Basic Income (UBI), tax-funded direct cash transfers by governments to their citizens (see also Chapter C2). No country currently has a national UBI program in place. Iran and Mongolia experimented with one for a short time, in Iran’s case offering a generous transfer equal to 29% of the median wage (Samuel 2020). Several countries had (and many still have) experimental UBI projects, including China, India, Kenya, Namibia, Spain, Germany, the Netherlands, Finland, Brazil, Canada, and the USA. Some commentators and activists anticipated that the direct income supports several HICs provided to ease the lockdown burdens of the pandemic would foreshadow rapid adoption of UBI; this has not yet occurred. HICs, instead, extended time limited income supplements, enhancements of existing cash transfers, or subsidies to employers to maintain workers’ wages even if partially or fully unemployed (and so retain their labor market attachment). It is probable that UBI will continue cycling around the edges of postpandemic fiscal agendas. Proponents will need to confront the fiscal hawks’ two main complaints: that UBI will dissuade people from working (evidence to date says no) and that it will cost too much (not really, as the next section details). A progressively expressed concern is that governments might be tempted to roll-up all of their non-cash welfare entitlements into a lump sum UBI cash payment. Doing so would fit with the neoliberal notion of “sovereign individuals” fending for themselves in the markets; but markets (via prices) can too easily pick the last penny from a poor person’s pocket. Publicly provided or subsidized goods and services (such as education, healthcare, housing, transportation, and the like) are less prone to such market capture. That is, UBI is one but not the only tool needed to create the social protection floors long called for by the International Labor Organization, unions, and organized labor worldwide, and supported by a coalition of several hundred civil society organizations (Global Coalition for Social Protection Floors 2020).

2. Reversing the redistributive decline Yes, UBI will cost a lot, but only a fraction of what HICs spent keeping their banks and large corporations afloat during, first, the 2008 financial crisis and, most recently, the pandemic (Brown 2020). It may be more affordable than many think. Increasing the amount and progressivity of taxation can offset much of that cost. But, as with labor’s declining market shares, tax measures across the rich world and, until recently, in most LMICs have fallen in the proportion of productive income being captured for public good purposes vs. privately retained for personal whims. A few measures tell the story: • The average top marginal income tax rates for OECD countries fell from 66% (1981) to 43% (OECD 2014) and globally now averages only 30% (OECD Directorate for Employment, Labour and Social Affairs 2014).

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• Statutory corporate tax rates (the nominal level) fell globally by almost 30% in just the ten years between 2005 and 2015, and in every region in the world were lower in 2020 than they were in 2010 (KPMG 2020). • The corporate tax actually paid (the “effective rate”) is much lower with companies shifting profits around so that most wind up in low- or no-tax haven countries (Tax Justice Network 2020). • As the amount of tax revenue captured by governments fell, corporate aftertax profits rose (Carr 2020), contributing to the wealth spike of the.01%. • Offshore tax havens cause the world to lose annually $245 billion in corporate and $182 billion in individual tax avoidance. If the indirect losses due to ongoing tax competition between countries are included, the annual corporate tax loss alone would be $980 billion (ibid.). As the Tax Justice Network concluded its 2020 report, “Put simply, the current global tax system is programmed to militate against taxing profits, income and wealth at the top end of the distribution” (Tax Justice Network 2020, 8). Monetizing this in actual dollars rather than rates (the absolute vs. relative issue again) reveals the stupendous growth in private (vs. public) capital in just the 17 years spanning 2002 and 2019 (Figure A1.7). There is more than enough

Figure A1.7  Growth in untaxed global income 2002–2019. Source: World Bank datasets. The dataset for untaxed income may be retrieved from https://data. worldbank.org/indicator/GC.TAX.TOTL.GD.ZS. The dataset for global GDP may be retrieved from https://data.worldbank.org/indicator/NY.GDP.MKTP.CD

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wealth (capital) sloshing around the planet to invest in most of what all the world’s peoples and their planet need. We just need to capture it for public use. To that end, there is no shortage of tax reforms that could be introduced (see Box A1.2).

Box A1.2: “Taxes are what we pay for a civilized society” The title’s aphorism was coined in 1927 by a US Supreme Court Justice, Oliver Wendell Holmes, and remains carved in the granite portico of the US Internal Revenue Service building. Holmes was not the first politician or jurist to make this point; nor will he be the last. Several tax reforms have been mooted in recent years, with the costs of the pandemic inflating their appeal on national and global policy agendas. For any of these tax measures to work, countries will need to re-regulate global finance to prevent corporations and high net worth individuals from shifting their wealth around in search of the lowest tax rates, a point returned to later in this chapter. For now, among the many tax reform suggestions:

Wealth tax: A wealth tax is a small levy charged on the net wealth (the value of all assets) owned by an individual. As with other taxes, our neoliberal era saw its slow erosion. In 1990, 12 EU countries had a wealth tax; in 2020, only four still had one (Zeballos-Roig 2019). Very few other countries impose a wealth tax, although many are now considering doing so. Tax rates will be low and would apply only on wealth exceeding a certain level. Applied globally, a 1% tax on assets above $1 million would yield around $1 trillion annually and be paid primarily by the global 1%, with most of it coming from the global.001%. A progressive EU wealth tax would raise over €350 billion annually, with a “wealth cap” tax (90% on wealth above €2.6 billion) generating almost €1.3 trillion a year (Kapeller, Leitch, and Wildauer 2021). Individual income taxes: In the 1970s, the top marginal tax rate on income in OECD countries averaged 66%. Today it barely tops 40% (Labonté and Ruckert 2019). A US study found that raising its current top rate from 35% to 68% would reduce poverty and inequality while maintaining economic growth through increased public spending (Fieldhouse 2013). A 2014 study applying a marginal rate of 90% on US incomes over $300,000 was considered “optimal” in terms of reducing inequality and poverty and improving well-being and happiness, even if it meant a slight decline in the economic growth rate (Kindermann and Krueger 2014). Even the International Monetary Fund (IMF) a few years ago argued that a top marginal rate of 60% was feasible within the confines of conventional capitalism.

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Indirect taxes: Indirect taxes are still individually paid but are based on consumption (such as sales or excise taxes). Such taxes are considered regressive (since people on lower incomes pay proportionately more than those on higher incomes) but could be progressive (rising steeply for “luxury” or non-essential commodities, while being lowered or removed on essential goods such as food). Corporate taxes: The main way to increase corporate tax revenue is to reduce or eliminate tax avoidance. Key initiatives include a unitary tax in which a multinational’s profits are calculated at a global scale and shared out between the countries where its real activity (measured by assets, employment, and sales) takes place. This would undermine what the OECD calls “base erosion and profit shifting” where corporations declare most of their profits in “letter-box” tax haven countries. There were also calls for a minimum effective corporate tax rate of 25% worldwide, although this was eventually lowered to 15% but was agreed upon by 136 countries in late 2021 (Tankersley and Rappeport 2021). Another means is to levy a tax on “excess profits,” with proposals suggesting a 50% to 80% tax on profits beyond 7.5%, especially where oligopolies dominate certain sectors (Chowdhary, Uribe Teran, and Othim 2020). Such taxes were used by countries including the USA and UK during World War I and II and are now proposed as one means to reduce or prevent “pandemic profiteering” (Hemingway 2020). Taxes on digital services (revenues from search engines, social media services, online marketplaces) are being widely considered, and are already in place in the UK, EU, and a few other countries (Mitchell 2020). Financial transaction taxes: Although the above tax reforms are feasible for all countries, most of the world’s wealthy domicile in wealthy countries. As such, these reforms in themselves would not help most LMICs and would not put much of a dent in global inequalities. The same applies to individual marginal rates, and unitary multinational taxes. Enter financial transaction taxes (FTTs), an idea in discussion for over 40 years as a way of slowing down arbitrage (rapid speculative currency exchanges). Over 60 countries have endorsed the idea of an FTT, although few have acted on it. The EU is still trying to formalize one that could generate up to €57 billion annually (Inman 2013, 79); France and Italy have already gone it alone raising, respectively, €2.5 billion and €1.2 billion over a two-year period (Castillo Espinosa, n.d.). At.01% (one cent for every $100) applied globally, an FTT would raise up to $420 billion annually. At.05% and enforced rigorously to prevent evasion, the total could exceed $8 trillion (McCulloch and Pacillo 2011). In an era of the SDGs and Paris Accord on Climate Change, and with most LMICs struggling with the costs of

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the pandemic, half or more of the FTT revenues could be streamed into established (or proposed) UN funding pools to finance global public goods (funds for health, education, environment, and social protection) for needsbased distribution to poorer countries. Doing so would add real bite to the long-pledged global solidarity promise to “leave no one behind.”

It will take time and considerable lobbying effort to build (or rebuild) momentum on even just some of these tax reforms. But they are doable. They are just policies, which means politics, which requires confronting the power of elites who may not like to see their gilded and (neo)liberalized era come to an end. But for some, there is the more immediate marvel of modern monetary theory. Monetary theory generally considers inflation an anathema and, in response to 1970s “stagflation,” used an interest rate “shock” to quell it, wrecking the developing world economy in the process. Then came 2008. Faced with rescuing the global economy from bankers’ inordinate greed, several HICs (Japan, the UK, the USA, the EU) embraced “quantitative easing” (QE), in which their central banks purchased commercial bank assets (many of them “distressed”), re-inflating banks’ balance sheets and lowering interest rates to near zero. The idea was that commercial banks would loan the new money to companies and individuals to jumpstart the standby production/consumption economy. But many banks were more interested in using the new money for their own speculative investments which helped to create a new stock market bubble that persists to the present (Labonté and Ruckert 2019). Enter the pandemic. Given near-zero interest rates, QE is less likely to fix the pandemic’s economic fallout on its own. But countries with their own sovereign currency and central banks can debt-finance their way out of crisis with little economic risk. The essential features of this modern monetary theory (MMT) is that central banks commit to purchasing government debt indefinitely (Putnam and Norland 2020). This allows governments to spend big on big-ticket items. Because the debt is held by central banks that are owned by governments, the only theoretical downside is a return to undesirable rates of inflation (monetary theory’s traditional concern). In HICs invoking MMT, inflation rates have remained low since the early 2000s. In Canada, where the federal government has been issuing $5 billion in debt every week since March 2020 to finance its $300 billion+ pandemic rescue spending, its central bank expects inflation to remain low for years or decades to come (Macklem 2020). The US central bank (the “Fed”) intends to continue buying huge sums of US Treasury bonds for some time to come, while keeping interest rates close to zero (Irwin 2020). As long as public debt is in a country’s sovereign currency and held by its central bank, there is little risk of default or insolvency, and government bond issuing can continue indefinitely. The longer the time horizon (the UK is issuing its

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“gilts” with 20-year maturities) the better (Moyo 2020). The EU approach is issuing €750 billion in bonds for private purchase with maturity dates extending to 2058, with member states’ fiscal deficits held by the European central bank in a hybrid form of MMT (Dansk Research Team 2020). Few countries have these options, or the fiscal capacity to cope with the pandemic’s immediate economic devastation. For many, especially LMICs, financing their way out of the pandemic involves taking on more external debt, often denominated in US dollars. Currency fluctuations and interest rate increases become real hazards (if rates are floating or bond terms are short), and especially given already high foreign debt burdens many of these countries carry, most of it private sector. Zambia is the first country to default due to the pandemic and faces slashing health and social protection spending to maintain minimal external debt servicing (Moyo 2020). There is fear other poorer countries will soon be in the same place, renewing global calls for debt moratoria, “haircuts,” or cancellation. G20 countries have offered some relief, but only temporary (deferrals, not cancellations) and insufficient; and private creditors are refusing to participate (Inman 2020). But even for the privileged few with MMT capabilities, inflation may eventually set in, especially given post-pandemic reboots emphasizing the importance of energizing consumer demand which, if it starts to outstrip supply (production), will kickstart a new round of rising prices. As of mid-2021, there are already signs of rising inflation in HICs and, as parts of the world with high COVID-19 vaccination rates are inching towards a pre-pandemic near-normal (an Omicron or new variant wave notwithstanding), governments are beginning to unwind their central bank’s bond-buying practices, with interest rates likely to increase slowly.4 MMT is not a substitute for addressing the more systemic problem of private capital’s meteoric rise and public capital’s comparative decline. Tax reforms to routinely capture more private capital for public good is also needed, as is attention to increasing income/wealth transfers from an over-consuming North to an under-consuming South.

3. Re-greening the future In the early months of the pandemic and lockdowns, the world’s fossil fuel driven consumption went fallow. Smog lifted. The Himalayas were again visible to people in India. Blue skies were seen over Beijing. Car traffic dwindled to almost nothing. But the lapse was short-lived with little work stoppage in the oil fields and coal mines and the pandemic leading to weakened environmental regulation and enforcement worldwide (Barbier 2020). Rhetoric of a green build back runs through most countries’ post-pandemic plans, but most stimulus packages are likely to do more environmental harm than good. Two studies are particularly revealing. The first study found that, collectively, the G20 countries were committing 53% of their energy recovery packages to fossil fuels and only 35% to “clean” sources,

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most of which still carry large ecological footprints (EnergyPolicyTracker.org 2021). The USA and UK fared worst in terms of the amount of public money bailing out the carbon industries. The second study, applied to all stimulus spending, found the EU to be greenest, followed individually by France, Spain, the UK (though no longer an EU member), and Germany (VividEconomics and Finance for Biodiversity Initiative 2020). Canada was neutral, its tar sands deposits dragging down an otherwise green stimulus package. India’s decision to open new coal mines and finance environmentally intensive industry overwhelms its sizeble re-greening investments. China’s “Belt and Road” initiative and continued industrialization-by-coal outweigh its positive environmental spending, challenging its commitment to be carbon-neutral by 2060. The USA again scores poorly. The Biden presidency hopes to change this. Since 2019, the Democrats have mooted a multi-trillion-dollar multi-year “Green New Deal” that combines pledges for greater health and social security, education opportunities, housing security, and employment guarantees, alongside key environmental goals: • • • •

100% renewable, zero-emission energy Net zero emission by 2050 Infrastructure retrofits to reduce demand and pollution Overhauling transport sector (zero-emission electric vehicles, or EVs, highspeed trains) • Employment-creating growth in green technology sector • Reduction in agriculture pollution and greenhouse gas footprints (Biden n.d.) The Green New Deal, if fully implemented, “would be a transformative shift” incentivizing a global green race-to-the-top (Harvey 2020). If public monies are joined by an anticipated $5 trillion more in private investments, the USA would overtake Europe in its re-greening boldness. The downside: the Republican Party did better in 2020 state elections than anticipated and, although the Democrats narrowly won control of the Senate, it will be challenging for the new administration to enact the radical environmental policies now so urgently needed. The US 2021 budget modestly proposed only $36 billion for climate change (Newburger 2021). The Biden administration’s subsequent and narrowly approved $3.5 trillion 10-year “Build Back Better” plan (The Associated Press 2021) was scaled down to $2 trillion, albeit retaining about $555 billion for green energy, climate change mitigation, and new climate change technology (Farrington and Sprunt 2021). If it survives Trump’s legacy of radical right Republicanism (as of late November 2021, still an unknown), it is a substantial platform on which to build, but such building must be rapid. There is also concern over statements made by the US climate envoy, John Kerry, that “I am told by scientists that 50% of the reductions we have to make to get to net zero are going to come from technologies that we don’t yet have” (Murray 2021). This wholly unscientific

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forecast may be comforting to those who think tinkering on the tech edges will be sufficient, but it hardly heralds a “transformative shift.” Across the Atlantic, the EU’s multi-trillion euro Next Generation Recovery Fund and European Green Deal are considered by many environmental groups to be the greenest of post-pandemic plans, committing 30% of stimulus spending to de-carbonizing ends (European Commission 2019; 2020). Similar to the US Green New Deal and to commitments made by many other countries, it has a target of carbon-neutrality by 2050 but, unlike the American one, it is legally binding. It also speeds up its five-year targets for greenhouse gas emissions, includes a shift to a circular economy (cradle to grave resource-throughput control, with minimal waste), and a “farm to fork” program to improve the green-sustainability of agricultural practices. This last policy could prove the toughest, as it means undoing many of its current, eco-unfriendly and politically charged farm subsidies in the EU’s Common Agricultural Policy, which have done considerable harm to LIC food exports for decades. But like the US Green New Deal, the EU plan could be undermined by radical right populism, specifically from two of its member states: Poland and, to a lesser extent, Hungary (Söderström, Loss, and Dennison 2021). The EU’s estimated annual increased budget requirements of €260 billion is also considered insufficient to meet its climate change ambitions; that would require new annual investments across the 27 member countries of €855 billion – a large amount but still considered fiscally achievable (Kapeller, Leitch, and Wildauer 2020). Both plans, and their less ambitious versions across several other countries, nonetheless give some cause for proverbial “cautious optimism.” A potential alliance with labor concerns over workers’ futures exists in far more jobs per dollar investment being created in green technologies and efficiency retrofits than in fossil fuel and related industries. Even the wealthiest countries have deficits in care work, whether for environmental restoration or in providing for the health, education, and welfare (well/fair) needs of many. Care work is very low carbon-intensive. And so, the post-pandemic playbook supported by most activists has been branded “eco-just,” one that pays simultaneous attention to the doughnut’s ecosystem outer circle and its social justice inner circle. But there are several moderating caveats to our cautious optimism: • China, India, and Brazil, amongst others of the major-emitting pack, need to be brought more on side. India’s and China’s last-minute softening of the November 2021 26th UN Climate Change Conference of the Parties (COP 26) agreement to phase out coal by 2050, agreeing only to “phase down” its use, is one of the pressing concerns arising from what were billed as “the last chance to save the planet.” • Globally, there is concern that many countries in their post-pandemic recovery spending continue to offer more support to fossil fuel-intensive industries than

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•

•

•

•

to clean energy sectors (International Institute for Sustainable Development and Global Studies Initiative 2021). There is little support being provided to LMICs to follow suit, although they are still amongst the lower emitters (in both absolute and per capita measures) when compared to the USA and the EU. Climate change is only one of our existential ecological crises, although if we fail this one, as the 2021 IPCC report makes frighteningly clear, none of the rest matter. But policy and activist attention must avoid a focus on climate change alone. Most of the re-greening packages rely heavily on technological innovation, with much less consideration going to the unsustainability of our “consumptogenic” economy. Even the best of the lot (Biden’s Green New Deal and the EU’s Next Generation Recovery Fund) sell their plans on the basis of continuous economic growth (albeit less carbon-intensive) and the desire to dominate global competition in the world’s green energy and tech sectors.

The limitation of the focus on re-greening as an economic growth strategy by decoupling it from carbon emissions reduction is most apparent in the emphasis given in both plans, and in those of many other countries, to promoting electric vehicles (EVs). EVs are the low-hanging fruit of meeting Paris Accord commitments. They allow governments to support displaced auto workers (just change the fuel, not the number of cars being built), to apply infrastructure stimulus money to building or repairing roads and bridges, and to create EV refueling stations across their countries. Yes, emissions from fossil fuel cars will go down. But EVs are not emission-free, and many models emit more greenhouse gases in production than conventional cars. Vehicle lifetime emissions will be lower (Hausfather 2019), but only if the fuel source (electricity) is also de-carbonized and not based on oil-, coal-, or gas-powered generation. There is also an insufficient supply of the materials for electric batteries (e.g., lithium and copper), which leads many to argue that EV priority should be given to heavy delivery and mass transportation vehicles, and not to those driven by neoliberalism’s “sovereign individuals.” Damming rivers, erecting wind turbines, and installing solar energy fields to supplant fossil fuel energy without addressing the huge material throughputs required for each alternative source and their own (albeit diminished) negative environmental externalities is short-term problem-solving. Unless net energy consumption levels also fall dramatically, primarily by those in the over-consuming North (again). Taming capitalism? Democracy is egalitarian. Capitalism is inegalitarian … (Wolf 2016)

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Martin Wolf put it rather nicely: capitalism is inegalitarian. Can it be displaced? Will the pandemic be a crisis of sufficient size that alternatives become viable? Will the perfidies of inequality, the imminence of ecocide, and the resulting mass movements of humanity cause not a post-pandemic “reboot” but a complete “reset?” Three different post-pandemic futures have been suggested: 1. A return of neoliberalism: zombie, primordial, or mutant (pick your own adjective). 2. Increased authoritarian government (citizen control, discontent control), cue AI software and the expansion of the surveillance state. 3. Growth, growth, growth. Setting aside the first two futures, however plausible they might be, the third is the one currently most heard from governments’ policy shops. It rests

Image A1.2  “Who sustains life?” (2020). Source: Belén Marco Crespo, Tricontinental: Institute for Social Research, New York City, United States.

40   |  Global Health Watch 6

on an assumption that capitalism might be tamed and, indeed, most of the post-pandemic policies discussed in this chapter are precisely of that ilk: doses of possible interventions whereby the public (and public governance) might tackle our three existential crises. These taming policies tweak capitalism, but do not try to escape its more binding chains. Other, more systemic options exist, and these are topics explored in Chapter A3. But whether “taming” or more radically transforming capitalism, and as the 2020 Report of the United Nations Conference on Trade and Development stated with a political candour that is infusing many of the UN agencies: The status quo ante is a goal not worth the name. And the task is urgent, for right now, history is repeating itself, this time with a disturbing mix of both tragedy and farce. (Secretariat of the United Nations Conference on Trade and Development 2020, iv)

Notes 1  As of late August 19, 2021, COVID-19 has been reported in over 210 countries and territories, with the number of deaths at 4.4 million. The highest number of cases have been in the USA, India, and Brazil (https:// www.statista.com/statistics/1043366/novelcoronavirus-2019ncov-cases-worldwide-bycountry/). Official reported deaths in many parts of the world are considered undercounts of the total number of fatalities (see “COVID-19 Data: Tracking Covid-19 Excess Deaths Across Countries,” The Economist, August 19, 2021. https://www.economist.chttps://www. economist.com/graphic-detail/coronavirusexcess-deaths-tracker). India’s death toll, as one example, is estimated at 4 million, ten times its official count (see Sushmita Pathak, Lauren Frayer, and Marc Silver, “India’s Pandemic Death Toll Estimated At About 4 Million: 10 Times The Official Count.” NPR, July 20, 2021, sec. The Coronavirus Crisis. https://www.npr.org/ sections/goatsandsoda/2021/07/20/1018438334/ indias-pandemic-death-toll-estimated-at-about4-million-10-times-the-official-co). 2  Poverty data are calculated by taking the poverty threshold from each country based on the value of the minimal amount of goods (food, shelter, clothing) needed to sustain one adult. Using the thresholds for the world’s poorest 15 countries, and data for internationally comparable prices, the World Bank creates an “international poverty line.” The $1.90/day level is set as an extreme poverty line for the World

Bank’s group of low-income countries. For lowermiddle-income countries, the level is now set at $3.20/day; for middle-income countries at $5.50/ day; and for high-income countries at $21.70/day. See Francisco Ferreira and Carolina SánchezPáramo, “A Richer Array of International Poverty Lines,” October 13, 2017. https://blogs.worldbank. org/developmenttalk/richer-array-internationalpoverty-lines. 3  The USA and many other HICs experienced declines in life expectancy in 2020 largely attributed to COVID-19. The USA experienced the sharpest decline amongst HICs, averaging a loss of 1.87 years inequitably distributed by racialized groups (–3.88 for Hispanics, –3.25 for non-Hispanic Blacks, and –1.36 for non-Hispanic whites) (see “News Release: Decreases in Life Expectancy in 2020 Much Larger in the US than Other High Income Countries,” British Medical Journal, 2021, in EurekAlert! June 23, 2021. https://www. eurekalert.org/news-releases/750488). Life expectancy also decreased in most EU member states for which data were available (see “Life Expectancy Decreased in 2020 Across the EU,” Eurostat, April 7, 2021. https://ec.europa.eu/ eurostat/web/products-eurostat-news/-/edn20210407-1). At the time of writing, similar data for LMICs are not available. 4  By the start of 2022 inflation has increased significantly. Many economists regard this as temporary, part of increased demand with limited supply and an excess of money in the

FROM PRE-PANDEMIC PATHOLOGIES TO POST-PANDEMIC HOPEFULNESS  |  41 economies of HICs. Corporate profiteering may also be a factor. Tax and regulatory measures, including price controls, could be used to

manage inflation risks without sharp increases in interest rates, which would risk debt crises in many LMICs.

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FROM PRE-PANDEMIC PATHOLOGIES TO POST-PANDEMIC HOPEFULNESS  |  45 Index.” https://www.vivideconomics.com/ wp-content/uploads/2020/10/201028-GSIreport_October-release.pdf. Wadhwa, Divyanshi, and Donna Barne. 2019. “Year in Review: 2019 in 14 Charts.” Feature Story. December 20. https://www.worldbank. org/en/news/feature/2019/12/20/year-inreview-2019-in-charts. Whitmee, Sarah, et al. 2015. “Safeguarding Human Health in the Anthropocene Epoch: Report of the Rockefeller Foundation–Lancet Commission on Planetary Health.” The Lancet 386 (July): 1973–2028. Wolf, Martin. 2016. “Capitalism and Democracy: The Strain Is Showing.” Financial Times. August 30. https://www.ft.com/content/ e46e8c00-6b72-11e6-ae5b-a7cc5dd5a28c. World Health Organization. 2017. “WHO: Why Reform?” Geneva, Switzerland: World Health Organization. World Meteorological Organization. 2020. “New Climate Predictions Assess Global

Temperatures in Coming Five Years.” World Meteorological Organization. July 8. https:// public.wmo.int/en/media/press-release/ new-climate-predictions-assess-globaltemperatures-coming-five-years. Yonzan, Nishant, R. Aguila, Christoph Lakner, Daniel Mahler, Haoyu Wu, and Melina Fleury. 2020. “Updated Estimates of the Impact of COVID-19 on Global Poverty: The Effect of New Data.” October 7. https://blogs. worldbank.org/opendata/updated-estimatesimpact-covid-19-global-poverty-effect-newdata. Zeballos-Roig, Joseph. 2019. “4 European Countries Still Have a Wealth Tax. Here’s How Much Success They’ve Each Had.” Business Insider. November 7. https://www. businessinsider.com/4-european-countrieswealth-tax-spain-norway-switzerlandbelgium-2019-11.

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A2  |  GENDERED INEQUITIES DURING COVID-19 TIMES: A VIEW FROM THE GLOBAL SOUTH

The COVID-19 pandemic is one of the biggest challenges that the global community has faced in recent times. Along with having a devastating impact on the social, cultural, economic, and public health systems of countries across the world, the pandemic is bringing to light a deeply problematic narrative of inequality, precipitated on the one hand by the sustained structures of gender, caste, race, religion, work, location, ability, sexual orientation, and ethnicity, and on the other by neoliberal global structures and institutions. While some COVID-19-related vulnerabilities are shared by most people, it is important to acknowledge how the pandemic has widened pre-existing inequalities and the disproportionate effect it has had on persons with various gender identities. Based on the wheel of privilege (Duckworth 2020), this chapter recognizes that on the gender spectrum, cisgender women, trans persons, intersex persons, and non-binary persons are more likely to be marginalized. In this chapter, all of these identities will be referred to collectively as “various gender identities” for the sake of brevity. Gender, though, is not the only factor in such inequalities as it interacts with many more social and personal identities to create lived realities, as will be discussed in later sections of this chapter. The pandemic, apart from having direct health outcomes, has also had indirect health outcomes for various genders – it has increased gender-based violence (UN Women 2020), it has brought to light gendered inequalities within the health system, and it has disrupted essential sexual and reproductive health services. These times have made the widening gaps between the haves and have-nots more evident. Prior to COVID-19, it was well established how inequities on these grounds lead to vast gaps in health outcomes – be they in access to the social determinants of health and healthcare facilities or in receiving successful treatment. These inequities worsened significantly during the pandemic (Makau 2021). While countries in the Global South for decades have experienced serious challenges in obtaining ideal health outcomes due to a variety of socio-structural factors (Orach 2009), they are now also struggling with additional pandemicrelated difficulties including the repercussions of lockdowns on their economies, weak social protection schemes, poor health infrastructures, and political conflicts, all of which have further worsened their response to COVID-19 (UNICEF 2020). In light of these concerns, this chapter focuses on the gendered impact of the COVID-19 pandemic with an emphasis on experiences in the Global South, and with reference to current health activism seeking to mitigate gendered health inequities.

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Gendered implications and experiences of COVID-19

Prior to the pandemic, researchers, feminist scholars, and activist organizations had written extensively about pervasive gender inequalities, gendered differences in health outcomes (Sen 2007), and the role played by inequitable access to social determinants of health including education and employment opportunities, healthcare, safe workspaces, healthy food, and social protection. COVID-19 has worsened these conditions, furthering the severity of the infection: The elderly, immunocompromised, and those with preexisting conditions – such as asthma, cardiovascular disease (CVD), hypertension, chronic kidney disease (CKD), or obesity – experience higher risk of becoming severely ill if infected with the virus. Systemic social inequality and discrepancies in socioeconomic status (SES) contribute to higher incidence of asthma, CVD, hypertension, CKD, and obesity in segments of the general population. Such preexisting conditions bring heightened risk of complications for individuals who contract the coronavirus disease (COVID-19). (Singu et al. 2020)

Women, who constitute the majority of healthcare, social, and domestic workers, along with trans persons, who often have to engage in high-risk livelihoods, are both at greater risk of infection. This is especially so in low-income countries where their relative poverty further renders them more vulnerable due to their existing physical, social, and health conditions (Levine et al. 2021). Lack of access to COVID-19 testing and treatment also threatens the health and lives of women and adolescent girls. At the time of writing (June 2021), only 52 countries out of 194 are reporting sex-disaggregated data on infections and mortality (Global Health 5050 2021). For countries that have reported data, a majority report more infections in men. In countries such as Afghanistan, Pakistan, and Yemen, less than 30% of COVID-19 cases are female compared to the global average of 50% (Peyton 2020). Some of the causes for the low reporting of cases in women include some testing facilities are not designed to be accessible to all genders, women’s health is not given as much priority as men’s and women’s symptoms are not taken as seriously, loss of livelihood for various genders is not seen as important as its loss for men, and general prioritizing of pandemic-related resources and money on men. Additionally, there is a growing vaccination gap with more men getting vaccinated than women in India (Srishti 2021), and an even harsher vaccination gap for trans persons, as a report from India has shown (Deol 2021). Since vaccinated men can continue to be carriers of COVID-19, such disparities put people from various genders at risk as they continue to perform duties as frontline and domestic workers, or as they continue to engage in high-risk livelihoods. Indirect impacts on health of women, intersex, trans, and non-binary persons due to COVID-19 include loss of livelihood and financial independence, the additional burden and stress of housework due to the pandemic restrictions, as well as care work for COVID-19 patients. In low- and middle-income countries

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(LMICs), where larger systemic support systems like social protection, maternity benefits, and pensions fail to reach the most vulnerable, the pandemic has shaken any feeling of security. Many young girls have had to stop their education due to lack of access to digital infrastructure and have been pushed to undergo child, early, and forced marriages, putting them at greater health risks (Girls Not Brides 2020). COVID-19 has rendered persons of diverse genders at further risk of COVID-19’s negative impacts, with additional restrictions on mobility, gaps in health-related information that is usually received from their social networks, suppression of voices and rights, and being left behind in the race for adoption of digital technology (Mehrotra 2021). A curb on movement has led to many people losing livelihood opportunities and the safety of spaces outside the home and being pushed back into norms that they had fought hard to counter. The “shadow pandemic” of gender-based violence

The crisis of gender-based violence (GBV) and its enduring negative health impacts on survivors received renewed global attention after the UN Women termed it a “shadow pandemic.” This followed the emerging data and reports from those on the frontlines which show that all types of violence against women and girls, particularly domestic violence, has intensified. The issue of GBV has long been known to be exacerbated in humanitarian settings, disasters, etc. (see Chapter C4), as it remains linked to myriad risk factors originating in the chaos of the crisis such as being separated from the family or community, lack of safe spaces, or having to undertake new responsibilities such as foraging for food (Peterman et al. 2020). The attention to GBV during COVID-19, albeit limited largely to violence within homes, has sharpened the focus on the issue (Manzoor and Bukhari 2020). Before the advent of the pandemic, more than 40% of women in Southeast Asia faced violence at the hands of their intimate partners. This number is thought to have surged during lockdowns. For instance, a domestic violence hotline in Malaysia reported a 57% increase in calls when the country’s movement control order was in force (Gerard et al. 2020). A similar trend was observed in other parts of the world with more women seeking help against domestic violence during the lockdowns: a 30% rise in emergency calls related to domestic violence in Cyprus, 40%–50% in Brazil, 60% in the European Union, and a 100% rise in India (Seth 2021). Additionally, persons of diverse genders have also had to cope with different forms of systemic violence thrust upon them by the state. These have included violent and harsh lockdowns, being engulfed in an atmosphere of fear and misinformation, being stuck in workplaces that do not adhere to protocols, loss of livelihood, forced migration, and inadequate social protection. In India, the trans community faced, and still faces, additional challenges in getting access to social protection since their official documents often have incongruities (Mittra 2020). It is important that systems working on COVID-19, health, and gender

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issues recognize their responsibility in identifying, preventing, and addressing violence especially for persons rendered more vulnerable during these times.

Box A2.1: The struggle for women’s health and rights and the setbacks in the discourses and practices of the Brazilian government The struggle for sexual and reproductive rights is historic in the world, especially for women who face patriarchal social norms in which the bodygeopolitical relationship is inseparable. In Brazil, powerful barriers still exist in accessing these rights. Among the major challenges is the feasibility and implementation of equitable and integrative social policies that effectively incorporate gender, race, and health issues facing cis, trans, lesbian, and bisexual women at all stages of life. The country has recently also experienced marked setbacks guided by radicalized conservatism. In 2018, the Plan of Action for Women’s, Children’s, and Adolescents’ Health 2018–2030 was negotiated and approved by the 56th Directing Council of the Pan American Health Organization (PAHO) (PAHO 2018a). This Plan urges countries “to address the immediate causes of preventable mortality, morbidity, and disability in women, children and adolescents, as well as their underlying determinants in the framework of rights, gender, life course, and cultural diversity, and to promote positive development, health, and well-being” (PAHO 2018b). Until the end of the meeting, no consensus had been reached on the Plan, especially by US opposition to the use of the terms “human rights,” “sexual and reproductive rights,” “gender,” and “comprehensive sexuality education.” Brazil, along with countries such as Panama, Canada, and Ecuador, strongly defended maintenance of these terms and approval of the Plan, which had broad support from other PAHO countries. The USA nonetheless requested that the plan be put to a vote (a rare situation in this forum), which resulted in approval by 24 countries, abstentions of three, and a contrary position from only the US government (PAHO 2018c). Exactly one year later, with the new far-right government in Brazil, the country sided with the USA, Guatemala, Iraq, Poland, and Hungary at the High-Level Meeting of the United Nations General Assembly on Universal Health Coverage. Brazil supported one of the most regressive speeches concerning these rights, opposing the use of agreed terms, as well as arguing against the provision of services and rights already achieved to advance the quality of life and health of people (UN Web TV 2019). And it was not just the speech that Brazil changed, with gender rights setbacks being identified daily in the country: • The participation of women in the Bolsonaro government is one of the smallest in the world.

GENDERED INEQUITIES DURING COVID-19 TIMES  |  51 • The Women’s Secretariat, under the management of church representatives, promoted a disinvestment in actions that provide care for and promote the financial autonomy of women victims of aggression. • Amendment of Decree No. 8,086/2013, which established the Women’s Program: Living Without Violence (Secretaria-Geral Subchefia para Assuntos Jurídicos 2013), excluding all references to “gender,” implying that such violence had no underlying gender dynamics or determinants. • Repeal of the Ministry of Health’s rule that authorized nurses to insert IUDs (Valda da Silva 2019). • Return of the Bill of the Statute of the Unborn, which overlays the right of the fetus to that of the woman and typifies abortion as a heinous crime, even precluding legal abortion already guaranteed. Although unsafe abortion is one of the main causes of maternal death in the country, the issue has not been treated as a public health issue but, instead, has been treated using the punitive logic of a religious approach. • Federal Government campaign in 2020 on the prevention of adolescent pregnancy, which promotes sexual abstinence and paves the way for blaming adolescents without considering data from the Ministry of Health itself, which indicate that almost 70% of girls under 14 years who had children were rape victims who had suffered violence in their own residence (Ministério da Saúde 2018). • Publication of an Ordinance of the Ministry of Health that makes it difficult to perform legal abortion and can revictimize women and girls who are victims of sexual violence (Ministério da Saúde 2020). In addition to these setbacks, other factors are important threats to women’s rights, such as environmental and land deregulation and frequent public disasters. During the COVID-19 pandemic, for example, cases of violence against women and girls increased considerably. Contrary to the evidence, the Ministry of Health withdrew guidelines dealing with the continuity of assistance services to cases of sexual violence and the strengthening of sexual and reproductive planning in the context of the pandemic. A repudiation note was published and signed by 98 organizations (Centro Feminista de Assessoria, Grupo Curumim Gestação e Parto, and Observatório de Sexualidade e Política 2020). To prevent access to abortion, even in cases authorized by law, governments of Brazil, the USA, Egypt, Hungary, Indonesia, and Uganda, led by the US Trump administration, created and signed a 2020 initiative called the “Geneva Consensus Declaration” (Bomfim 2020) (from which the US Biden administration quickly withdrew). Intentional state violence that reproduces racism, epistemicide (the destruction of local knowledge systems associated with colonization), and Indigenous extermination in service of colonialism, capitalism, imperialism,

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and patriarchy particularly affects women. It is necessary to break with the alliance between the Brazilian oligarchy and imperialism, which has been reproduced for over 500 years and is a fundamental reason for the subjective and objective genocide of social groups targeted by white supremacy. Existing in and actively resisting the current Brazilian and international social and political context has been challenging. But women’s movements and the struggle for the right to health are actively resisting such policies and fighting against anti-gender offensives. The Feminist Alert (#AlertapelaVidadasMulheres #AlertapelaDemocracia), for example, calls for everyone to support feminist, anti-racist actions against all forms of oppression, in support of rights, and in support of lives free of violence in the firm defense of reproductive justice (Frente Nacional PLA 2020). Other initiatives, such as the Observatory of Favelas, seek to build experiences that overcome inequalities and violence, and strengthen democracy based on the affirmation of favelas and suburbs as territories of powers and rights (Observatório de Favelas do Rio de Janeiro n.d.). The COVID-19 pandemic has further exposed the contradictions between care and capital and the greatest burden on women. It is imperative to socialize care, implement technologies of decolonization, and radicalize solidarity at all levels. Projects and initiatives such as the case of female sex workers in Brazil point out that mutual aid can also be “a space for political and personal connection like a measure of survival that is also transformative” (Moraes, Santos, and Assis 2020). We have a social order that is collapsing, and another must be born against a background of human emancipation in dispute.

An impediment to sexual and reproductive health services

Already overwhelmed inadequate healthcare resources were diverted from “lesser priority” areas to managing the pandemic. It is little surprise that these “lesser priority” areas comprised sexual and reproductive health services, such as maternal healthcare, abortion services, and treatment for diseases like hypertension, diabetes, cancer, and cardiovascular emergencies. The World Health Organization (WHO) stated that the most common reasons for discontinuing or reducing such services were cancellations of planned treatments, decrease in public transport available, and lack of a healthcare workforce which had been routed to support COVID-19 services. One in five countries among the ones that were surveyed reported disruptions or suspension of their healthcare services for non-communicable diseases (NCDs) due to shortage of medicines, diagnostics, and other health technologies (Brunier and Harris 2020). The lockdowns imposed in 2020 had an unprecedented impact on people’s abilities to access safe abortion services due to suspension of transport and lack of adequate services for non-COVID-related healthcare issues. The International

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Planned Parenthood Federation (IPPF) reported that over 5,000 reproductive health clinics across the world were shut down when lockdowns were initially put into effect (Gomez Sarmiento 2020). The Ipas Development Foundation modeled abortion access and estimated that 1.85 million abortions, or nearly 47% of an expected total, were likely compromised because of the lockdown restrictions (Ipas Development Foundation 2020a; Jain et al. 2021). Similarly, a Nepalese study found that the number of women accessing safe abortion services at a tertiary healthcare center during the lockdown dropped by 25% in the lockdown’s first three months because of mobility issues and financial constraints (Aryal et al. 2021). Later, in September 2020, the Nepal government approved home-based medical abortion through an outreach model and telemedicine, which was a critical move in addressing barriers to accessing safe abortion (IPPF 2020). In Bangladesh, the Rohingya refugees settled in the city of Cox’s Bazar were dependent on the reproductive health clinics being operated by non-governmental organizations inside the camps. However, when lockdown was initially imposed, menstrual regulation was not designated as an essential service, which led to the temporary suspension of these health clinics. After weeks of advocacy by civil society representatives, the Refugee Relief and Repatriation Commissioner provided reproductive healthcare workers with “vehicle pass(es)” so that they could resume their work (Ipas Development Foundation 2020b).

Box A2.2: The Argentine “green wave” On December 30, 2020, the National Congress of Argentina passed by a large majority a bill that legalizes the voluntary termination of pregnancy until the 14th week of gestation. The path that led to this historic achievement has been a long one. The Argentine feminist movement has its own tradition that began with the return to democracy in 1984 and entails the National Women’s Meetings, held uninterruptedly for 34 years, which take place in different provinces each year so that the movement can have a genuinely federal (national) reach. Within this context, in 2003 began the “Workshop of Strategies for the Right to Abortion,” which advanced year after year onwards. At the same time, the Campaign for Legal, Safe, and Free Abortions helped to unify all the groups that had been working towards achievement of this right in Argentina. In 2015, following the atrocious femicide of a pregnant teenager by her partner and family simply because they did not want the pregnancy, the #Niunamenos (#Notoneless) movement arose which was later taken up internationally. In 2016 the movement began to call for the right to abortion, joining both claims in the fight against gender-based violence. In

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2018 a proposal to legalize abortion was presented for the eighth time. This was the closest such a proposal had come to passing, as it was approved in the Chamber of Deputies before losing in the Senate. However, what was unstoppable was the social debate regarding the issue that led to a mobilization of unprecedented scope. The so-named “green wave” used green-colored handkerchiefs that traversed the entire country and that were named heirs of the white handkerchiefs belonging to the Madres de Plaza de Mayo (Mothers of Plaza de Mayo).1

Image A2.1  A young woman wears the trademark green handkerchief of Argentina’s “green wave” movement. Source: Photo by María Laura Collasso.

What happened to the health system during that period? For 100 years, Argentina’s Penal Code has allowed abortion in cases of risk to the life of the pregnant woman and of rape by an “idiot or insane person.” In 2012, the Supreme Court of Justice interpreted this article, expanding the possibility of abortion to include any case of rape against women and, in addition to the risk of life, the risks for health. From that moment, a window of possibility opened for the application of abortion on three grounds: rape, risk of life, and risks for health, which was referred to collectively as the ILE (the Spanish acronym for Legal Interruption of Pregnancy). The Ministry of Health developed an implementation guide that interpreted health as integral, widening further the unevenly accepted legal spectrum. Since then, the health system’s behavior has been uneven. A very important commitment at the level of primary care, where interdisciplinary

GENDERED INEQUITIES DURING COVID-19 TIMES  |  55 pre- and post-abortion counseling was introduced, in which psychologists and social workers actively participated. This practice progressively expanded to outpatient abortion using medications and, in a few jurisdictions, also manual vacuum aspiration (MVA), all being performed by general practitioners. An interdisciplinary network of primary care professionals was created to support the right to decide, coining the phrase “you can count on me.” Meanwhile, at the level of secondary care, most specialists in obstetric gynecology in general hospitals were opposed to this right. A very important autonomous movement emerged from civil society, under the name Socorristas en Red, inspired by the Women on Waves Movement.2 This movement, which arose from a collective in the province of Neuquén, went national. By means of a cell phone passed between volunteers, the movement offered a line that guaranteed a safe abortion and the necessary support (food, lodging, medications, company) free of charge to any woman who needed it. This movement, together with the network of professionals for the right to decide and the political action of the National Campaign for Legal, Safe, and Free Abortion,3 achieved the social decriminalization of abortion, which permitted the attainment of its legal decriminalization. What are the current challenges? Two are particularly important: 1) undergraduate and post-graduate training in health professions to ensure healthcare workers are updated on the practices of the current framework of this achieved right; 2) monitoring compliance with current regulations without delays, knowing that the sectors that oppose this achievement will try to fight it through conscientious objection and delay with every woman and procedure that passes through their hands. In this landscape, the Latin American Social Medicine movement (ALAMES), the People’s Health Movement, and the health feminist movement have an unparalleled opportunity to act together for the expansion of rights. We hope to rise to the occasion offered by the history we were able to achieve.

Thus, one realizes that amidst pre-existing social, cultural, and systemic impediments, the pandemic merely highlighted that sexual and reproductive health rights have little priority in government policy or programs and continue to be neglected. The repercussions of this neglect are expected to persist unless there is an urgent push for commitment and accountability from the state as well as community solidarity and support to pressure fulfilment of these health rights. Community health workers and COVID-19

Women comprise 70% of the global health workforce but earn substantially less than men, 28% lower on an average. This gender gap exists mostly because

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women are less likely to be in “highly skilled” jobs than their male counterparts and because of variations in working hours. However, even with “equal work” and “equal pay,” a gap of 11% remains. The gender inequity that is ingrained in the health system has resulted in women health workers being relegated to lower stature and lower paid work and being often required to take on unpaid roles even in the health workforce. The harsh realities of gender inequities they face has only worsened with COVID-19 (Boniol et al. 2019). While health systems globally grappled with the challenge of the pandemic, in many countries Community Health Workers (CHWs) played a pivotal role in mitigating the crisis, often putting their own lives at risk. In India, CHWs have assisted various state governments in contact tracing, spreading awareness about precautionary measures, and conducting regular follow-up visits. CHWs are known as Accredited Social Health Activists (ASHAs) in most states across India, or by colloquial names like “Mitanin” in the state of Chhattisgarh or

Image A2.2  Demands for accredited social health activists (ASHAs) in the form of a poster. Source: Photo by the Sama Resource Group for Women. http://www.samawomenshealth.in/

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“Sahiya” in Jharkhand.4 As one example, in the State of Uttar Pradesh, CHWs helped in contact tracing of three million migrants who were returning from urban areas to their villages following lockdown orders early in the pandemic (“ASHA workers played” 2020). In Bangladesh, over 1,400 Rohingya refugees were trained as Community Health Volunteers (CHVs) to provide essential health services in cramped refugee camps and surrounding areas of Cox’s Bazar. The CHVs not only acted as a bridge by building trust between refugee communities and health facilities, they also countered misinformation and rumors that restrained a vulnerable community from accessing health facilities (Bezbaruah et al. 2021). In Thailand, Village Health Volunteers (VHVs), a cadre of CHWs originally established in 1977, played a pivotal role in the management of COVID-19 crisis in rural areas (Tejativaddhana 2020). During the Songkran New Year period in midApril of 2020, lockdown measures led to several Thai residents living in urban areas returning to their rural homes. Without the VHVs, it would have been a Herculean task to trace the returnees who had contracted COVID-19 in their respective villages (Narkvichien 2020; Bezbaruah et al. 2021). Despite their pivotal role in the management of COVID-19, CHWs have had to deal with the risk of infection, heightened by state negligence and lack of preparedness due to inadequate personal protective equipment (PPE). In countries like India, Bangladesh, and Nepal, CHWs’ lives were endangered due to an acute shortage of supplies in the early days of the pandemic (Antara and Narayanganj 2020; Basnet 2020; Chauhan 2020; Rahman 2020). CHWs did not receive adequate training on infection prevention and control, including on how to use PPE in their work; they received negligible reimbursement for their work and no social security, unlike their medical counterparts (Bezbaruah et al. 2021). The prevalent bias against CHWs, considered to be the lowest rank of healthcare provider in the medical hierarchy – no matter what name they go by in different countries – was reflected in the minimal concern for their safety by most countries’ health system responses (Bezbaruah et al. 2021). The experiences of CHWs during the pandemic garnered from various South

Box A2.3: Nurses’ health is unfairly affected during the COVID-19 pandemic: a look into the reasons why The current COVID-19 pandemic has directed visibility to the vulnerability nurses across the world face in their everyday work (WHO 2020a). Professional nurses and nurse aides, the majority of whom are women, are disproportionately affected by COVID-19 (Hughes et al. 2020). The International Council of Nurses (ICN) has reported that as of December 31, 2020, the cumulative number of reported COVID-19 deaths of nurses

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in 59 countries out of the world’s 195 countries is 2,262 (International Council of Nurses 2021). Nurses’ health is influenced by several factors and the political context significantly affects nursing employment and working conditions, ultimately creating health inequalities (Gunn et al. 2019). Prior to the pandemic, the 2008 economic crises led to neoliberal austerity measures imposed in many countries that significantly curtailed government spending. One of the measures implemented set caps on employment in the public sector which had a substantial impact in the precarization of nurses. For example, in Croatia, austerity resulted in overburdening already employed nurses while the inability of newly professional nurses to access employment led to an increase in migration and a deepening of the serious shortage of nursing personnel (Friganovic et al. 2020). Similar consequences of austerity were noticed in other countries, e.g., Spain, Italy, and Mexico, where prioritization in hiring nurse aides instead of professional nurses first started as a response to the economic development plans of the 1970s (Squires and Juarez 2012). Several countries in South Asia also followed a similar trajectory (Baru 2003). At the same time, to date only 41 countries have ratified the International Labour Organization (ILO) Nursing Personnel Convention of 1977 (No. 149) and the accompanying Recommendation (No. 157) that set standards for fair employment conditions for nursing personnel. Currently, countries’ general policies on COVID-19 do not address nursing work and needs. The declaration of COVID-19 as an occupational disease has been uneven, and several countries have not yet developed this policy. Furthermore, while students and retired nurses are employed as actual workers during the COVID-19 crisis, they are not always covered by existing labor laws, and collective bargaining coverage in this sector of workers is unknown. Global economic dynamics also play a critical role in countries’ purchasing capacities, availability of personal protective equipment (PPE), vaccine production capacities, vaccine distribution, and the international competition over scarce health workers. Nursing vulnerabilities are heightened by gender inequalities. A predominantly female nursing staff requires a range of work time arrangements, such as extended work shifts, night work, and on-call scheduling. The inappropriate use of these arrangements has been shown to negatively impact nurses’ health (ILO 2018). During this pandemic, female nurses worked on the “second shift,” undertaking higher workloads while maintaining their unpaid job as key caregivers within their families, which in turn added additional stress and fear of infecting cohabiters (Fernandez et al. 2020). During the first wave of COVID-19 pandemic, there was a lack of consensus and clear information regarding risks for pregnant women workers and breastfeeding mothers exposed to COVID-19, which resulted in hospitalizations and deaths (Topping 2020).

GENDERED INEQUITIES DURING COVID-19 TIMES  |  59 Violence against the nursing workforce is reported worldwide and within all types of healthcare settings. During the COVID-19 pandemic, health workers in India have been excluded from their communities, evicted from their homes, and forced to sleep in hospital bathrooms and on floors for fear that they may carry the coronavirus (Ellis-Petersen and Rahman 2020). In the city of Rimini in Italy, 70 cars of health workers were damaged overnight outside the hospital (Rimini 2020). In Mexico, cases of physical and verbal assaults on health workers, including nurses, have been documented both inside and outside hospital facilities, as well as while making home visits to assess patients and as health workers make their way home (Caldera-Villalobos et al. 2020). Working conditions of nurses during the pandemic have also been complicated because of pre-existing discrimination based on nurses’ races, ethnicities, and castes. During COVID-19, data from the Centers for Disease Control and Prevention (CDC) from six US states showed that American Indian, Asian, and black health workers are at higher risk of case fatality (Hughes et al. 2020). Many nurses who migrated in search of better job opportunities in the UK were held up and unable to register due to COVID-19 and the lockdown. The Nursing and Midwifery Council (NMC) brought temporary registration to those migrant nurses who completed competitive skill examinations, while others were forced to wait for more than two to three months for the registration. In India, the United Nurses Association had to arrange safe repatriation of nurses stranded in Saudi Arabia. Discrimination and racism surrounding a lack of job opportunities, poor career progression, or poor learning environment are causes of poorer health among migrant and minority nurses compared to native-born nurses (Schilgen 2017). Yet, globally, one in eight nurses practice in a country other than the one where they were born or trained (International Council of Nurses 2020). Professional nursing associations, educational institutions, nursing regulatory bodies and unions, nursing student and youth groups, grassroots groups, and global campaigns such as “Nursing Now” are valuable contributors to strengthening the role of nursing in healthcare teams and to helping them achieve better employment and working conditions (WHO 2020). In many instances, unionization has helped to improve the working and income conditions for nurses. It also has an impact in terms of patient morbidity and mortality from COVID-19 (Dean, Venkataramani, and Kimmel 2020). However, collective organizing and legal rights are still insufficient in many countries. On a positive note, the pandemic has sparked new solidarity actions by nurses to bring more attention to their needs as a collective, with calls for post-pandemic international and nationally enforceable standards.

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Asian countries, their positive contributions, and their relative neglect by health systems, underscore the importance of sustained investments in CHW programs. A step up on the healthcare worker hierarchy finds that conditions for nurses were not much better (Box A2.3). Conclusion

COVID-19 has left no country unscathed. Gender analysis has become pertinent in the response to COVID-19 because it has become increasingly visible how socially constructed roles and gendered identities affect not only risk of exposure and biological susceptibility to infection, but also individuals’ experiences of the kind of treatment received (WHO 2020b). It is important to go beyond the gender binary lens and ascribed gender roles in order to address inequalities embedded in the larger health system. Adopting a gender analytical approach should not translate into simplistic messaging that “pandemics affect women and men” differently. Rather, it should aspire to surpass a narrow-gendered focus where one tends to homogenize diverse experiences. Instead, a gender analysis must also take into account other intersecting factors such as disability, indigeneity, race or ethnicity, and migration or refugee status. It should also locate gendered and intersectional differences in health in the context of structural health determinants, such as precarious housing, employment status, patriarchy, and political and environmental stressors (Hankivsky and Kapilashrami 2020). The reiterated concerns in the current context, some of which have been discussed above (gender-based violence, structural marginalization of sexual and reproductive health and rights, precarious environments within health systems for women and other frontline workers), point towards gendered fault lines in our societies and systems globally. Taking cognizance of these is critical towards developing an intersectional perspective and learning from these diverse situations. Gender justice and equality must remain at the center of health movements globally to make those movements inclusive and fair. As we look back at the Argentine experience (Box A2.2), we see the power of a sustained grassroots struggle where people refused to give up. It is an example of how people’s movements have the power to hold their governments accountable for recognizing and upholding systems that respect intersectionalities and vulnerabilities on the basis of gender, caste, class, ability, sexual orientation, religion, or more, whether before, during, or after COVID-19 as we leave the pandemic’s shadow. Notes 1  A movement of mothers who gathered in 1978 to call for the reappearance of their arrested children, disappeared during the civilmilitary dictatorship (1976–1983). This movement is still active and is famous worldwide for its

defense of human rights. These mothers wear a white headscarf as a reminder of their children’s diapers. 2  A European movement that had a ship sailing in international waters providing

GENDERED INEQUITIES DURING COVID-19 TIMES  |  61 abortions in countries whose laws did not permit it. 3  A social actor fundamental to this process that since 2005 unites all the groups in the

country that defend the right to abortion. See www.abortolegal.com.ar. 4  Mitanin or Sahiya refers to a “female friend” in local dialect of Chhattisgarh and Jharkhand respectively.

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62   |  Global Health Watch 6 Ellis-Petersen, Hannah, and Shaikh Azizur Rahman. 2020. “Indian Doctors Being Evicted from Homes over Coronavirus Fears.” The Guardian. March 30. http:// www.theguardian.com/world/2020/mar/30/ indian-doctors-being-evicted-from-homesover-coronavirus-fears. Fernandez, Ritin, Heidi Lord, Elizabeth Halcomb, Lorna Moxham, Rebekkah Middleton, Ibrahim Alananzeh, et al. 2020. “Implications for COVID-19: A Systematic Review of Nurses’ Experiences of Working in Acute Care Hospital Settings during a Respiratory Pandemic.” International Journal of Nursing Studies 111: 103637. Frente Nacional PLA. 2020. “Leia agora o Alerta Feminista 2020.” September 18. https://frentelegalizacaoaborto.wordpress. com/2020/09/18/alerta-feminista-2/. Friganovic, Adriano, Sladana Režić, Biljana Kurtović, Sandro Vidmanić, Renata Zelenikova, Cecilija Rotim, et al. 2020. “Nurses’ Perception of Implicit Nursing Care Rationing in Croatia – A Cross-Sectional Multicentre Study.” Journal of Nursing Management 28 (8): 2230–2239. https:// onlinelibrary.wiley.com/doi/abs/10.1111/ jonm.13002. Gerard, Kelly. 2020. “Advancing Gender Equality in South East Asia after COVID 19.” East Asia Forum. July 9. https://www.eastasiaforum. org/2020/07/09/advancing-gender-equalityin-southeast-asia-after-covid-19/. Girls not Brides. 2020. “COVID-19 and Child, Early and Forced Marriage: An Agenda for Action.” https://www.girlsnotbrides.org/ learning-resources/resource-centre/covid19-and-child-early-and-forced-marriage-anagenda-for-action/. Global Health 5050. 2021. “The COVID-19 SexDisaggregated Data Tracker April Update Report.” The Sex, Gender and COVID-19 Project. https://globalhealth5050.org/thesex-gender-and-covid-19-project/. Gomez Sarmiento, Isabella. 2020. “The Pandemic and Legal Abortion: What Happens When Access is Limited?” NPR. June 8. https://www.npr.org/sections/ goatsandsoda/2020/06/08/864970278/ lockdown-limits-access-to-legal-abortion-incolombia-telemedicine-is-now-an-opti. Gunn, Virginia, Carles Muntaner, Michael Villeneuve, Haejoo Chung, and Montserrat Gea Sanchez. 2019. “Nursing

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GENDERED INEQUITIES DURING COVID-19 TIMES  |  63 during COVID-19.” September 29. https://www.ippfsar.org/resource/nepalgovernment-approves-home-use-medicalabortion-services-though-certified-providers. Jain, Dipika, Anmol Diwan, Kavya Kartik, and Joshika Saraf. 2021. Legal Barriers to Abortion Access during the COVID-19 Pandemic in India. Centre for Justice, Law and Society, Jindal Global Law School. https://jgu.s3.ap-south-1.amazonaws.com/ cjls/SRHR+Pandemic+Report+6.pdf. Levine, Madison, Niccolo Meriggi, Ahmed Mushfiq Mobarak, Vasudha Ramakrishna, and Maarten Voors. 2021. “How is COVID-19 Affecting Gender Inequality in Low-Income Countries? Insights from Sierra Leone.” March 8. https://www.theigc.org/blog/ how-is-covid-19-affecting-gender-inequalityin-low-income-countries-insights-fromsierra-leone/. Makau, Winnie M. 2021. “The Impact of COVID-19 on the Growing North–South Divide.” March 15. https://www.e-ir. info/2021/03/15/the-impact-of-covid-19-onthe-growing-north-south-divide/. Manzoor, Mehr, and Nadia Bukhari. 2020. “Domestic and Gender Violence amidst COVID-19.” May 18. https://www.thenews. com.pk/print/660195-domestic-and-genderviolence-amidst-covid-19. Mehrotra, Aakash, Rahul Chatterjee, Saloni Tandon, and Sonal Jaitly. 2021. “Gender: The Blind Spot of the COVID-19 Response in Low- and Middle-Income Countries.” February 24. https://www.microsave. net/2020/10/05/gender-the-blind-spot-ofthe-covid-19-response-in-low-and-middleincome-countries/. Ministério da Saúde. 2018. “Saúde Brasil 2017: Uma Análise Da Situação de Saúde e Os Desafios Para o Alcance Dos Objetivos de Desenvolvimento Sustentável.” Brasília: Ministério da Saúde. https://bvsms.saude. gov.br/bvs/publicacoes/saude_brasil_2017_ analise_situacao_saude_desafios_objetivos_ desenvolvimento_sustetantavel.pdf. Ministério da Saúde. 2020. “Portaria No 2.282, de 27 de agosto de 2020.” August 28. https:// www.in.gov.br/web/dou. Mittra, Prerna. 2020. “How the Pandemic has Exacerbated Troubles for the Trans Community.” The Indian Express. August 11. Moraes, Carolina, Juma Santos, and Mariana Prandini Assis. 2020. “‘We Are in Quarantine

but Caring Does Not Stop’: Mutual Aid as Radical Care in Brazil.” Feminist Studies 46 (3): 639–652. doi: 10.15767/ feministstudies.46.3.0639. Narkvichien, Montira. 2020. “Joint Intra-Action Review of the Public Health Response to COVID-19 in Thailand.” World Health Organization Regional Office for South-East Asia. https://www.who.int/docs/defaultsource/searo/thailand/iar-covid19-en.pdf. Observatório de Favelas do Rio de Janeiro. n.d. “Apresentação.” Accessed June 15, 2021. http://of.org.br/apresentacao/. Orach, Christopher G. 2009. “Health Equity: Challenges in Low Income Countries.” African Health Sciences 9 (Suppl. 2): S49–S51. PAHO [Pan American Health Organization]. 2018a. “Resolution CD56.R8: Plan of Action for Women’s, Children’s, and Adolescents’ Health 2018–2030.” In 56th Directing Council, 15–17. Washington, DC: PAHO. PAHO [Pan American Health Organization]. 2018b. “Plan of Action for Women’s, Children’s, and Adolescents’ Health 2018–2030.” In 56th Directing Council. Washington, DC: PAHO. https://iris.paho. org/bitstream/handle/10665.2/49719/CD56R8-e.pdf?sequence=1&isAllowed=y. PAHO [Pan American Health Organization]. 2018c. “56th Directing Council.” PAHO/ WHO | 56th Directing Council. June 26. https://www3.paho.org/hq/index. php?option=com_content&view=article&id= 14469:56th-directing-council&Itemid=40507 &lang=en. Peterman, Amber, Alina Potts, Megan O’Donnell, Kelly Thompson, Niyati Shah, Sabine Oertelt-Prigione, and Nicole Van Gelder. 2020. “Pandemics and Violence against Women and Children.” Working Paper 528. Washington, DC: Center for Global Development. Peyton, Nellie. 2020. “In Conflict-Hit Countries, Coronavirus Testing May Not Reach Women.” June 24. https://www.reuters.com/ article/us-health-coronavirus-women-trfnidUSKBN23V0G5. Rahman, Areez T., and Iffath Yeasmine. 2020. “Refugee Health Workers Lead COVID-19 Battle in Bangladesh Camps.” United Nations High Commissioner for Refugees. July 24. https://www.unhcr.org/en-au/news/ stories/2020/7/5f198f1f4/refugee-health-

64   |  Global Health Watch 6 workers-lead-covid-19-battle-bangladeshcamps.html. Rimini, Buscaglia G. 2020. “Rimini danneggiate settanta auto. ‘E’ un attacco a medici e infermieri.’” il Resto del Carlino. 1603686611000. https://www. ilrestodelcarlino.it/rimini/cronaca/autodanneggiate-medici-infermieri-1.5647731. Schilgen, Benjamin, Albert Nienhaus, Oriana Handtke, Holger Schulz, and Mike Mösko. 2017. “Health Situation of Migrant and Minority Nurses: A Systematic Review.” Public Library of Science (PLoS) One 12 (6). https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5484487/. Secretaria-Geral Subchefia para Assuntos Jurídicos. 2013. “Decreto No 10.112, de 12 de Novembro de 2019.” Presidência da República (Brasil). http://www.planalto.gov. br/ccivil_03/_Ato2019-2022/2019/Decreto/ D10112.htm#art1. Sen, Gita, Piroska Östlin, and Asha George. 2007. “Unequal, Unfair, Ineffective and Inefficient. Gender Inequity in Health: Why It Exists and How We Can Change It.” Final Report to the WHO Commission on Social Determinants of Health. World Health Organization. Seth, Payal. 2021. “As COVID-19 Raged, the Shadow Pandemic of Domestic Violence Swept Across the Globe.” The Wire. January 23. https://thewire.in/women/covid-19domestic-violence-hdr-2020. Singu, Sravani, Arpan Acharya, Kishore Challagundla, and Siddappa N. Byrareddy. 2020. “Impact of Social Determinants of Health on the Emerging COVID-19 Pandemic in the United States.” Frontiers in Public Health 8. doi: 10.3389/fpubh.2020.00406. Squires, Allison, and Adrian Juarez. 2012. “A Qualitative Study of the Work Environments of Mexican Nurses.” International Journal of Nursing Studies 49 (7): 793–802. Srishti, Chaitanya. 2021. “Why are Fewer Women Being Vaccinated for COVID, and What Can We Do about It?” May 16. https://www. womensweb.in/2021/05/gender-gap-invaccination-india-may21wk3sr/. Tejativaddhana, Phudit, Wichukorn Suriyawongpaisal, Vijj Kasemsup, and

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A3 | FROM UNETHICAL GROWTH TO ETHICAL DEGROWTH: CAN CAPITALISM BE TRANSFORMED?

Introduction A post-pandemic recovery must be anchored in economic growth and productivity while including newer policy thinking around inclusivity. (Speer, Fagan, and Glozic 2020)

So wrote a group of Canadian global policy wonks, emphasizing that ramped up economic growth is a “crucial precondition for addressing many of the challenges facing our society” from “funding for education, health, care and social services” to improving “employment, wages, and, ultimately, living conditions” (Speer, Fagan, and Glozic 2020). The former governor of the Bank of Canada was similarly blunt about normalizing post-COVID-19: “The main thing is for us to focus on growth … to do some things that will boost growth forever” (Armstrong 2021). These arguments are the lingua franca of many economists. They echo those made in the recessionary aftermath of the 2008 financial crisis. They also bump up against the one (literally burning) challenge usually missing from their list of economic priorities: climate change. Climate change is only one of the pressing ecological crises we face (Chapter A1). We, but most notably the wealthier global quintile of us, are cannibalizing the environmental bases of our survival. The rich country members of the Organization for Economic Cooperation and Development (OECD) presently consume annually 1.7 times the ecological resources the earth can regenerate and provide. If everyone in the world consumed at the level of OECD countries, we would need 4.75 earths to meet our consumable wants. Yet the (still) poverty and disease burdened majority of the world needs to consume more to achieve an ethical life expectancy at birth, pegged at around 74 years. The only way this discordance can be resolved is for our over-consuming global minority to go on a strict diet in which their present levels of material consumption shrink dramatically so that consumption can increase, within planetary limits, for others. Such a resolution is anathema to capitalism and something for which our present economic systems are ill-equipped. Previous editions of Global Health Watch have taken a critical stance on the neoliberal model of global capitalism, including some aspects of its growth imperative. Questioning the necessity of endless economic growth is not new. Since 1972’s publication of the Club of Rome’s Limits to Growth, a study based on computer simulation models (Meadows et al. 1972), researchers have repeatedly

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argued that it is impossible for populations, food production, industrialization, natural resource exploitation, and pollution to continue growing without the closed planetary system eventually collapsing. A half century later with daily reality eclipsing computer modeling, what alternatives might we invoke? Localization/deglobalization: taming capitalism

The early years of the new millennium saw two differently coined but overlapping roadmaps for a break for our consumptogenic societies. In 2007, Localization: A Global Manifesto was published, arguing the need to reject economic globalization in favor of localized production and consumption (Hines 2007). The pandemic has embraced this to an extent as the collapse of global supply chains for medical equipment led some countries to begin enhancing their national manufacturing capacities and to look inwards with respect to economic stimulus. But the localization manifesto went much further, urging a return to import protections to safeguard national and regional economies, localized money flows to rebuild community economies, national (not global) competition policies to ensure high-quality and affordable products, progressive and resource taxation measures to finance an equitable transition to an ecologically sustainable level of production, and trade and aid to assist rebuilding local economies rather than to increase international competitiveness. Food, the Manifesto insisted, should be regionally sourced, one of the axioms of an agroecological food system (Chapter C5) and of a resilient human livelihood (Cristiano 2021).

Image A3.1  Capitalism, the high price of healthy foods, and the hidden environmental cost. Source: Sketch by Kriti Shukla for Global Health Watch 6 (dining cartoon).

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These localizing strategies are all reasonable, but they are also ones that work better for larger, already well-endowed nation states. They are more challenging for smaller countries lacking certain key resources for food, energy, and industrial inputs that would allow for such localized self-sufficiencies. Trade might be environmentally and equitably better if practiced on a more local or regional basis (Chapter D2), but some degree of global trade would still be needed. Almost 20  years ago, Walden Bello, a Philippines-based economist and founder of the NGO Focus on the Global South, laid out a platform for what he called “deglobalization” through which national economies are strengthened even as pluralist global governance is improved (Bello 2002). Deglobalization is not a withdrawal from global trade and the international economy so much as a reorientation of national economies away from production for export to production for local needs (think crops for local food markets rather than tobacco leaf for global export). Many of the redistributive “taming” policy reforms mentioned in Chapter A1 are needed, but alongside these is the replacement of “growth” with “equity” as the main metric of economic decision-making. Economies should be localized as much as possible, while redefining and strengthening the cooperative (workerowned and run) models that have fallen prey to liberalized global capitalism. Enlarging the role of worker, producer, and consumer cooperatives is one of the feasible means to erode capitalism’s dominance of political economy. Cooperatives undermine capitalism’s defining ethos of private accumulation. Such social enterprises still enjoy a strong foothold in the European Union (EU), where they account for 6.3% of the continent’s GDP (OECD 2020) and have been a source of resilience during the pandemic. In the aftermath of the 2008 global financial crisis, cooperatives in some localities enjoyed a populist uptick, as activists negotiated social pacts with local organizations, businesses, and governments based on principles of reciprocal solidarity. By 2015, 10% of Barcelona’s economy took this form (Neyra 2019). These are revitalizing harbingers of what is more simply referred to as a social economy, defined by its “… focus on economic practices that are sustainable and inclusive … by addressing societal (i.e., social and/or environmental) needs [and] by organizing economic activities building on local roots … using participatory and democratic governance …” (Schwab 2019; OECD 2020). Transforming capitalism: from circular economies to degrowth

Strengthening social economies in the face of current inequalities in wealth and power will be important. Doing so will require strong government support via financing and regulation along the lines argued in Chapter A1, some of which we return to in this chapter. But social economies will still need to tackle the inequitable excess consumption of some at the ecological peril of many. As a policy study for a post-pandemic economy noted: Over the last four decades, global material use has not only increased, it accelerated … largely driven by expanding populations and changing

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consumption trends … driving a 71% rise in per capita resource use. And in today’s industrial systems, more than 90% of this material is used only once, then thrown away – a design that has been characterized as a ‘take-make-waste’ linear economy. (Cairns and Cyrus Patel 2020, 9)

Governments in their post-pandemic rebuilds are now urged to prioritize the “circular economy,” an idea that shares much in common with localization/ deglobalization policy ideas. Environmental activists for years have argued the need for “cradle-to-grave” regulatory protection from the ecologically damaging externalities of industrial production. The idea of a circular economy takes this one step further: government policies through carrots (incentives) and sticks (regulations) should promote an economic model in which there is “a continuous recirculation of post-consumer materials” such that “there is no such thing as waste” (ibid., 6–7). There is certainly no reason why governments could not immediately place conditions on public purchases from private suppliers, including performance requirements for equity-enhancing labor conditions and environmental protective measures. Since government procurement accounts for 12% of global GDP (Bosio and Djankov 2020), implementing this practice could have widespread positive impacts. The circular economy model focuses principally on achieving a net zero carbon energy system, critical with respect to climate change and a target many of the world’s governments have pledged to achieve by 2050. While the model, by institutionalizing the “reuse” and “recycle” mantras of 1980s environmentalism, should also “reduce” our exploitation of natural resources, it does not explicitly address our economy’s fatal addiction to endless consumption. A perfectly circular model is not feasible, since new resources are required at every rotation and increased efficiency is likely to boost accelerated demand for consumption (Cristiano et al. 2020). Over the past decade a more radical discourse has been gaining ground that pushes the circular economy in a more revolutionary direction: an ecological transition based on a rejection of the standard economic growth model. Increasingly bundled up under the rubric of “degrowth,” at its simplest it argues for a planned reduction in all energy and resource use so that it fits within ecosystem limits (Hickel 2020). Its demands rest heaviest on over-consuming high-income countries (HICs) even as it acknowledges the need for greater fiscal and ecosystem space for under-consuming low-income countries (LICs) to achieve a basic livelihood and an ethical life expectancy (see Chapter A1). A growing number of economists, environmental scientists, and civil society activists see degrowth as key to resolving the climate crisis and other key environmental overshoots. Degrowth is not a technical agenda and does not promote recession or austerity; rather, it aims to create flourishing societies outside of the growth mantra, respectful of fundamental and systemic caring about environmental justice, social equity, and shared well-being (D’Alisa, Demaria, and Kallis 2014a). Unlike the circular economy, which upholds the idea of continued economic growth so long as it is decoupled from resource

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throughput, degrowth argues that historic evidence puts a lie to this possibility (Parrique et al. 2019). Rather, growth itself is seen as the problem. Consider, first, that growth in economic terms continues to be measured almost exclusively by GDP (gross domestic product). GDP measures the total market value of all finished goods and services within a country and is regarded as “a comprehensive scorecard of a given country’s economic health” (Fernando 2021). It is so embedded in our political discourse and public imagination that its rise or fall is always big news. It defines whether we are in a recession or a depression, and often becomes an election issue by which governments rise or fall. The political centrality of GDP persists, even though its blindness to environmental sustainability or distributive justice has long been criticized. As far back as 1968, Robert Kennedy in a famous speech described GDP as something that “measures everything in short, except that which makes life worthwhile” (Jackson 2018). Much of what we do not want and that imperils a worthwhile life, and certainly what our planet can no longer afford, adds to our economic growth. From environmental pollution that requires government clean-up costs to wars and “natural” catastrophes that lead to what Naomi Klein calls “disaster capitalism” (Klein 2017), the GDP ticks relentlessly upwards, paying no ethical heed to what societies, people, and the planet need. As a measure of human or ecological well-being, it fails. Several alternative measures now attempt to capture more of what matters (see Box A3.1). These have informed policy and legislative processes in several countries (Stiglitz, Fitoussi, and Durand 2018), although none have yet to displace or even routinely accompany GDP as an axiomatic measure of societal well-being. Neither do these alternatives prescribe what needs to be done, a challenge picked up by the degrowth movement.

Box A3.1: Gross domestic product or gross national happiness? One of the best-known alternatives to GDP is the Kingdom of Bhutan’s Buddhist-inspired Gross National Happiness (GNH). Who doesn’t want to be happy? In 2008 the Kingdom began to use an in-depth survey to examine living standards, health, governance, ecological diversity, resilience, time use, psychological well-being, cultural diversity, and community vitality (“Gross National Happiness” 2021) to inform its policies. Responding to the Bhutanese initiative, a global partnership of academic centers has been producing annual World Happiness Reports1 since 2012, drawing on multiple data sources, primarily the Gallup World Poll, and combining indicators of GDP, social support, life expectancy, freedoms of choice, generosity, and corruption. The Nordic countries always perform best, and the measures that appear to matter most are social support, generosity, freedom of choice, and absence of corruption (Helliwell et al. 2020).

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The GNH inspired similar initiatives elsewhere, the most significant and recent one being the 2019 New Zealand decision to base its government budget on how well it progresses on several “well-being” goals: reducing child poverty, supporting Indigenous peoples, moving to a low-carbon-emission economy, and flourishing in a digital age. A new set of measures will be used to track loneliness, trust in government, water quality, and everything in between (Samuel 2019). Like the GNH, Canada’s Index of Wellbeing (CIW) started first with extensive community consultations on what mattered for people’s life quality, and then organized the responses into eight domains (healthy populations, democratic engagement, community vitality, environment, leisure and cultures, time use, education, and living standards). Each domain is comprised of eight indicators drawn from routinely collected government data (“About the Canadian Index of Wellbeing” 2012). The CIW’s main use to date has been to highlight the “massive gap between how well the economy is doing and Canadians’ wellbeing,” a gap which grew after the 2008 recession (“Our Index” 2012). The indicator created by The New Economics Foundation’s Happy Planet Index combines four measures: well-being (people’s self-rated life satisfaction derived from the World Gallup Poll), life expectancy (using data from UN agencies), inequality of outcomes (which adjusts for distributional differences), and ecological footprint (developed by the Global Footprint Network)2 which measures consumption of earth resources, measured in global hectares per capita (“About the HPI” n.d.). Its ecological emphasis is apparent. A key finding is that most wealthy HICs score poorly. Small Costa Rica scores in the first place, the USA in the 108th place (Andester 2019). In contrast to other alternatives, the Genuine Progress Indicator (GPI) adopts the GDP default to a dollar sign (“Genuine Progress Indicator” n.d.). Rather than just tabulating the income gains of what economies generate (the GDP), it also calculates the monetary costs of the negative externalities economies create (e.g., inequalities, underemployment, pollution, loss of environmental resources, CO2 emissions, crime, and loss of leisure) (“Genuine Progress Indicator” 2021). Its bottom line is still a number, estimating how much a person or an economy can consume in each period without decreasing that consumption in the next period. The Canadian government and several Canadian provinces have applied the GPI in their legislative decisions, and some US states have adopted its use. As with other alternative measures, there is little relationship between the GPI and the GDP. The OECD has also been studying alternatives to the GDP for some years. In the wake of the global financial crisis, the French government

FROM UNETHICAL GROWTH TO ETHICAL DEGROWTH  |  71 convened a commission of leading economists to examine how better to measure economic and social progress. Building on this work, the OECD in 2012 created a Better Life Index to measure the well-being of its member countries across 11 dimensions: income/wealth, work, housing, health, knowledge/skills, subjective well-being, safety, work-life balance, social connections, civic engagement, and the four “capitals” (natural, economic, human, and social) (“OECD Better Life Index” n.d.). Several OECD member nations and other countries have developed their own well-being metrics for use in policy formulation, implementation, and evaluation (Stiglitz, Fitoussi, and Durand 2018). Subsequent OECD work called for a suite of measures rather than any one index, while emphasizing that a critique of GDP limitations did not imply “anti-growth.” Growth, instead, needed to be equitable and sustainable. But, as its 2018 Beyond GDP report acknowledged, “economic growth” at least as present “is not environmentally sustainable” (Stiglitz, Fitoussi, and Durand 2018, 26). The growth/sustainability contradiction is left unresolved. All of the above attempts to distill “what matters” into a single metric have limitations. But so does GDP. The alternatives, especially those that incorporate measures of distributional equity and ecological sustainability, are not panaceas, but they offer activists new arguments and evidence to counter the uncritical acceptance of the growth, growth, growth mantra.

Explaining degrowth

The term “degrowth” has been subject to considerable debate in activist circles, especially from the Global South (Rodríguez-Labajos et al. 2019). Originally coined in French (décroissance) in the 1970s (Georgescu-Roegen 1979), its English version only recently began to diffuse following an international conference on the concept in 2008. It is specifically intended to be a “missile word” for a radical re-politicization of environmentalism, both as an idea and as a challenge. The narrative of degrowth developed as “a response to the urgency of the present physical, ecological, social, and economic limits of complex societies” (Sekulova et al. 2013). It challenges the hegemony of growth and calls for a democratically led redistributive downscaling of production and consumption and an equitable reallocation of wealth “within and across the Global North and South, as well as between present and future generations” (Demaria et al. 2013). To many activist movements in the Global South, however, degrowth is seen as an idea arising from HICs. This is perhaps apt since that is where the consumptogenic diet must start. But there are many ecojustice movements in the Global South that pre-date the degrowth movement and the concern that their pluralistic/multicultural concepts could be subsumed by what is still largely

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seen as a “Eurocentric” idea. There is also much in the idea of “growth” (apart from its economic materialism) that is to be valued (people grow, crops grow, understanding grows), and so the negative phrasing is problematic for some grassroots activist groups. Although degrowth shares with ecojustice movements an overarching concern with ecological sustainability, many activists focus as much on the profit-seeking and exploitative actions of transnational capitalists (and the governments that support them) as on a critique of economic growth itself, or of its GDP mismeasurement. Finally, if consumption levels in many LICs need to rise for people to approach their ethical life expectancy, this implies some form of economic growth provided it is (or rapidly becomes) non-fossil fuel-based with a declining rate of material throughput. Jason Hickel, an economic anthropologist, in responding to some of these concerns, argues that if degrowth is used to refer only to “ecologically de­ structive and socially less necessary production” it is, in fact, a positive term (Hickel 2020). It is also consistent with many goals and concepts promoted by ecojustice movements worldwide, such as the South American concept of Buen Vivir (Gudynas 2014) (see Chapter C4) and initially was drawn from African-sourced critics to development (Latouche 2004). Degrowth is explicitly critical of capitalism’s voracious appetite for over-accumulation and its “missile word” intent is largely meant to undermine capitalism’s core hegemonic idea: the absolute need for continuous economic growth (D’Alisa, Demaria, and Kallis 2014b). In that sense degrowth is intrinsically anti-capitalist. Stated differently, as a fully realized political economy, degrowth cannot be achieved within capitalism, at least as currently conceived. These degrowth characteristics distinguish it from green growth (Green New Deal) approaches described in Chapter A1, which are more ambivalent on the role that capitalist markets might play in a post-COVID world provided they are regulated to “decouple” growth from its material throughputs, notably by decarbonizing energy requirements. Green growth also places a heavy responsibility on development and deployment of new technologies, such as carbon capture and green energy, but – at least in its superficial narrative – shares with degrowth advocates the need for a shift in our consumption (Stratford 2020). The green growth agenda, like that of localization, deglobalization, and circular economies, is vitally important, but only if it does not simply mask business as usual. It is also insufficient. Global economic growth at 2% per annum (green or otherwise) still means a doubling in the scale of consumption every 35 years (Stratford 2020). This is a pace that technological innovation is unlikely to keep up with if the current growth/consumption “coupling” relationship remains as present. Even the Intergovernmental Panel on Climate Change (IPCC) a few years ago argued the necessity of a “low energy demand” scenario aimed at reducing global energy consumption by 40% by 2050 (Hickel 2019, 56). This would make it easier for a transition to 100% clean energy but would also mean a decline in industrial production and consumption of 42% in HICs and 12% in LICs (ibid.).

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Image A3.2  Too much for some, too little for others; homeless person seeks shelter in front of overstocked store with a sale on its goods. Source: Photo by Dan Burton on Unsplash. https://unsplash.com/photos/w3TwyZMlfPg

The Canadian environmental emeritus, William Rees, co-founder of the “global footprint” methodology to measure per capita ecosystem consumption, is more forthright in challenging the technological optimism of some of the green growth movement. In an essay where he asks “Am I wrong?” he points out that the world is steadily urbanizing, that urbanization demands energy, that global energy demand outpaces growth in renewables, and that renewables to scale would consume huge amounts of rare mined metals, steel, aluminum, and non-renewable plastics (Rees 2019b), to say nothing of the human and environmental exploitations that such mining and production often entails (McKie 2021). In sympathy with the degrowth idea, Rees reaches a simple conclusion: we must consume less of everything, accompanied by a radical redistribution in who consumes (less for the rich, more for the poor) and what is consumed (less in footprint-heavy material goods, more in footprint-light caring services). From degrowth laboratories to a degrowth political agenda

It’s been said that degrowth unfolds “not in discourse, but in practices of reciprocity that promote community self-sufficiency” (Neyra 2019). This ethos is an ancient one, and variations of it have been pursued throughout the capitalist era with differing emphases on cooperatives, non-monetary barter systems, eco-communities, direct action (civil disobedience), and communal systems of food production. Today’s digital technologies create new possibilities such as localized community currencies; think online exchange platforms but with a local

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form of public banking thrown in. In common with most ecojustice movements globally, such degrowth innovations seek the decommodification of basic needs, modeling alternative (non-capitalist) forms of barter, exchange, and mutualism. Kate Raworth’s Doughnut Economics model encountered in Chapter A1 represents another theory that is often discussed in degrowth conferences, articles, and policy proposals, and one that is starting to infiltrate post-COVID economic thinking (Raworth 2017). The model doesn’t define a precise set of policies but, instead, offers a framework for policy agenda setting. The goal is no longer “growth” but getting the metrics of its various environmental overshoots and social undershoots within the safe “doughnut” space, where there are minimum social thresholds to be guaranteed and upper ecological thresholds not to be trespassed. In 2020, Raworth launched a Doughnut Economics Action Lab to bring together individuals and groups keen to put the framework into action (Raworth 2017). At present, the online community and its members’ practices focus primarily on a few European cities. This does not make the ideas inherent in the framework Eurocentric or fit for the rich world only. Like the degrowth concept, however, its diffusion into low- and middle-income countries (LMICs) and across the socioeconomic gradients in HICs requires skilled communication, respectful listening, and critical contextualization. This is especially important since many of the people in the lower rungs of our socioeconomic, gendered, and racialized hierarchies are already living within the doughnut’s per capita ecological safe space, but fall well outside it in experiencing critical social shortfalls. Although some argue that this makes such groups “too poor to be green” (Martinez-Alier 1995), the roots of ecological unsustainability and social inequality are often the same. Degrowth, it’s been argued, “is not a political platform, but rather an ‘umbrella concept’” (Mastini, Kallis, and Hickel 2021, 3); others prefer to describe it as an “interpretative frame for a new (and old) social movement where numerous streams of critical ideas and political actions converge” (Demaria et al. 2013). The same can be said of doughnut economics. But these concepts or interpretative frames need to become political platforms or, at the very least, agendas, and to do so quickly if they are to supplant or at least modify the insufficient incrementalism of most post-COVID reboot, reset, and reform packages. But how?

Box A3.2: The degrowth movement in Italy As a social movement, degrowth attracts academic professionals, practitioners, activists from other movements, some of which who are fiercely militant. Like other movements, it subsumes a range of political visions from oppositional activism to green reformism, from eco-Marxism to anarchism, and

FROM UNETHICAL GROWTH TO ETHICAL DEGROWTH  |  75 including marked eco-feminist claims. The degrowth movement embraces both science and the creative arts. It “grows” its ideational values, practices, and proposals through international meetings, an informal global network and working groups, and local events (“What Is Degrowth?” n.d.). Italy provides two examples of more localized degrowth activism. The Movimento per la Decrescita Felice (MDF) (The Movement for Happy Degrowth) was founded in 2007 and its structure is composed of more than 20 local groups with 400 members across Italy. Its distinguishing trait is a pragmatic approach to the concept of degrowth. MDF serves as a reference point to disseminate degrowth ideas, provide its supporters with the opportunity to discuss and further elaborate the concept, and – above all – to put it into practice, here and now. Its members promote a new cultural model by acting simultaneously on three pillars: politics, technology, and lifestyles. The movement promotes both individual and collective experimentation with new, more sustainable lifestyles; it advocates for local and national policies towards greater equity and sustainability, and it promotes and researches technologies that make it possible to reduce the consumption of resources and energy. MDF also promotes values and cultural practices that are radically alternative to those proposed by the dominant growth model such as sharing of resources and power, mutualism, conviviality, self-production and autonomy, attention to social marginality, feminism, respect for cultural diversity, nonviolent political action, care of the ecosystem, and attention to the spiritual and meaningful dimension of daily life. It is particularly active in challenging the idea of “decoupling” as a green growth strategy.3 The Associazione per la Decrescita (Italian for Association for Degrowth) was founded in 2004 and defines itself as a cultural-political collective, a post-bureaucratic meeting and sharing platform. It is committed to cultural promotion, public thinking and debate, and social and political action inspired by ecological sustainability and social equity. It is active in highlighting, revealing, and denouncing all forms of violence and dominion, particularly those linked to and justified by the ideology of progress, growth, and development. The association is organized in multiple forms according to local and regional peculiarities. At a wider level, it was among the first and main promoters of the third International Conference on Degrowth, Ecological Sustainability, and Social Equity, held in Venice in 2012. The association takes part in local, regional, national, and international networks related to sustainability and public health. It does not seek power, but rather promotes values of caring for oneself, other human beings, and the entire world.4

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To start, there is much in the incremental green growth playbook that is urgent and compatible with a degrowth future. Green New Deals propose an overhaul of the energy system away from fossil fuels. This is essential. The transition, as many environmental economists have pointed out, is also likely to increase rather than decrease employment, especially if energy utilities are brought back under public ownership. Many of the skills workers employ in fossil fuel extraction are needed in green energy development, the safe decommissioning of abandoned oil and gas wells, and the improvement of energy efficiencies through new housing designs and existing retrofits. However, “greening” the energy sources without reducing its material demands must still be addressed. There is a worsening undersupply of care workers globally, notably in the health sector (see Chapters A2 and B1) but also in education and social protection. The patriarchal legacy of much of society’s care work being relegated to an unpaid, informalized, and predominantly female workforce needs undoing. Social and labor reforms, including job guarantees, universal basic incomes, and massively expanded support for welfare (well/fair) programs, are key elements in most green growth platforms, as well as within degrowth movements. More skilled workers are needed to clean and restore despoiled environments. Restoring our ecological commons and caring for others are low-resource intensive activities. Whether counted within GDP ledgers or via alternative metrics (Box A3.1), these activities comprise a form of green economic “growth” that is centered on equitable well-being and a livable planet rather than simply on economic expansion. Reforming labor markets is fundamental; a degrowth political agenda that does not pay close attention to employment concerns will fail right out of the gate. For well over a century there have been multiple forecasts of an imminent era where our economic needs would be fulfilled with just a few days of work per week. The remaining time could be devoted to leisure, sociability, and culture. This idyllic era has yet to manifest itself. In HICs we see, instead, overwork for some and underwork for others, alongside the rise of the part-time gig economy. In LMICs much of the labor force remains informal, unbenefited, and insecure. The pandemic has only worsened these conditions (see Chapter C2). Redistributing work from industrial activities (producing things we don’t need and can’t afford without going into debt) to socially productive activities (a caring and environmentally restorative economy) will help. But work weeks also need to be shorter and “living wages” must be established. Multiple immediate government policies (akin to changing procurement rules) can nudge our economies into a degrowth trajectory. Taxation policies are critical, as Chapter A1 argued. Governments can place high taxes on resource-consuming things that are not needed and/or are socially/ecologically damaging (luxuries from big cars and houses to fast fashion excesses) while eliminating taxes on things that are essential (healthy foods). Utility taxes (for electricity, heating)

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can be tiered so that beyond a minimum level required for health and comfort consumption costs skyrocket. At present, many of these degrowth starter policies are ones that HICs might find it easier to advance. But all governments can pursue these policy goals through increased taxation rates on carbon, wealth, land value, resource extraction, profits, marginal incomes, capital gains, and excess consumption, especially if there are systems for redistributing tax revenues globally. The world is awash with an abundance of wealth with the potential for its progressive capture for public good purposes. A fairer distribution of existing income and wealth can improve human health and welfare globally without the necessity of resource-consuming growth. Stated more systemically, a degrowth economy will rely upon an expansion of public goods and services and an end to centuries-old practices of enclosures and rentier classes in which wealth for some is accumulated by dispossessing the resources of others. It will require a move away from the state as a backstop to markets (the regulator of last resort) to the state as a democratic tool that will allow citizens, collectively and autonomously, to determine priority essential public goods and services and where the fulsome use of public money finances their provision, with the slow erosion of reliance on private capital and debt as the basis of market-delivered growth. Is a post-capitalist, post-pandemic degrowth possible?

One of the pandemic’s silver linings may well be the extent to which it has revealed the dependence of contemporary capitalist economies on people spending money they haven’t got on things they don’t need. A year of pandemic stay-home requirements and a closed, partially open, closed again economic arrhythmia may see more of us embracing an era where we have more appetite for simpler lives than ones predicated on a treadmill of borrow, buy, consume, toss away, worry, borrow more, repeat. But we must also acknowledge that a realized degrowth political agenda will lead to a dramatic reduction in material standards in HICs or for the wealthy, regardless of their geographic locale. But material standards are not the same as, or even related to, living standards or quality of life. That association is the product of a century of deliberate brainwashing, better known as advertising. Material standards (including income growth) need to improve for much of the world’s population that has yet to access the basic resources essential for their enjoyment of a healthy and achievable ethical life expectancy. But they will decline for many of us, as environmentally, proportionally, and ethically they should. The pandemic has further highlighted existing tensions between expanding and predatory economies on the one hand, and health and healthcare access on the other. Ecological thresholds continue to be exceeded and minimum social goals remain widely unreached. At the same time, the pandemic has placed

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governments once again in the economic driver’s seat – at least for now. If contemporary human societies are to move into an ecologically sustainable and socially just safe “doughnut space,” there are a few necessary degrowth elements that might guide such a transformation: • Recognize that no economy that grows or maintains itself by depleting essential capital is sustainable; instead, stop pursuing material growth as a goal and focus on ensuring basic needs and universal human rights. • Embrace the need to construct a new foundation for economics that is consistent with bio-physical reality. • Set hard targets for less production and consumption while lowering net levels and reallocating globally by basic need and not by manufactured want. • Set hard targets for reduced demand for all energy and material throughput and not be content with substituting fossil fuel with green alternatives. • Ration the remaining carbon budget to low-intensity food production, mass transit, and redistribution to make reparation for HICs’ historic hoarding. • Use radically progressive fiscal (tax and spend) measures to redistribute income and wealth at local, national, and global scales and to provide public assistance for sustainable lifestyles. • Ensure that the human population does not continue growing to an ecologically unsustainable size (Rees 2019c).5 Canadian “global footprint” ecologist William Rees acknowledges that these actions “will seem outrageously radical” (Rees 2019a, 145) and will be challenged and dismissed as utopian or unrealistic, as would be any threat to elite power. But, as he continues, “we really have no choice but to act upon what our best science has been telling us for decades” (Rees 2019a, 145–146). And so, a starting point for health activists wherever they might be: support a collective and, when required, transiently state-centered platform of genuinely Green New Deal economic programs and reforms where some substantial forward movement seems achievable, but with critical oversight and efforts to ensure responsiveness to local needs and cultures. Do not directly or indirectly support or abet ecologically hazardous and socially unjust products, practices, and/or structures. Reframe as needed the language and practical consequences of degrowth to accommodate different cultures, contexts, or populations but retain its core arguments and evidence which could be regarded as universal. Use these arguments and evidence and apply them to the socioecological doughnut economics framework, identifying which essential and livable policy goals are best suited to initiate a contextualized degrowth transformation that could herald a new form of post-capitalist society, even if not yet fully imagined. In this activist work, it will be necessary to develop synergies across the different social, ecological, and health movements, and to promote simultaneously bottom-up approaches which, from grassroots and local practices, could create

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new social imaginaries to confront the still hegemonic, growth-based neoliberal capitalism. Notes 1 See https://worldhappiness.report/archive/ for the archive of past publications of World Happiness Report. 2  For more information on the Global Footprint Network, please consult https://www. footprintnetwork.org/. 3  For more information on the Movimento per la Decrescita Felice, please visit https:// www.decrescitafelice.it/. 4  For more information on the Associazione per la Decrescita, please visit https://www. decrescita.it/associazione/

5  Rees argues that the human population should decrease over time to reach an ecologically sustainable level and calls for equitable and ethical policies to achieve this. What is an optimal population size that planetary resources can sustain, assuming they are consumed responsibly and fairly, remains a contested topic, especially given a colonial and neocolonial legacy of racist population control policies. There is less disagreement over the main point of keeping population growth within the limits of ecosystem boundaries.

References “About the Canadian Index of Wellbeing.” 2012. Canadian Index of Wellbeing | University of Waterloo. June 13. https://uwaterloo.ca/ canadian-index-wellbeing/about-canadianindex-wellbeing. “About the HPI.” n.d. Happy Planet Index. Accessed May 12, 2021. http:// happyplanetindex.org/about. Andester, Nikita. 2019. “GDP Alternatives: 7 Ways to Measure a Country’s Wealth.” Ethical.Net (blog). June 10. https://ethical. net/politics/gdp-alternatives-7-ways-tomeasure-countries-wealth/. Armstrong, Peter. 2021. “Where the Lopsided Economic Impact of COVID-19 in Canada Goes from Here.” CBC News. January 26. https://www.cbc.ca/news/business/ covid-coronavirus-economic-recoveryinequality-1.5886384. Bello, Walden. 2002. Deglobalization: Ideas for a New World Economy. London: Zed Books. Bosio, Erica, and Simeon Djankov. 2020. “How Large Is Public Procurement?” February 5. https://blogs.worldbank.org/developmenttalk/ how-large-public-procurement. Cairns, Stephanie, and Sonia Cyrus Patel. 2020. “Innovation for a Circular Economy: Learning from the Clean Growth Journey.” Smart Prosperity Institute. https://institute. smartprosperity.ca/sites/default/files/ Report_CE_Innovation.pdf. Cristiano, Silvio. 2021. “Organic Vegetables from Community-Supported Agriculture in Italy: Emergy Assessment and Potential for

Sustainable, Just, and Resilient Urban-Rural Local Food Production.” Journal of Cleaner Production 292 (April). doi: 10.1016/j. jclepro.2021.126015. Cristiano, Silvio, Amalia Zucaro, Gengyuan Liu, Sergo Ulgiati, and Francesco Gonella. 2020. “On the Systemic Features of Urban Systems. A Look at Material Flows and Cultural Dimensions to Address Post-Growth Resilience and Sustainability.” Frontiers in Sustainable Cities 2 (12). doi: 10.3389/ frsc.2020.00012. D’Alisa, Giacomo, Federico Demaria, and Giorgos Kallis, eds. 2014a. Degrowth: A Vocabulary for a New Era. New York: Routledge. D’Alisa, Giacomo, Federico Demaria, and Giorgos Kallis, eds. 2014b. “Introduction.” In Degrowth: A Vocabulary for a New Era, 1–18. New York: Routledge. Demaria, Federico, Francois Schneider, Filka Sekulova, and Joan Martinez-Alier. 2013. “What Is Degrowth? From an Activist Slogan to a Social Movement.” Environmental Values 22 (April): 191–215. doi: 10.2307/23460978. Fernando, Jason. 2021. “Gross Domestic Product (GDP).” Definition – Investopedia. April 25. https://www.investopedia.com/terms/g/gdp. asp. “Genuine Progress Indicator.” 2021. Wikipedia. https://en.wikipedia.org/w/ index.php?title=Genuine_progress_ indicator&oldid=1016988904.

80   |  Global Health Watch 6 “Genuine Progress Indicator.” n.d. Accessed May 12, 2021. http://www.sustainwellbeing.net/ gpi.html. Georgescu-Roegen, Nicholas. 1979. Demain la décroissance. Entropie, écologie, économie. Edited by Pierre Marcel Favre. Lausanne: Favre Editions. “Gross National Happiness.” 2021. Wikipedia. https://en.wikipedia.org/w/ index.php?title=Gross_National_ Happiness&oldid=1013387392. Gudynas, Eduardo. 2014. “Buen Vivir.” In Degrowth: A Vocabulary for a New Era, edited by Giacomo D’Alisa, Federico Demaria, and Giorgos Kallis, 201–204. New York: Routledge. Helliwell, John, Richard Layard, Jeffrey D. Sachs, and Jan-Emmanuel De Neve, eds. 2020. World Happiness Report 2020. New York: Sustainable Development Solutions Network. http://worldhappiness.report. Hickel, Jason. 2019. “Degrowth: A Theory of Radical Abundance.” Real-World Economics Review 87 (March): 54–69. http://www. paecon.net/PAEReview/issue87/whole87.pdf. Hickel, Jason. 2020. “What Does Degrowth Mean? A Few Points of Clarification.” Globalizations September: 1–7. doi: 10.1080/14747731.2020.1812222. Hines, Colin. 2007. Localization: A Global Manifesto. London: Earthscan. Inman, Robert P. 2013. “Managing Country Debts in the European Monetary Union: Stronger Rules or Stronger Union?” In Political, Fiscal, and Banking Union in the European Union, edited by E. Carletti, J. Gray, and F. Allen, 36–140. Philadelphia: FIC Press. Jackson, Tim. 2018. “‘Everything, in Short, Except That Which Makes Life Worthwhile.’” CUSP (blog). March 18. https://www.cusp.ac.uk/ themes/aetw/rfk-gdp50/. Klein, Naomi. 2017. “Naomi Klein: How Power Profits from Disaster.” The Guardian. July 6. http://www.theguardian.com/us-news/2017/ jul/06/naomi-klein-how-power-profits-fromdisaster. Latouche, Serge. 2004. Survivre au développement. Paris: Editions Mille et Une Nuit. Martinez-Alier, Joan. 1995. “The Environment as a Luxury Good or ‘Too poor to be green?’” Ecological Economics 13 (1): 1–10.

Mastini, Ricardo, Giorgos Kallis, and Jason Hickel. 2021. “A Green New Deal without Growth?” Ecological Economics 179: C. McKie, Robin. 2021. “Child Labour, Toxic Leaks: The Price We Could Pay for a Greener Future.” The Guardian. January 3. http:// www.theguardian.com/environment/2021/ jan/03/child-labour-toxic-leaks-the-price-wecould-pay-for-a-greener-future. Meadows, Donella H., Dennis L. Meadows, Jørgen Randers, and William W. Behrens. 1972. The Limits to Growth: A Report for the Club of Rome’s Project on the Predicament of Mankind. New York: Universe Books. Neyra, Raquel. 2019. “Constructing the People: Left Populism and Degrowth Movements.” The European Legacy 24 (5): 563–569. doi: 10.1080/10848770.2018.1550896. OECD. 2020. “Social Economy and the COVID-19 Crisis: Current and Future Roles.” OECD. July 30. https://www.oecd.org/coronavirus/ policy-responses/social-economy-and-thecovid-19-crisis-current-and-future-rolesf904b89f/. “OECD Better Life Index.” n.d. OECD Better Life Index. Accessed May 12, 2021. http://www. oecdbetterlifeindex.org/#/11111111111. “Our Index.” 2012. Canadian Index of Wellbeing | University of Waterloo. June 28. https:// uwaterloo.ca/canadian-index-wellbeing/ what-we-do/how-it-works/our-index. Parrique, Timothée, Jonathan Barth, François Briens, Joachim Spangenberg, and Alejo Kraus-Polk. 2019. “Decoupling Debunked. Evidence and Arguments Against Green Growth as a Sole Strategy for Sustainability. A Study Edited by the European Environment Bureau EEB.” July 8. https://eeb.org/library/ decoupling-debunked/. Raworth, Kate. 2017. Doughnut Economics: Seven Ways to Think like a 21st-Century Economist. White River Junction, VT: Chelsea Green Publishing Company. Rees, William E. 2019a. “End Game: The Economy as Eco-Catastrophe and What Needs to Change.” Real-World Economics Review no. 87 (March): 132–148. http://www. paecon.net/PAEReview/issue87/whole87. pdf. Rees, William E. 2019b. “Don’t Call Me a Pessimist on Climate Change. I Am a Realist.” The Tyee. November 11. https://

FROM UNETHICAL GROWTH TO ETHICAL DEGROWTH  |  81 thetyee.ca/Analysis/2019/11/11/ClimateChange-Realist-Face-Facts/. Rees, William E. 2019c. “Memo from a Climate Crisis Realist: The Choice before Us.” The Tyee. November 12. https://thetyee.ca/ Analysis/2019/11/12/Climate-Crisis-RealistMemo/. Rodríguez-Labajos, Beatriz, Ivonne Yánez, Patrick Bond, Lucie Greyl, Serah Munguti, Godwin Uyi Ojo, and Winfridus Overbeek. 2019. “Not so Natural an Alliance? Degrowth and Environmental Justice Movements in the Global South.” Ecological Economics 157 (March): 175–184. doi: 10.1016/j. ecolecon.2018.11.007. Samuel, Sigal. 2019. “Forget GDP – New Zealand Is Prioritizing Gross National Well-Being.” Vox. June 8. https://www.vox.com/futureperfect/2019/6/8/18656710/new-zealandwellbeing-budget-bhutan-happiness. Schwab, Klaus. 2019. “The Universal Purpose of a Company in the Fourth Industrial Revolution.” Davos Manifesto 2020: World Economic Forum. December 2. https:// www.weforum.org/agenda/2019/12/ davos-manifesto-2020-the-universalpurpose-of-a-company-in-the-fourthindustrial-revolution/.

Sekulova, Filka, Giorgos Kallis, Beatriz Rodríguez-Labajos, and Francois Schneider. 2013. “Degrowth: From Theory to Practice.” Journal of Cleaner Production 38: 1–6. doi: 10.1016/J.JCLEPRO.2012.06.022. Speer, Sean, Drew Fagan, and Luka Glozic. 2020. “Recovery Plans Must Be Built on a Foundation of Economic Growth.” Policy Options. October 8. https://policyoptions. irpp.org/magazines/october-2020/recoveryplans-must-be-built-on-a-foundation-ofeconomic-growth/. Stiglitz, Joseph E., Jean-Paul Fitoussi, and Martine Durand. 2018. “Beyond GDP: Measuring What Counts for Economic and Social Performance.” Paris: OECD Publishing. https://www.oecd-ilibrary.org/ content/publication/9789264307292-en. Stratford, Beth. 2020. “Green Growth vs Degrowth: Are We Missing the Point?” OpenDemocracy. December 4. https:// www.opendemocracy.net/en/oureconomy/ green-growth-vs-degrowth-are-we-missingpoint/. “What Is Degrowth?” n.d. Degrowth.Info | Web Portal on Degrowth (blog). Accessed May 12, 2021. https://www.degrowth.info/en/.

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Introduction

Universal Health Coverage (UHC) has become one of the major health strategies pursued by countries and global health actors. UHC policy and its discourse are driven by the World Health Organization (WHO) and the World Bank (WB) and have become embedded in the Sustainable Development Goals (SDGs). The genesis of UHC was discussed in Global Health Watch (GHW) 4 and 5 (Chapters B1 in both editions), including how its principles have become firmly embedded and accepted as basis for health sector reforms. Notably, these analyses highlighted the difference between a Primary Health Care (PHC) approach versus a UHC policy orientation. The Alma-Ata PHC discourse incorporates a focus on building and supporting the PHC sector, including a prominent role for community health workers and community involvement. The PHC approach envisages health systems working closely with their communities on the social and environmental determinants of health. In contrast, the UHC policy approach focuses on financial protection and argues explicitly for public, single payer financing, but not necessarily single provider (public) care. It commits to health systems strengthening and stresses the importance of primary care but doesn’t address issues of community engagement, nor is it critical about the role of private providers in driving up costs or posing a barrier to equitable access for all: The term coverage rather than care either suggests a limited scope of care or is being used to suggest enrolment in an insurance scheme …. Involving the forprofit private sector in providing health care has allowed for funding imbalances and provider capture, with more funds from these public schemes going into the private health sector, thereby reinforcing existing health inequities. Insurancebased models of UHC risk being promoted at the expense of funding PHC and other public health programmes. (Sanders et al. 2019)

This chapter traces UHC global policy developments and processes implemented during the period 2015–2020 and reflects on the implications in driving the global health agenda. It touches on the impact of the COVID-19 pandemic, and how it risks derailing efforts to implement UHC, notably in low- and middle-income countries (LMICs). It then assesses in more detail and in a critical manner how UHC is being implemented in a number of countries, notably the problematic approach of “purchasing” services.

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Universal Health Coverage and the Sustainable Development agenda

In the development of what became the SDGs, the WHO and UN commissions argued for UHC to become the main health goal (Leadership Council 2013). It became eventually just one of the 13 sub-targets (3.8) for SDG 3 that has the umbrella goal to “Ensure healthy lives and promote well-being for all at all ages” (see GHW5 Chapter A1 for a critique of the SDGs) (UNDESA 2016). Target 3.8 is to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” (ibid.). With UHC having only a relatively marginal role in the SDGs and PHC not being mentioned specifically as a strategy to attain UHC, it became clear soon after adoption of the SDGs that the right to health as a principle for human capabilities and development, and the role of healthcare services therein, was not prioritized as such. This probably has to do with other pressing global challenges such as climate change, biodiversity loss, and growing economic inequities (see Chapter A1). Analyses of global health governance in the context of the SDGs indicate that the subsequent focus on increasing domestic financing to improve healthcare systems implied an acceptance that many low-income countries (LICs) would have difficulty securing essential health services for their citizens (Van de Pas et al. 2017). Shared responsibility and solidarity by states for attaining the right to health are neglected in the actual policy implementation of the SDGs; instead, the dominant principle is that governments are domestically responsible to finance UHC for their constituencies (ibid., 4). In a study on financing health systems to achieve the health SDGs in 67 LMICs, WHO estimated that an additional $274 billion of annual spending on health would be needed by 2030 to make progress towards the SDG 3 targets (progress scenario). In the ambitious scenario, $371 billion would be needed to reach health system targets, the equivalent of an additional $41 (range 15–102) or $58 (22–167) per person, respectively, by the final years of scale-up (Stenberg et al. 2017). A major question, then, is what would be a global strategy to attain these essential health system needs? WHO and the World Bank, since the release of the 2010 World Health Report 2010, have jointly pursued a strategy of expanding UHC in LMICs based on the three consecutive strategies of domestic resource mobilization, pooling of funds, and strategic purchasing (Etienne et al. 2010). WHO continues to argue the primacy of UHC, that it “is the target that underpins and is key to the achievement of all the others” (World Health Organization 2015a, 196) while remaining oddly silent about its earlier-lauded PHC approach. The WHO’s close collaboration with the World Bank led to their first joint annual UHC monitoring report which appeared in 2015 (World Health Organization 2015b). They applied tracer indicators to monitor UHC progress in countries using coverage of a number of health service indicators (e.g., immunization services and antenatal care) and financial protection indicators

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(e.g., catastrophic health expenditure). Although coverage is thus reported on in the report, inequities in coverage are not. Both organizations regard UHC as having equity “hardwired into it” and, thus, it is a somewhat secondary concern to trace, albeit recognizing a need for “global monitoring” (World Health Organization 2015a, 59). That general coverage of health service and financial protection indicators prevail in monitoring is an accountability weakness because average coverage numbers may mask important, and increasing, health and financial risk inequities at the country level. The primacy of UHC

In 2016, formally as a transformation of the International Health Partnership + Network, the UHC2030 was formed as a multi-partner initiative, with the secretariat jointly hosted by the WHO and World Bank. After an initial consultation in Geneva with its several international partners (International Health Partnership 2016a) the UHC2030 global movement (now known as the Compact) was announced, articulating a model UHC approach that: … includes strengthening multi-sectoral and multi-stakeholder policy dialogue and coordination of health system strengthening efforts at global and country levels, which should be reflected in country compacts or equivalents as appropriate; fostering political will, nationally and globally, for sufficient, sustainable and equitable investment in health systems for UHC; and facilitating monitoring and accountability for equitable progress towards UHC so that no one is left behind. (International Health Partnership 2016b)

It is important to stress the multistakeholder approach the Compact is taking, as it aligns with the SDG “partnership” ideas, legitimizing a “new universalism” thinking and “private providers” engagement in advancing the UHC agenda (multistakeholder and private-public partnerships are becoming increasingly ubiquitous across the WHO and UN system, with criticisms of this trend found in several GHW6 chapters). UHC2030 provides technical advice to WHO member states and development partners on several themes relevant to UHC policy implementation, including public financial management, UHC in fragile settings, financial sustainability, health systems assessment, and multi-sectoral action. It intends to function as the international mechanism to bring actors, finance, and leadership together to advance the UHC agenda, and includes a civil society alliance, the UHC2030 Civil Society Engagement Mechanism (CSEM).1 Despite its lofty goals, it seems difficult for the UHC2030 movement to really make a difference in securing access to essential services globally, as both international and domestic public finance and attention to health systems strengthening and UHC has stagnated over the recent years. The WHO in the meantime was making the case that UHC is the essential financial strategy to advance PHC (Chan 2017). It celebrated 40 years of the PHC Alma-Ata declaration in 2018 by convening a global meeting in Astana.

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The 2018 Astana declaration made it clear that for WHO and its member states “PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals” (Global Conference on Primary Health Care 2018). UHC as a financial strategy and social protection mechanism became “a fait accompli” and a broader development goal to pursue, to which PHC was relegated a supporting role. This decision indirectly endorsed the public–private financing and collaborative discourse of UHC, neglecting to consider countries’ different health systems and contexts. UHC has become the de facto international strategy for financing health services. The implication of this is institutional acceptance and legitimation of policies that encourage private health actors and private insurance providers to take active roles in resource mobilization, pooling, and purchasing of services with the assumption that national governments would then regulate and govern the health financing domain and actual performance of actors. One step forward, two steps backwards

Such strategies might work well in countries where government capacity and fiscal space is considerable, but they are likely to be counterproductive and likely to undermine health equity in states where this capacity is not available, as the empirical cases described later in this chapter show. In a WHO technical briefing on building the economic case for PHC (background for the Astana conference), there is surprisingly little attention on the interrelation between PHC and UHC. Although the briefing identifies three ways in which PHC provides economic benefits (improved health outcomes, health systems efficiency, and health equity), UHC as an outcome is not mentioned as such (World Health Organization 2018). This suggests, first, a lack of coherence in how WHO and public health experts see the interrelation between UHC and PHC. Second, and more critically, it indicates that UHC is not so much a continuation of the principles and values of the comprehensive PHC approach as defined in 1978 but, 40 years onwards, a rather sharp divergence from it. There are marked differences between the Alma-Ata and Astana declarations on how they describe the economic development goal to be pursued by countries. Where the Alma-Ata declaration spoke about “Economic and social development, based on a New International Economic Order (NIEO),” the Astana approach focuses on the SDGs and attaining the UHC target. There is a huge difference between calling for a NIEO and supporting the SDGs: PHC was considered unlikely to succeed without the establishment of a NIEO based on ensuring the rights of states and peoples under “colonial domination” to restitution and full compensation for their exploitation and that of their resources; regulation of transnational corporations; preferential treatment for low-income and middle-income countries (LMICs) in areas of international

THE UNIVERSAL HEALTH COVERAGE/PRIMARY HEALTH CARE DIVIDE  |  87 economic cooperation; transfer of new technologies; and an end to the waste of natural resources. With the 1980s rise of neoliberal economics, the UNsupported NIEO was abandoned. (Sanders et al. 2019)

Indeed, replacing the lodestar of PHC with UHC threatens to be one step forward and two steps back for advancing Health for All. Peak UHC: not so much …

The zenith of the UHC movement occurred in 2019, when a UN HighLevel Meeting (UN-HLM) on UHC was convened alongside the Annual UN General Assembly in New York. This led to a UN-HLM political declaration on UHC (UN General Assembly 2019). Two reflections on this declaration and outcome merit attention. In a side-event before the actual declaration, the WHO presented the 2019 UHC global monitoring report “Primary Health Care on the road to Universal Health Care” (World Health Organization 2019). This report states that while there has been progress in the UHC service coverage, measuring progress on SDG indicator 3.8.1, from a global average of 45 (of 100) in 2000 to 66 in 2017, progress has slowed since 2010. The poorest countries are especially lagging far behind. With current trends, it is projected that only 39% to 63% of the global population will be covered by essential health services by 2030, which basically implies a stagnation from where coverage stands today. Worryingly, and one of the reasons that the UHC approach needs to be so critically scrutinized, the figures indicate that the incidence of catastrophic health expenditure (SDG indicator 3.8.2), defined as large out-of-pocket (OOP) spending in relation to household consumption or income, increased continuously between 2000 and 2015, with about 930 million people spending more than 10% of their household income on healthcare in 2015. Overall, financial protection is deteriorating, although countries with more public investments in health tend to fare better (UN General Assembly 2019). A major reason for this impediment is the overall socioeconomic environment and the prevalence of weak health systems, including human resource gaps, poor quality services, and low trust in health practitioners. Even as the WHO argues for a PHC approach, albeit only as a means to achieve UHC and not as an end in itself, it falls into the global financing line that argues for the need for domestic investments in healthcare of around $200 billion a year. The key is to improve domestic tax and revenue performance in line with the Addis Ababa Action Agenda, to increase government revenues. All countries should immediately allocate or re-allocate at least an additional 1% of GDP [gross domestic product] to primary health care. UHC is, after all, a political choice. (ibid.)

This conclusion that UHC is a political choice, reiterated by the UN-HLM leaders and major actors, means that UHC is a choice countries can opt for

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domestically, something for which international partnerships and investments and multistakeholder partnerships may be options but not necessarily essential (Kirton and Kickbusch 2019). But this focus on investment is a crucial fallacy if one does not consider structural economic conditions and their governance arrangement. To stay with the words of Greta Thunberg, spoken during the UN climate summit held around the same time, “all you can talk about is money and fairytales of eternal economic growth” (Van de Pas 2019a) (see also Chapters A1 and A3). Many countries do not have the political and economic choice to opt for UHC. They find them themselves (by choice or obligation) enmeshed in systems-deep economic globalization. As part of the international economic conditions and structural arrangements (trade rules, debts, austerity, and monetary policies), many LMICs simply do not have the domestic fiscal space to finance and invest in inclusive UHC by the 2030 target date, unless more heterodox economic approaches in public investment are considered (Rowden 2019). As for the international solidarity enunciated in the UN-HLM political declaration, that seemed to be a hollow shell from the onset (Van de Pas 2019b). UHC meets the pandemic

Only four months after the UN-HLM and the political declaration on UHC, WHO declared the COVID-19 outbreak a Public Health Emergency of International Concern (PHEIC) (World Health Organization 2020). Since then, the global public health community, leaders, and societies alike have been in the grip of the COVID-19 pandemic. What is striking is that the UHC discourse, and broader SDG agenda, was quickly neglected and replaced by international calls for emergency public investments for the preparedness and response to the SARS-CoV-2 and future pandemics. The SDGs and UHC (social protection) approach, in essence, appeared to be irrelevant in dealing with a pandemic. However, economic disruption will be felt most strongly in LMICs, and more than 80 LMICs have demanded financial help from the International Monetary Fund (IMF) to deal with the economic impact of the crisis. The eventual impact on health outcomes and health systems will be much deeper and lasting than that of the viral disease itself (Van de Pas 2020). Optimistically, the pandemic may lead the global health community to reflect on how to strengthen health financing, primary health care, and essential public health functions in a balanced matter, recognizing that public investments, shared financial responsibilities by governments, strong public regulatory governance, and accountable service provisions are required to provide social and human security (Assefa et al. 2021). It is not sufficient to focus on resilient health systems only (Kutzin and Sparkes 2016); health systems need to become transformative as part of broader socioeconomic reforms that are inclusive, equitable, and respecting of the globe’s ecological barriers. In the post-pandemic period, the

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public–private partnership approach to UHC policy should be replaced by a solidarity vision and strategy that supports human dignity and secures essential healthcare services globally. This becomes obvious when we consider how the UHC story has so far played out in many LMICs globally.

Box B1.1: Universal Health Coverage and the neglect of health workforce employment With UHC policies focusing so much on financial risk protection and service coverage, they take as a given the other crucial elements of a health system. A major bottleneck in many countries for the provision of essential healthcare services is the availability of a skilled, decently employed, and well-remunerated health workforce. Moreover, power relations embedded in existing social inequalities such as gender, class, caste, migrant status, and ethnicity have been profoundly shaped by global and country-level health workforce policies, leading to more precarious and exploitative conditions for those at the lower levels of the health workforce hierarchy, such as community health workers, nurses, and auxiliary health workers (see Chapter A2) (Writing Group for PHM 2021). The WHO estimated in 2015 that 18 million health workers’ jobs, 12 million of them in LMICs, are missing relative to the numbers required to provide the essential health services needed to attain the SDGs (Scheffler et al. 2018).2 Despite more than 15 years of health systems strengthening (HSS) approaches via global health initiatives and other mechanisms such as WHO’s Working for Health program, it has proven difficult for many countries to expand fiscal space for health workforce development, with some notable exceptions like Rwanda, Ethiopia, Thailand, Ecuador, and a few others. This difficulty is related to the overall political economy of health and global economic governance that provides the macro-economic conditionalities (and limitations) for generating resources and financing health employment. The WHO acknowledged the financial gap and proposed a $1 billion healthcare investment fund aimed at increasing access to PHC through investing in infrastructure (health facilities and educational institutions) and job creation. The proposal was presented at the 2019 UN-HLM on UHC (ILO-OECD-WHO 2021).3 The COVID-19 pandemic has brought to the fore how crucial the health workforce is in providing emergency care, providing essential public health functions such as epidemic surveillance, and conducting vaccination campaigns. The WHO designated the year 2021 as the International Year of Health and Care Workers (ILO-OECD-WHO 2021). Despite all the applause and vocal support for the health workforce, it remains to be seen

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whether any of this translates in actual new financing and job creation. The prevailing global economic orthodoxy considers health workforce salaries a recurrent economic cost that should be financed via domestic budgets, and not by international development finance, a utopian impossibility for many LMICs. Moreover, economic conditionalities and austerity measures have restricted critical public employment in the lead-up to the COVID-19 crisis. Of the 57 countries identified by the WHO as facing critical health worker shortages, 24 received advice from the IMF to cut or freeze public sector wages in the past three years (Hyde 2020). In reaction to persisting global austerity measures (see Chapter C1) and a neglect of public sector care roles, Action-Aid published some clear and excellent recommendations on how gender responsive public services should be financed: • Governments should pursue expansionary macro-economic policies and countercyclical investments … resisting the IMF cult of austerity and wider constraints to public financing. • Governments should invest more in non-military public sector personnel – particularly investing in public sector care roles that are presently underpaid and undervalued. • Governments of developing countries should set ambitious targets for increasing tax to gross domestic product (GDP) ratios in a progressive way to ensure a long-term sustainable resource base to deliver gender responsive public services. • Governments should renegotiate existing debt and push for new and independent debt workout mechanisms. • All governments should factor progress of human rights and SDGs, including unpaid care and domestic work, into national economic measurements and targets, moving away from the simplistic focus on GDP and towards a care economy (see Chapter A3). • Governments should focus on rebuilding the national social contract around public services, resisting the ideological push for privatization and public–private partnerships (PPPs) (see Chapter B3) (Ambrose and Archer 2020).

UHC in implementation

While in the UHC discourse there has always been an emphasis and consensus on public funding in order to ensure financial protection, in its provisioning, it has been influenced by “new universalism” – that is, a belief that in healthcare provision the ownership and nature of provider (private or public) do not matter and instead efficiency, quality, competition, and provision are key. A provider– purchaser split is envisaged. The state is supposed to play a role not so much in providing services but instead in stewardship, funding, and establishing systems

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to purchase services from private providers. Purchase or service contracts are also seen as a way to regulate the private sector in LMICs. In many LMICs, such arguments and narratives have been built under the UHC discourse, favoring public funding for private provisioning, thereby providing opportunities for PPPs, publicly funded health insurance schemes, and further commercialization of healthcare. These privatization initiatives are being undertaken under the paradigm of “strategic purchasing for UHC,” under the pretext of achieving efficiency and quality by opening the door to competition (for providers) and choice (for people) and by “engaging” with the for-profit private sector. Most of the models of “strategic purchasing” from the private sector under UHC include the explicit objective of favoring the private sector or promoting commercial interests; there is over-reliance on digitalization and information technology (IT) systems, creating opportunities for data mining by the for-profit sector. However, most models are non-transparent with little public accountability (see Chapter B2). In most instances we find that a strategic purchasing or facilitating agency is set up, operating outside the Ministries of Health and promoted in partnership with the for-profit private sector and global actors. The National Health Authority in India and the Philippine Health Insurance Corporation are examples of such arrangements that also open the door for corporate capture, creating possibilities for conflicts of interest. Global actors such as the Gates Foundation, global health academia, and global institutions (WHO, World Bank, and the Asian Development Bank, for instance) have been proactively offering support to health (and finance) ministries, academic institutions, and resource agencies of various countries for “strategic purchasing” (Tichenor and Sridhar 2017; Kelley and Cashin 2018); the Strategic Purchasing Africa Resource Centre (SPARC) is one example.2 The dangers of “purchasing” from the for-profit private sector

In many countries, especially in LMICs, UHC is often conflated with coverage by publicly funded health insurance (PFHI) schemes. These schemes have recruited the private sector to provide healthcare services using public funding. Evidence from around the world shows that these schemes, especially in countries which engage the for-profit private sector, may not have led to financial protection from healthcare expenses, nor universal access, and may in fact have exacerbated existing health inequities. The experiences differ greatly if healthcare delivery is by the public or non-profit private sector (Garg 2019). Among LMICs, Thailand is falsely portrayed as a successful “strategic purchasing” initiative by proponents of that model in order to make it a case. Thailand’s health system neither relies on private sector provisioning, nor is it based on principles of “competition” and “choice.” In Thailand, nearly 89% of hospitalization care and 86% of outpatient care are in the public sector, something which most global commentators fail to mention (Tangcharoensathien et al. 2018). The other successful experiences in PFHI schemes often quoted

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are those of Ghana and Costa Rica. The Costa Rican model resembles that of Thailand in terms of its reliance mainly on the public sector for provisioning, with facilities having greater autonomy (Hernández and Salgado 2014). The Ghanaian health insurance scheme relies mainly on faith-based non-profit organizations. However, these organizations recently seem to be working more in semi-urban and urban areas instead of the remote or more vulnerable areas where they were traditionally located (Grieve and Olivier 2018). Ghana’s PFHI scheme has shown some impact on financial protection, however OOP expenditure still exists (Okoroh et al 2018). The biggest failure of PFHI is seen in its dominant model of “purchasing” clinical care from the for-profit private sector. Experiences of countries such as India, Indonesia, and Philippines exemplify this. Indonesia: Indonesia has had a PFHI scheme for outpatient and in-patient health, called the Jaminan Kesehatan Nasional (JKN)/National Health Insurance. Studies show that while the coverage is high and utilization of health services increased, it has not had a significant effect on OOP expenditure or catastrophic health expenditure (Darius 2018). Moreover, there is inequitable access to health services as the health facilities are urban-centric and health services do not reach remote areas, with indigent populations facing several barriers in access (Salaheddine and Karasneh 2020). The Indonesian government has also been increasing the share of premium to be paid by people (non-poor). The insurance model has also led to funding imbalances between the public and private sectors with around three-fourths of the insurance funds going to the private sector. Philippines: The Philippines has been implementing health insurance for many decades, though currently the Philippine Health Insurance Corporation (PHIC) is located within the UHC narrative. The scheme promotes both private healthcare and insurance sectors. While enrolment figures have increased, there is a lack of financial protection as it mandates co-payments for people availing services, leading to OOP expenditures (People’s Health Movement 2019). Morocco: In Morocco’s PFHI scheme, problems such as cost escalation, over-billing, and patients having to make additional payments have been documented. The scheme has led to imbalances in financial flows between the private and public sectors, with 90% of the claims going to the private sector, leaving fewer funds for the public sector. This has debilitated the public sector further with health workers shifting to the rapidly growing private sector (Mathauer 2017; Dkhimi et al. 2017). Kenya: In Kenya, the National Health Insurance Fund was set up as a separate organization to act as “purchaser.” However, it has failed to promote quality, efficiency, or equity and there is a pro-rich pattern of utilization of health services, inequity in enrolment and financial protection, and geographical inequity in the distribution of hospitals (Munge et al. 2018). There is very little consumer engagement, and feedback or grievance-redressal systems are not established (Mbau et al. 2018).

THE UNIVERSAL HEALTH COVERAGE/PRIMARY HEALTH CARE DIVIDE  |  93 Box B1.2: AB-PMJAY. The largest PPP in health initiated by the Indian Government In 2018, the National Health Insurance Scheme, or RSBY, was expanded (in terms of population and annual amount coverage) through the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). PMJAY is considered to be the largest PPP initiated by the Indian government, as a strategy to achieve UHC and the SDGs (Nandi 2021). But the scheme has not enabled free hospital healthcare, and patients continue to incur very high OOP costs and catastrophic health expenditures, mainly in the for-profit private sector (Garg et al. 2020). This is due to illegal payments demanded by private hospitals, for which families face huge financial hardships, often being forced to pay from savings, loans, or the sale or mortgage of jewelry, land, or other assets. The private sector has captured the market under the PMJAY and in most states a larger proportion of the claims amount has been going to the private sector (Nandi 2021). For example, up until August 2020, 75% of PMJAY money went to the private sector. The PMJAY itself has seen huge increases in its budget, relegating important programs such as primary health care, disease control, immunization, women’s and children’s health, etc. to a lower priority with reductions of their respective budgets in real terms. It has also led to the under-funding of the public sector that mainly caters to women, the poor, and other vulnerable communities, thereby further exacerbating inequity in access. Moreover, funds meant for marginalized groups in under-served and rural areas are appropriated by the private sector which is located in urban centers and less vulnerable regions. The insurance scheme has failed to provide protection or access during the COVID-19 pandemic. Under India’s scheme, the institutional and governance arrangements for PFHI were modified with the formation of the National Health Authority (NHA) which bypasses the Ministry of Health. The NHA has people from the corporate sector on its Board, thereby legitimizing the role of the for-profit private sector in scheme governance. The NHA is now also implementing the National Digital Health Mission, illustrating the convergence of corporate and private interests. The digital mission’s plans have been criticized by People’s Health Movement (PHM) India over concerns regarding data privacy, selling sensitive medical data to commercial entities for profit, exclusions, etc. (ibid.). PHM India (Jan Swasthya Abhiyan) is providing resistance through evidence building and documentation. It is gathering testimonials and along with statements, position papers, and demands incorporating perspectives of health and other activists. PHM India is putting them forward in public meetings and in submissions to government. It is circulating these positions

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through media and other publications within India. The global PHM’s Health Systems thematic circle is bringing together similar experiences internationally.

Global financing for healthcare: boosting the private sector

Below we look at three examples of healthcare financing, including by countries of the Global North, that promote the private sector in health directly or through “technical assistance” in the Global South. The examples below highlight the damage that PPPs are doing to countries’ health systems, including increasing financial burden and health inequity. Dutch Aid & Trade in Health: Wemos, an advocacy organization focusing on access to health in LMICs, studied the Dutch Aid and Trade (A&T) agenda and the Dutch government’s official development assistance (ODA) mechanisms regarding healthcare in Africa in terms of its characteristics and (potential) impact from a health equity and UHC point of view (Wemos 2019; 2020). They found that in sub-Saharan Africa there had been a significant increase in Dutch A&T instruments in healthcare in the past five years, including (mainly) ODA and some non-ODA instruments (Wemos 2021). The primary objectives of A&T in healthcare were to promote private sector development and improve the business climate. In health in Africa, A&T “stimulates private (enterprises in) healthcare and health insurance, research & development of health products, innovations in public or private healthcare infrastructure, and technical assistance for private sector contracting in the public sector” (ibid.). Dutch A&T matched funds for development of relatively expensive public healthcare infrastructure that was mostly at the higher/tertiary levels and more suitable for big (multinational) companies. Tanzania, which has a limited health budget, had to finance its half of the funds through deferred payments to the contracted company (ibid.). Various financing modalities are used with the explicit purpose of furthering Dutch business interests in the healthcare sector through the promotion of PPPs. In Kenya, A&T provided financial support for Dutch businesses along with funding for technical assistance and studies for the fast realization of PPPs in public healthcare (with a role for Dutch companies). However, most A&T projects in healthcare lack “an evidence-based Theory of Change as to how to reach universal and equitable access to health services” which was “also reflected in a lack of monitoring, evaluation and impact assessment in terms of progress towards universal access to health without financial barriers” (ibid.). Healthcare for all? How UK aid undermines universal public healthcare. A new report by Global Justice Now: Research by Global Justice Now has found that the UK development bank, CDC Group, with a private healthcare portfolio of £420 million, has prioritized supporting private, for-profit businesses over services which reach the world’s most marginalized communities

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(Global Justice Now 2021). This includes financial support for a series of highly questionable projects, such as the following: • The now defunct Abraaj Growth Markets Health Fund, the former CEO of which is facing fraud and corruption charges for his involvement in the “biggest collapse in private-equity history.” • Serious allegations of systemic overcharging made against a UK-backed hospital in Kenya. The Nairobi Women’s Hospital, unaffordable to many Kenyans, has been accused of overcharging patients, with staff claiming the hospital “resembled a trading floor.” • Hospitals in Bangladesh and Pakistan accused of overcharging patients throughout the COVID-19 pandemic, including Evercare Dhaka and Evercare Lahore which lists its price for a hospital room with a ventilator as approximately £350 a day (over four times the average monthly wage). • Other UK-backed hospitals face criticism for closing departments during the COVID-19 pandemic or, in the case of Vikram Hospital in Bengaluru, India, being forced to close after refusing to treat government-referred coronavirus patients. • Investments with no apparent development impact, including a “premium and budget” fitness club chain in Brazil which runs “one of the most expensive fitness centers based in Sao Paulo” (ibid.). International Specialized Hospital of Uganda (ISHU) PPP at Lubowa, Wakiso District, Kenya (contributed by PHM Uganda 2021): In 2019, the Ugandan Parliament approved a PPP worth 1.3 trillion Ugandan shillings (approximately $379.7 million) with public financing provided to a private sector actor, FINANSI/ROKO Construction SPV Ltd. for the design, construction, and equipping of the International Specialized Hospital of Uganda (ISHU) at Lubowa, Wakiso District. As per the PPP agreement, the private actor will build, operate, and transfer the hospital to the government (the “build-own-transfer” or B-O-T model for PPPs), with the transfer scheduled after eight years of operation. This expensive tertiary level PPP has poor relevance to the health needs of the majority of Ugandans, as the disease burden centers on diseases such as acute childhood diarrhea, malaria, pneumonia, and HIV/AIDS that are best prevented and treated within communities through comprehensive primary health  care. Moreover, the massive costs of the PPP in the face of an otherwise underfunded government health system, leading to long-standing gaps in the health workforce, poorly functioning medical supply chains, corruption in health sector procurements, and neglected health facilities, is criminal. In addition to these concerns, the ISHU PPP entails specific problems related to legal compliance that are typical to many PPPs, identified by the Ugandan civil society as follows: • The PPP agreement between the Government of Uganda and FINANSI/ ROKO Construction SPV Limited is not in compliance with the Uganda

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•

•

•

•

•

PPP Act (2015). Instead, it was approved based on the advice of the Attorney General, overriding public procedures and positioning the state executive branch as firmly in support of the PPP. Cost overruns for the ISHU PPP are not supported by market financial rates. The initial estimate of $345.2 million for the PPP ($249.9m for construction and $95.3m for financing costs) has escalated to $557.9 million, a 61% increase within 18 months of the PPP agreement. Even the Uganda Medical Association has called out the massive cost escalation related to the ISHU facility. The Ugandan Ministry of Health, which will be the notional owner of the hospital, will pay an annual fee to cover the provided specialized services over each of eight years of operations to the contractor. This expenditure will take away funds from community health, HIV/AIDS and malaria control, sexual and reproductive health rights, and other essential health services. Therefore, not only is the government financing the initial investment; it is also paying annual from the Treasury to the private partner for health services that the government itself could provide, closer to communities, relevant to people’s health needs, and at lower cost. The public treasury not only bears 100% of the financing and pays for operating costs; it also bears 100% of the project risk in this PPP, which contravenes Uganda’s PPP Act (2015). In the event of a dispute, the Investor-State Dispute Settlement (ISDS) provision of the PPP agreement specifies arbitration in the London Court of International Arbitration, rather than in a legal venue in Uganda. Finally, government financing for the project adds to its international debt, creating a debt trap that threatens to absorb increasing amounts of the public budget and limits the ability of the government to negotiate favorable terms for financing other health and public services (PHM Uganda 2021).

The ISHU PPP therefore prioritizes the needs of a small, elite segment of the population over the health needs of the majority of Ugandans and diverts health sector funds away from filling nationwide gaps in the health workforce and infrastructure and towards a single, specialized facility. It “normalizes” the democratic deficit surrounding PPP projects in Uganda, with elites in government making decisions about public funds to serve private interests without respect for public health needs, rule of law, or long-term national welfare. PHM Uganda, working with the Initiative for Social Economic Rights and others, is engaged in developing a coalition to oppose PPPs in Uganda’s health system. The aim is to popularize an alternative narrative to PPPs that is peoplecentered and that promotes enhancement of critical public services including health and healthcare delivery.

THE UNIVERSAL HEALTH COVERAGE/PRIMARY HEALTH CARE DIVIDE  |  97 Private provisioning destroys all advantages of public funding

The most critical question to be asked is: who should be providing health services if the goal is to achieve universal healthcare and health equity? It is clear from the experiences above that private provisioning destroys all advantages of public funding. However, dominant discourse on UHC has given little emphasis to the importance of public provisioning of healthcare. Instead, “strategic purchasing” and PPP models are promoted, with both public funds and private finance being diverted to the for-profit private sector in the name of healthcare access and UHC (see Chapter B3).

Image B1.1  “Neoliberalism” (2020). Source: Greta Acosta Reyes, from the Anti-Imperialist Poster Exhibitions, Cuba. https:// thetricontinental.org/review-of-anti-imperialist-poster-exhibition-ii-neoliberalism/

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Reliance on the for-profit private sector in the provisioning of healthcare with public funding undermines the public health system, exacerbates health inequities, and increases financial hardship. Public hospitals cater to the more vulnerable groups, which especially include women from poor, rural, and indigenous communities, and are more equally distributed geographically. But, as a result of the diversion of funds through “purchasing” arrangements to the private sector, less funds are available for supply-side financing in the public sector, i.e., to pay for human resources, equipment, infrastructure, medicines, and other supplies. The private health sector mushrooms as a result of such policies, and health workers often shift from public to private sectors or engage in dual practice. Provider and regulatory capture by the private sector are seen in many countries. New systems of governance are being set up at national and global levels to pursue such interventions, leading to corporate capture and infiltration of governance mechanisms by private interests (DAWN 2021; TNI 2021). Returning to this chapter’s theme (the UHC/PHC divide), such schemes have also led to a neglect of PHC, though there are increasing attempts to introduce and expand “strategic purchasing” in primary health care services. This is evident from the new “Operational Framework for Primary Health Care” by the WHO and United Nations Children’s Fund (UNICEF) that uses the same narrative of “strategic purchasing” (WHO and UNICEF 2020). The Framework talks about how governments must play more of a “stewardship” role, transforming from the “traditional role of health ministries as providers of services,” and that this will require capacity and skills (ibid.). It is a big concern to health movements that bringing primary health care, especially in LMICs, under health insurance or other “purchasing” arrangements involving the private sector will inevitably lead to further privatization and commercialization. Global evidence shows that countries with strong public health systems and publicly provided healthcare such as Sri Lanka and Thailand have done much better in terms of financial protection and equity in access than countries with a dominant private sector. Given the nature of health markets, “public financing without public provisioning will not adequately address either distribution of services or necessary prioritisation of preventive, promotive and essential curative services” (People’s Health Movement et al. 2019). A universal healthcare approach oriented towards strengthening public sector provisioning and “care,” not “coverage,” can contribute to improving people’s health.

Box B1.3: The future is public: cases of remunicipalization and deprivatization While we are seeing the trend towards privatization of public services, there has also been a steady counter trend of bringing back privatized services into public hands. This is known as deprivatization or (re)municipalization,

THE UNIVERSAL HEALTH COVERAGE/PRIMARY HEALTH CARE DIVIDE  |  99 which is understood as “the creation of a new public service – municipalisation – or reversals from a period of private management–remunicipalisation” (Kishimoto, Steinfort, and Petitjean 2020, 19). The Transnational Institute along with its partners has documented such cases across sectors. They found that between 2000 and 2019 more than 2,400 cities in 58 countries had brought public services under public control. These moves towards deprivatization starkly illustrate the political and financial failure of privatized and neoliberal models of public services and the failure of healthcare to provide universal and quality services based on environmental and human rights perspectives (ibid.). A global database of de-privatized municipal services is available on the Public Futures website.3 Activists and organizations are also invited to submit information regarding new cases on the website. Jan Swasthya Abhiyan Chhattisgarh contributed a case in 2021 of the Chhattisgarh government taking over the Advanced Cardiac Institute in Raipur city. The Institute was previously being operated by for-profit private companies (International Database of De-privatized Public Services 2019).

Conclusion

The failure of the global community to call for and provide assistance to strengthening public sector service delivery is one of the main reasons behind the current crisis in healthcare, which has been made more evident during the COVID-19 pandemic. Health activists and social movements must build solidarities at all levels on this issue and resist it. We must remain vigilant while documenting and scrutinizing the evidence and policy push towards PPPs, PFHI schemes, and other purchasing arrangements under UHC. We must demand higher public investment in strengthening of the public sector to provide secondary and tertiary health services along with primary level healthcare, and in strengthening regulation of healthcare providers, especially those of the for-profit private sector. We must interrogate and critique the dominant narratives that put profit before people and intervene wherever these dialogues get captured by the private sector, including in the WHO. We must demand labor rights for health workers and other frontline workers, the majority of whom are women, and demand expansion of public employment, especially in LMICs, which would be beneficial both for the workers and for society (Ghosh 2021). It is essential to shift the normative environment in healthcare from a market-based commercialized provisioning of healthcare to a system based on solidarity, human rights, and public accountability, one which ensures financial protection, quality, and equity.

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Notes 1  For more information on the UHC2030 Civil Society Engagement Mechanism (CSEM), visit their website at https://csemonline. net/.

2  For more information on the Strategic Purchasing Africa Resource Centre (SPARC), visit their website at www.sparc.africa. 3  To access this database, visit the Public Futures website at www.publicfutures.org.

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102   |  Global Health Watch 6 Okoroh, Juliet, Samuel Essoun, Anthony Seddoh, Hobart Harris, Joel S. Weissman, Lydia Dsane-Selby, and Robert Riviello. 2018. “Evaluating the Impact of the National Health Insurance Scheme of Ghana on Out of Pocket Expenditures: A Systematic Review.” BMC Health Services Research 18 (1): 426. doi: 10.1186/s12913-018-3249-9. People’s Health Movement, Partners in Health, Sama, Medicus Mundi International, and Public Services International. 2019. “A Civil Society Assessment of the Political Declaration of the UN High Level Meeting on Universal Health Coverage.” https://phmovement.org/wp-content/ uploads/2019/09/Civil-Society-Assessmentof-UHC-HLM-declaration_16-Sept.docx.pdf. People’s Health Movement. 2019. “PHM Philippines: Universal Health Coverage: Everyone, Everywhere – At What Cost to the People?” https://phmovement.org/ phm-philippines-universal-health-coverageeveryone-everywhere-at-what-cost-to-thepeople/. PHM Uganda. 2021. “International Specialized Hospital of Uganda (ISHU) PPP at Lubowa, Wakiso District, Kenya.” Case study submitted by Denis Bukenya and Ravi Ram for Global Health Watch 6. Rowden, Rick. 2019. “Advocates of the SDGs have a Monetarism Problem.” Sheffield Political Economy Research Institute. http:// speri.dept.shef.ac.uk/2019/09/09/advocatesof-the-sdgs-have-a-monetarism-problem/. Sanders, David, Sulakshana Nandi, Ronald Labonté, Carina Vance, and Wim Van Damme. 2019. “From Primary Health Care to Universal Health Coverage – One Step Forward and Two Steps Back.” The Lancet 394 (10199): 619–621. Scheffler, Richard M., James Campbell, Giorgio Cometto, Akiko Maeda, Jenny Liu, Tim A. Bruckner, David R. Arnold, and Tim Evans. 2018. “Forecasting Imbalances in the Global Health Labor Market and Devising Policy Responses.” Human Resources for Health 16 (1): 1–10. Stenberg, Karin, Odd Hanssen, Tessa T.T. Edejer, Melanie Bertram, Callum Brindley, Andreia Meshreky, et al. 2017. “Financing Transformative Health Systems Towards Achievement of the Health Sustainable Development Goals: A Model for Projected

Resource Needs in 67 Low-income and Middle-income Countries.” The Lancet Global Health 5 (9): e875–e887. Tangcharoensathien, Viroj, Woranan Witthayapipopsakul, Warisa Panichkriangkrai, Walaiporn Patcharanarumol and Anne Mills. 2018. “Health Systems Development in Thailand: A Solid Platform for Successful Implementation of Universal Health Coverage.” The Lancet 391 (10126): 1205–1223. doi: 10.1016/S01406736(18)30198-3. Tichenor, Marlee, and Devi Sridhar. 2017. “Universal Health Coverage, Health Systems Strengthening, and the World Bank.” British Medical Journal 358: j3347. doi: https://doi. org/10.1136/bmj.j3347. TNI (Transnational Institute). 2021. “The Corporate Capture of Global Governance and What We Are Doing about It.” January 22. https://www.tni.org/en/article/thecorporate-capture-of-global-governance-andwhat-we-are-doing-about-it. UNDESA (UN Department of Economic and Social Affairs). 2016. “#Envision2030 Goal 3: Good Health and Well-Being | United Nations Enable.” March 3. https://www. un.org/development/desa/disabilities/ envision2030-goal3.html. UN General Assembly. 2019. “Political Declaration of the High-level Meeting on Universal Health Coverage ‘Universal Health Coverage: Moving Together to Build a Healthier World.’” United Nations. https://www.un.org/pga/73/wp-content/ uploads/sites/53/2019/09/UHC-HLM-silenceprocedure.pdf. Van de Pas, Remco, Peter S. Hill, Rachel Hammonds, Gorik Ooms, Lisa Forman, Attiya Waris, Claire Brolan, Martine McKee and Devi Sridhar. 2017. “Global Health Governance in the Sustainable Development Goals: Is It Grounded in the Right to Health?” Global Challenges 1 (1): 47–60. Van de Pas, Remco. 2019a. “Change is Gonna Come.” International Health Policies Blog. September 27. https://www. internationalhealthpolicies.org/featuredarticle/change-is-gonna-come/. Van de Pas, Remco. 2019b. “The Universal Health Coverage Divide.” September 26. https://www.internationalhealthpolicies.org/ blogs/the-universal-health-coverage-divide/.

THE UNIVERSAL HEALTH COVERAGE/PRIMARY HEALTH CARE DIVIDE  |  103 Van de Pas, Remco. 2020. “The Coronavirus Pandemic and the Irrelevance of the SDGs.” Ghent Centre for Global Studies. https://www.globalstudies.ugent.be/thecoronavirus-pandemic-and-the-irrelevanceof-the-sdgs/2/. Wemos. 2019. “Best Public Value for Public Money: The Case of Match-Funded Multihospital Infrastructure Development in Tanzania.” Discussion paper. https://www. wemos.nl/wp-content/uploads/2019/11/ Wemos_discussion-paper_Aid-for-Trade_BestPublic-Value-for-Public-Money_Oct-2019.pdf. Wemos. 2020. “In the Interest of Health for All? The Dutch ‘Aid and Trade’ Agenda as Pursued in the African Healthcare Context.” Discussion paper. https://www.wemos.nl/ wp-content/uploads/2020/10/Dutch-AT-inHealth-Kenya_Wemos-discussion-paper_Oct2020.pdf. Wemos. 2021. “Dutch Aid & Trade in Health: Summary Brief Based on Two Discussion Papers.” Discussion paper. https://www. wemos.nl/wp-content/uploads/2021/01/ Wemos_Summary-brief-Dutch-Aid-andTrade-in-Health_Jan-2021.pdf. WHO and UNICEF. 2020. Operational Framework for Primary Health Care: Transforming Vision into Action. Geneva: World Health Organization.https://www. who.int/publications/i/item/9789240017832. World Health Organization. 2015a. Health in 2015: From MDGs to SDGs. Geneva: World Health Organization.

World Health Organization. 2015b. Tracking Universal Health Coverage: First Global Monitoring Report. Geneva: World Health Organization. World Health Organization. 2018. Building the Economic Case for Primary Health Care: A Scoping Review. Geneva: World Health Organization. https://apps.who.int/iris/ handle/10665/326293. World Health Organization. 2019. “Primary Health Care on the Road to Universal Health Coverage: 2019 Global Monitoring Report.” https://www.who.int/healthinfo/universal_ health_coverage/report/uhc_report_2019.pdf. World Health Organization. 2020. “Statement on the Second Meeting of the International Health Regulations (2005) Emergency Committee Regarding the Outbreak of Novel Coronavirus (2019-nCoV).” https://www.who. int/news/item/30-01-2020-statement-onthe-second-meeting-of-the-internationalhealth-regulations-(2005)-emergencycommittee-regarding-the-outbreak-of-novelcoronavirus-(2019-ncov). Writing Group for PHM Health Systems Thematic Circle. 2021. “A Political Economy Analysis of The Impact of the COVID-19 Pandemic on Health Workers: Making Power and Gender Visible in the Work of Providing Care.” Paper commissioned by the Global Health and Justice Partnership of Yale Law and Public Health Schools. https://law.yale. edu/sites/default/files/area/center/ghjp/ documents/phm_commentary_v2.pdf.

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B2  |  GLOBAL HEALTH 2.0? DIGITAL TECHNOLOGIES, DISRUPTION, AND POWER

Introduction

The global expansion of digital infrastructures, devices, big data analytics, and artificial intelligence (AI) has been popularized by the World Economic Forum as “our fourth industrial revolution” (Schwab 2015), with “a disruptive potential for healthcare [that] is only beginning to be grappled with” (Bustreo, Jha, and Germann 2018). The promise of this revolution to improve health outcomes has generated enormous enthusiasm in the global public health field in recent years, with the World Health Organization (WHO) identifying digital health as essential to achieving the UN’s Sustainable Development Goals (SDGs). At the same time, there is growing debate about the possible risks of an uncritical embrace of digital technologies in the medical and public health spheres. Bernardo Mariano, who is responsible for coordinating WHO’s digital health vision and strategy, himself acknowledges that “this rapidly developing field raises transnational ethical, legal and social concerns about equitable access, privacy, appropriate uses and users, liability, bias and inclusiveness” (Mariano 2020). Technological innovations are not value neutral in their design, nor in their social impacts. They are developed and deployed in specific social and political contexts: they are susceptible to biases, embedded in the technology itself, as well as adoption by harmful institutions, and other unforeseen side effects. The rapid expansion of these technologies is all too often aligned with the interests of economically dominant institutions, experts, and countries. The concentration and overlap of technological and economic power have raised urgent concerns over questions of inequity, representation, and democratic accountability (Storeng et al. 2021). This chapter discusses some of the critical issues relating to the digital health revolution globally, situating the rise of digital health within the broader political determinants of health. This approach examines digital health in relation to how politics and political alignments, social norms and ideologies, power disparities, and global governance processes both shape health, and create health inequities (Ottersen et al. 2014). We first define the term “digital health” and outline areas in which digital technologies are being applied to improve health. We then summarize the anticipated benefits of these applications and juxtapose these with some of the risks that are being uncovered as digital health technologies are implemented in diverse health sector settings. Our analysis focuses on the digital health

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Image B2.1  A sticker that reads “Big Data is watching you.” Source: Photo by ev on Unsplash, taken in Lyon, France. See https://unsplash.com/photos/ gpjvRZyavZc

revolution emerging from the rising power and influence of American-dominated global commercial technology, acknowledging that there are also numerous tech initiatives – both private and state-run – in South and East Asia and elsewhere working on digital health. Our focus reflects the aggressive expansion of Silicon Valley-based American “Big Tech” corporations in healthcare markets globally, alongside an intensifying fight for “digital sovereignty” between corporations and states. We then discuss how Big Tech’s involvement in the response to the COVID-19 pandemic that is still raging globally, and Big Tech’s consideration of low- and middle-income countries (LMICs) as a burgeoning market, creates tech “disruption” not only in their novel partnerships with health systems but also in their ability to potentially undermine those systems. What is digital health?

“Digital health” is a broad term whose parameters change as new technologies develop. In many ways, it defies simple categorization: one study review of 1,527 sources found 95 different definitions (Fatehi, Samadbeik, and Kazemi 2020). We use digital health here to describe the application of computing platforms, connectivity, software, and hardware for healthcare and related uses – whether targeted at individual patients, healthcare workers, managers, or systems. These applications can range in sophistication from basic health-promoting SMS messages to smartphone apps capable of diagnosing, monitoring, and facilitating

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treatment for a wide range of conditions, and from algorithms and AI tools that draw on “big data” to diagnose, treat, and predict disease trajectories and organize the delivery of healthcare, to digital financial services for the payment of health insurance and direct healthcare costs. Furthermore, the term can also encompass health information campaigns or health advice delivered through mobile phone (mHealth), telephone, and video consultations (eHealth), predictive disease modeling, personal health tracking through wearable devices, and electronic health records. Such technologies are transforming healthcare in rich and poor countries across the world. The promotion of digital health by many international health non-governmental organizations (NGOs), donor agencies, and major philanthropic organizations is consistent with their embrace of market-based solutions and technologies that are believed to produce cost-effective solutions to the world’s problems. In LMICs, this vision is especially associated with The Bill & Melinda Gates Foundation and the Gates-funded non-profit PATH, which describes itself as “a global team of innovators working to accelerate health equity.”1 Alongside these philanthrocapitalist endeavors, some government donor agencies are arguing for open-source data, algorithms, and code as part of a move to secure “digital public goods” and sometimes insisting that grantees produce open-source technologies. The Norwegian development agency Norad, for example, sees digitalization as important to achieving the SDGs and funds several digital health projects. The most prominent project they support is the District Health Information Software (DHIS2), described as “a global public good transforming health information management around the world.” Developed by the Health Information Systems Programme at the University of Oslo, DHIS2 is being used in more than 73 LMICs (District Health Information Software 2 2021). These digital health expansions are occurring against a backdrop of intensive investment in health data and technologies by corporations and private investors. For example, Google and Microsoft have been aggressively acquiring health data and platforms from non-profits and corporate partners. Africa, having already served as a site of intensive investment and experimentation in financial technology, is being cultivated as the next big place for health tech investment (Quartz 2021). Fueled by support from agencies like the World Bank, start-ups from within and beyond Africa have been encouraged to see African health systems as ripe for disruption (Friederici, Wahome, and Graham 2020), such as in a recent “Global Tech Challenge” sponsored by the World Bank and The Consumer Technology Association, which focused on health tech in East Africa, resilience in India, and gender equality. As an outcome of that challenge, the World Bank Group, through its International Finance Corporation, has awarded 17 new tech start-ups in healthcare in East Africa access to a grant pool of $1 million alongside “technical and advisory support.”2

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Techno-optimism

Sweeping claims about the clinical and health systems benefits of digital health are frequent. According to the WHO, for example, “digital health plays an important role in strengthening health systems and public health, increasing equity in access to health services, and in working towards universal health coverage” (WHO Europe 2021). In the USA, the Food and Drug Administration (FDA) maintains that digital health provides opportunities to improve medical outcomes, enhance efficiency, reduce costs, increase quality, make medicine more personalized, and “empower” patients and consumers to better manage and track their health and wellness-related activities (FDA 2020). Such benefits are assumed to be achievable globally; it is increasingly common to claim that digital health will transform health in poor countries by “leapfrogging” over poor infrastructure such as constrained telecom systems in Africa and Asia to reach the most rural population (Neumark 2020). However, there is limited systematic evidence to support the notion that digital health has had, or will have, demonstrable health benefits. Instead, most digital health interventions are unproven public health interventions in the sense that claims of effectiveness and cost-efficiency are often based on unsystematic assessments or anecdotes. Moreover, digital health interventions often take the form of pilots that may not cater to the needs and priorities of specific health systems, with some “scaled up” or transferred to other country settings despite lack of evidence of effectiveness (Al Dahdah 2019). Although initiatives like the International Telecommunication Union (ITU)-WHO Focus Group on Artificial Intelligence for Health are working on benchmarking AI in health devices,3 there are currently no standard criteria for assessing their effectiveness. Producing such evidence is complicated by privacy policies that limit data access or because data and AI systems are considered proprietary (Storeng and Puyvallée 2021). The risks of digital solutions to health challenges

An uncritical embrace of digital health technologies in medicine and public health carries important risks of shifting public health agendas and approaches, not least because digital solutions focus on the most proximate, individual-level biomedical health determinants, and are often endorsed without adequate regard for social determinants like socioeconomic status, housing, employment, or access to social support networks and healthcare. Investments in digital health solutions often occur at the expense of less costly and more established interventions in the management of healthcare systems and can have high opportunity costs. For example, digital contact tracing apps developed during COVID-19 not only have substantial development costs, but high running costs, using up resources that might better have been invested in strengthening manual contact tracing systems (Erikson 2020). Digital health solutions are often promoted as a way to increase access to healthcare to geographically or socially marginalized populations, but their

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benefits usually do not go to those populations. Despite the major digitalization that has taken place globally in recent years, the gap between rich and poor is exacerbated by “digital divides” in both rich and poor countries, and reliance on digital health can reinforce existing inequalities, even when technologies like mobile phones are used informally to overcome systematic gaps in healthcare systems (Hampshire et al. 2021). Digital solutions can also have high costs for users, for example, requiring ownership and use of expensive digital devices or having electricity or reliable mobile network access. They also generate demand for expensive but ultimately unnecessary interventions, like wearable devices, and lead to harms caused at least in part by the application of health information technology, so-called e-iatrogenesis (Weiner et al. 2007). As reliance on digital technologies for tracking and surveillance of health grows, there is a further danger that those without access may become increasingly invisible or uncounted, and therefore ultimately not receive the care that they need (Davis 2020). Critical social scientists are providing important insights into how the introduction of new digital technologies is changing the production of knowledge about health, power relations, work practices, and the patient-doctor relationship, and even how we perceive and respond to our bodies. For example, lay people can now blog about their illnesses or set up crowdfunding websites to pay for medical expenses. They can use gaming console technologies for fitness and health-promoting activities, and healthcare institutions can establish far-reaching social media networks that enhance their reputation and directly appeal to clients (Lupton 2017). Moreover, digital technologies are also reshaping how individuals conceptualize and exercise their right to healthcare. Nora Kenworthy’s (2019) ethnographic research into the rise of medical crowdfunding, for example, shows how technologies are shifting political norms about an individual’s personal responsibility for health and their entitlement to publicly provided healthcare. Kenworthy calls medical crowdfunding through platforms like GoFundMe “the antithesis of Universal Health Coverage.” The application of digital technologies to broader social and commercial determinants of health presents even greater concerns. These include the corporate and government capture of personal data and its use for private profiteering and/ or political surveillance, such as by oppressive governments, police, and security services, or even social service agencies (Eubanks 2018). Here, corporate and government interests intersect to use technologies and data in ways that spread misinformation about health (Snyder, Zenone, and Caulfield 2021), undermine democracy, citizenship rights, and cybersecurity (with respect to infrastructures, elections, or military-related technologies), and even lead to negative impacts on global financial stability (IMF Blog 2020; Focus on the Global South 2021). There is a growing awareness that digital platforms such as Facebook are particularly prone to misuse by powerful individuals and corporations, contributing to “infodemics” (an overabundance of conflicting information, both online and offline, including deliberate misinformation) as well as discourses that fuel

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extremism, hate, and anti-democratic sentiment. Corporate interests and private control of platforms and their digital architectures mean there is little corporate incentive to diminish these harms, and little public oversight or regulation of the technology that contributes to them.

Box B2.1: Digital surveillance The rapid creation and adoption of digital surveillance tools by both corporations and government agencies poses challenges for considering rights, privacy, and regulation around the world. Digital surveillance tools encompass not only video and audio surveillance but also voice and facial recognition tools, geospatial tracking, biometric data collection, web and online tracking, spyware, and drone-enabled surveillance (Electronic Frontier Information 2021). The video surveillance market alone was estimated at more than $40 billion in 2019, larger than more than 50% of the world’s economies by gross domestic product (GDP) (Valuates Reports 2020). Many of these technologies are developed and sold by private corporations that market them indiscriminately to governments, police and security forces, and other private companies. While some corporations have faced litigation for exporting surveillance tools to regimes that use them to violate human rights, such as China, surveillance is largely an unregulated market (Electronic Frontier Foundation n.d.(a)). Regulation failures occur at several levels: at the level of production (whether an invasive technology should be produced at all), sale (to what entities these technologies are sold, and for

Image B2.2  A sign on a wall in Nicaragua warning visitors about video surveillance. Source: Photo taken by Tobias Tullius on Unsplash. See https://unsplash.

GLOBAL HEALTH 2.0?  |   111 what purposes), and use (how they are used to violate rights and privacy, particularly of repressed and minoritized groups). Digital repression Digital surveillance technologies are being created for, and sold to, states for the purposes of repression and human rights violations. While there is a tendency to focus on China’s excessive surveillance of its own people and export of repressive technologies, these narratives are often Sinophobic, overlooking how ubiquitous surveillance technology use has been in “democratic” countries and other regions, and how much of it has also been developed by US and European firms (AI Now Institute 2021). China does employ extensive facial recognition technology, video surveillance, and biometric tracking to police and punish ethnic minority groups as well as control workers. During the pandemic, these practices expanded in the name of epidemiologic surveillance as part of efforts to build a “digital wall” against the pandemic (French Press Agency 2021). While China’s use of technology may be more extensive than other states, digital surveillance has been used against protesters of the Arab Spring and against Palestinians and has been extensively deployed by police forces in the USA, to name a few examples. The Electronic Frontier Foundation documents dozens of efforts by activists to resist repressive surveillance; many of these efforts have focused on allegedly democratic regimes in Europe and North and South America (Electronic Frontier Foundation n.d.(b)). Racialized surveillance and policing Whether used against Uighur communities in China or black neighborhoods in the USA, such digital surveillance is in many places racialized, disproportionately used on, and punitively affecting, racially marginalized populations. Not only are such tools more often likely to be used in minoritized communities, but the tools serve broader agendas of racial monitoring and oppression. In addition, many tools rely on AI systems that have been built to reinforce racism, for example by more often misidentifying and misrecognizing darker faces. Even seemingly innocuous technologies are embedded in complex networks of private and public surveillance. Take the Amazon Ring as one example: a doorbell that provides video footage to homeowners of who comes to their doors. In addition to being built on histories of racial segregation in neighborhoods and perceived threat of non-white Others entering those spaces, the Amazon Ring was built through partnerships with US police departments which allow police to access camera footage for community surveillance. As numerous groups have noted, this technology encourages racist judgements of who does and does not belong, facilitates digital surveillance of communities by police, and encourages a “racialized surveillance” that is engaging consumers in

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“watching from below” to reinforce and protect racial hierarchies (Poster 2019). These technologies contribute to the widespread over-policing and disproportionate incarceration of communities of color and the poor in the USA and elsewhere (Our Data Bodies Project n.d.). Surveillance gatekeeping In addition to its uses in repression and policing, digital surveillance is increasingly used as a form of gatekeeping for access to public spaces, public goods, and other entitlements. Digital tracking is now a ubiquitous part of many welfare state services. Biometric data is required in many spaces, by both governments and corporations, to gain access, verify identity, or obtain new identity documents. Even more ubiquitous but no less insidious is the extensive access to phone users’ usage and geospatial data that is demanded by apps, websites, and even states. The COVID-19 pandemic has ushered in many new forms of surveillance gatekeeping – from vaccine passports to digital contact tracing apps. As consenting to surveillance is becoming increasingly necessary for access to spaces, resources, and digital tools, citizens risk becoming inured to these incursions, and even seeing them as potentially beneficial. Without far more regulation of, and citizen resistance to, digital surveillance tools, differentiating between the potential benefits and harms of surveillance is likely to become ever more complicated.

Image B2.3  An umbrella protest in Hong Kong. Hong Kong’s famous umbrella protests were not simply about “branding” a populist movement. The umbrellas were used to prevent police and other surveillance devices from face recognition of protesters. Source: Photo by Joseph Chan on Unsplash. See https://unsplash.com/photos/uNHrmuZ6VKE

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Because digital health increasingly relies on sophisticated computational analytics drawing on “big data” and AI, there have been growing concerns about the ethical and security issues related to the collection, sharing, repurposing, sale, and potential for misuse of big data and of sensitive personal health information. For example, the Financial Times reported on mounting concerns about the increased participation of tech companies in managing hospital data in the USA, where 33 of the 50 hospitals examined were working with Amazon, Google, or Microsoft without standardized or open rules over data protection management (Financial Times 2020). The same story noted widespread surreptitious data sharing in the consumer healthcare space: one review of medicine-related apps on the Android mobile platform found 79% of those sampled shared user data with third parties including advertising companies, private equity firms, and credit agencies. Health data from both high- and low-income countries is a highly valuable commodity, and its acquisition and use by both private companies and powerful global health institutions, such as the Institute for Health Metrics and Evaluation, is especially hard to track (Tichenor and Sridhar 2019). Concerns about the commercialization of data which was shared in good faith by users is not restricted to personal health information, but extends to a wide range of behavioral, contextual, and social data. This raises concerns about how this commercialization is driving the rise of a process of “data colonialism” that is normalizing the exploitation of human beings through data (Couldry 2019). Tracking and commercializing such “surplus” data is at the core of the business model that has pushed Amazon, Apple, Alphabet (Google), and Facebook to become the most dominant businesses in the global technology sector. Shoshana Zuboff (2019) describes this as a whole new era of “surveillance capitalism,” marked by an expansion not only in the collecting of bio-behavioral data, but in the leveraging of machine learning and AI systems to generate new value through marketing and speculative data trading. Crucially, “behavioral surplus” data generated from user interactions with digital platforms and wearables have become highly profitable because of their value in predicting and manipulating individual purchasing behavior, including health-related products and services. Government agencies in different countries are also increasingly appropriating such behavioral data to institute a new form of “digital governmentality” in which the state deploys algorithms drawing on big data to automate decisionmaking in the health and welfare sectors and, increasingly, in other areas, such as law enforcement. Such state-corporate surveillance is not only happening in authoritarian societies but also in liberal democracies. For example, in her book Automating Inequality, Virginia Eubank (2018) discusses how “high-tech sorting and monitoring programs” are increasingly used to surveil, police, and discipline the poor in the USA. Similarly, the United Nations (UN) Rapporteur on Human Rights, Philip Alston, noted the rise of a “digital welfare state” in the UK (United Nations 2019). As he explains, vast quantities of data are collected from

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a wide range of sources, connected between government silos. These data are then processed to enable “automated” decision-making by algorithms applying predictive analytics to calculate potential risks, such as fraud, and to estimate outcomes. Key uses of predictive analytics in healthcare are in diagnosis (for example, predicting likelihood of certain diagnoses in a patient cohort), prognosis (which patients are at greatest risk of readmission) and treatment (the best course of treatment for patients with chronic conditions). All of these uses can have important implications for equity if used as the basis for priority-setting in rationing healthcare resources. For example, one frequently used algorithm for assessing kidney function in the USA assigns healthier scores to black patients despite poor functioning, contributing to delayed or denied healthcare for this population, and reinforcing racism in medicine (NPR 2020). Critics have also drawn attention to the dangers of using biometric data systems in humanitarian crises, calling them a form of “surveillance humanitarianism” (Benjamin 2019b; Noble 2018; New York Times 2019). Bias in the big data that is used in such algorithms – as well as bias in the algorithms themselves – can exacerbate discrimination along lines of gender, race, class, and other categories of disadvantage. When combined with behavioral economics, this allows governments to target public health messages to change social and health-related behaviors. Although behavior-change health promotion has long been a standard public health practice, it has also been subject to decades of critique for its potential “victim-blaming.” Ilona Kickbusch, chair of the Financial Times/Lancet Commission on digital health, argues that from a human rights perspective, such big data uses in health promotion make the most vulnerable and powerless in society “subject to demands and forms of intrusiveness without accountability” (Kickbusch 2020). While citizens are increasingly visible to their governments, the same transparency and accountability does not flow in the other direction.

Box B2.2: Activism in health data governance The shift from traditional statistical systems to big data and allied technologies has changed the role of data in public health. The networked environments in which machine-readable health data sets are collected, processed, and accessed have created a new infrastructural dimension for public health policies. In addition, planetary-scale “datafication” creates new possibilities for health research with predictive models that combine personal and non-personal data sets. Understood this way, data infrastructures bring new concerns for the right to health for all. The potential risks to privacy associated with the marketization of public data sets have been the subject of recent contestations,

GLOBAL HEALTH 2.0?  |   115 as seen in the case against the National Health Service in the UK, challenging the extension of what should have been a short-term COVID-related contract with the US data firm Palantir. The secret deal allowed Palantir’s access to NHS data with implications for citizens’ privacy, and sidestepped due process obligations, including a public consultation (British Broadcasting Corporation 2021). Another crucial concern is the absence of checks and balances – essentially, a rule of law for holistic data governance – that would ensure corporations do not monopolize and capture public data for their own profits (IT for Change 2020). Global policy shifts over the past decade favoring open data (Ubaldi 2013) and emerging discourses of open digital ecosystems promoted by corporate philanthropy (Omidyar Network and Boston Consulting Group 2020) have brought to sharp relief the urgent case for fairness and equity. Without appropriate boundaries to protect and promote the enormous public and social value of digital health infrastructures, openness in and of itself may deepen inequality (Singh and Gurumurthy 2014). The governance deficit in health data and a laissez-faire data marketplace are already leading to the subordination of the social and human dimensions of health services to commercial priorities (Kelsey 2020), with innovations locked up in corporate trade secrets or patents. Governments’ sharing of data with private sector entities to enable innovation, such as India’s National Digital Health Mission (NDHM 2020), highlights the need to rein in the private capture of data. The infrastructure of open data must remain oriented towards positive outcomes for universal healthcare and citizen welfare. To address these challenges, activist groups are calling for the establishment of more equitable and inclusive frameworks for the governance of private and public data (Transform Health Coalition 2020). These governance frameworks would broaden the scope of advocacy beyond data privacy and security to ensure that emerging public digital health infrastructures are designed to facilitate increased data sharing, realize research and innovation, and maximize community benefit. Institutional models that may help realize such visions are already being developed in the form of various data trusts and data cooperatives that offer patients more agency in how their data is shared and with whom, as seen in citizen projects such as “PatientsLikeMe” or “midata.coop” (Bass and Old 2020). By and large these initiatives originate in the Global North, offering a useful compass for pooling and managing data through ethical approaches towards uses for the common good. While recognizing the importance of previously highlighted efforts to strengthen individual control of personal data, these approaches stress the importance of acknowledging the relational nature of people and of data

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through solidarity-based data governance models (Pransaick 2021). Such models advocate for strengthened benefit sharing to ensure that commercial benefits accrued from data use are also returned to the public domain from which it arises. Individual-controlled data ecosystems, however, are only part of the solution, and cooperative data pooling based on values such as privacy and security, in and of itself, may not lead to appropriate data use in the public interest. Overarching health data policies are needed to incentivize research and innovation for public interest and health equity. Laws and rules for patient-led data stewardship models must therefore be complemented by suitable policies legitimizing health data as a public good. Such policy frameworks need to straddle data protection rights (of individuals and groups) with positive rights that guarantee equitable distribution of the benefits of data (Just Net Coalition 2021). The efficacy of such governance models requires strong international institutional frameworks. As highlighted by the Third World Network, the call to recognize health data as a global public good by the WHO (WHO 2021) can threaten data sovereignty of nation states (Third World Network 2020). Similarly, the strong push in the context of the pandemic for a global agreement on health data as a public good (Open Data Institute 2021), without a clear regime of data ownership and control, could jeopardize the rights of people in developing countries as data flows out of these nations over global digital supply chains. A clear framework of international cooperation to advance equity, accountability, and democratic control in relation to health data, promoting an Ostromian idea of nested governance of the data commons (Williams 2018), is the need of the hour.

State-corporate cooperation in the pandemic response

The COVID-19 pandemic has accelerated the development and use of digital health technologies worldwide, whether by using AI to identify patterns in big data to forecast the spread of outbreaks, expanding online medical consultations, or by using smartphone apps designed to automate and assist established manual contact tracing (see Chapter B3). While China and other South-East Asian countries including South Korea were front-runners in the application of digital technologies in the pandemic response, Western countries quickly followed suit. In August 2020, a Lancet commentary even claimed that “countries that have quickly deployed digital technologies … have remained front-runners in managing disease burden” (Whitelaw et al. 2020). The embrace of digital solutions in Western countries has often taken the form of partnerships between private technology companies and public health authorities, with Big Tech executives included among advisors on national and

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international authorities’ pandemic response. For example, a co-founder of Google’s AI DeepMind division attended a meeting of the secretive Scientific Advisory Group for Emergencies (SAGE) group advising the UK Prime Minister on the COVID-19 response (Storeng and Puyvallée 2021). In addition, the WHO organized a consultation with Silicon Valley executives in the early stages of the pandemic to receive assistance with managing the emerging “infodemic” of misinformation. Big Tech companies and major telecommunication firms also worked with public health agencies to track the spread of the pandemic, providing them with users’ aggregated and anonymized localization data for use in modeling the effects of social countermeasures like travel restrictions on population mobility. These efforts built on their previous experiments with syndromic surveillance based on scanning of social media and use of mobile data in humanitarian settings and in LMICs. Facebook, for example, has posted freely available data useful for modeling COVID-19, including high-resolution population density maps and social connectedness indices (Facebook 2020).4 Most strikingly, Apple and Google have partnered for the first time, cooperating to develop unique technology known as Google-Apple Exposure Notification (GAEN) which public health authorities all over the world have adopted as the basis for so-called contact tracing apps. According to the Financial Times, during the pandemic, health agencies have been “striking partnerships with tech companies at a speed and scale hard to imagine under normal circumstances” (Financial Times 2020). The National Health Service (NHS) in the UK, for example, is working with Amazon, Microsoft, and Palantir to create data models to optimize the allocation of ventilators, hospital beds, and staff, while governments worldwide loosen regulatory restrictions on digital health. The US and Australian governments have both approved reimbursement for telemedicine consultations to keep people away from overstretched hospitals, while the UK government has launched a coronavirus chatbot to relieve the pressure on the NHS and reduce in-person contact (Financial Times 2020). These innovations are often implemented hastily with little assessment or oversight but are forecast to become permanent features even after the pandemic is over. Far larger impacts, however, are being felt with Big Tech companies’ direct involvement in the pandemic response. Apple and Google claim that their contact tracing endeavors are motivated by a “shared sense of responsibility to help governments and our global community fight this pandemic” (Google 2020). Many other efforts harness Big Tech and major telecommunication companies’ expertise in scaling mobile big data analytics and AI for various corporate social responsibility schemes, branded “Big Data for Social Good.” Engagement in “social responsibility” borrows a critical tactic from other harm industries, burnishing reputations while benefiting companies in multiple ways. Their involvement in the pandemic response establishes greater demand for their platforms, services, or devices. It also appears to be boosting their public

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image at a time when they are facing antitrust lawsuits for their monopolistic behavior in the USA and in Europe, along with growing criticism about their impact on privacy, free speech and censorship, and national security (The Guardian 2019). Big Tech companies’ contribution to the pandemic also detracts attention from past scandals, such as that which erupted in the UK in 2017 when the NHS shared citizens’ personal medical records with Google’s AI arm, DeepMind (Roberts 2020). Indeed, the pandemic appears to be providing an impetus for Big Tech companies to “disrupt” healthcare markets in the USA and globally. According

Image B2.4  Data is the new oil. But for whom? Source: Sketch by Kriti Shukla for Global Health Watch 6.

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to a recent report by a research firm focused on digital transformation, these companies are “gunning to carve out spaces within the (American) healthcare market, each targeting different areas to transform and disrupt” (Insider Intelligence 2021). As the report points out, “Microsoft is focused on its race with Amazon and Google to lay claim to the healthcare cloud market, Apple is knuckling down on clinical research initiatives via its wearables, Alphabet is focusing on its AI expertise to drive precision medicine, and Amazon is shaping up to disrupt the pharmacy, virtual care, and telehealth realms” (ibid.). The impact of these efforts being provided by private companies threatens existing healthcare services offered by both public and private providers, the report warns: Amazon’s prescription delivery service, for example, has traditional pharmacies looking for ways to retain their customer bases, while Alphabet is building an ecosystem that could be at odds with established experts in the electronic health records industry (Insider Intelligence 2021; Healthcare Success 2018). In LMICS, too, the expansion of corporate social responsibility projects is difficult to disentangle from efforts at monetization and market expansion. For many years, Facebook has provided “free” internet access in LMICs through its “Internet.org” initiative, which allows users to access the internet only via the Facebook platform. This initiative has come under enormous criticism for fueling extremism, violence, and hate speech in places such as Myanmar (Stevenson 2018). More recently, Facebook announced plans to partner with telecom providers in a nearly $1 billion project to expand internet access in Africa. It is not difficult to see that such initiatives greatly enhance Facebook’s customer base and the data and governance power it wields in poor countries. But Facebook has also leveraged its “Data for Good” project to assist UNICEF with vaccination programs, and the Institute for Health Metrics and Evaluation with COVID-19 models for countries around the world (Facebook 2020). Increasingly, Big Tech seems as keen to export its models for innovation to LMIC health systems as it is to import data from these countries. A recent study from the University of Washington, for example, used Amazon algorithms to develop an “Amazon Prime-type service” for HIV treatment home delivery in South Africa during the pandemic. While expanded access shows success, it also normalizes charging low-income, immuno-suppressed patients fees for delivery of what should be essential health services (Medpage Today 2021). Big Tech companies are also becoming involved in global health financing, alongside government donor agencies and private philanthropists. Google is among the private sector partners and foundations that mobilized significant new resources for the Gavi COVAX AMC (see Chapters B4 and D1), committing $2.5 million, and donating an additional $15 million in ad credits through its charitable arm, Google.org, according to a Gavi news report in April 2021 (Gavi 2021). In the long term, “Google.org engineers will support Gavi’s broader innovation agenda” (Gavi 2021), though what this will entail in practice remains opaque.

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The fight for digital sovereignty

Big Tech companies’ involvement in the pandemic response not only signals their incursion into healthcare markets and public health practice but also reveals their growing political power and the broader fight between states and corporates over control of the digital realm, or “digital sovereignty” (Floridi 2020). Tech corporations have expanded their products across the globe, extracting data and profit from users all around the world while concentrating power and resources in one country, namely the USA, and with China as a growing competitor (Couldry and Mejias 2019; Kwet 2019). Kwet argued that such activities amount to “US transnational corporations … reinventing colonialism in the South through their ownership and control of intellectual property, digital intelligence, and the means of computation” (Kwet 2021). While poorer countries struggle to compete, Big Tech corporations take control of digital infrastructure, use proprietary software, corporate clouds, and centralized internet services to spy on users, process their data, and “spit back manufactured services to subjects of their data fiefdoms” (Kwet 2019). Concerns about foreign tech companies’ societal impact are not just felt in LMICs with poor regulatory systems, however, increasingly in Europe as well. The digital contact tracing experiment, which first drew accusations of growing state surveillance and control, has instead become an exemplar of how limited the power of European states can be relative to the tech giants (Storeng and Puyvallée 2021). EU governments such as Latvia ran into “a Silicon Valley-built brick wall” when they initially tried to design their own versions of digital contact tracing apps, but were blocked by Apple and Google (The Guardian 2020; 2021). Apple and Google effectively managed to settle the debate about privacy versus public health benefit to their own advantage; subsequently, their exposure notification technology was widely adopted by public health authorities, with the latter forced to accept the corporations’ terms and conditions, most critically their stringent privacy protections. Apple and Google refused to share contact cases’ identities with public authorities, thus undermining governments’ abilities to follow up to ensure individuals test, quarantine, and isolate where appropriate, as well as their limited ability to identify additional exposures and more rapidly contain the spread of the virus. Many consider such protection of private data desirable, especially where there is a risk that autocratic governments can abuse those data, but opinions about privacy are ambiguous.5 Citizens may consent to public institutions having access to their health data for improving health services but may be concerned about it being shared with other public or private agencies, such as insurance companies and law enforcement. Nevertheless, the contact tracing phenomenon raises broader questions about corporate power over the public decision-making of democratically elected governments and, as a recent Chatham House Report remarks, the “significant differences in levels of accountability and transparency between public and private sectors” (Hakmeh et al. 2021).

GLOBAL HEALTH 2.0?  |   121 The global governance of digital health

The pandemic has exacerbated an emerging “technological wild west,” where concentrated power and market control among Big Tech companies combines with inadequate regulation to constitute a powerful political determinant of health (Storeng and Puyvallée 2019; 2021). Weak or non-existent regulation of digital tech companies is a global challenge that affects LMICs disproportionately. In India, the combination of a strong tech sector and a chaotic health system marked by unregulated privatization has made the country a center for the development of AI aimed at the health sector. Yet there are no agreed frameworks for ensuring that this burgeoning technology reduces rather than increases India’s vast health inequities. There is growing awareness amongst global health scholars and activists that the trends outlined here require a concerted global response if we are to tackle the lack of normative, regulatory, and technical standards to govern the digital health revolution, as well as to ensure that it serves to promote equity in health and beyond, fairness, and distributive justice. As a normative body, the WHO identifies itself as the appropriate institution for determining how the digital transformation of the healthcare sector can improve quality of care, reduce healthcare costs, and increase accessibility in line with the goal of universal health coverage. In 2018, the World Health Assembly passed a resolution on digital health (WHO 2018). Strengthening governance for digital health at both global and national levels is at the core of the WHO’s new Global Strategy on Digital Health (2020–2025), which aims to enshrine the value of health data and associated digital health products as a global public good (WHO 2020). Meanwhile, the Digital Public Goods Alliance has been established as a multistakeholder initiative that aims to accelerate the attainment of the SDGs in LMICs by facilitating “the discovery, development, use of, and investment in digital public goods” (Digital Public Goods Alliance 2021), understood as open-source software, open data, open AI models, open standards, and open content. The UN Secretary-General has also elaborated a Roadmap for Digital Cooperation, which sets out how stakeholders can advance “a safer, more equitable digital world” (United Nations 2020). There are also burgeoning policy initiatives that deal directly with the potential governance issues around digital health in lower income countries, notably the Financial Times/Lancet Commission on Digital Futures launched in 2019 (Alami et al. 2020; WHO Bulletin 2020). These global-level debates and efforts are starting to engage with how discriminatory design, weak regulations, high costs, and questionable effectiveness challenge the ideal of digital public goods capable of advancing health equity. However, they deal insufficiently with the broader political determinants of digital health. As activists such as the Third World Network have pointed out, regulation of digital platforms is extremely difficult in the face of ongoing trade negotiations in which Big Tech has demanded extreme intellectual property protections for data and source codes.

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Global-level debates about the governance of digital health seem to assume that partnerships between public and private sectors will help harness digital health technologies for health equity, viewing such partnerships as the means to alter or reform technology, bending the technology to the pursuit of more benevolent ends. Yet as Ruha Benjamin warns (Benjamin 2019a), “technobenevolence” is a spell, and approaches that emphasize “fixes” or “tweaks” can be magical thinking. Benjamin calls for an abolitionist approach that reimagines technology with justice at its core. Such imaginings are not out of reach. The global health community would do well to listen to, and learn from, activist networks that have been working to develop ethical tech alternatives, and to educate and empower communities to realize and exercise their digital rights. Examples of such efforts include the Our Data Bodies project (and its Digital Defense Playbook), the Algorithmic Justice League, Allied Media Projects, Data for Black Lives, the Feminist Data Justice project, and Bot Populi. Conclusion

As we have shown, there are massive expectations about the positive disruptive potential of digital technologies in healthcare and public health. This disruption is all too frequently couched in positive terms, without any critical evaluation of the effectiveness of the use of such technologies for improving healthcare globally, especially relative to their high opportunity costs. Techno-optimism has increased rapidly under the COVID-19 pandemic, with Big Tech expanding into what have traditionally been governmental and public domains, setting agendas and requiring governments to accept corporate terms and conditions, without any seeming attendant public debate. While there is a growing recognition that global governance frameworks are needed urgently to mitigate potential ethical and public health risks, concerns in the public health domain are only parts of a greater process underway: the broader contestation over power between private technology corporations and public authorities that is unfolding globally. Too much governance power in these negotiations has already been ceded to technology corporations. Thus, there is an urgent need for civil society organizations and global health activists to include digital justice and regulation as a key part of their agendas. Addressing digital technology as an issue of global health justice requires pushing back on the commercial, governmental, and ideological powers that have given digital technologies so much control over lives and livelihoods, while also embracing alternate systems of knowledge generation, connectivity, and innovation that will achieve health for all. Notes 1  As described on PATH’s website: https://www.path.org/. Until 2014, PATH was an acronym for Program for Appropriate Technology in Health.

2  See for example: https://www.ces.tech/ Global-Tech-Challenge.aspx; https://www.ces. tech/Global-Tech-Challenge/IFC-TechEmergeHealth-Tech-Challenge.aspx; https://www.

GLOBAL HEALTH 2.0?  |   123 techemerge.org/country/tech-emerge-eastafrica. The International Finance Corporation (IFC) offers low-cost loans to the private sector and actively promotes private healthcare in LMICs. As Chapter B3 notes, most of the World Bank COVID-19 health assistance is being directed through the IFC, raising concerns about deepening the privatization of healthcare, notably in Africa.

3  See Terms of Reference for all details at: https://www.itu.int/en/ITU-T/focusgroups/ai4h/ Pages/default.aspx. 4  See Google’s website at: https://www. google.com/covid19/exposurenotifications/. 5  See Susan Landau, People Count: ContactTracing Apps and Public Health. Cambridge, MA: MIT Press, 2021.

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126   |  Global Health Watch 6 Quartz. 2021. “The COVID-19 Pandemic Has Created Africa’s Next Big Investment Opportunity.” Quartz. May 3. https://qz.com/ africa/1986528/the-covid-19-pandemic-hasboosted-african-health-tech-startups/. Roberts, Stephen. 2020. “COVID-19: The Controversial Role of Big Tech in Digital Surveillance.” LSE Business Review. April 25. https://blogs.lse.ac.uk/ businessreview/2020/04/25/covid-19-thecontroversial-role-of-big-tech-in-digitalsurveillance/. Schwab, Klaus. 2015. “The Fourth Industrial Revolution.” Foreign Affairs. December 12. https://www.foreignaffairs.com/ articles/2015-12-12/fourth-industrialrevolution. Singh, Parminder Jeet, and Anita Gurumurthy. 2014. “Establishing Public-ness in the Network: New Moorings for Development – A Critique of the Concepts of Openness and Open Development.” In Open Development: Networked Innovations in International Development, edited by Matthew L. Smith and Katherine M.A. Reilly, 173–195. Cambridge, MA: MIT Press. Snyder, Jeremy, Marco Zenone, and Timothy Caulfield. 2021. “Crowdfunding Campaigns and COVID-19 Misinformation.” American Journal of Public Health 111 (4): 739–742. American Public Health Association. doi: 10.2105/AJPH.2020.306121. Stevenson, Alexandra. 2018. “Facebook Admits It Was Used to Incite Violence in Myanmar.” New York Times. November 6, sec. Technology. https://www.nytimes. com/2018/11/06/technology/myanmarfacebook.html. Storeng, Katerini Tagmatarchi, and Antoine De Bengy Puyvallée. 2019. “Global Health and the Digital Wild West: Short Report from the Tek4HealthEquity Conference.” IHP. November 14. https:// www.internationalhealthpolicies.org/ featured-article/global-health-and-thedigital-wild-west-short-report-from-thetek4healthequity-conference/. Storeng, Katerini Tagmatarchi, and Antoine De Bengy Puyvallée. 2021. “The Smartphone Pandemic: How Big Tech and Public Health Authorities Partner in the Digital Response to COVID-19.” Global Public Health 16 (8–9): 1–17. doi: 10.1080/17441692.2021.1882530.

Storeng, Katerini Tagmatarchi, Sakiko Fukuda-Parr, Manjari Mahajan, Sridhar Venkatapuram. 2021. “Digital Technology and the Political Determinants of Health Inequities: Special Issue Introduction.” Global Policy 12 (S6): 5–11. Third World Network. 2020. “WHO: Draft Global Strategy on Digital Health Threatens Data Sovereignty.” https://www.twn.my/title2/ health.info/2020/hi200203.htm. Tichenor, Marlee, and Devi Sridhar. 2019. “Metric Partnerships: Global Burden of Disease Estimates within the World Bank, the World Health Organisation and the Institute for Health Metrics and Evaluation.” Wellcome Open Research 4: 35. doi: 10.12688/wellcomeopenres.15011.2. Transform Health Coalition. 2020. “Transform Health Coalition Strategy.” https:// transformhealthcoalition.org/wp-content/ uploads/2021/05/Coalition-Strategy.pdf. Ubaldi, Barbara. 2013. “Open Government Data: Towards Empirical Analysis of Open Government Data Initiatives.” OECD Working Papers on Public Governance, No. 22, 1–60. Paris: OECD Publishing. doi: 10.1787/5k46bj4f03s7-en. United Nations. 2019. “Report of the Special Rapporteur on Extreme Poverty and Human Rights.” November 10. https://undocs.org/ pdf?symbol=en/A/74/493. United Nations. 2020. “Secretary-General’s Roadmap for Digital Cooperation.” June. https://www.un.org/en/content/digitalcooperation-roadmap/. Valuates Reports. 2020. “Video Surveillance Market Size Is Expected to Reach USD 144.85 Billion by 2027.” Valuates Reports. May 11. https://www.prnewswire.com/news-releases/ video-surveillance-market-size-is-expectedto-reach-usd-144-85-billion-by-2027--valuates-reports-301056561.html. Weiner, Jonathan P., Toni Kfuri, Kitty Chan, and Jinnet B. Fowles. 2007. “‘E-Iatrogenesis’: The Most Critical Unintended Consequence of CPOE and Other HIT.” Journal of the American Medical Informatics Association: JAMIA 14 (3): 387–388. doi: 10.1197/jamia. M2338. Whitelaw, Sera, Mamas A. Mamas, Eric Topol, and Harriette G.C. Van Spall. 2020. “Applications of Digital Technology in COVID-19 Pandemic Planning and Response.”

GLOBAL HEALTH 2.0?  |   127 The Lancet Digital Health 2 (8): e435–440. doi: doi.org/10.1016/S2589-7500(2010.1016/ S2589-7500(20)30142–4. WHO. 2018. “A71_ACONF1-En.Pdf.” Draft Resolution on Digital Health. https:// apps.who.int/gb/ebwha/pdf_files/WHA71/ A71_ACONF1-en.pdf. WHO. 2021. “Global Strategy on Digital Health 2020–2025.” https://www.who. int/docs/default-source/documents/ gs4dhdaa2a9f352b0445bafbc79ca799dce4d. pdf. WHO Bulletin. 2020. “WHO | Balancing Risks and Benefits of Artificial Intelligence in the Health Sector.” https://www.who.int/ bulletin/volumes/98/4/20-253823/en/.

WHO Europe. 2021. “Digital Health.” https:// www.euro.who.int/en/health-topics/Healthsystems/digital-health. Williams, Jeremy. 2018. “Elinor Ostrom’s 8 Rules for Managing the Commons.” The EarthBound Report. January 15. https://earthbound.report/2018/01/15/ elinor-ostroms-8-rules-for-managing-thecommons/. Zuboff, Shoshana. 2019. The Age of Surveillance Capitalism: The Fight for a Human Future at the New Frontier of Power: Barack Obama’s Books of 2019. Profile Books.

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B3  |  HEALTHCARE AND COVID-19: PRIVATIZATION BY STEALTH

Introduction

Privatization has been a major international trend in healthcare systems reform during the last four decades. Although there is no consensus on what privatization consists of, the World Health Organization (WHO) defines it as the process through which non-governmental actors get gradually more involved in the provision and financing of healthcare services (Muschell 1995). It entails a wide set of policies ranging from precursors of privatization (such as autonomization, fiscal decentralization, and internal market reforms), to mild (such as contracting-out) and more direct forms, such as liquidation of public assets, public–private partnerships (PPPs), and privatization of healthcare financing (Table B3.1, Maarse 2006). In most countries, especially in low-income countries (LIC) and lower middleincome countries (LMIC), privatization has been promoted by international organizations such as the World Bank (WB) and the International Monetary Fund (IMF). In 1993, the WB in its World Development Report called for the increased participation of private actors in the provision and financing of services, especially in the former European socialist countries and in LatinAmerican countries (World Bank 1993), linking financial support and loans with the promotion of market-oriented reforms. Twenty years later, the IMF made the same call for increased participation of private providers and increased competition in healthcare systems (IMF 2010), linking its loans to indebted EU countries to extensive healthcare privatization conditionalities. The COVID-19 pandemic poses enormous challenges on healthcare systems globally. This chapter explores how privatization has affected the preparedness of healthcare systems around the world, undermining in most cases their ability to timely and effectively control the epidemic and manage its health and social consequences. The chapter also reports on new emerging trends in healthcare privatization during the pandemic and explores the future role of international funding organizations in the promotion of healthcare commercialization after the COVID-19 epidemic crisis.

130   |  Global Health Watch 6 TABLE B3.1:  The seven main types of privatizations in healthcare systems Type

Definition

Rationale

Termination (or liquidation)

The process of state divestment of public assets (like hospitals or primary care centers). It entails the transfer of shares or the direct selling of public infrastructure to private owners.

To reduce the scope of public intervention so to reduce the “burden of public sector financing.”

Contracting-out (or outsourcing)

The partial or total shift of responsibility for provision of clinical or non-clinical services to the private sector, keeping financing responsibilities with the public sector.

Under contracting, the state releases itself from the “burden of direct provision,” while retaining the political and financial responsibility over the contracted services.

Fiscal decentralization

The transfer of the responsibility for pooling revenues and spending healthcare resources from national governments to local authorities (e.g., regional authorities or municipalities).

The state shifts responsibilities within the public sector. Fiscal decentralization can facilitate direct privatization at local levels.

Autonomization

The transfer of decision-making responsibilities and – often – of revenue rights from central government to providers’ level (e.g., hospitals).

Hospitals or primary care centers remain public or semi-public legal entities but operate as private corporates. Autonomization in many cases is the first step towards full privatization.

Internal (or “quasi”) market reforms

Also known as regulated competition, this involves competition on the supply side of the healthcare system while maintaining a single source of public health financing.

Regulated competition is usually combined with the autonomization of public providers and the introduction of contractual relationships between them and the single public health financing body.

Public–private partnerships (PPPs)

Long-term contractual arrangements between public authorities and corporates, which aim to ensure the funding, construction, renovation, management, or maintenance of new public healthcare infrastructure.

Types of PPPs may vary. In most cases the public sector sets the requirements for the new public infrastructure, while the private sector designs, builds, finances, operates, or manages the new project. The public sector reimburses the private contractors for their services.

Privatization of healthcare financing

The increasing involvement of private actors in the financing of healthcare services.

Usually promoted through increased out-of-pocket payments, or by increased participation of private-forprofit insurance schemes in the health coverage of the population.

Source: Table based on Kondilis (2016).

Privatization of healthcare systems prior and during the epidemic and its impact on COVID-19 policy responses

1. Privatization of public health services and functions Control of an epidemic requires sufficient public health infrastructure, with local public health teams able to test symptomatic and suspicious cases, trace their contacts, support individual patients during self-quarantine, and inform local communities on how to apply social distancing measures and use personal

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protective equipment (PPE) against infection (WHO 2020a). Effective control of any infectious disease epidemic also requires that data collected through testing and tracing systems is timely synthesized and transparently communicated, allowing introduction of targeted containment measures and increasing public compliance and trust during their implementation (O’Malley et al. 2009). Over the last 25 years these basic public health functions have gradually been eroded even in high-income countries (HICs), mainly due to low government prioritization and underfunding. The Center for Disease Control and Prevention (CDC) in the USA lost almost 35% of its budget between 2018 and 2020 (Garrett 2020). England’s local public systems of communicable diseases control were gradually dismantled over a longer period lasting several decades (Roderick et al. 2020), while in Greece public funding on epidemiological surveillance was reduced by 40% during the European Commission, Central Bank, and IMF mandated fiscal consolidation program between 2010 and 2018 (Kondilis et al. 2020). When the COVID-19 pandemic unfolded, public health services around the world were ill-resourced and unprepared to carry out their basic functions for the control and management of the epidemic. Immediately, necessary testing, tracing, data management, and communication functions in many cases, as outlined below, were outsourced to private-for-profit corporations. In most countries, testing remains a private individual responsibility, carried out in private-for-profit laboratories and covered by private health insurance or out-of-pocket payments (OOPPs). Even in countries where the state or social security organizations assume the financial responsibility of testing, this is still mostly outsourced to private diagnostic providers. In the USA, for example, local public-school authorities pay private contractors to test students and staff for SARS-CoV-2 (Rafiei and Mello 2020); in the UK, the “Pillar 2” program for testing the wider population is fully outsourced to a network of corporates (including Boots, Sodexo, Deloitte, AstraZeneca, and GlaxoSmithKline labs) responsible for receiving and analyzing samples and managing testing results (Roderick et al. 2020). Similarly, contact tracing is often fully contracted out to private providers or facilitated through partnerships with private-for-profit actors. Serco Plc in the UK runs on behalf of the National Health Service (NHS) call centers with 3,000 newly recruited call handlers and contact tracers (Roderick et al. 2020). The Indian government launched its publicly developed COVID-19 contacttracing app (“the Aarogya Setu App”) using the Android and iOS platforms, after Google and Apple had made them compatible to such tracing applications (French et al. 2020). Less is known about corporate actors’ participation and involvement on COVID-19 data analysis and management. In the UK, Palantir (an American software company specialized in big data analytics) offered to assist the British government in constructing a COVID-19 database, which was received with

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widespread unease (French et al. 2020). In Greece, a similar contract between Palantir and the Greek government was terminated due to concerns over health data privacy raised by the opposition. This “corporate testing and contact tracing system” is responsible for the failure of even developed health systems to have comprehensive and timely knowledge of how SARS-CoV-2 is spreading in the community, a fact that led to significant resurgences, forcing public authorities to control the second or even third wave of the epidemic mainly through stay-at-home orders (lockdowns) instead of targeted measures with less social and economic consequences. The US’s fragmented and privatized epidemiological surveillance system has been unable to collect and report at the federal level comprehensive racial and ethnic data on COVID-19 cases (Schneider 2020; Krieger et al. 2020). UK testing results were lost or partially reported by private laboratories as reporting obligations were not included in their contracts (Gill et al. 2020), while contact-tracing information from private contractors was incomplete and not communicated to public health authorities, leading to local outbreaks that could have been prevented (Torjesen 2020).

2. Privatization of healthcare financing Private contributions represent a significant share of current health expenditure and a major cause for unmet healthcare needs and bankruptcy among the lowincome segments of the population. Although the share of OOPPs to current health expenditure appears to be slowly decreasing, in absolute terms they are rapidly increasing in all countries, for all income groups, and in the most regressive fashion. Health systems in LMICs remain much more dependent on OOPPs than those in HICs. On average, 40% of current health expenditure in LMICs comes from OOPPs; in middle-income countries it is 30%, while the average in HICs fluctuates between 15% and 20% (WHO 2020b). Amid a global pandemic, the fact that access to healthcare services is linked to people’s ability to pay becomes a life-threatening aspect that adversely affects the poorest and unhealthiest segments of society. Many countries, even those with publicly funded health insurance, are at least partly reliant on private health insurance for some services. Amongst highincome countries, the US has the most extensive private healthcare and health insurance system. There, the average amount of co-payments and deductibles for the cheapest insurance plan amounts to $6,506: a sum that discourages sick patients from seeking appropriate care and one possible contributor to skyrocketing COVID-19 infections and avoidable deaths in the country (Huff 2020). Although some states have waived private contributions for COVID-19 hospitalization during the pandemic, the measure does not extend to treatment costs that average between $1,600 and $1,900 for insured patients and up to $75,000 for uninsured ones (Wapner 2020). In India providers have increasingly redirected patients away from publicly subsidized beds to private

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hospital units, where bills for COVID-19 treatment range from $6,000 to over $20,000 (Thiagarajan 2020). In some cases, insured patients have struggled to get their insurance claims paid for their treatment with their claims denied on the grounds that they had pre-existing conditions, that the infection was only mildly symptomatic, or that the price charged by private hospitals did not match insurance’s reimbursement rates (Parashar 2020). In countries where COVID-19 treatments are available free of charge, private contributions continue to pose a barrier to access to other services. In Ireland, for example, the majority of the population incurs a fee for GP (general practitioner) consultations, although this co-payment has been waived for patients with COVID-19 symptoms (Kennelly et al. 2020). The pandemic-driven rise of unemployment and wage reductions means that the segment of population unable to access services due to high costs will inevitably increase (Navarro 2020).

Box B3.1: A particularly American failure Mr. Morris was a 31-year-old man originally in good health who was experiencing houselessness and precarious low-wage work in a mid-sized city in the American South. One evening during the spring Mr. Morris began experiencing fatigue, weakness, and blurred vision, and was hit by a car while crossing a street, leading to a broken leg. He was taken by ambulance to the emergency department of the large academic hospital in his city where he received surgery on his leg and a new diagnosis of Type 1 diabetes. He stayed in the hospital until he was medically stable enough to be discharged and received insulin and instructions on how to manage his new condition. Two months later, Mr. Morris presented to the same emergency department with acute symptoms due to uncontrolled diabetes. He was again admitted to the hospital where his condition was brought back under control by the medical team. He expressed confusion about why his condition had worsened, as he believed he had been following the instructions given to him after his last hospitalization. The medical team explained again the insulin regime, confirmed his understanding, and discharged him. Two weeks after this second hospitalization Mr. Morris was found unresponsive in his tent. A friend called an ambulance, but Mr. Morris was pronounced dead at the hospital. The friend had brought the remaining insulin in Mr. Morris’s backpack along to the hospital where the providers were able to calculate that he had been using his insulin at the prescribed rate. Because of Mr. Morris’s lack of refrigeration, which went unnoticed or unaddressed during his prior medical stays, his insulin had spoiled in the rising summer heat, causing his death.

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The field of Social Medicine would call this a “stupid death,” or even “social murder.” This is because of the many (unnecessary) instances of structural violence which led to his death. First, there is the simple lack of refrigeration, but this was missed by the medical team whose analysis and planning excluded understanding of the social and structural determinants of health. Mr. Morris’s second hospitalization would have been an opportunity to ask “why,” instead of assuming that he had made an uneducated mistake. These proximal realities are set in a larger context. The American healthcare system generally does not incentivize preventative or holistic care, making it less likely to be addressed. For example, procedure-based medical care is reimbursed significantly higher than non-procedural medical care. Additionally, most insurance plans require the patient to pay 100% of costs until the point where the insurer begins to pay, leading many patients to forgo preventative care, turning only to medical care when dire need arises. Neoliberal austerity changes have defunded public health departments and prevent them from taking a proactive stance towards the vulnerable. The state in which Mr. Morris lived and died was not a “Medicaid Expansion” state, one of 12 states where politicians rejected federal dollars from the 2013 Affordable Care Act that could have been used to expand medical access for the poor and uninsured. State politicians justified this decision by claiming that doing so would “increase dependency” upon the government, or by using racialized narratives to claim that undeserving people would abuse these services. The ecosystem of medical providers and payers in the United States is a frayed patchwork quilt of governmental, non-profit, and for-profit organizations which many vulnerable patients are unable to navigate or financially afford. Like many American municipalities, the local government has a history of clearing people out of homeless encampments using police, increasing their vulnerability and transience. It has not pursued “housing first” approaches for people experiencing houselessness, even though certain other forward-thinking programs have shown this to be effective and humane. Finally, American society has continued to promote and to embrace an individualistic, commodified, and predominantly biomedical approach to healthcare, instead of one based in human rights and universal human dignity. Mr. Morris’s life and death show the interlocking ways in which housing, medical care, and social exclusion interact. Let that be his legacy, highlighting the necessity for addressing these human rights in an integrated matter that supports all patients, especially those facing the greatest vulnerabilities.

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3. Privatization of primary health care Primary health care (PHC) has been privatized in different ways, each one having a different impact on the COVID-19 response. A strong and well-coordinated PHC network is a key pillar for effective epidemic management, especially in cases of high community transmission (Lim and Wong 2020). However, the predominant first point of contact may vary according to the structure of a country’s health system and its PHC network. In South Asian and sub-Saharan African countries, decades of structural adjustment programs and austerity have weakened PHC networks, led to a chronic shortage of healthcare professionals, and created a heavy dependence on – most of times unpaid and informal – community health workers (CHWs) as first point of care (Barria et al. 2018). In Bangladesh and in the South African Western Cape Province, CHW programs have been outsourced to large NGOs. With the rise of COVID-19 infections, the role of CHWs in tracing and monitoring COVID-19 spread in the community became even more indispensable (see Chapter A2). Their efforts, however, are hampered by precarious working conditions, inadequate training, support, and supervision, lack of PPE, difficulty to access transport, and an excessive workload since CHWs also ensure continuity of all essential services. In effect, the most vulnerable cadre of the health workforce is left to carry the cost of keeping the system running.1 In other middle-income countries, such as Brazil, Sri Lanka, and Thailand, a well-developed public PHC network is often complemented by formal CHWs which remain the first point of contact for care. In Thailand’s semi-urban and rural areas, public health networks have been a strong point of their local pandemic response (Patcharanarumol et al. 2020). More recent trends of underfunding and outsourcing, however, might be eroding this trend. In Brazil, the dismantling of community and family-focused PHC networks since 2017 set the stage for a constrained PHC, with reduced CHW numbers and lower budgetary allocations. These changes have discouraged a territorial approach to the management of the epidemic and have weakened healthcare system accountability to the population.2 In most HICs, access to PHC is free at the point of use or partly reimbursed by social insurance funds, although co-payments remain common practice. PHC is organized around private GPs and specialists whose services are fully or partially integrated to the healthcare system, depending on country contexts. In South Korea, the government moved the role of first point of care from private GPs and clinics to its public health centers for test and trace activities. In normal times, South Korean public health centers are only entrusted with public health measures and do not provide individual medical care. While South Korea has been lauded for its extensive and effective test and trace capacity, the lack of coordination and referral system between public health centers and (mostly private) hospitals led to poor linkages between test and trace activities and COVID-19 treatments.3

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Finally, even before the pandemic, countries witnessed a push for digitalization and telemedicine in PHC (Greenhalgh 2012) (see Chapter B2). COVID-19 accelerated this trend. When most public and private primary care practices had to downsize their services to fight the rise of infections, telemedicine, e-prescriptions, and digital screenings with prediction algorithms (Fagherazzi 2020) were gradually introduced to replace GPs and to counterbalance the disruption in provision. These algorithms, however, rely on unregulated private technology, yet another step away from the public system (see Chapter B2). Digitalization also increases inequalities, such as in Italy where elderly people and migrants face higher barriers in accessing digitalized welfare benefits and healthcare and social services.4

4. Privatizations of hospital provision The effects of continuous privatization have not strengthened healthcare systems, as neoliberal theories argue, and, instead, have eroded the first line of emergency public health response. The more the system is commodified, the less it is prepared to effectively react to and recover from emergencies. In LMICs, healthcare commodification has been promoted by international agencies to rapidly expand services in countries with weak public health systems. These policies, however, have meant the inevitable weakening of health systems. In war-torn Afghanistan, for example, the WB encouraged outsourcing of healthcare functions as a valid alternative to strengthening public healthcare services, leading to further fragmentation (Palmer et al. 2006). In India and South Africa, hospital care has been contracted out to private providers under the rationale of broadening accessibility to existing services (Palmer et al. 2006). In HICs efficiency prescriptions have facilitated the expansion of privatefor-profit providers. Over the last two decades, PPP hospitals in the UK have proliferated, despite evidence that they are a more expensive and inadequate alternative to publicly financed and built hospitals (Romero 2015). In Italy and Spain, fiscal decentralization has facilitated regional outsourcing of hospital provision to private accredited actors (Rotulo et al. 2020). The limits of private hospital provision have been exposed since the early stages of the COVID-19 pandemic by the inability of health systems to address healthcare needs. The lack of adequate public hospital beds, intensive care units (ICUs), public healthcare workers, and PPE were the main causes for public overload and discontinuity of care. Governments of Italy and Spain responded to the rapid saturation of their hospitals through legal requisitioning of private resources for a reimbursement fee. The aim of this policy was to quickly increase ICU wards’ capacity – downsized by years of privatization and budget cuts – and to guarantee the treatment of COVID-19 patients (Kruse and Jeurissen 2020) (See Table B3.2). Governments of the UK and Ireland, on the other hand, allocated large sums of public resources to private companies to outsource nonCOVID-19 procedures and treatment of COVID-19 cases to private practices.

HEALTHCARE AND COVID-19: PRIVATIZATION BY STEALTH  |  137 TABLE B3.2:  Private hospital sector’s involvement for the treatment of COVID-19 patients Type of involvement

Country

Description

Public–Private Contracts Rent of private assets for a flat rate or cost-price reimbursement

India

Punjab, Tamil Nadu, Andhra Pradesh, and Jharkhand governments leased private facilities to build local capacity for COVID-19 treatment.

Ireland

Lease of 40% of total private beds, 47 ICU beds, 194 ventilators, and nine laboratories. Fees are based on average costs for similar procedures in public hospitals and on costs related to staff and consumables.

South Africa

Purchase of private hospital beds, medicines, equipment, and staff for a flat rate ($164 per patient per day for ICU use), plus any extra treatment required by COVID-19 patients

UK

$547 million for block-buying of private resources for COVID-19 treatment and for nonCOVID-19 procedures

Greece

Seizing of two private clinics for two weeks for treatment of COVID-19 patients.

Italy

€150 million public funds to reimburse private firms over control of private hospital facilities, ICUs, PPE, and hotels for the treatment of COVID-19 patients.

Spain

Management of private health clinics, hotels, laboratories, and testing facilities for the treatment of COVID-19 cases.

Requisitioning Direct state control of privately owned resources for a reimbursement fee. Does not imply change of ownership

Source: Table based on Thiagarajan (2020); Bolger et al. (2020); Dunhill (2020); Patcharanarumol et al. (2020); PHM South Africa (2020).

Reluctance to take possible COVID-19 cases and unwillingness to compromise in their more profitable services were the common responses of for-profit hospitals (Williams 2020). In Bangladesh, many private providers refused to treat COVID-19 patients (Al-Zaman 2020). In Greece, private clinics refused to admit COVID-19 cases and contracted beds to the Greek NHS only for non-COVID-19 cases and for a high reimbursement fee (Kondilis et al. 2020). In India, private hospitals charged exorbitant fees to COVID-19 patients, bypassing price caps and ignoring national government calls for cooperation (Thiagarajan 2020). At a later stage of the epidemic, a general trend saw private hospitals accepting COVID-19 patients either as part of a PPP or because of requisitioning. In both cases private hospitals received either a flat-rate or a cost-price reimbursement for their services. Some Indian states required that a fraction of private hospital beds be reserved for COVID-19 patients for a capped fee reimbursed by the government. However, private providers kept redirecting COVID-19 cases to

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unsubsidized private beds, for which patients were charged higher, unregulated fees (Thiagarajan 2020). In Greece, private hospitals refused to treat COVID-19 cases, fearing that potential contamination of their facilities could jeopardize their businesses. The government responded by requisitioning only two out of almost 144 private clinics to allow access to COVID-19 patients for two weeks. Patients’ treatment was reimbursed by the Greek National Health Service (NHS) (Kondilis et al. 2020).

Box B3.2: Privatization of care homes contributes to high COVID-19 deaths among elderly in HICs There has been a lack of public investment and political will to address longterm care policy and provision in high-income countries for decades. Public care homes were known to be chronically under-funded and under-staffed. Pressures to cut public spending over the last decade led commercialized elderly care facilities to flourish to meet the need of aging populations (Corporate Europe Observatory 2021). These commercialized elderly care facilities were under-resourced despite government subsidies, and staff were often underpaid and undertrained; some facilities did not even have medical professionals among the staff (Public Services International 2020). Consequently, care homes for the elderly in Europe, Australia, and North America were ill-prepared to face the pandemic. As of mid-2020, care home resident deaths were reported to make up a large share of total COVID-19 deaths in a number of countries: 50% in Belgium, 46% in France, 24% in Hungary, 82% in Canada, around 30% in Italy and Germany, 47% in England and Wales, 75% in Australia, around 69% in Spain, and suspected to be more than 50% in the United States (Declercq et al. 2020). In all these countries, residents and staff of both public and private facilities were not provided with adequate supply of PPE and tests at the early stage of the pandemic, leaving them unable to contain the spread of the virus. Public or government-run care homes, however, performed better during the pandemic than private for-profit institutions (Corporate Europe Observatory 2021). State-run aged care facilities operating under strict patient care regulations and guidelines in Australia reported fewer COVID-19 cases and deaths (Cousins 2020). In Ontario, Canada, the number of COVID-19 cases and deaths among long-term care residents in private-for-profit facilities was found to be almost twice as high as the number in public/non-profit facilities (Stall et al. 2020). Private operators tend to cut corners in staffing and equipment to maximize profits which often result in lower quality of care. The deadly consequences of these deregulations had been especially highlighted during the pandemic.

HEALTHCARE AND COVID-19: PRIVATIZATION BY STEALTH  |  139 Box B3.3: Effects of the privatization of India’s health system on COVID-19 response Indian health system financing is one of the most privatized in the world with 70% total health expenditure coming from private health expenditure, in most cases OOPPs. The role of the private sector is also expanding. While private companies are concentrated in both specialized care in large urban areas and primary care in both urban and rural areas, private firms have also recently taken over hospital care services in smaller urban centers through PPPs. Despite a government-backed insurance scheme, the number of households unable to access care owing to economic hardship or having fallen into poverty due to medical expenses remaining very high accounted for 55 million people in 2015 (Sengupta et al. 2017). India has been harshly affected by the pandemic: both the sudden introduction of a strict lockdown (Mukhra et al. 2020) and the for-profit organization of its healthcare system have taken a toll on the population. The government’s early response to the pandemic was to guarantee public treatment for COVID-19 cases, which required reducing provision of other health and essential services as public facilities were repurposed for COVID-19 care. To facilitate access to treatment in private hospitals, a COVID-19 package was made available under the public health insurance program. However, the package only covers hospitalization fees and does not account for costs related to consultations, testing, and treatment. Following the widespread occurrence of private hospitals refusing to admit COVID-19 cases and the charging of expensive fees for treatment, some states imposed price caps for COVID-19-related interventions. To maximize profits, private hospitals responded with medical malpractice, including violation of infection control measures, informal employment, wage reductions, and inadequate supply of PPE. The private health workforce in West Bengal and Delhi reacted with mass resignations. The country’s unreliable epidemiological surveillance is also an effect of earlier fiscal decentralization and extreme fragmentation. Testing does not follow a coordinated strategy but relies on individual responsibility. In large urban areas, testing capacity is concentrated in private laboratories, whereas in semi-urban areas tests are carried out in primary care centers and public medical colleges. As a result, the government’s Integrated Disease Surveillance Program is unable to map out deaths and cases precisely. Kerala – with a history of strong administration and integrated role of the public sector in diagnostics and surveillance – stands as an exception and a positive example of surveillance during the pandemic (Ariyari 2019). In the face of escalating costs, public pressure resulted in varying state-based caps on the price of diagnostic tests.

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Pre-existing capacity constraints, including staff vacancies, means that the country relies heavily on an over-stretched workforce. The municipality of Delhi mobilized the dengue and malaria prevention workforce for case monitoring and tracing, which was already working at 80% undercapacity before the pandemic and could therefore not complete both tasks. Similarly, CHWs were simultaneously deployed for community outreach, delivery of relief, surveillance, and continuity of essential care (Nanda et al. 2020). Shortage of PPE throughout the country has fueled a series of discriminatory behaviors among municipalities and in public management of low supplies. In areas with strong public procurement such as Tamil Nadu, Kerala, and Rajasthan, however, the supply chain proved to be more effective.

Future developments on privatization of healthcare after the COVID-19 pandemic

Economic recession triggered by the pandemic left countries scrambling for loans from international financial institutions. The liquidity needs of emerging economies to weather the pandemic were estimated at around $2.5 trillion (Stubbs et al. 2021). In March 2020, the IMF and the WB announced their commitment to provide $50 billion and $14 billion respectively in emergency loan assistance to LMICs. By the end of 2020, the IMF had approved 130 loans totaling $88.08 billion, although disbursement has been very slow. It is also important to note that many of these countries were already undergoing loan programs prior to the pandemic and are therefore still tied up in debt repayment; some are even categorized as high risk or in debt distress. Despite the large amount of loans provided to these countries, only a small portion is allocated for emergency COVID-19 spending while the rest is used to bail out private lenders (Jubilee Debt Campaign 2020). A recent report by Oxfam showed that a majority of IMF’s COVID-19 loans suggested or demanded spending cuts and wage bill restraints to service debt repayment (Oxfam International 2020) and 72 countries are projected to begin these fiscal consolidation measures as early as 2021 (Munevar 2020) when there is still great uncertainty surrounding the scale of the pandemic and the depth of economic crisis (see Chapters C1 and D4). The WB loans are also conditional on structural adjustment policies mandating deregulation and trade liberalization, with a focus on scaling up PPPs (Dimakou et al. 2020). The WB channels the larger portion of its COVID-19 assistance ($8 billion) through its private financing arm, International Finance Corporation (IFC), which aims to support private companies including those in the healthcare sector (Engel et al. 2020).

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Whatever the financing mechanism, the resources do not necessarily go to those in need in this time of crisis and are not being invested in building a resilient and strong public system. The IMF and the WB have long been criticized for conditionalities attached to their loans, typically involving a mix of privatization, liberalization, and fiscal austerity, which generally result in negative health and social costs. The growing body of evidence shows that the programs increase socioeconomic inequality and result in lower economic growth than expected in the medium- and long-term (Ruckert et al. 2015). These institutions drive the proliferation of privatization in health and social sectors actively by promoting commodification of services (Gideon and Unterhalter 2020) and passively by requiring austerity and structural economic reforms. The devastating pandemic and expected prolonged economic recession have not substantively changed this practice despite their top-level rhetoric. As noted above, there is already a trend of resorting to PPPs to handle the pandemic, which may be further catalyzed by the WHO’s continued support for engagement of the private sector to achieve Universal Health Coverage (UHC) (Moeti and Salah 2020) (see Chapter B1). Post-COVID-19, we will almost certainly see an acceleration of this trend as countries face high debt repayment and immense pressure for fiscal consolidation. Conclusions

The COVID-19 pandemic has exposed health system vulnerabilities around the globe. Most of these vulnerabilities are related to the chronic under-investment in public health and healthcare services, and their fragmentation due to privatization. Given the current global power dynamics, the COVID-19 pandemic created new opportunities for the involvement of private-for-profit actors in the delivery and financing of services. Corporates are heavily involved in COVID-19 testing, tracing, and data management systems, in many occasions undermining the ability of public health services to control the epidemic in a targeted and comprehensive manner. They are also engaged in the facilitation or direct delivery of telemedicine services which expanded rapidly to compensate for disrupted public primary care services. These new areas of activity create new opportunities for profit-making at the expense of patients and public financing bodies. In areas where private-for-profit corporates were already playing a significant role, alarming trends have been reported. Private-for-profit hospitals refused to treat COVID-19 patients and only agreed to engage at a price after legal action was taken by governments or new lucrative PPP contracts were signed. In the private-for-profit nursing home market, high COVID-19 mortality rates have been recorded mostly related to the low staffing rates, the lack of PPEs, and the loose oversight of these facilities by public agencies. Contracting-out, new PPPs, and privatization of healthcare financing have been the major trends of healthcare privatization during the pandemic. These trends may accelerate in the near future given that multiple countries are facing

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COVID-19 induced recession and loan agreements with IMF and WB, wellknown proponents of market-oriented options in healthcare. The COVID-19 pandemic has set the alarm. Strengthening public healthcare systems is a prerequisite for controlling the current epidemic and a necessary investment for managing future public health threats and emergencies (PHM 2021). Increased public financing (predominantly through progressive taxation), direct public investments for new public infrastructure and modernization of existing public facilities, empowerment and support of public healthcare workers, strict regulation of digital health services and big data, and the re-socialization of essential health services (including long-term care) are the necessary steps that must be taken to increase public healthcare capacity and to safeguard public goods. Notes 1  Interviews by the People’s Health Movement (PHM): Leslie London, Chair of Public Health Medicine, University of Cape Town, and Lauren Paremoer, Lecturer at the Department of Political Studies, University of Cape Town, January 12, 2021; Indranil Mukhopadhyay, Associate Professor, Jindal School of Government and Public Policy, December 14, 2020.

2  PHM interview, Aquilas Mendes, Professor at the Public Health Department, University of São Paulo, December 28, 2020. 3  PHM interview, Chang Yup Kim, Professor at the School of Public Health, Seoul National University, December 16, 2020. 4  PHM interview, Chiara Bodini, University of Bologna, March 1, 2021.

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B4 | OLD/NEW POLITICS OF ACCESS TO MEDICINES

Introduction

Mention the words “access to medicines” and one’s mind is immediately cast back to the battles to make HIV/AIDS medicines available to people in Africa in the 1990s. But despite some significant wins, inequities in access have persisted over time and have been growing in importance in recent years due to the increasing number of high-cost technologies entering markets. The COVID-19 pandemic has brought urgent attention to solving the problem of inequitable access to pharmaceuticals, with the future of the world’s 7.8 billion people dependent on affordable, timely access to new diagnostics, treatments, and vaccines. In this chapter we explore the problem of inequitable access to medicines, the way it has changed over time, and the entrenched global power structures that perpetuate the status quo, including the power of the pharmaceutical industry. We examine the way in which intellectual property (IP) regimes allow for monopoly pricing and the exclusion of competition and trace the expansion of IP protections through trade agreements over the last two and a half decades. We also explore regulatory processes and the ways in which these can also limit access. Special attention is given to the global politics of access to COVID-19 products, efforts to provide timely and affordable access globally, and the persistent barriers encountered in meeting this aim. Throughout, current debates about how to make medicines more affordable, options that are being investigated, and the efforts of activists to change the status quo are described, and opportunities provided by the COVID-19 pandemic to reimagine how to provide access into the future are considered. Inequities in access to medicines

Access to “safe, effective, quality and affordable essential medicines and vaccines for all” forms a core part of Target 3.8 under the United Nations Sustainable Development Goals (SDGs), and is seen as key to achieving universal health coverage and SDG Goal 3 (“Good Health and Well-being”) (United Nations 2015). Access to medicines and vaccines is also important for meeting many of the other Goal 3 targets (such as Targets 3.3, “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases,” and 3.4, “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being”) (United Nations 2015).

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Over the last few decades, significant advances in medical technologies have seen large reductions in morbidity and mortality due to infectious diseases such as polio, HIV/AIDS, rotavirus, and hepatitis C, as well as non-communicable diseases including various cancers and autoimmune diseases (United Nations Secretary-General’s High Level Panel on Access to Medicines 2016). For large parts of the world’s population, however, lack of access to affordable medicines remains a significant problem. The World Health Organization (WHO) estimated in 2004 that almost 2 billion people did not have access to essential medicines (WHO 2004). In 2015, the WHO and the World Bank (2015) estimated that 400 million people were still missing out on access to medicines, vaccines, diagnostics, and medical devices. The report found that, globally, only 37% of people living with HIV had access to anti-retroviral treatment, while treatment coverage for hypertension ranged from 7%–61% of people with high blood pressure, with effective coverage ranging from 1%–31% (WHO and World Bank 2015). Large numbers of people also continue to go without treatment for neglected tropical diseases, which lack sufficient investment in research and development (United Nations Secretary-General’s High Level Panel on Access to Medicines 2016). A large proportion of those who lack access to medicines, vaccines, and other medical products live on low incomes in middle-income countries (ibid.). Middleincome countries, often referred to by the pharmaceutical industry as “pharmerging markets” (IQVIA Institute for Human Data Science 2019), can face steeply increasing tiered pricing arrangements that make it difficult to provide access for low-income groups; for example, increasing gross national income (GNI) per capita is associated with sharp increases in prices for vaccines (WHO 2018). For low-income countries, medicines account for the largest proportion of outof-pocket care costs, with the proportion dedicated to medicines increasing as national income decreases (Vialle-Valentin et al. 2008). But people on low incomes in wealthy countries can also experience difficulties obtaining affordable access. Gender equity with respect to access to medicines and vaccines has been little-studied as a global phenomenon, although gender differences in access are common when examining specific nations, treatments, and conditions (Stephens et al. 2013). Depending on the setting, women and girls’ access to medicines can be limited by many factors other than socioeconomic status including gender discrimination, religious and cultural practices, lack of financial independence, and gender-based violence (Mike 2020). Affordability as a key determinant of access

Access to medicines depends on many factors including financing, information systems, procurement and distribution systems, health service delivery, and human resources (United Nations Secretary-General’s High Level Panel on Access to Medicines 2016). However, medicine affordability is crucial to achieving equitable access (Wirtz et al. 2017). An important historical case study is the lack of access to HIV/AIDS treatments in Africa in the 1990s. In 2000, HIV/AIDS

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treatments costed more than $10,000 per patient per year until social struggles to provide access to generics in 2001 brought the cost down to a fraction of the original price thanks to the Indian generics producers’ reaction to mounting mobilization around this piercing issue (Médecins Sans Frontières 2002). In recent years, high-cost medicines such as cancer and immunotherapy treatments, along with treatments for hepatitis C, have seen rising pharmaceutical expenditure which has challenged the ability even of high-income countries (HICs) to provide access. In 2019, the global pharmaceutical market was predicted to be worth more than $1.5 trillion by 2023, growing at 3%–6% per year (IQVIA Institute for Human Data Science 2019). A 2015 Organization for Economic Cooperation and Development (OECD) report found that pharmaceutical expenditure, which accounted for approximately 20% of health expenditure in OECD countries in 2013, was continuing to rise, mainly driven by increasing numbers of high-cost medicines becoming available, some of which only provide minor improvements in comparison with existing drugs (OECD 2015). In 2015, the median price of a 12-week course of sofosbuvir, a breakthrough treatment for hepatitis C, was $42,017 across 26 OECD countries, with lower-income countries paying higher adjusted prices than higher-income OECD members (Iyengar et al. 2016). A cross-country study of access to medicines for cardiovascular disease found that these medicines were “unavailable and unaffordable for a

Image B4.1  Inequitable access to COVID-19 vaccines. Source: Sketch by Indranil for Global Health Watch 6.

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large proportion of communities and households in upper middle-income, lower middle-income, and low-income countries” (Khatib et al. 2016: 61). In many low- and middle-income countries (LMICs), particularly in South-East Asia and Africa, out-of-pocket spending on medicines is one of the main causes of catastrophic health expenditure (World Health Organization and International Bank for Reconstruction and Development 2020), with high prices acting as a barrier in any public provisioning of medicines in LMICs (Ewen et al. 2017).

Box B4.1: Colonial control: pharmaceuticals access in Palestine Access to essential medicines, as part of the right to the highest attainable standard of health, is well founded in international law. This extends to ensuring the right of countries to develop their own pharmaceutical manufacturing capacity, which can grant long-term affordable access to essential medicines. Pharmaceutical production in Palestine started in the West Bank and Gaza Strip in the 1970s. There are many Palestinian companies that produce pharmaceuticals for the local market and for export: Birzeit Pharmaceutical Company, Jerusalem Pharmaceuticals, Dar Al-Shifa Pharmaceutical Company (Pharmacare), Beit Jala Pharmaceutical Company, Sama Pharmaceuticals Manufacturing, Gamma (now closed), and Middle East (Megapharm) (Social and Economic Policies Monitor 2013, 54). These companies cover around 60% of the Palestinian market’s pharmaceutical needs. They also export to Eastern Europe, Jordan, Algeria, Qatar, and Germany. In its latest report, the Palestinian Authority’s Ministry of Health revealed that it spends around 366 million Shekels on medicines, vaccines, laboratory supplies, and medical consumables, which constitutes 18% of its budget. The procurement of medicines from abroad constitutes around 40% of the Palestinian Authority’s delayed payments (debt) budget line (around 336 million Shekels) (Palestinian Ministry of Health 2019, 70). The regulation of the Palestinian pharmaceuticals market is subject to the Paris Protocol, which governs the economic and financial relations between “Israel” and the Palestinian Authority. The Protocol also regulates importing, exporting, and taxation mechanisms. This has led to the occupation government imposing restrictions on Palestinian pharmaceutical manufacturers, leading to the pharmaceutical market being flooded with competitively priced “Israeli”-produced medicines, undermining the local industry. The occupation government also slows the production process of Palestinian pharmaceutical companies by delaying imported needed raw materials allegedly to conduct security checks (Social and Economic Policies Monitor 2013, 54). The occupation’s Ministry of Health allows only medicines registered in “Israel” to be imported by the West Bank and Gaza Strip, denying

OLD/NEW POLITICS OF ACCESS TO MEDICINES  |  151 Palestine the ability to maintain pharmaceutical importing or exporting relations with its closest markets. Pharmaceutical products to which access is being prevented include inexpensive generic medicines manufactured in India and China, as imported medicines registered in “Israel” come mainly from the EU, North America, and Australia (Who Profits from the Occupation 2012). Under agreements with the Palestinian Authority, “Israeli”-produced or imported medicines enter Palestine without the need to pay any customs, change their products, or change their product packaging. “Israeli” and multinational companies can sell medicines to Palestinians without having to provide any instructions in Arabic, and without considering different social categories based on income when drug prices are set. This situation led to “Israeli” companies monopolizing the medicine manufacturing and distribution market in occupied Palestine while ignoring the human rights guidelines, with a huge increase in the capital of those companies. The outcome of these policies is a loss of Palestinian pharmaceutical manufacturing capacity. In 2018, the value of imported medicines increased from the previous year and ranked seventh of the top ten products imported from “Israel” (Palestinian Central Bureau of Statistics 2019, 153). If the Palestinian Authority stopped importing pharmaceuticals from “Israel,” local companies could increase their current level of coverage in the local market from between 50% and 60%, to between 70% and 80%. The Palestinian Authority will still need to import some medicines which are too costly to produce domestically or that require special production lines, but its ability to do so should not be confined to “Israeli”-registered products only and should not be at the cost of weakening its own domestic manufacturing. Authors’ note: We took the decision to write “Israel” in quotation marks because we, as Palestinian people, do not recognize the legitimacy of the “Israeli” state on the lands that have been colonized in 1948 by Zionist entities. Palestinian people have lived under colonization since 1948, under occupation since 1967, and under apartheid regime from the river to the sea for decades. We will never stop demanding the respect of our right to self-determination based on international law.

The COVID-19 pandemic: highlighting global inequities

The COVID-19 pandemic has starkly highlighted global inequities in access to medicines and vaccines and in access to other medical products such as devices and diagnostics. Trade in medical products was already highly concentrated and inequitable due to neoliberal policies disincentivizing local manufacturing, with the top ten importers, all HICs, accounting for 65% of the world’s medical imports (including personal protective equipment and ventilators) in 2019 (World Trade Organization 2020a). Similarly, the top ten exporters of medical

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products (all HICs except for China) accounted for 74% of exports (WTO 2020a). These inequities were exacerbated during the pandemic, with per capita imports of COVID-19 medical products in HICs exceeding those of low-income countries (LICs) by a factor of around 100 (United Nations Conference on Trade and Development 2020). Early in the pandemic, the WHO along with several global health and private organizations (including the Bill & Melinda Gates Foundation) established the Access to COVID-19 Tools Accelerator (ACT Accelerator) to support the development and distribution of COVID-19 medical technologies (see Chapter D1). The ACT Accelerator includes four pillars: diagnostics, treatments, vaccines, and health systems strengthening. The vaccines pillar, COVAX, aimed to allocate at least 2 billion doses of vaccine equitably amongst participating countries according to population, providing 20% coverage by the end of 2021. These mechanisms to promote affordable access have not attracted sufficient investment: by June 2021 the ACT Accelerator was $16 billion short of its funding targets (Business Standard 2021), and by the end of August 2021 COVAX had shipped less than 230 million vaccine doses (UNICEF n.d.), putting it way behind its goal of delivering 2 billion by the end of the year. Meanwhile, by November 15, 2020, governments had negotiated pre-purchase agreements directly with pharmaceutical companies for almost 7.5 billion doses of COVID-19

Image B4.2  Inequitable distribution of COVID-19 vaccines. Source: Sketch by Indranil for Global Health Watch 6.

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vaccines, 51% of which had been reserved by wealthy countries representing only 14% of the global population (So and Woo 2020). This imbalance has only worsened over time. On August 4, 2021, the director general of the WHO pointed out that “So far, more than 4 billion vaccine doses have been administered globally. More than 80% have gone to high- and upper-middle income countries, even though they account for less than half the world’s population” (WHO 2021). By this stage, while HICs had administered close to one dose per person on average, low-income countries had only managed to administer 1.5 doses per 100 people (WHO 2021). Many HICs have begun stockpiling reserves for booster programs, ignoring an appeal by the WHO for a moratorium on booster shots until health workers and older adults could be vaccinated in all countries (The Straits Times 2021). G7 countries are expected to have close to a billion stockpiled vaccine doses left over by the end of 2021, even after completing their booster programs (Lovett 2021). This inequitable distribution of COVID-19 vaccines could greatly slow the global recovery from the pandemic. A study undertaken by researchers at Northeastern University (Chinazzi, Davis et al. 2020) modeled two vaccine distribution scenarios based on the hypothetical case of 3 billion doses of a single dose vaccine available on March 16, 2020. The first (uncooperative) scenario assumed the first 2 billion doses would be reserved for HICs with the remaining billion distributed equitably according to population. The second (cooperative) scenario involved equitable sharing of all 3 billion doses according to population. For a vaccine of 80% effectiveness, they found that the cooperative strategy would avert 61% of deaths by September 1, 2020, while the uncooperative strategy would only avert 33%. Estimates of the global economic costs of vaccine nationalism by the RAND Corporation (Hafner et al. 2020) and the International Chamber of Commerce (Cakmakli et al. 2021) found that hoarding of vaccines by wealthy countries could result in a gross domestic product (GDP) loss to the global economy of around $1.2 trillion (in GDP terms) and between $1.5–$9.2 trillion respectively. The global intellectual property regime and its effects on access to medicines

One of the root causes of inequitable access to medicines and vaccines is the global regime of intellectual property rights (IPRs) for pharmaceuticals. Intellectual property rights provide a period of exclusivity where the rights holder can prevent third parties from making or selling the product. The rationale for providing these exclusive rights is to offset the high development cost and provide incentives for investment. However, arguments that IPRs and monopoly pricing are necessary to incentivize innovation are not supported by sound evidence – in fact, there is evidence to suggest that intellectual property can hamper drug development (Government Accountability Office 2006). Estimates of research and development (R&D) costs are often based on non-transparent industry information from confidential surveys or proprietary databases and vary widely,

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from the low hundreds of millions to close to a billion dollars per new discovery (Morgan et al. 2011). Much of the R&D that results in new drugs is publicly funded (Galkina Cleary et al. 2018) and prices of new drugs are often set so high they generate income that greatly exceeds the likely R&D costs (Tay-Teo et al. 2019). Increasing IPRs has not been shown to incentivize innovation or increase technology transfer in LMICs (Sweet and Eterovic Maggio 2015) or to give rise to greater R&D for diseases that mainly affect the Global South (Kyle and McGahan 2012). The global IPR regime is underpinned by the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), established in 1995, which set into place an agreed minimum standard for IPRs for all members of the World Trade Organization. These IPRs included a minimum 20-year patent term for both product and process patents in all fields of technology, including pharmaceuticals. The TRIPS Agreement represented a profound change. Prior to TRIPS, countries had varying patent periods, with many LMICs not providing patent protection at all, or at least not for pharmaceuticals (‘t Hoen 2009). The negotiation of TRIPS involved intense lobbying by the pharmaceutical industry and HICs and opposition by many LMICs, which ultimately agreed to adopt TRIPS in the vain hope that it would reduce unilateral trade retaliation over perceived IPR breaches from the US (‘t Hoen 2009). As Peter Drahos describes, “TRIPS was the outcome of a sophisticated networked power wielded by a coalition of powerful developed states and corporate actors seeking greater economic rents for their intellectual property assets” (Drahos 2007, 12). Over the last 25 years, the TRIPS Agreement has legally prevented manufacturing of generic pharmaceutical products and has legitimized private ordering of pharmaceutical production and supply in low- and middle-income countries (LMICs). TRIPS, however, does provide certain flexibilities to allow members to meet the public health needs of their populations, thanks to the relentless efforts of some countries in the Global South during the General Agreement on Tariffs and Trade (GATT) negotiations (particularly India and Brazil). The rights of World Trade Organization (WTO) members to use these flexibilities were re-affirmed in the Doha Declaration on the TRIPS Agreement and Public Health adopted in 2001 (World Trade Organization 2001). One of these flexibilities is compulsory licensing, which allows for a patented invention to be exploited without the permission of the patent holder in certain circumstances. While this remains an important mechanism for enabling access, in the two and a half decades since TRIPS compulsory licensing has remained relatively littleused, mainly limited to HIV/AIDS drugs (Son and Lee 2018), with countries that do invoke their right to use it facing pressure from the USA, the EU, and other wealthy countries (Navarro and Vieira 2021). In the meantime, bilateral and regional trade agreements negotiated outside of the WTO umbrella have incrementally added to the IPRs enshrined in TRIPS, lengthening patent terms, expanding the scope of patentability, and adding

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further layers of IP rights that delay generic competition (see Chapters C3 of Global Health Watch 3 and D4 of Global Health Watch 4). This is particularly the case for trade agreements negotiated by the United States and the EU, where most of the transnational pharmaceutical corporations are headquartered (Lopert and Gleeson 2013). IPRs commonly sought by the US in its trade agreements include patent term extensions, data exclusivity (exclusivity for test data are submitted to regulatory agencies for the purpose of obtaining marketing approval), patents for new uses, processes, and/or methods of using known products, and patent linkage (creating a dependent relationship between patent status and marketing approval) (Lopert and Gleeson 2013). These IPRs all appeared in the Trans-Pacific Partnership Agreement (TPP) (Gleeson et al. 2018) and then subsequently in the United States-Mexico-Canada Agreement (USMCA) (Labonté et al. 2019), at least until it was renegotiated and amended to get it through the US Congress, when some TRIPS-Plus provisions were altered or removed (Labonté et al. 2020). EU agreements have included a similar set of IPRs; for example, the Comprehensive Economic and Trade Agreement (CETA) between the EU and Canada included data exclusivity provisions along with an additional period of protection following the end of the patent term (Lexchin and Gagnon 2014). The pharmaceutical industry has lobbied heavily for increased IPRs in these trade agreements. This is particularly notable in the USA, where the industry associations and pharmaceutical companies have direct input to the US trade negotiating positions through its formal trade advisory committees, as well as exercising influence through other avenues including political donations and close informal relationships with trade negotiators (Gleeson et al. 2017). The IPR expansionist agenda has not gone unopposed; significant civil society movements have countered the pharmaceutical industry lobbying which has mitigated US and EU agendas and, in some cases, completely overturned them. The US and EU proposals have also met with resistance from other countries. In the TPP negotiations, the initial US proposals were mitigated significantly during the negotiations and when the Trump administration withdrew the USA from the agreement in 2017, the remaining parties suspended many of the TRIPS-Plus IPRs from the re-named Comprehensive and Progressive Agreement for Trans-Pacific Partnership (Pusceddu 2018). After the USMCA was signed, the agreement was renegotiated to ensure it obtained enough support from Democrats to be ratified by the US Congress. The amendments included removal of the controversial provision for extended exclusivity for biologics, along with removal or modification of several other TRIPS-Plus provisions (Labonté et al. 2020). IPRs as barriers to access for COVID-19 products

During the COVID-19 pandemic, IPRs have created barriers to the rapid scaling up of treatments and vaccines. In the early stages, patents on N95 masks

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threatened to prevent sufficient numbers being manufactured (Watkins 2020). Later, patents on the potential COVID-19 treatment remdesivir, together with restrictive licensing practices by its maker Gilead Sciences, prevented middleincome countries from accessing either the highly priced originator product, or the lower-priced version made by licensed manufacturers in India, Pakistan, and Egypt (see Box B4.1). Voluntary efforts to facilitate sharing of IP such as the COVID-19 Technology Access Pool (C-TAP), established by the WHO following a proposal by Costa Rica (WHO 2020a), have largely failed to gain support from high-income countries and pharmaceutical companies. By the end of August 2021, C-TAP was supported by only 43 countries (almost all LMICs), but not by a single research-based biopharmaceutical company. At the time of writing, C-TAP remained unused. While some pharmaceutical companies have made voluntary promises to share IP during the pandemic, most have not, and with the notable exception of AstraZeneca, many clearly intend to profit from the COVID-19 products they make. Moderna, maker of one of the first COVID-19 vaccines to finish Phase III trials, issued a statement indicating that: … while the pandemic continues, Moderna will not enforce our COVID-19 related patents against those making vaccines intended to combat the pandemic. Further, to eliminate any perceived IP barriers to vaccine development during the pandemic period, upon request we are also willing to license our intellectual property for COVID-19 vaccines to others for the post pandemic period. (Moderna 2020, para. 3)

This statement was greeted with skepticism by some civil society organizations, who expressed reservations about the value of Moderna’s commitment not to enforce patents given that it made no commitment to sharing the other types of information and resources that would be needed to make its vaccine (HealthGap 2021). Despite large injections of public funding (Martin and Jani-Friend 2021), pharmaceutical companies hold the rights to determine who can access vaccines that are desperately needed the world over, and on what terms. According to Médecins Sans Frontières (2020a), the development and manufacturing of the six most promising vaccine candidates attracted $12 billion in public funding. The KENUP Foundation (2021) estimated that by January 2021, 93 billion euros of public financing (including advance market commitments) had been invested in COVID-19 vaccines and treatments, with over 95% of this amount devoted to vaccines. Yet some pharmaceutical companies are expected to profit handsomely from COVID-19 vaccines. Makers of two of the front-runner vaccines, Pfizer/BioNTech and Moderna, indicated in March 2021 that they expected to generate $15 billion and $18.4 billion in revenue respectively in 2021 based on existing supply agreements (Kollewe 2021, 6 March). By the end of July 2021, Pfizer was predicting COVID-19 sales worth approximately $33.5 billion for 2021, including expected sales of booster shots (Hopkins and Grossman 2021).

OLD/NEW POLITICS OF ACCESS TO MEDICINES  |  157 Box B4.2: IP and barriers to access during the COVID-19 pandemic: the example of remdesivir Remdesivir was a candidate for COVID-19 treatment which appeared promising in the early months of the pandemic and was given emergency use authorization in some countries for severe cases of COVID-19. WHO later issued a recommendation against its use in hospitalized patients due to lack of evidence that its use reduced mortality and other significant outcomes (WHO 2020b). Gilead Sciences, a US company, owns patents for remdesivir in more than 70 countries (Médecins Sans Frontières 2020c). For a five-day course of treatment (six vials), it set the price at $2,340 for US government buyers and purchasers in other high-income countries (Gilead Sciences 2020). The cost of production has been estimated at around $1 per day, or $6 for a full treatment course (Hill et al. 2020). The development of the drug was underpinned by at least $70.5 million in public funds (Public Citizen 2020). Gilead negotiated voluntary licenses with pharmaceutical companies in India, Pakistan, and Egypt to produce the drug much more cheaply (Silverman 2020). One company, Cipla, planned to sell the drug for $66 dollars per vial (Reuters Staff 2020). But the terms of the licenses limited exports of these cheaper versions to 127 mainly low-income countries (Maybarduk 2020). Many middle-income countries – such as China, Brazil, and Mexico, for example – along with high-income countries were excluded from the deal. The US government bought up almost all of the first three months’ supply of remdesivir from Gilead (U.S. Department of Health & Human Services 2020), leaving many countries unable to source the drug from Gilead, and prohibited from either making it or sourcing it from other suppliers.

Some companies producing COVID-19 medical products have negotiated voluntary licenses with other manufacturers. However, these licenses are commercial contracts which are often non-transparent and can tightly restrict what companies with these licenses can do with the product, including how much they can manufacture, who they can sell or export it to, and for what price (Médecins Sans Frontières 2020b).

1. The TRIPS waiver for COVID-19 products In October 2020, India and South Africa made a proposal to the WTO TRIPS Council that IPRs for COVID-19 products should be waived for the duration of the pandemic (WTO 2020b). This waiver would enable WTO members to elect to declare that their IP laws would not apply to COVID-19 products during the pandemic, thus paving the way for increased manufacturing of critical tools to

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fight the pandemic (Dhar and Gopakumar 2020). While WTO members can use compulsory licensing to bypass patents, it is a time-consuming, cumbersome, and contestable mechanism. Compulsory licensing also only applies to patents, whereas several other IPRs, such as trade secrets protection, can block access to biologic treatments and vaccines by preventing competitors from accessing information about manufacturing processes, discussed later in this chapter, and biological resources such as cell lines (Levine 2020). By March 2021, the TRIPS waiver had gained the support of more than 100 of the WTO’s 164 member states but was blocked from moving to text-based discussions by the opposition of several wealthy countries including the USA, the European Union, the United Kingdom, Japan, Canada, Switzerland, Brazil, and Norway (Third World Network 2021). In May 2021, the USA made an historic move in declaring its support for a waiver limited to vaccines (Office of the United States Trade Representative 2021). This development makes the success of negotiations for a waiver far more likely; several of the opposing countries have since fallen in line with the USA, although the EU continues to express the lack of need for such a waiver. It is not clear how long text-based waiver negotiations may take, although the new WTO Director-General is hoping for a consensus to be reached by November 2021. Meanwhile, wealthy countries that have opposed the TRIPS waiver have continued to hoard vaccines and, in some cases, squabble over preferential access. In January 2021 the EU, facing supply shortfalls of the Pfizer/BioNTech and AstraZeneca vaccines, introduced regulations requiring export notifications and threatened to introduce export bans (Lee 2021). France and Germany made legal threats against AstraZeneca after production problems reduced its promised supply for the first quarter of 2021 by 75% (Boffey 2021). The underlying issues for the shortages – monopolies over the IP and production of the vaccines – are the very issues that the TRIPS waiver is intended to assist in addressing. Some of the short-term access problems for COVID-19 products could be addressed through the TRIPS waiver along with incentivizing or requiring pharmaceutical companies to contribute to mechanisms for sharing knowledge and data (such as C-TAP) and investing in technology transfer and local production in LMICs. In the longer term, greater attention needs to be given to more fundamental changes to the way in which R&D is funded and to shifting the entrenched power imbalances that reinforce the status quo. Alternative mechanisms that have been proposed for funding R&D in ways that promote rather than obstruct access include financial incentives like grants and prizes, and other incentives to invest in R&D, along with shared licensing mechanisms such as patent pools, as discussed in Chapter B5 of Global Health Watch 2. A global R&D treaty, as called for by many civil society organizations and recommended by the WHO Consultative Expert Working Group (CEWG) on Research and Development: Financing and Coordination (2012), would help to ensure a more equitable distribution of the costs and rewards of pharmaceutical

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R&D. Shifting power away from industry also requires improving transparency in pharmaceutical markets, to ensure that information about prices, sales, marketing expenditure, public financing, and so on, which is currently considered commercial-in-confidence, is available to governments and the public. Building support for these types of initiatives in the face of trenchant opposition by the pharmaceutical industry requires civil society action, as in the case study of Universities Allied for Essential Medicines described in Box B4.3.

Box B4.3: Universities Allied for Essential Medicines UK: public return for public investment Universities Allied for Essential Medicines (UAEM) is a student-led movement based at university campuses across 20 countries. We see universities as key to reimagining an innovation system that is fair for all. Up to a third of new drugs originate from public sector research, and universities are critical to the scientific progress underlying advances in health (Nayak et al. 2019). UAEM is therefore advocating for universities to implement equitable research and technology transfer policies that ensure affordable access downstream. In spring 2020, UAEM UK gathered online to foster a new generation of student campaigners. We experienced first-hand how grassroots activism can flourish during a pandemic, even when there is no physical space to come together and organize. UAEM grew out of the HIV/AIDS crisis in the early 2000s, when students and staff at Yale University, supported by Médecins Sans Frontières, campaigned successfully against the prohibitively high price of the essential antiretroviral stavudine, developed at the university (Kapczynski et al. 2005). At the time 95% of HIV-infected people in the developing world did not have access to antiretroviral therapy. Following protests, the university was pressured to renegotiate the license with Bristol-Myers Squibb, which enabled a 30-fold drop in price. UAEM grew globally from this experience, focusing on improving technology transfer policies of publicly funded research institutions. Following advocacy efforts by UAEM students, Johns Hopkins University in the USA licensed the tuberculosis drug sutezolid to the Medicines Patent Pool (UAEM 2015). At the start of the current pandemic, we recognized the need to invigorate our member base to tackle anticipated access challenges around COVID-19 health technologies, including drugs, vaccines, and diagnostics. The student body is a powerful voice within the university and can advocate for change at institutions otherwise inaccessible to other health activists. University-level decisions regarding technology transfer can impact the lives of millions of people downstream following transfer of a health technology to the private sector. We trained teams across the UK in the fundamentals of university

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technology transfer, campaigning strategy, and creative activism, empowering students to address policies and practices at their own institutions. The first year of the pandemic also saw the finalization of the Equitable Technology Access Framework (ETAF) (UAEM 2020). This policy guidance framework aims to support universities in adopting policies for global equitable access and affordability of biomedical innovation. In collaboration with a local UAEM chapter, we saw the University of Edinburgh in December 2020 update its essential medicines policy as outlined in the ETAF framework. We hope to further expand the implementation of ETAF across higher education institutions in the UK. To track the amount of public funding pledged towards COVID-19 R&D at universities, UAEMers from 15 countries collected and visualized this information on the interactive website publicmeds4covid. The Tracker illustrates that the public are the key investors and risk-takers for COVID-19 innovation, supporting the argument against upholding intellectual property rights and profit-making during the pandemic. For example, the British government, through direct research grants to universities and research institutions, spent approximately $169 million on the development of diagnostics, vaccines, and therapeutics for COVID-19 (UAEM 2021). A team of UAEM UK students also found that the research behind the Oxford-AstraZeneca vaccine was 97% publicly funded (Cross et al. 2021). Undertaking these research projects provided us with data to support our advocacy efforts, allowed us to challenge ideas about the origins of innovation, and strengthened our negotiation position with individual universities. With many access issues being decided on a (inter)national level, we continued fostering our collaboration with other civil society organizations in the Missing Medicines Alliance (https://missingmedicines.org/) and the People’s Health Movement. We mobilized young activists’ voices for issues such as the COVID-19 Technologies Access Pool (C-TAP) and the TRIPS waiver proposal, as well as informing national debates in the UK Parliament on access to COVID-19 technologies (UAEM UK 2020). In collaboration with the Free the Vaccine Campaign and Act Up London, we organized a socially distanced protest to call for COVID-19 vaccines, drugs, and diagnostics to be sustainably priced, available to all, and free at the point-of-delivery. If we are to achieve health equity worldwide, we need fundamental reform of the biomedical innovation system so that it puts people over profit, and we believe that student grassroots advocacy is part of this solution.

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Image B4.3  The Free the Vaccine Campaign Carnival March in London on July 27, 2020, supported by UAEM UK student activists. Source: Photo by Poppy Hosford, member of UAEM UK.

Regulatory regimes that constrain access to medicines

1. Industry involvement in international regulatory standard-setting processes While the quality of medicines is critical to ensure the credibility of the health system, the norms and standards related to quality, safety, and efficacy (QSE) of medicines are not free from conflicts of interest. These norms and standards are being used by the research-based pharmaceutical industry to manage competition in the market. The primary forum for norms and standards setting related to QSE is the multistakeholder platform known as the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH). The ICH was established in 1990 as a public–private partnership primarily to reduce development costs and hasten marketing approval processes for pharmaceuticals (Lexchin 2012). It has been criticized for lowering marketing approval standards for new chemical entities and for setting standards in a way that builds a set of technical barriers to prevent competition from the generic industry (Ohno 2002).

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The founding members of ICH are the drug regulatory authorities of the EU, Japan, and the USA, and the research-based pharmaceutical industry associations of those countries. Prior to 2018, the steering committee of ICH, its highest decision-making body, constituted these founding members along with the International Federation of Pharmaceutical Manufacturers Associations (IFPMA, a federation of national associations of research-based pharmaceutical industry associations), WHO, Health Canada, and the European Free Trade Area. Only the founding members enjoyed voting rights. Until recent years, the ICH secretariat operated from the office of IFPMA (Nagarajan 2014). In 2018, the governance mechanism of ICH underwent reform, and the steering committee was replaced with a 14-member management committee which included, along with the six founding members: • two standing regulatory members (Health Canada and Swissmedic); • two Standing Observers (IFPMA and WHO); • regulatory agencies from Brazil, Singapore, the Republic of Korea, and China; and • two industry associations, the International Generic and Biosimilar Medicine Association and Biotechnology Innovation Organization (BIO). The research-based pharmaceutical industry remains firmly embedded in the decision-making structures of ICH. Further, until 2018 there was no representation of the generic medicines industry. ICH’s role in norms and standards setting therefore raises serious concerns regarding conflicts of interest and accountability. As per its mission statement, the aim of ICH is to harmonize various technical and scientific aspects of pharmaceutical registration. While the word harmonization sounds attractive, harmonization of QSE norms and standards bears the dangers of compliance costs and impacts on the prices of medicines. The ICH initiatives have often resulted in the ratcheting up of the QSE norms and standards in ways that benefit the big firms and the members of ICH, at the expense of smaller or publicly funded firms and patients (Berman 2012). This concern was shared by a committee appointed by WHO to examine the impact of ICH guidelines in non-ICH countries which found that: In many countries, essential drugs required for the prevention and treatment of locally endemic conditions are not supplied by the major multinationals, but by local industry or by generic manufactures. If these suppliers are unable to meet what may be unsubstantiated quality standards, adverse impact of the withdrawal of these drugs on the population might well be far more dramatic than of any hypothetical risk posed by failing to achieve the ICH standards. (WHO 2002)

In short, the ICH standards set high standards claiming to protect patients but have limited “clinical relevance” (Timmermans 2004).

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In 2014 there was an attempt to mainstream the ICH standards through a World Health Assembly resolution on regulatory system strengthening for medical products (WHO 2014a). The draft resolution urged member states to follow ICH guidelines and to implement the guidance of international harmonization initiatives such as the Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (Gopakumar 2014). While direct references to ICH and harmonization were removed from the draft due to opposition from many low- and middle-income WHO member states such as India, harmonization efforts continue, and may be used as a tool to manage competition. Another example of legitimization of ICH is WHO’s criteria for a stringent regulatory authority. The WHO’s observer role in ICH and the adoption of ICH norms and standards as part of WHO’s advice to member states undermines the organization’s integrity, independence, and credibility. Further, it violates the principles of WHO’s Framework on Engagement with non-State Actors (FENSA) which states that any engagement with such actors must “protect WHO from any undue influence, in particular on the processes in setting and applying policies, norms and standards” (WHO 2016).

2. Regulatory regimes for follow-on biologics Access to biologic products (including biotherapeutics and vaccines) is becoming critical due to their use in treating diseases such as cancer and autoimmune disorders, and the development of novel therapies and vaccines to address emerging diseases such as COVID-19. These products can be very expensive and there is a need to bring cheaper follow-on versions to market as soon as possible. However, there are formidable barriers to doing so, including international guidelines for assessing safety and efficacy. When considering an application for marketing approval for a generic small molecule medicine, regulatory agencies primarily assess bioequivalence, i.e., whether a competitor’s generic product is an identical copy of the originator. Therefore, a manufacturer of a generic medicine need not prove the safety and efficacy of the medicine through clinical trials, and instead can rely on the data produced by the originator to obtain marketing approval (once any period of exclusivity on the test data has expired). This means the generic medicine can be produced much more cheaply than the originator. For biologics, however, which are much more complex, the assumption is that the manufacturing process is critical in determining the clinical properties of the drug and therefore a follow-on product developed through a different manufacturing process (which cannot be an identical copy and therefore is referred to as a “biosimilar”) needs to have its safety and efficacy established through extensive clinical trials. Since the originators protect their knowledge about the manufacturing process through trade secret protections and are not required to share information about the manufacturing process and the cell lines in the public domain, the competitor is

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forced to depend on a different manufacturing process. In the absence of access to the originator’s manufacturing process, which is protected as a trade secret, the competitor must use independently developed manufacturing processes and carry out clinical trials to prove safety and efficacy, which requires time and resources and makes the development process costly. The WHO (2009) Guidelines on Evaluation of Similar Biotherapeutic Products (SBP) provide guidance on how to develop a non-originator product with a smaller number of clinical trials than those required for originator biologics. These guidelines, which set the norms for the marketing approval of biotherapeutics, are based on outdated precautionary assumptions and put onerous requirements on their assessment, creating entry barriers. Many scientists have questioned the science behind the requirements and have asked the WHO to reconsider the need for such extensive clinical trials for follow-on biotherapeutics (New 2019). In 2014 the World Health Assembly adopted Resolution WHA 67.21 (WHO 2014b), which requested the director-general to convene an expert committee to update the 2009 guidelines in the context of technological advances and national regulatory needs and resources. It wasn’t until 2020 that this expert committee finally decided to revise the SBP guidelines (WHO 2020c). Meanwhile, the lack of competition in the biosimilar market due to outdated regulatory barriers has compromised affordable access in LMICs. Currently, Canada, the EU, and the USA account for 77% of the market for monoclonal antibodies (the largest class of biotherapeutics), while the Asian Pacific accounts for 16%, Latin America 4%, the Middle East 2%, and Africa only 1% (International AIDS Vaccine Initiative 2021). In the case of vaccines, there is no regulatory pathway currently existing to obtain marketing approval for a non-originator vaccine. As a result, every competing manufacturer is treated as a new vaccine developer and must carry out extensive clinical trials. If this regulatory insistence on clinical trials is not re-examined in the light of developments in science and technology, it risks using the façade of safety and efficacy concerns to stifle competition, thereby eliminating the possibility of affordable vaccines. The COVID-19 pandemic highlights the urgent need to explore reforming the regulatory framework to establish an approval pathway for non-originator vaccines.

3. Targeting of regulatory processes in trade agreements Regulatory processes for pharmaceuticals, including the assessment of safety, efficacy, and quality, along with procedures for pricing and reimbursement, have increasingly been targeted in recent trade agreements, particularly those negotiated by the USA (Gleeson et al. 2019). The Australia–US Free Trade Agreement (AUSFTA) which came into force in 2005, for example, saw provisions targeting national coverage programs for pharmaceuticals introduced in a trade agreement for the first time. Similar provisions have since appeared in the Korea–US Free Trade Agreement (KORUS), the TPP (before the USA withdrew

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from it), and the USMCA. While varying between agreements, these provisions generally impose detailed procedural requirements in the pharmaceutical industry’s favor, including time limits for assessing proposals for listing drugs on national formularies, disclosure of decision-making criteria and reasons for decisions, and review or appeals processes for unsuccessful listing applications. Opportunities for industry input during decision-making and for consultation between trade partners about pharmaceutical policy must also be provided (Gleeson et al. 2019). These requirements raise concerns about the potential for reduced flexibility and industry interference in pharmaceutical decision-making and for pressure from trade partners such as the USA (Gleeson et al. 2019). These types of rules are generally unpalatable to other countries, as evidenced by the suspension of the procedural rules from the CPTPP after the collapse of the TPP. However, their inclusion in three US trade agreements in force (AUSFTA, KORUS, and the USMCA) suggests that its trade partners are in many cases prepared to accept them in exchange for access to US markets. Recent US free trade agreements have also included provisions pertaining to marketing authorization processes and pharmaceutical inspections. The TPP and USMCA contain provisions seeking to harmonize processes for assessing safety and efficacy and align them with international standards; depending on how it is done, this may drive standards downwards or towards industry-favorable norms (Gleeson et al. 2019). These agreements also set criteria for making marketing authorization decisions, which may reduce flexibility and opportunities for requiring companies to submit data needed for transparency purposes, such as R&D costs or public financing received (Gleeson et al. 2019). Other provisions in these texts may increase pressure for accelerated decision-making about drug approval (with concomitant safety risks), protect information about pharmaceutical inspections from public disclosure, and encourage the participation of the pharmaceutical industry in the development of policies and standards (Gleeson et al. 2019). Conclusion

There have been few times in history when inequities in access to medicines have seemed so stark, the health, economic, and social costs so high, and the underlying causes so intractable as in the case of COVID-19. We have traced in this chapter how the problem of inequitable access to medicines is underpinned by global intellectual property, trade, and regulatory regimes that stifle competition and allow medicines and vaccines to be monopolized by private companies and wealthy countries. After 25 years of WTO rules, with increasing proliferation of TRIPS-Plus rules and ongoing difficulties with using TRIPS flexibilities, the medicines access problem that at the beginning affected primarily the Global South has become a problem affecting wealthy countries as well. The power of the pharmaceutical industry in influencing norm and standard setting at the international level, as well as the behavior of individual nation states, is

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long-standing and undeniable. Yet access to medicines activists and civil society organizations have continued to challenge and disrupt the status quo, with some important victories such as the Doha Declaration on the TRIPS Agreement and Public Health, the removal or mitigation of TRIPS-Plus provisions in many trade agreements, and the mobilizing of efforts to get approval at the WTO for the TRIPS waiver. Whether or not the TRIPS waiver campaign succeeds, there remains an urgent need for governments and activists to continue to challenge TRIPS and TRIPS-Plus intellectual property regimes, which deny new medicines to much of the world’s population while protecting pharmaceutical industry profits in high-income countries. The COVID-19 pandemic and the negotiations taking place at the WTO for a TRIPS waiver for COVID-19 medical products provide opportunities for activists and civil society organizations to further advance the cause of access to medicines, potentially opening the space for more fundamental reforms and power shifts. References Berman, Ayelet. 2012. “The Distributional Effects of Transnational Pharmaceutical Regulation.” CTEI Working Paper. Geneva: Graduate Institute of International and Development Studies. Boffey, Daniel. 2021. “France and Germany Threaten AstraZeneca over Vaccine Shortage.” The Guardian. January 31. https:// www.theguardian.com/society/2021/jan/31/ france-germany-threaten-covid-astrazenecavaccine-shortageeu-uk. Business Standard. 2021. “Covid: WHO Urges Countries to Bridge $16 bn Funding Gap for ACT Accelerator.” Business Standard. June 15. https://www.business-standard.com/ article/current-affairs/covid-who-urgescountries-to-bridge-16-bn-funding-gap-foract-accelerator-121061500070_1.html. Cakmakli, Cem, Selva Demiralp, S·ebnem KalemliOzcan, Sevcan Yesiltas, and Muhammed A. Yildirim. 2021. The Economic Case for Global Vaccinations: An Epidemiological Model with International Production Networks. Paris: International Chamber of Commerce. Chinazzi, Matteo, Jessica T. Davis, Natalie E. Dean, Kunpeng Mu, Ana Pastore Y Piontti, Xinyue Xiong, M. Elizabeth Halloran, Ira M. Longini Jr., and Alessandro Vespignani. 2020. Estimating the Effect of Cooperative Versus Uncooperative Strategies of COVID-19 Vaccine Allocation: A Modeling Study. Boston: Network Science Institute, Northeastern University.

Cleary, Ekaterina G., Jennifer M. Beierlein, Navleen S. Khanuja, Laura M. McNamee, and Fred D. Ledley. 2018. “Contribution of NIH Funding to New Drug Approvals 2010–2016.” Proceedings of the National Academy of Sciences of the United States of America 115 (10): 2329–2334. doi: 10.1073/pnas.1715368115. Crager, Sara. E. 2018. “Improving Global Access to New Vaccines: Intellectual Property, Technology Transfer, and Regulatory Pathways.” American Journal of Public Health 104 (11): e85–e91. Cross, Samuel, Yeanuk Rho, Henna Reddy, Toby Pepperrell, Florence Rodgers, Rhiannon Osborne, Ayolola Eni-Olotu, Rishi Banerjee, Sabrina Wimmer, and Sarai Keestra. 2021. “Who Funded the Research behind the Oxford-AstraZeneca COVID-19 Vaccine? Approximating the Funding to the University of Oxford for the Research and Development of the ChAdOx Vaccine Technology.” MedRxiv, 1–22. doi: 10.1101/2021.04.08.21255103. Dhar, Biswajit, and K.M. Gopakumar. 2020. “Towards More Affordable Medicine: A Proposal to Waive Certain Obligations from the Agreement on TRIPS.” ARTNeT Working Paper Series No. 200. Bangkok: United Nations Economic and Social Commission for Asia and the Pacific. Drahos, Peter. 2007. “Four Lessons for Developing Countries from the Trade Negotiations over Access to Medicines.” Liverpool Law Review 28 (1): 11–39.

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United Nations Secretary-General’s High Level Panel on Access to Medicines. 2016. Report of the United Nations Secretary General’s High Level Panel on Access to Medicines: Promoting Innovation and Access to Health Technologies. Geneva: United Nations. United Nations. 2015. “Sustainable Development Goals.” In Transforming Our World: The 2030 Agenda for Sustainable Development. A/RES/70/1. https://www. un.org/ga/search/view_doc.asp?symbol=A/ RES/70/1&Lang=E. U.S. Department of Health & Human Services. 2020. “Trump Administration Secures New Supplies of Remdesivir for the United States.” June 29. https://www.legistorm. com/stormfeed/view_rss/1855790/ organization/69541/title/trumpadministration-secures-new-supplies-ofremdesivir-for-the-united-states.html. Vialle-Valentin, Catherine E., Dennis RossDegnan, Joseph Ntaganira, and Anita K. Wagner. 2008. “Medicines Coverage and Community-based Health Insurance in Lowincome Countries.” Health Research Policy and Systems 6. Washburn, Jennifer. 2005. University Inc. – The Corporate Corruption of Higher Education. New York: Basic Books. Watkins, Morgan. 2020. “Kentucky Gov. Andy Beshear Calls on 3M to Release Patent for N95 Respirator Amid Pandemic.” Courier Journal. https://www.courier-journal.com/ story/news/2020/04/03/beshear-calls-3m-release-patent-n-95-respirator-amidpandemic/5112729002/. Who Profits from the Occupation. 2012. “Captive Economy the Pharmaceutical Industry and the Israeli Occupation.” https://bit. ly/2PScpWo 2012. Wirtz, Veronika J., Hans V. Hogerzeil, et al. 2017. “Essential Medicines for Universal Health Coverage.” The Lancet 389 (10067): 403–476. World Health Organization. 2002. The Impact of Implementation of ICH Guidelines in NonICH Countries: Report of a WHO Meeting, Geneva, 13–15 September 2001. Geneva: World Health Organization. World Health Organization. 2004. WHO Medicines Strategy: Countries at the Core 2004–2007. Geneva: World Health Organization. World Health Organization. 2009. Guidelines on Evaluation of Similar Biotherapeutic

OLD/NEW POLITICS OF ACCESS TO MEDICINES  |  171 Products (SBPs). Geneva: World Health Organization. World Health Organization. 2012. “Consultative Expert Working Group on Research and Development: Financing and Coordination.” Provisional Agenda Item 13.14. Sixty-Fifth World Health Assembly. World Health Organization. 2014a. “Regulatory System Strengthening for Medical Products.” EB134.R17. Geneva: World Health Organization. World Health Organization. 2014b. Access to Biotherapeutic Products Including Similar Biotherapeutic Products and Ensuring their Quality, Safety and Efficacy. WHA 67.21. Geneva: World Health Organization. World Health Organization. 2016. Framework of Engagement with Non-State Actors. Geneva: World Health Organization. https:// apps.who.int/gb/ebwha/pdf_files/WHA69/ A69_R10-en.pdf?ua=1. World Health Organization. 2017. WHO Expert Committee on Specifications for Pharmaceutical Preparations: Fifty-First Report. WHO Technical Report Series 1003. Geneva: WHO. World Health Organization. 2018. Global Vaccine Market Report. Geneva: World Health Organization. World Health Organization. 2020a. “COVID-19 Technology Access Pool.” https:// www.who.int/emergencies/diseases/ novel-coronavirus-2019/global-researchon-novel-coronavirus-2019-ncov/covid-19technology-access-pool. World Health Organization. 2020b. “WHO Recommends Against the Use of Remdesivir in COVID-19 Patients.” https://www.who. int/news-room/feature-stories/detail/whorecommends-against-the-use-of-remdesivirin-covid-19-patients.

World Health Organization. 2020c. “Main Outcomes of the Meeting of the WHO Expert Committee on Biological Standardization held on 9 and 10 December 2020.” https://www.who.int/publications/m/ item/ECBS-Executive-Summary.IF.IK.TW15_Dec_2020. World Health Organization. 2021. WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19 – 4 August 2021. https://www.who.int/director-general/ speeches/detail/who-director-general-sopening-remarks-at-the-media-briefing-oncovid-4-august-2021. World Health Organization and International Bank for Reconstruction and Development. 2020. Global Monitoring Report on Financial Protection in Health 2019. Switzerland: World Health Organization and World Bank. World Health Organization and World Bank. 2015. Tracking Universal Health Coverage: First Global Monitoring Report. Geneva: World Health Organization and the World Bank. World Trade Organization. 2001. Declaration on the TRIPS Agreement and Public Health. Geneva: World Trade Organization. World Trade Organization. 2020a. Trade in Medical Goods in the Context of Tackling COVID-19. Geneva: World Trade Organization. World Trade Organization. 2020b. “Waiver from Certain Provisions of the TRIPS Agreement for the Prevention, Containment and Treatment of COVID-19: Communication from India and South Africa. Council for Trade-Related Aspects of Intellectual Property Rights.” IC/C/W/669. October 2. Geneva: World Trade Organization.

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B5 | TRANSFORMING MENTAL HEALTHCARE GLOBALLY

Introduction

Mental health has historically been the Cinderella issue in global health. For decades, several assumptions have stymied action to respond to mental illnesses, in particular in non-European countries and populations. These assumptions included the notion that mental illnesses were entirely products of culture, and that psychiatry and psychology were products of European cultures and, therefore, of limited generalizability to the rest of the world. Indeed, some critiques argued that the use of diagnostic systems and interventions which had their origins in these disciplines to other contexts amounted to “psychiatric imperialism” (Patel 2014). The strong association of social disadvantage with poor mental health and the lack of a clear boundary between the normative human emotional response to such disadvantage and mental illnesses fueled the position that the only interventions which mattered were those which targeted upstream social determinants. On the other hand, health economists argued that mental illnesses lacked objective biomarkers and their assessment relied entirely on self-report, compared to mortality outcomes of infectious diseases and maternal and infant conditions which dominated global health priority lists. Furthermore, it was assumed that mental health problems were too expensive to treat, and so were relegated to being a luxury item in the basket of health goods for poor people and poor countries. Global mental health, a discipline of global health which seeks to reduce disparities in the attainment of good mental health between and within populations, has been a powerful force to interrogate these assumptions (Patel and Prince 2010). A large body of science from diverse contexts has clearly shown that mental health problems are in fact universal health experiences with similar “core” features and responses to interventions, though cultural factors do greatly influence the way these illnesses are experienced, understood, and acted upon. Mental health is inseparable from one’s personal life history, physical health, and socioeconomic conditions and context, and care for mental health problems must be tailored to these unique characteristics. Mental healthcare must, therefore, embrace a diversity of perspectives, experiences, and providers, and every community, irrespective of professional mental health resources, can offer at least basic mental healthcare. There is a growing recognition of the need for a rights-based approach which emphasizes the central role that people with the lived experience of mental illness must play in designing, delivering, and holding mental healthcare to account.

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The COVID-19 pandemic has had a significant impact on the recognition of mental health as a critically important aspect of human health. In response, we have witnessed a flourishing of initiatives to address the mental health distress consequent to the unprecedented uncertainties and disruptions to daily life around the world (Kola et al. 2021). Importantly, this wave of suffering is occurring in the context of a global crisis of inadequate and inequitable access to quality mental health interventions which existed even before the pandemic. All countries of the world to varying extents were under-performing in terms of their mental healthcare, as reflected in low levels of coverage of quality care and little evidence of reducing the incidence of mental illness. The incidence of mental illness has also been increasing in certain contexts and demographic groups, for example amongst young people, a crisis whose causes are poorly understood. While the pandemic offers a historic opportunity to invest in mental healthcare globally, we will need to mobilize political will not only to enhance the meager sums spent on mental health but also to spend this money wisely, guided by principles of human rights and equity and a commitment to evidence-informed practices and community expectations. This chapter will propose what those investments should be, starting with setting the stage on the state of mental health in the global context, the barriers towards achieving parity and justice for people with mental health problems, and the impact of the pandemic. It then turns to a discussion of strategies which can address these limitations, emphasizing how mental health can be fully integrated within the framework of universal health coverage across dimensions from promotion and prevention to care and recovery.

Box B5.1: Defining mental health problems Several terms are used, by specific scholarly disciplines, to describe the human experience of a mental health problem. This diversity of terminology is also reflected in the ways in which suffering associated with impairments of mental health is described. Mental illnesses or disorders, as defined by the diagnostic categories in the International Classification of Diseases (ICD), comprise a wide range of conditions across the life course, all of which share one core feature: the impairment of mental functions such as the way a person thinks, feels, and interacts with others. Apart from this shared feature, there is actually very little in common from an aetiological or therapeutic standpoint between autism and intellectual disability in childhood, mood, anxiety, psychotic, and substance abuse disorders which emerge in youth, and dementias which emerge in older age. Moreover, without exception, we do not have a clearly delineated aetiology or biomarker for any of these diverse conditions, and we rely entirely on self-reporting of

TRANSFORMING MENTAL HEALTHCARE GLOBALLY  |   175 inner states or observations of behavior to arrive at a “diagnosis.” Thus, it is clear that the current diagnostic categories are dynamic, imperfect, and prone to considerable subjective and cultural variations between individuals and across contexts. An exemplar of the fluidity in defining mental health problems is homosexuality, which was considered a mental illness by biomedical classification systems right up to the 1970s. Another term, preferred by human rights advocates, is “psychosocial disability,” which conveys the idea that the suffering associated with impairments of mental health are the result of social arrangements and discrimination rather than a biological process.

The global mental health crisis before the pandemic

Mental illnesses are leading causes of suffering in all countries of the world, affecting at least 10% of the global population at any given point in time. The relative burden, measured in terms of Disability Adjusted Life Years (DALYs), has been rising in all countries, driven by multiple factors including the falling burden of other health conditions, the failure to reduce the incidence of mental illness, and the rise in the proportion of the population entering the age of risk of onset, in particular the growing number and proportions of youth and of older adults (Patel et al. 2018). Suicide is a leading cause of death in young adults, and suicide rates amongst young people are rising in many countries in the past decade. At least half of the burden of mental illness in adulthood has fallen on adults younger than 24 years old. This is due to the interaction of unique neurodevelopmental processes occurring in adolescence and young adulthood with the dramatic psychosocial and biological transitions which occur during this relatively brief period of the life course, during which an individual makes the journey from being a child who is totally dependent on one’s parents to becoming an independent adult who might be caring for children. People with mental illness, particularly those living with psychotic disorders and substance use disorders, die much earlier than they should, mostly due to the poor quality of medical care for comorbid chronic diseases. The latter is one of the consequences of the pervasive levels of stigma and discrimination associated with mental illness, which leads to abuses of human rights including incarceration, torture, and denial of fundamental rights to dignity, freedom, and access to care (Patel and Farmer 2020). Indeed, the published estimates of the global burden of mental illness is actually much lower than their actual burden, thanks to the vagaries of how health conditions are categorized in the Global Burden of Disease models. For example, suicide and self-harm are not counted as mental health conditions, chronic pain syndromes which are often the result of mental health problems are entirely categorized as musculoskeletal disorders, and the significant contribution of severe mental illness to premature mortality

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is ignored. When these are taken into account, the actual disease burden for mental illness exceeds 30% of the global Years Lived with Disability and 13% of DALYs (Vigo, Thornicroft, and Atun 2016). A rich body of epidemiological literature has clearly demonstrated the higher risk of mental illness in contexts in which individuals are exposed to adverse social determinants, notably those associated with poverty, gender disadvantage, and discrimination. Populations which are disproportionately affected by these determinants, for example low-income groups, women, sexual and ethnic minorities, refugees, and those in conflict settings, bear a higher burden of mental illness (Lund et al. 2018). The inter-generational transfer of poor mental health and social disadvantage are closely linked through their association with adverse childhood experiences, the most consistently demonstrated risk factor for mental illnesses. These early life adversities can be compounded by oppressive experiences and violence during adolescence. Young people and disadvantaged or marginalized groups also have less access to appropriate care and experience the double stigma attached to their group identity in addition to the mental health problem. The mechanisms through which social disadvantage and poor mental health are related are bi-directional: social disadvantage causes mental illness, for example by increasing exposure to more uncertainties and stressors in daily life or reduced opportunities for education; meanwhile, poorer mental health leads to social disadvantage, notably through reduced productivity at work, being discriminated in diverse sectors of society, and increased healthcare costs (Ridley et al. 2020). Barriers to justice and equity

Despite strong evidence of the cost-effectiveness of a range of interventions for the prevention and care of mental illness (Patel et al. 2016), the vast majority of people in the world do not benefit from this knowledge. This is true even in wealthy countries, indicating that all countries can be considered “developing” when it comes to mental health. A vivid illustration of these “gaps” comes from a recent analysis of the World Mental Health Surveys, which found that while less than 5% of persons with depression in low- and middle-income countries (LMICs) receive adequate quality care, much wealthier countries are only reaching about a third of affected persons (Vigo et al. 2020). At least a part of this crisis can be attributed to the paltry spending on mental healthcare in most countries; indeed, no country in the world allocates resources for mental health proportionate to its burden of mental illness (Saxena, Sharan, and Saraceno 2003). The discourse on the barriers to equitable access to mental healthcare has been dominated by two narratives: lack of mental health professionals and stigma attached to mental illness due to “non-scientific” views (Saraceno et al. 2007). Unsurprisingly, both perspectives are heavily promoted by mental health professionals and are underwritten by an unswerving faith in the biomedical model of

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mental illness. This model is enshrined in disease classification systems which lead to a focus on mental health specialist-led “treatment” of an individual’s symptoms, dominated by a reliance on pharmacological agents. The inadequacy of this model to contribute to reducing the global burden of suffering of mental illness is evident from the large gaps in access to quality care and the lack of a reduction in the burden of mental illness in wealthy countries, which have most strongly embraced such a narrow, diagnosis-driven approach to mental healthcare. There are multiple reasons for this limited impact, ranging from the low demand for such mental healthcare to the inadequate recognition of the importance of psychosocial factors in both prevention and long-term recovery. Thus, even if we were able to mobilize more funds for mental health, as is desperately needed, the question that is most urgent to address at this juncture is how this money should be spent. Global mental health practitioners have robustly challenged these assumptions, and their findings are pointing to the need to reimagine the future of mental healthcare. Low-resource settings have offered an opportunity for some of the most transformative innovations to improve access to effective interventions for mental illness. These innovations almost universally deliver psychosocial therapies, a major departure from the dominating presence of psychotropic drugs, particularly in LMICs. Furthermore, these psychosocial interventions are typically simplified versions, comprising usually one or a few “elements” of complex psychological treatment packages, e.g., behavioral activation for depression, enabling elements to be learned and delivered by diverse providers with much greater ease (Singla et al. 2017). Innovators have also demonstrated the importance of interventions targeting adverse social determinants, e.g., enabling nurturing environments in early childhood, offering cash transfers for low-income populations, or promoting the school social environment for adolescent mental health (Shinde et al. 2018; Ridley et al. 2020), for the promotion of mental health and prevention of mental illness. In all these instances, human providers concerned with delivery are persons with no prior formal training in mental health. Typically, the providers are existing frontline providers such as community health workers or lay people engaged by the research or demonstration project. These innovations have shown that one does not require a psychiatric diagnosis to trigger care, greatly simplifying the dissemination of effective interventions, that these delivery models are highly acceptable to persons with mental illness, and that they demonstrate recovery rates comparable to specialist care models, and economic analyses find that these innovations are excellent value for money (Weobong et al. 2017). A parallel strand of knowledge generation and advocacy has focused on demonstrating the central role that the long and dark history of institutional coercion, violence, incarceration, and systematic exclusion experienced by persons with severe mental illness (a group some advocates refer to as “persons with psychosocial disabilities”) as the root cause of stigma associated with mental

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illness (Thornicroft 2006). A critical element of this effort is the engagement of and leadership by persons with the lived experience, as has been done with other marginalized groups such as persons with a disability (where the movement famously coined the slogan “nothing about us without us”) and those living with HIV/AIDS. The Global Mental Health Peer Network is an example of a social movement led by persons with the lived experience of mental health problems (Box B5.2), demanding the right to be heard and respected, and to enjoy the same rights as any other person in every aspect of their lives, from education and employment to marriage and healthcare. The singular policy landmark which has recognized the struggle for equality and justice in relation to mental health is the United Nations Convention on the Rights of Persons with Disabilities (CRPD) which requires: a paradigm shift from a medical model of disability to a social model that emphasizes overcoming the barriers to equality created by attitudes, laws, government policies, and the social, economic, and political environment. The approach adopted by the social model recognizes that people with psychosocial disabilities have the same right to take decisions and make choices as other people, particularly regarding treatment, and have the right to equal recognition before the law. (Sugiura et al. 2020)

A wide array of interventions have been identified to realize these rights, from legislations which prohibit or greatly limit involuntary treatment to supported

Box B5.2: The Global Mental Health Peer Network The Global Mental Health Peer Network (GMHPN) emerged as an initiative of the Movement for Global Mental Health in 2018. The focus of its work has involved the building of a sustainable structure to develop global lived experience leadership and create a sophisticated communication platform where the lived experience community can share their views, opinions, perceptions, and experiences. The mission of the GMHPN is “strengthening the voices of persons with lived experience globally through empowerment and inspiring respect and acknowledgement of their experiences, views and opinions as valued and equal citizens of the world.” The GMHPN’s rich and diverse lived experience expertise currently represents over 30 countries with 67 global mental health lived experience leaders. The GMHPN aspires to have lived experience leadership from all countries in the world, which is expected to be instrumental in driving change and transformation in mental health. Access the latest Annual Report: https://www.gmhpn.org/ uploads/1/2/0/2/120276896/gmhpn_annual_report_2019-2020_final.pdf.

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decision-making enabling a person with a psychosocial disability to decide about care which respects their will and preference (Sugiura et al. 2020). The role of peers (other persons with psychosocial disabilities) in providing such support is often at the heart of these interventions. Yet, the fact remains that the vast majority of countries in the world continue to operate under legislation where coercion, involuntary treatment, and incarceration under inhumane conditions are all too frequent. This blot on the human rights landscape of global mental health is the single most important contributor to stigma attached to mental illness. Another blind spot in global mental health has been the lack of attention to primary prevention despite the compelling cross-cultural evidence of the role of early life adversities, violence, and impoverishment on poor mental health and the evidence on the impact of interventions which target these determinants on improving mental health outcomes. A major reason for this is that most interventions fall well outside the health sector with little incentive for the mental health community to advocate for them. Unsurprisingly, mental health practitioners emphasize preventive interventions which target individuals, for example through curricular interventions to build social–emotional competencies in young people through teaching simplified versions of the psychological techniques used for the treatment of mood and anxiety disorders. While such interventions also have a role to play in the landscape of prevention, targeting upstream social determinants such as poverty, genderbased violence, early life adversities, quality education, and community social capital, all of which are Sustainable Development Goals (SDGs) in their own right, will likely have larger impacts on population mental health (Lund et al. 2018). Global mental health in the shadow of the pandemic

The advent of the COVID-19 pandemic threatens to magnify the existing crisis through several pathways. There are now widespread reports of the increase in self-reported distress in populations around the world, in particular in contexts which have suffered high levels of coronavirus infection (Kola et al. 2021). The pandemic has confronted individuals with a range of stressors, from loss of loved ones to the unrelenting threat of infection, loss of livelihoods, uncertainty about when, if ever, life will return to a semblance of what people used to experience, the torrent of mixed messages about the science (real or fake) around the virus, and the lack of consensus on what the post-epidemic scenario might look like. It is not at all surprising, then, that experiences of anxiety, fearfulness, sleep problems, irritability, and feelings of hopelessness have become widespread. Much of this mental health distress can be understood as a normative stress response to extraordinary levels of uncertainty and disruption to daily life. The persistence of these stressors extending well into a second year and the emergence of enduring changes in society and everyday life that

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is coupled with a massive increase in adverse social determinants, from levels of absolute poverty to rising inequality and gender-based violence, may herald a potential new “epidemic” (pandemic) of mental illness. Indeed, in the absence of any structural policies addressing these adverse social determinants, the increase in the average levels of distress in the population is a harbinger of a rise in the burden of clinically significant mental illness. “Deaths of despair” have been documented as the cause for the increased mortality and reduction in life expectancy in working-age white Americans following the economic recession in 2008 (Case and Deaton 2020). Suicide- and substance use- (the latter often even more discriminated against in healthcare than mental illness) related mortality accounted for most of these deaths. On this occasion, the pandemic threatens many, if not most, countries around the world. The threat is global and is likely to be far more persistent. The pandemic has also amplified the social determinants which affect subgroups in the population disproportionately. Low-income groups such as the homeless and daily wage workers, already living precarious lives, have been especially badly hit with tens of millions of persons being acutely impoverished with catastrophic consequences for their well-being and that of their children, whose adverse childhood experiences are risk factors for poorer mental health years later in adulthood (Cash and Patel 2020). Women have found themselves locked in homes with violent partners and bear the triple burden of caring for young children and domestic chores alongside their professional commitments (see Chapter A2). Children and young people, who are the least affected by the virus, are the worst affected by the policies to contain the pandemic, notably the closure of educational institutions which some have estimated will ultimately lead to poorer health and social outcomes for an entire generation of young people (Christakis, Van Cleve, and Zimmerman 2020). The COVID-19 pandemic has illustrated, yet again, how people with mental health conditions are not only more vulnerable to acquire infections but also more likely to suffer worse consequences, including death, as a result (Wang, Xu, and Volkow 2021). In part, these adverse outcomes are the result of the impact of lockdowns on disrupting general and mental healthcare services. While the pandemic has witnessed a flourishing of initiatives to address the rising tide of mental illness, most notably through telemedicine platforms (Kola et al. 2021), these suffer from the limitation that they rely heavily on mental health specialist providers who are very scarce in number and often unaffordable. This is compounded by the digital divide: digital literacy and adequate internet connectivity remains a distant goal for large swathes of the global population. Still, these initiatives are welcome for their demonstration of the feasibility of remote delivery and the value of psychological therapies, both of which should become cornerstones of efforts to reform mental healthcare systems after the pandemic recedes.

TRANSFORMING MENTAL HEALTHCARE GLOBALLY  |   181 Box B5.3: Overcoming individual solutions for collective problems: a testimony from a community-oriented mental health service during the COVID-19 pandemic in Italy In Italy, progressive funding cuts to the National Healthcare System, alongside the growing influence of private service providers, led to inadequate coverage of mental health needs. The answer to this shortage was sought in the free market with important consequences for social and health inequalities. Facing this situation, in 2013 a group of citizens, psychologists, and psychotherapists funded Sportello TiAscolto in Turin (northern Italy). This service today extends to the cities of Milan, Bolzano, Lecce, and Bologna and tries to respond to mental health needs through clinical and non-clinical practices. The core values of Sportello TiAscolto are accessibility, sustainability, and political engagement. Providing accessible mental healthcare is one of our key goals, but not the only one. We aim to render more collaborative and politicized the practice of clinical psychology, which is usually viewed as a merely technical one. This is why we consider it important to engage in various forms of social and collective action. Our clinical practice, for example, is made more accessible and sustainable through a system in which fees are negotiated based on patients’ financial resources. Following a principle of mutualism, people are asked to give a contribution consistent with their economic possibilities; all fees are then evenly redistributed among therapists (and thus, indirectly, among patients). This serves the purpose of granting equal opportunities for clinical counselling and preventing economic-based discrimination. We give importance to sensitizing our patients about the meaning of our system of fee redistribution: by taking care of themselves, they also take care of fellow citizens of their community. We believe that mental health problems which people experience on an individual level must be addressed also from a collective and political point of view to affect the structural and social causes of distress. Since health only exists in the interaction between people and their real-life contexts, no clinical practice is devoid of political implications. Diagnoses are therefore handled with a critical eye. As we explore our patients’ individual experiences, we encourage them to think how their personal story is connected to and shaped by the social, economic, and cultural structures that represent limits and opportunities for people’s well-being. In order to prevent excessive psychologization, we evaluate with our clients their real-life situations to assess the cases in which an external, rather than internal, course of action would be more effective. As an organization, we are involved in a variety of actions that aim to actualize our political engagement. These follow three main directions:

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• Participation in and promotion of local and national networks. • Work with disadvantaged social groups (including homeless people, migrants, refugees, and asylum seekers). • Promotion of a culture of health rooted in the understanding of its broader determinants. In promoting a culture of health, we oppose over-medicalization and profitdriven logics through awareness-raising campaigns, events, and trainings. A working group is developing a model to evaluate our experience and make it replicable. Participation is key for our project. Throughout the years, local partners and community actors have become increasingly engaged in the organization’s principles and goals. We’ve had the opportunity to share our model with like-minded colleagues willing to start similar projects. With the use of questionnaires, we have collected feedback and suggestions from our patients and used them as a tool for evaluation and planning. Former patients and students of our training courses propose joint projects with us, and sometimes have founded partner organizations. Sprouting in different territories, we have strengthened our capability to act and respond as a network and to engage in political dialogue. We feel that the approach is working towards the goal of making mental health more accessible, participative, collective, and politically informed, grounded in a communitarian dimension. However, the COVID-19 pandemic confronted us with the persistence with which our society in a time of crisis seeks and resorts to isolated individually based responses to collective health. Since 2020, we have been experiencing a troubling situation related to the COVID-19 crisis, which we collectively perceive to be a problem. The pandemic is having a differential impact on different social groups; such differences are heavily related to social inequalities and the “starting condition” from which each individual faces the situation, apart from any pre-existing mental health conditions. Nonetheless, individual narratives and needs of care show a remarkable alignment on a socially shared and collectively relevant matter. Despite these premises and the bases of our approach, we observed a tendency for people during an acute crisis creating socially shared distress (such as the pandemic) to seek individual help as the privileged avenue for coping and sense-making. This preference comes at the expenses of more collective forms of action and mutual care. At the same time, we noticed our own tendency – as a group of mental health professionals – to favor initiatives aimed at broadening access to individual psychosocial support. Effective as it may be on the individual situation, we are aware of how this can lead to fragmented responses to a widespread social emergency.

TRANSFORMING MENTAL HEALTHCARE GLOBALLY  |   183 We think it is a significant social symptom that, in such a time of collective crisis and socially shared distress, people in northern Italy mainly sought professional, medically defined individual care, which was promptly provided by mental health professionals, including ourselves. Still, our double vantage point as psychotherapists and politically involved citizens has allowed us to gather invaluable, if sometimes discomforting, information to direct future actions. We witnessed, for example, rage, resentment, and mistrust against society or one another; fear, anxieties, the loss of safety and confidence in the future; loneliness, sadness, and isolation; amidst overcrowded apartments and increased levels of domestic violence. On the brighter side, many people addressed this crisis as a chance of renewal and change, making key decisions to set their lives on new tracks: moving to another town, leaving a dead-end career, restoring long lost friendships, resuming political commitment. Altogether, we observed the need to mend healthier social bonds in contrast with a worrying disintegration of the links of our society. In this scenario, only active citizen participation can contribute to fairer life contexts. In professional healthcare, raising political awareness and engaging with communities become critical actions to promote widespread health.

Re-imagining mental health: from categories to people

To recap: there was a global mental health crisis even before the pandemic, and countries which spent much more on mental healthcare, but within narrow biomedical and specialist models of care, have not witnessed a reduction in the burden of mental health-related suffering in the population as one might have expected. This contrasts sharply with “physical” health outcomes where there is at least some correlation between healthcare spending and investing in prevention and a reduced burden of disease. The pandemic provides an opportunity to reimagine mental healthcare everywhere, at the heart of which is an explicit recognition of the need to embrace diversity, from the wide variations in how mental illness is experienced by individuals and across contexts, to the ways in which it can be addressed. The 2018 Lancet Commission on Global Mental Health usefully laid down three key principles for re-framing mental health (Patel et al. 2018). First, we need to move beyond the narrow diagnosis-driven approach to classifying and labeling mental illness, an approach which may work well for infectious diseases and be desirable for a psychiatry which seeks to be recognized as a legitimate discipline of medicine. But this approach is neither supported by decades of basic and epidemiological science, nor acceptable to communities globally. Given the dominating influence of this approach on research and practice

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for half a century, it is obvious that we will need to incrementally modify it to embrace the multi-dimensional nature of mental health and iteratively refine the approach to assessment and treatment planning. Indeed, the first steps in this direction have been taken by the latest classification of mental illness in the ICD-11. Ultimately, the goal may well be a multi-dimensional approach which could be applied at two levels to any individual to characterize specific mental health functions and experiences, such as mood, cognitive abilities, and impulsivity: first, at the higher level from overall well-being at the one end to psychosocial disability at the other and, second, at a more granular, neuro-scientifically aligned level. Practically speaking, this would entail assessing mental health across a number of discrete domains of psychological function and addressing impairments in specific domains in a person-centered way. We might no longer try to pigeon-hole the diverse presentations of mental health problems and individuals into superficially homogenous diagnostic categories and then apply a standardized treatment package or algorithm, as if one size fits all the persons who are given the same diagnosis (as one might do, for example, for malaria). Second, we need to reject once and for all the debate about whether mental health is determined by nurture or nature. The Lancet Commission proposed a convergent approach to understanding mental health (and mental illness) which recognizes the interaction of genetic factors, early and contemporary life experiences, and biological systems (ranging from neurodevelopmental processes to the gut microbiome). Importantly, each of these domains includes both risk and protective factors and, given the enormous heterogeneity in a population in even just one of these domains, the sum of the permutations of factors across all domains is potentially infinite. This is yet another reason why the artificial applications of categories of diagnoses fails to recognize the unique causal pathways for mental illness deeply embedded in the personal life story of each individual. Moreover, the convergent approach especially emphasizes the role of environmental determinants (social, economic, and physical), particularly in the first two decades of life when the brain is most plastic and responsive to environmental influences. This approach recognizes the critical importance of nurturing environments at home, in schools, in neighborhoods, in society, and, increasingly, in the digital space in promoting mental health and preventing mental illness. Third, we need to reframe mental health through the lens of human rights. At least three specific kinds of rights are particularly relevant to transforming mental health globally. The first is the right to be protected from known harms which adversely affect mental health, in particular adversities in childhood, violence through the life course, facing any form of discrimination, and the damaging effects on mental health on living in conditions of poverty. Second is the right to receive care, on par with any other health condition and regardless of the ability to pay for a mental health condition. Third, and most important

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of all, is the right to the freedom to choose what type of care, if any, a person wishes to receive, without any coercion or fear. This right is aligned with the CRPD’s vision of equality for persons with psychosocial disability on all matters, including the right to refuse treatment for a health condition. This latter right is the most contentious of all, as some argue that the capacity to fully understand and consent to healthcare interventions can itself be seriously compromised by a mental illness and, if this right is to be realized in spirit and letter, there is a risk that this may even lead to further deterioration of a person’s mental health. The intent to commit suicide by a person who is severely depressed is an example of such a “hard case” which eludes consensus between the differing views on the interpretation of this article of the CRPD (Mahomed, Stein, and Patel 2018). Implementing these lofty principles will require partnerships between a wide range of stakeholders, in particular frontline workers and care providers, ranging from peer support workers and community health workers to nurses, traditional healers, and midwives, who share the characteristics of not having had professional mental health training and living in the communities that they serve. The engagement of family members or significant others to support the recovery process is often a key strategy. The evidence clearly demonstrates that many, perhaps the majority, of people affected by mental illness can be effectively helped to recovery by appropriately trained and supervised frontline workers (Singla et al. 2017), yet there remains virtually 0% coverage of such an approach globally. Key barriers to improving the coverage of this transformative mental healthcare model include the lack of commercial and vested interests to promote psychological treatments, in contrast to the strong corporate lobbying power of Big Pharma. It is therefore essential that we build a robust movement for the right to access quality care that emphasizes psychosocial interventions and demands concerted action by governments and donors to support approaches to scaling up. Scaling up will also require a dramatically different approach to the traditional strategy of expert-led workshops and supervision, which are inherently non-scalable but also tether the innovation forever to “experts” who are often scarce and costly in the first place. Recent innovations seeking to scale up these approaches demonstrate the acceptability and effectiveness of digital training in the delivery of psychological treatments and of peer supervision for quality assurance (Singla et al. 2014; Muke et al. 2020). This range of innovations, when combined and scaled up, can transform access to one of the most effective interventions in medicine. This is exactly the goal of the EMPOWER platform which seeks to use a range of digital tools to enable frontline providers to learn, deliver, and master psychosocial interventions. That said, one size does not fit all for mental healthcare (nor for any noncommunicable health condition). There will always be persons who need more specialized care including medications, which can be transformative (think of generic antipsychotic drugs for schizophrenia, antidepressant medication

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Box B5.4: Building the frontline workforce to deliver mental healthcare The evidence of the effectiveness of frontline worker-delivered brief psychosocial interventions offers the most promising opportunity to transform mental healthcare globally. A major barrier towards scaling up this evidence is the historic reliance on expert-led, in-person, workshop-based training and supervision. EMPOWER is a program which is building an innovative digital platform comprising a suite of tools for non-specialist health workers to learn, master, and deliver psychological interventions for a wide range of mental health problems.

Figure B5.1  The elements of the EMPOWER platform. Source: Figure by Vikram Patel; Vikram Patel, “EMPOWER: A Digital Solution for Learning, Mastering, and Delivering Quality-Assured Psychological Treatments.” Powerpoint, Department of Global Health and Social Medicine, Harvard Medical School.

At the time of writing this chapter, the program is completing a randomized controlled trial comparing two versions of digital training of India’s Accredited Social Health Activists (ASHAs) to deliver the Healthy Activity Program for depression, with orthodox in-person training (Muke et al. 2020). The scripts for the training are being adapted for the US context (making this a rare example of an intervention developed in the Global South being adapted for use in a wealthy country) for initial roll-out in Texas in 2021. Designing and testing the digital tools for supervision and quality assurance will begin in India in 2021, as will the addition of new curricula for problem-solving for adolescents and early child development. For more information, please consult: www.empower.care.

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for severe depression, lithium for bipolar disorder, and methylphenidate for childhood hyperactivity as outstanding examples), and brief hospital stays for acute exacerbations. Even the much-maligned electroconvulsive therapy has an important role when used judiciously for persons with severe and potentially life-threatening depression. Thus, collaborative care, involving a close partnership between primary and community care providers with mental health specialists working in tandem to help the person realize their desired outcomes (the hallmark of person-centered care) in a coordinated, seamless manner, would comprise the best evidence-informed delivery model. This is, of course, the same delivery model for all chronic conditions, and offers the opportunity to integrate the care of physical and mental health concerns, bridging a chasm which has historic roots in the evolution of modern medicine. The integration of mental and physical healthcare is, perhaps, the central vision of universal health coverage. A key task now is to translate this evidence to unleash the power of communities, through empowering people to inform the process of scale-up of evidence-informed interventions, acquire skills to deliver these interventions, mobilize political will and resources for scaling up and enabling access to specialized mental health services for those who need such care, and hold mental health services accountable. This effort should especially focus on empowering

Box B5.5: The “5C” approach to integrating mental health in universal health coverage • Person-centered – focusing on what matters to the patient rather than what is the matter with the patient, which translates into attending to functional needs, multiple morbidities, and social suffering and to the empowerment of the person to harness their personal and community resources to enable recovery with dignity. • Continuing or long-term planning – recognizing that “cures” are rare and the goal of care is to optimize the quality of life and health. • Community platform of delivery – engagement with families and the broader community to tackle stigma, adherence, and other barriers to the uptake of effective care. • Collaborative care – with seamless coordination by community health workers or case managers of primary care and specialist providers to ensure high coverage of quality care and early “stepping up” of the intensity of care when needed. • Compassionate stance – instills hope, a key ingredient for patient engagement, motivates health-promoting behaviors, and harnesses the placebo effect (which has a robust neuroscientific basis).1

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persons with the lived experience of mental illness. They must not face exclusion or discrimination in any sector of society, notably education, employment, and civil rights. Their engagement is also critical for addressing the pervasive stigma and discrimination associated with mental illness, for social contact with persons with the lived experience is the most effective strategy to address this enormous barrier to inclusion and parity (Thornicroft et al. 2016). The recognition of the inseparable association of mental health with social determinants demands actions at the structural level, for example cash transfers to alleviate acute indebtedness and supporting low-income families to offer nurturing environments to young children, as well as ensuring that the care of persons with mental illness addresses social determinants simultaneously with their clinical symptoms (Lund et al. 2018). This is a key strategy to improve long-term recovery rates, which remain stubbornly low for many affected persons. Governments need to build leadership across the health system for implementing interventions for the promotion of good mental health, for the prevention and care for mental illness, and for the recognition of and coordination between sectors spanning diverse ministries. Beyond health, other key sectors which must be party to this collective stewardship are those concerned with education, disability, finance, and labor. Such inter-sectoral action has been the hallmark of psychosocial programming in contexts affected by conflict (Inter-Agency Standing Committee 2007), which led to the shift from the earlier dominating focus of clinical interventions for post-traumatic stress disorder (PTSD) to recognizing the need for a broader, community-oriented emphasis on social determinants, basic needs, and mental health. Established policies which reduce harm to mental health and promote well-being must be implemented across these sectors, for example, policies which address bullying or workplace harassment, establish parity with physical health in employee assistance programs, offer training for learning effective stress management techniques, provide cash transfers for low-income groups, or promote healthy school environments for all children. The challenge inherent in coordinating actions across such diverse sectors and ministries may be addressed by vesting the responsibility of stewardship for mental health to an inter-sectoral group drawn from all relevant ministries. Similarly, the approach towards accountability must monitor a range of indicators which span from the upstream determinants of mental health to the effective coverage of evidence-informed interventions and social inclusion of persons with mental illness (Saxena et al. 2019). Mental health professionals play a central role in this reimagined mental healthcare system, but their contribution will need to go beyond clinical interventions and include providing support to collaborative care models, participating in capacity-building and quality assurance efforts, offering referral pathways for patients who need their expertise, and joining hands with diverse groups to address structural barriers in one voice. The foremost barrier is the sustained

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under-investment in mental health at both national and global levels (Gilbert et al. 2015), a dismal situation which is likely to be worsened thanks to the diversion of health funds towards the pandemic and the downturn of the economy which reduces resources for the social and development sectors. This happened earlier in the late 1990s when it appeared that mental health would finally be recognized as a priority by the world’s leading development agencies, thanks to the publication of the first Global Burden of Disease report which identified a number of mental illnesses amongst the leading contributors. But mental health then was left entirely off the table in the Millennium Development Goals of 2000. Fifteen years later, mental health found its rightful place in the SDGs. And now, with the pandemic still sweeping the world, mental health risks are being shoved back into the shadows. The engagement of and leadership by persons with the lived experience in such movements will be a critically important strategy to successfully addressing these barriers. Conclusion

Mental illnesses were already a leading cause of suffering and the most neglected health issue globally before the pandemic. The pandemic will, through worsening the social determinants of mental health, compound this crisis. Still, the pandemic also presents a unique and historic opportunity to reimagine mental healthcare, for its mental health impacts have been widely documented and recognized and the inability of the existing mental healthcare system to respond to these populations-wide impacts have also been fully exposed. This may well represent an opportune moment to mobilize the political will, resources, and community demand for scaling up the science which demonstrates the need to embrace the diversity of experiences and interventions to address this crisis. Political will is needed not only to contribute materially but also to support the engagement of a more diverse workforce to deliver mental health interventions and to empower persons with the lived experience to hold services accountable. In the spirit of the Sustainable Development Goals, the moral imperative for mental healthcare is to leave no one behind by implementing evidence-informed community delivered programs for the care and prevention of mental illness, embedded in a universal health coverage and empowerment framework. Investing in such a reformed mental health system can enable individuals to regain hope for the future and the necessary cognitive and emotional capabilities to be effective in their work and personal lives and to participate meaningfully in one’s social world. Collectively, it can help to build stronger, more cohesive communities, improving their capacities to confront not only the pandemic but also the economic and ecological crises that loom in our post-pandemic future. Ultimately, we need to recognize and celebrate mental health as a fundamental, universal human quality, an indivisible part of health important to all people in all countries, and for which care should be regarded as a global public good.

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Note 1  From Patel and Saxena 2019.

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TRANSFORMING MENTAL HEALTHCARE GLOBALLY  |   191 Depression, and Anxiety: Causal Evidence and Mechanisms.” Science 370 (6522). doi: 10.1126/science.aay0214. Saraceno, Benedetto, Mark van Ommeren, Rajaie Batniji, Alex Cohen, Oye Gureje, John Mahoney, Devi Sridhar, and Chris Underhill. 2007. “Barriers to Improvement of Mental Health Services in Low-Income and MiddleIncome Countries.” Lancet 370 (9593): 1164– 1174. doi: 10.1016/S0140-6736(07)61263-X. Saxena, Shekhar, Devora Kestel, Charlene Sunkel, Elisha London, Richard Horton, Vikram Patel, and Soumya Swaminathan. 2019. “Countdown Global Mental Health 2030.” Lancet 393 (10174): 858–859. doi: 10.1016/S0140-6736(19)30424-6. Saxena, Shekhar, Pratap Sharan, and Benedetto Saraceno. 2003. “Budget and Financing of Mental Health Services: Baseline Information on 89 Countries from WHO’s Project Atlas.” The Journal of Mental Health Policy and Economics 6 (3): 135–143. https:// pubmed.ncbi.nlm.nih.gov/14646006/. Shinde, Sachin, Helen A. Weiss, Beena Varghese, Prachi Khandeparkar, Bernadette Pereira, Amit Sharma, Rajesh Gupta, David A. Ross, George Patton, and Vikram Patel. 2018. “Promoting School Climate and Health Outcomes with the SEHER Multi-Component Secondary School Intervention in Bihar, India: A Cluster-Randomised Controlled Trial.” Lancet 392 (10163): 2465–2477. doi: 10.1016/S0140-6736(18)31615-5. Singla, Daisy R., Brandon A. Kohrt, Laura K. Murray, Arpita Anand, Bruce F. Chorpita, and Vikram Patel. 2017. “Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries.” Annual Review of Clinical Psychology 13 (May): 149–181. doi: 10.1146/annurevclinpsy-032816-045217. Singla, Daisy R., Benedict Weobong, Abhijit Nadkarni, Neerja Chowdhary, Sachin Shinde, Arpita Anand, Christopher G. Fairburn, et al. 2014. “Improving the Scalability of Psychological Treatments in Developing Countries: An Evaluation of Peer-Led Therapy Quality Assessment in Goa, India.” Behaviour Research and Therapy 60 (100): 53–59. doi: 10.1016/j.brat.2014.06.006. Sugiura, Kanna, Faraaz Mahomed, Shekhar Saxena, and Vikram Patel. 2020. “An End to

Coercion: Rights and Decision-Making in Mental Health Care.” Bulletin of the World Health Organization 98 (1): 52–58. doi: 10.2471/BLT.19.234906. Thornicroft, Graham. 2006. Shunned: Discrimination against People with Mental Illness. Oxford: Oxford University Press. https://oxfordmedicine.com/view/10.1093/ med/9780198570981.001.0001/med9780198570981. Thornicroft, Graham, Nisha Mehta, Sarah Clement, Sara Evans-Lacko, Mary Doherty, Diana Rose, Mirja Koschorke, Rahul Shidhaye, Claire O’Reilly, and Claire Henderson. 2016. “Evidence for Effective Interventions to Reduce Mental-HealthRelated Stigma and Discrimination.” Lancet 387 (10023): 1123–1132. doi: 10.1016/S01406736(15)00298-6. Vigo, Daniel, Josep Maria Haro, Irving Hwang, Sergio Aguilar-Gaxiola, Jordi Alonso, Guilherme Borges, Ronny Bruffaerts, et al. 2020. “Toward Measuring Effective Treatment Coverage: Critical Bottlenecks in Quality- and User-Adjusted Coverage for Major Depressive Disorder.” Psychological Medicine October: 1–11. doi: 10.1017/ S0033291720003797. Vigo, Daniel, Graham Thornicroft, and Rifat Atun. 2016. “Estimating the True Global Burden of Mental Illness.” The Lancet. Psychiatry 3 (2): 171–178. doi: 10.1016/S22150366(15)00505-2. Wang, QuanQiu, Rong Xu, and Nora D. Volkow. 2021. “Increased Risk of COVID-19 Infection and Mortality in People with Mental Disorders: Analysis from Electronic Health Records in the United States.” World Psychiatry 20 (1): 124–130. doi: 10.1002/ wps.20806. Weobong, Benedict, Helen A. Weiss, David Mcdaid, Daisy R. Singla, Steven D. Hollon, Abhijit Nadkarni, A.-La Park, et al. 2017. “Sustained Effectiveness and CostEffectiveness of the Healthy Activity Programme, a Brief Psychological Treatment for Depression Delivered by Lay Counsellors in Primary Care: 12-Month Follow-up of a Randomised Controlled Trial.” Public Library of Science (PLoS) Medicine 14 (9): e1002385. doi: 10.1371/ journal.pmed.1002385.

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C1 | AUSTERITY RERUN

The austerity decades (2010–2025)

Since 2010, governments around the world have been cutting public expenditure. By late 2021, austerity cuts are expected in 154 countries, and as many as 159 countries in 2022. The trend is expected to continue at least until 2025, with an average of 139 countries each year. Austerity is projected to affect 5.6 billion persons in 2021 or about 75% of the global population, rising to 6.6 billion or 85% of the world population in 2022. By 2025, 6.3 billion people or 78% of the total population may still be living under austerity. However, as we present later in this chapter, it does not need to be this way. There are policy alternatives. Analysis of government public expenditure projections, based on data for 189 countries in the October 2020 World Economic Outlook database (International Monetary Fund 2020), shows that two major global crises led to periods of fiscal expansion, limited to one or two years, followed by long periods of socially painful austerity. This happened in 2008–2009, at the beginning of the global financial and economic crisis, and then in 2020 during the first waves of the COVID-19 pandemic. After these short periods of fiscal expansion, governments – advised by the International Monetary Fund (IMF), the G20,1 and others – rapidly scaled back much-needed public support with adverse consequences for the majority of the population. The high levels of expenditures needed to cope with the COVID-19 pandemic and the resulting socioeconomic crises have left governments with growing fiscal deficits and debt. However, rather than continuing to explore financing options to provide desperately needed support for people and the economy, since 2021 governments are entering into another period of fiscal austerity. Figure C1.1 shows the number of countries contracting public expenditure, calculated as a percentage of gross domestic product (GDP), from 2008 to 2025 (Ortiz and Cummins 2021). Contrary to public perception, austerity is not limited to European countries, but is more prevalent in developing countries.2 The post-pandemic shock appears to be much more intense than the one that followed the global financial and economic crisis. The average expenditure contraction in 2021 is projected at 3.3% of GDP, which is nearly double the size of the previous crisis, and 1.7% of GDP in 2022. Even more worrisome is the commonplace use of excessive budget contraction, defined as spending less than the (already low) pre-pandemic levels. When looking at real changes, more than 40 governments are forecasted to have budgets that are, on average, 12% smaller in 2021–2022 than in 2018–2019, including countries with high

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Figure C1.1  Number of developing and high-income countries contracting public expenditure, expressed as a percentage of GDP, 2008–2025. Source: Ortiz and Cummins (2021), based on IMF (2020).

developmental needs such as Ecuador, Equatorial Guinea, Kiribati, Liberia, Libya, Republic of Congo, South Sudan, Yemen, Zambia, and Zimbabwe. The fiscal choices made by most governments over the decade of 2008 to 2019 were alarming. Nearly $10 trillion were allocated to the financial sector, and $2.4 trillion was used for fiscal stimulus plans, while just $0.24 trillion was provided in official development assistance (ODA) to developing countries. Another $0.75 trillion – more than triple the amount of ODA – was assigned to the IMF to support/influence developing countries (IMF 2010c; Ortiz and Cummins 2019). While trillions were given to bail out the financial sector, the costs of adjustment were thrust upon populations in many countries in 2010–2019. The IMF’s advice underwent a major change in 2010, supported by the Organization for Economic Cooperation and Development (OECD) and the G20, that influenced policies in many countries. Two IMF Board papers called for large-scale fiscal adjustment “when the recovery is securely underway” and for structural reforms in public finance to be initiated immediately “even in countries where the recovery is not yet securely underway” (IMF 2010a; 2010b). Reforms of universal pension and health entitlements were called for, accompanied by minimal safety nets for the poorest, also known as rationalizing and narrow-targeting welfare, often using the euphemism “strengthened safety nets” (IMF 2010a, 15–32). On the composition of fiscal adjustment, it was advised that most of it could come from: (a) unwinding the previously adopted fiscal stimulus packages; (b) reforming pension and health entitlements to reduce the long-term financial obligations of the state by way of avoiding “a rise in spending as a share of GDP” (IMF 2010a, 16); (c) containing other spending, by means

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such as eliminating subsidies; and (d) increasing tax revenues, often focused on regressive consumption taxes or value-added tax (VAT). The Fund’s austerity agenda soon became mainstream policy advice in a number of international organizations and a majority of countries, thrusting the costs of adjustment on populations (see Chapter D4). A review of 779 IMF country reports between February 2010 and August 2019 showed that six main policies were considered to consolidate budgets, and two measures to boost revenues (Ortiz et al. 2015; Ortiz and Cummins 2019). These measures are also being advised at country level after 2020: 1. Wage bill cuts or caps in 130 countries, reducing or freezing the salaries and number of public sector workers who provide essential services to the population, including education, health, and social workers. These cuts or caps adversely impact public service delivery. 2. Reducing subsidies (fuel, food, agriculture) in another 130 countries, despite periods of high food and energy prices. When basic subsidies are withdrawn, food and transport costs increase and can become unaffordable for households. Higher energy prices also tend to contract employment-generating economic activities. 3. Rationalizing and narrow-targeting welfare (“safety nets”) in 107 countries, often by revising eligibility criteria and targeting the poorest, rather than appealing to options consistent with the Sustainable Development Goals (SDG) agenda, such as financing universal social protection systems. In most developing countries, the middle classes have low incomes, and targeting the poor while excluding them increases their vulnerability. 4. Pension and social security reforms in 105 countries, cutting benefits and eroding public systems. Reforms include raising contribution rates, increasing eligibility periods, prolonging the retirement age and/or lowering benefits, and structural reforms moving towards private systems, despite the failure of pension privatization in earlier decades (Box C1.1). As a result, future pensioners will receive lower benefits. 5. Labor flexibilization reforms in 89 countries, such as revising minimum wages downward, limiting salary adjustments, decentralizing collective bargaining, and increasing the ability of enterprises to fire employees. In a context of economic slow-down, such measures encourage labor market “precarization” and depress workers’ incomes (see Chapter C2). 6. Reforming healthcare systems in 56 countries, including raising fees and co-payments for patients as well as introducing cost-saving measures in public healthcare centers. These measures risk excluding populations from receiving critical assistance at a time when it is needed most. 7. Increasing consumption taxes or VAT on basic goods and services in 138 countries to increase revenues. This regressive policy generates inequality and may further contract economic activity.

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8. Privatizations in 59 countries and strengthening public–private partnerships (PPPs) in 60 countries. Privatization proceeds produce short-term budget gains but long-term losses given the lack of future revenues. Additional privatization risks include layoffs, tariff increases, and unaffordable and/or low-quality basic goods and services (see Chapter B3). PPPs are promoted as a solution for countries under fiscal constraints, however PPPs have a much larger cost to the public budget. Citizens end up paying more than if services were publicly provided, as private companies add profits, and have much larger transaction costs as well as higher costs; private operators tend to charge higher prices to users.

Box C1.1: The failure of pension privatization reforms From 1981 to 2014, 30 countries privatized fully or partially their public mandatory pensions. Fourteen countries were in Latin America, another 14 countries in Eastern Europe and the former Soviet Union, and two in Africa. It must be noted that this is a very small number of countries (only 30 of 192 countries in the world). Most of the privatizations were supported by the World Bank, IMF, OECD, US Agency for International Development (USAID), and Asian or Inter-American Development Banks, against the advice of the International Labor Organization (ILO). As of 2018, 18 countries have reversed pension privatization fully or partially: Venezuela (2000), Ecuador (2002), Nicaragua (2005), Bulgaria (2007), Argentina (2008), Slovakia (2008), Estonia, Latvia and Lithuania (2009), Bolivia (2009), Hungary (2010), Croatia and Macedonia (2011), Poland (2011), the Russian Federation (2012), Kazakhstan (2013), the Czech Republic (2016), and Romania (2017). The reasons why governments reversed pension privatizations are: • Coverage rates stagnated or decreased • Pension benefits deteriorated significantly • Poverty, gender, and income inequality increased • Expensive: high transition costs created large fiscal pressures • High administrative costs • Financial market and demographic risks transferred to individuals • Weak governance: capture of regulation and supervision functions • Social dialogue deteriorated • Concentration of the private insurance industry • Limited effect on capital markets in developing countries • Ultimately, the financial sector benefitted from people’s pension savings

Sources: ILO 2017; Ortiz et al. 2018.

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Austerity had a detrimental impact on populations. Inequalities grew, and millions were pushed into poverty, with women particularly affected (UNWOMEN 2015). In some European countries, citizens challenged these policies and courts declared austerity cuts unlawful and unconstitutional, such as Portugal (2013), Latvia (2010), and Romania (2010), and benefits had to be restored (ILO 2014a and 2017, OHCHR 2013). However, as shown in Figure C1.1, the majority of affected countries were developing countries where no legal action was taken. The United Nations (UN) (2016a and 2019) and the Center for Social and Economic Rights (CESR) (2018) argue that, according to standards of international law, both states and international financial institutions (IFIs) may be held responsible for complicity in the imposition of economic reforms that violate human rights. The health impacts of austerity

We organize the mechanisms linking austerity with health into (1) direct effects, (2) indirect effects, and (3) effects on social determinants.

1. Direct effects Austerity led to reductions in public health spending, impacting the volume and quality of healthcare services (Reeves et al. 2014; Stubbs and Kentikelenis 2018). Empirical studies assessing the effect of declining health spending found a significant and detrimental relationship with infant mortality, under-five mortality, and several other health outcomes (Thomson et al. 2017). In Eurozone countries, where austerity was either unilaterally implemented or imposed by IFIs, government spending cuts translated into shrinking numbers of healthcare personnel, hospital bed reductions and closures of facilities, reduced opening hours, and increased waiting times for medical procedures, all of which worsened healthcare access (Kentikelenis et al. 2014; UN 2016b). The introduction or increase of user fees and co-payments for medicines in several countries (e.g., Czech Republic, France, Italy, Netherlands, and Romania), and more stringent eligibility criteria for subsidized health services (e.g., Greece), meant vulnerable populations such as migrants were unable to access necessary care (Maresso et al. 2015). One study estimated that between 2010 and 2012, amid a new round of austerity, unmet medical needs increased across the European Union by 1.23% points each year (Reeves et al. 2015). In developing countries, it was typically the IMF that advised governments to undertake austerity either as part of its regular surveillance missions or when countries sign up to its structural adjustment programs to borrow money. While the IMF claims to protect social spending in these programs, independent research has challenged the veracity of these claims (e.g., Kentikelenis et al. 2016; Stubbs and Kentikelenis 2018). For example, a study of West African countries found that, on average, each binding IMF policy reform reduced government health expenditure per capita by 0.25% (Stubbs et al. 2017), primarily driven by

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budget deficit targets that reduced investment in health and limited expansion of doctors and nurses. These measures lowered the accessibility and affordability of healthcare and increased neonatal mortality (Forster et al. 2019b). Adjustment measures also sought to enhance the role of the private sector and non-governmental organizations (NGOs) in healthcare provision. When coupled with rollbacks in expenditures, government health provision was outsourced to NGOs, often less equipped to provide comprehensive health services of sufficient quality (Kentikelenis and Shriwise 2016; Pfeiffer and Chapman 2019). Sometimes this was linked to health system decentralization – transference of fiscal and operational responsibilities to the sub-national level. In principle, decentralization can make health systems more responsive to local needs; but in practice it contributed to inadequate health system coordination and budget execution problems, since local authorities lacked technical capacities or diverted funds to alternative uses (Stubbs et al. 2017). It also impaired responses to nationwide disease outbreak, as occurred during the West African Ebola epidemic (Kentikelenis et al. 2015).

2. Indirect effects Privatization of state-owned enterprise and natural resources – in addition to interventions in health systems described above – resulted in losses to reliable public revenue sources used as fiscal foundations for effective health systems (King et al. 2009); and where state-owned enterprises provided health coverage to employees, these benefits were withdrawn and former employees lost access to healthcare (Stuckler, King, and McKee 2009). While regressive consumption taxes were introduced or increased to raise budget revenues and counterbalance shortfalls, these measures did not increase overall tax revenues; they merely altered the tax structure: more revenues from consumption taxes, less from trade taxes (Reinsberg, Stubbs, and Kentikelenis 2020). By shedding qualified civil servants, austerity prescriptions also undermined the administrative ability of governments to deliver effective services (Reinsberg et al. 2019a), such as public health and pandemic preparedness and response. Moreover, privatizations and public sector layoffs and wage cuts increased corruption, as civil servants tried to supplement diminishing incomes (Reinsberg, Kentikelenis, and Stubbs 2019; Reinsberg et al. 2020). 3. Effects on social determinants Austerity measures had a profound impact on a complex web of macro-level factors that affect population health. First, they are linked to an erosion of labor rights, dwindling incomes, increases in unemployment, higher poverty head-counts and poverty gaps, and greater income inequality (Kentikelenis et al. 2014; Reinsberg et al. 2019b; Rickard and Caraway 2019; Stubbs et al. 2021b). In the past decade, public sector salary freezes and restrictions on hiring were introduced in Cyprus, Greece, Ireland, Portugal, and Tunisia, amongst others.

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These layoffs led to declines in unionization (since unions are more prevalent in the public sector), expansions in the informal sector, and increased poverty and inequality (Forster et al. 2019a; Martin and Brady 2007). In the United Kingdom, there was a mass rise in referrals to food banks, especially in local authorities that suffered the greatest cuts in spending on local services and welfare benefits (Loopstra et al. 2015). Lack of gainful employment is linked to alcoholism and suicide (Stuckler, King, and McKee 2009), and is a root cause of health problems over the life course. Second, austerity measures affect educational outcomes, impacting social mobility opportunities and people’s knowledge about healthcare. Resources for an effective education sector – infrastructure and a well-trained workforce – were cut in some countries during austerity rounds, eroding the quality of educational provision. A study of developing countries between 1990 to 2014 found the education sector was not protected from austerity and documented IMF reforms that explicitly targeted reductions to teachers’ payroll and employment cuts (Stubbs et al. 2020). Third, austerity increased rights abuses by weakening governments’ abilities to enforce civil rights (Stubbs and Kentikelenis 2017). The protection of civil rights requires government expenditures for properly trained and adequately compensated judges, police, and military and for institutions to monitor the activities of enforcement entities. One study showed austerity is linked to deteriorating levels of respect for women’s rights because it undermines government ability and willingness to protect such rights (Detraz and Peksen 2016). Hardships caused by austerity also resulted in increased social unrest, in some instances leading to violent repression by the ruling government. Studies demonstrate a significant rise of world protests since governments adopted austerity policies in 2010 (Ortiz et al. 2013; 2021) (Box C1.2). Other research shows that austerity increases incidents of conflict (Hartzell et al. 2010; Casper 2017), resulting in injuries and casualties, destruction of health facilities, and collapse of health systems. Fourth, austerity eroded social cohesion and trust, a vital requirement for governments to mount a successful pandemic response (Kentikelenis 2017). These psychosocial effects are linked to a range of negative health outcomes. For example, privatizations and labor flexibilization increased stress, resulting in adverse mental health consequences and increases in alcoholism and suicide (Antonakakis and Collins 2015; Stuckler, King, and McKee 2009). Further, austerity and the resulting distrust in governments fueled the rise of the radical right (Evans and McBride 2017). How austerity created the conditions for inequitable pandemic outcomes

The health effects of the pandemic vary by public policy responses between countries which imposed austerity and those which opted to maintain public spending and social protection programs. As McKee and Stuckler (2020)

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Box C1.2: Anti-austerity protests In recent years, the world has been shaken by protests. From the Arab Spring to the “Indignados” (outraged), from Occupy to food riots, there have been periods in history when people rebelled about the way things were, demanding change, such as in 1848, 1917, or 1968; today we are experiencing another period of rising outrage and discontent. An analysis of 2,809 protests occurring between 2006 and 2020 in 101 countries covering over 93% of world population shows there was a major increase in protests beginning in 2010 with the adoption of austerity measures in all world regions. Not only is the number of protests increasing but also the number of protesters. Crowd estimates suggest that 52 events had one million or more protesters; some of those may well be the largest protests in history (e.g., 250 million in India in 2020 and 17 million in Egypt in 2013). The main grievances are: • Anti-austerity and economic justice: About 1,500 protests (below). • Failure of political representation and political systems. Over 1,500 protests on lack of real democracy; corporate influence; corruption; failure to receive justice from the legal system; transparency and accountability; surveillance of citizens; and anti-war/military. • Civil rights: Over 1,360 protests on issues such as ethnic/indigenous/racial rights; women’s rights; right to freedom of assembly/speech/press; religious issues; rights of lesbian/gay/bisexual/transgendered people (LGBT); immigrants’ rights; and prisoners’ rights. It must be noted that a small number of protests focus on denying rights to specific groups (e.g., radical right anti-immigrants, anti-gay).

Figure C1.2  Anti-austerity protests in 101 countries, 2006–2020 (in number of protests/year). Source: Ortiz et al. forthcoming.

AUSTERITY RERUN  |   201 • Global justice: About 900 protests were against the IMF and other IFIs, for environmental justice and the global commons, and against imperialism, free trade, and the G20. Regarding anti-austerity protests, the most prevalent cause is the reform of public services. Citizens march against full and partial privatization, rationalization of services, cost-recovery measures, and other reforms that reduce the quality and quantity of public services in areas such as health, education, and water, among others (e.g., Australia, Chile, Egypt, France, Russia, Turkey). Low living standards and inequalities are issues raised in most protests (e.g., Angola, Iran, Lebanon, Philippines, Tunisia, United States). Related protests are workers’ demand for jobs and decent wages (e.g., Argentina, Bangladesh, China, India, Indonesia, Jordan, Mexico, South Africa, South Korea), against budget cuts (e.g., Canada, Greece, Ireland, Italy, Sudan, Spain, United Kingdom), pension reforms (e.g., Chile, France, Greece, Latvia, Portugal, Ukraine), protesting evictions and demanding affordable housing (e.g., Ireland, Spain, United Kingdom, United States), the removal of subsidies (Ecuador, Kyrgyzstan, Mozambique, Nigeria, Peru, Uganda), and rising prices of goods and services (e.g., Brazil, Burkina Faso, Egypt, Ethiopia, Haiti, India, Nicaragua, Niger, Romania, South Africa, Tunisia).

Sources: Ortiz et al. 2013 and 2021 (forthcoming).

articulate, “an outbreak that requires social distancing and quarantine is likely to develop very differently in a setting in which there is a workforce with access to universal health coverage and social protection, than in one in which employment is casual and people must choose whether to go to work when ill or starve” (640). Years of austerity have starved health systems and social protection programs of resources, creating a context in which many countries were wholly unprepared for the COVID-19 pandemic (see Chapter B3). This has exacerbated pre-existing inequalities, as vulnerable populations face the dual challenge of retrenched public services – on which they are more reliant – and economic crises. Within advanced countries, inequalities in COVID-19 prevalence and mortality rates have been documented between more and less affluent neighborhoods, and higher and lower socioeconomic groups. For example, COVID-19 infection is seven times higher in the most deprived areas of Spain’s Catalonia region compared to the least deprived; in England and Wales, black, Asian, and minority ethnic groups account for 34.5% of critically ill COVID-19 patients despite only 14% of the

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population from such backgrounds; and in Chicago COVID-19 mortality rates for black residents was 34.8 per 100,000, compared to 8.2 for white residents (Bambra et al. 2020). Developing countries have also been deeply affected by the pandemic, where the funding gap for COVID-19 responses remains vast (Stubbs et al. 2021a). In the face of reductions in tourism, capital inflows, and remittances, an estimated 150 million additional people will have fallen into extreme poverty in 2021 (World Bank 2020). The weak state of public health systems – overburdened, underfunded, and understaffed from the previous decade of austerity – has left countries prone to healthcare failures and total breakdown in healthcare services, with catastrophic effects for poorer populations. For example, in debt-distressed Ecuador, fiscal austerity measures endorsed by the IMF led to a fall of 64% in public investment in the health sector in the last two years, including expenditures vital for a pandemic response, such as construction of hospitals and purchase of medical equipment, and 3,680 public health workers were laid off in 2019 (Badillo and Fischer 2020). The country’s handling of the COVID-19 crisis has been especially poor; and it is the country’s marginalized populations – Indigenous peoples, women, elderly, informal workers, and households of the lowest-income quintiles – that have been disproportionately affected by the pandemic, as they are more dependent on public services (Corkery et al. 2020). Despite health systems being strained to the breaking point during the pandemic, in the world’s poorest countries investment in public health has been – and continues to be – limited because governments are prioritizing debt repayments to private creditors over providing basic care for the population (Jubilee Debt Campaign 2020). The threat of austerity 2020 onwards

In 2020, there was an initial respite from austerity as the pandemic forced governments into emergency health expenditures to build intensive care units, procure ventilators, drugs, masks, and COVID-19 tests, as well as temporary socioeconomic expenditures – e.g., social protection, income/food support, subsidies to utilities and care services, furlough schemes, support to enterprises, loan guarantees, tax deferrals – to facilitate compliance with lockdowns and economic recovery. The unexpected expenditures to cope with the pandemic have resulted in significantly increased debt and fiscal deficits. Figure C1.1 above demonstrates how the post-pandemic shock appears to be even more premature and severe than the one that followed the global financial crisis. Current projections indicate that 154 countries will be contracting expenditure by an average 3.3% of GDP in 2021, which will increase to 159 countries in 2022, and the trend continues at least up to 2025. The incidence and depth of fiscal austerity varies across regions. Europe and Central Asia have the highest proportion of countries contracting expenditure in 2021 (46 out of 49 countries, or 94%). All other

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regions are close behind, ranging between 73% and 80% of countries affected. This includes the Middle East and North Africa (16 out of 20 countries or 80%), sub-Saharan Africa (37 out of 47 countries, or 79%), Latin American and the Caribbean (25 out of 33 countries, or 76%), South Asia (6 out of 8 countries, or 75%), and East Asia and the Pacific (22 out of 30 countries, or 73%) (Ortiz and Cummins 2021). A new general allocation of $650 billion Special Drawing Rights (SDRs) by the IMF in 2021 was welcome, but new lending may still come with strings attached, requiring governments to implement austerity policies. At a time when many countries are experiencing third and fourth waves of COVID-19 surges, vaccine rollouts are extremely uneven, lockdowns are resurfacing, economic recessions are being prolonged, job losses are growing, and record poverty numbers continue being shattered. Prioritizing fiscal adjustment is simply irrational. Other analyses of IMF staff reports for 80 primarily developing countries show that 72 countries are projected to begin a process of fiscal consolidation in 2021 in order to free-up resources to stabilize debt levels and meet debt service (Eurodad 2020; Oxfam 2020). The austerity cuts in these 80 developing countries will place an increasing burden on vulnerable populations. Revenues will be increased through regressive consumption taxes for two-thirds of countries for which data is available, and over half the countries will be left below pre-pandemic government expenditure levels. Fourteen countries, including Tunisia which had just 13 doctors per 10,000 people when COVID-19 struck, are expected to freeze or cut public sector wages and jobs, which could mean lower quality of healthcare and fewer nurses, doctors, and community workers in countries already short of healthcare staff (Oxfam 2020), with such cuts in the past often leading to skilled health worker outmigration. For its part, the World Bank continues to support private sector solutions by focusing on PPPs, despite that these have resulted in adverse global health outcomes (Eurodad 2018) (Box C1.3). Studies estimate that it earmarked 60% of the $14bn of the Fast-Track COVID-19 Facility through its private sector arm, rather than using it to strengthen public health systems (Dimakou et al. 2020).

Box C1.3: The failure of hospital PPPs: the cases of Lesotho and Sweden Lesotho’s Queen Mamohato Memorial Hospital: This PPP contract was signed in 2008 to build a national hospital to replace an old one and upgrade the network of urban clinics. The World Bank assured that the PPP would bring vast improvements at the same annual cost as the old hospital and was promoted as a flagship model for Africa’s health systems. However, a 2014 report by Oxfam and the Lesotho Consumer Protection Association denounced that the real cost of the PPP was 51% of the total health budget

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of Lesotho, or over three times the cost of running the old hospital. A 2017 UNICEF-World Bank public expenditure review showed that the annual cost had only minimally declined and still consumed more than one-third of the total health budget. According to Lesotho’s Deputy Prime Minister Monyane Moleleki, “the Queen Mamohato Memorial Hospital is bleeding government coffers” (People’s Health Movement et al. 2017, 88). Sweden’s Nya Karolinska Solna (NKS) Hospital: This PPP contract was signed in 2010 to build and manage the new NKS hospital, which was planned to open in 2015. The European Commission advised to opt for a PPP model based on certainties around efficient delivery on time, cost-savings and value for money. However, at the end of 2018, the hospital was significantly delayed and faced massive cost overruns, which led to a public investigation. Today, the NKS holds the renowned status of being the most expensive hospital in the world (for a fuller discussion of the politics leading to PPPs, see Global Health Watch 5 Chapter B5).

Sources: Ortiz and Cummins 2019; EURODAD 2018; Romero 2015; PSI 2015.

No more austerity: financing alternatives for health and social protection

Austerity measures are being used as a Trojan horse to reduce government intervention, under the assumption that universal public health and other development policies are not affordable or that government expenditure cuts are inevitable. This is simply not true. There are alternatives, even in the poorest countries. There is a wide variety of options to expand fiscal space and generate financing resources, supported in policy statements of the UN and IFIs (see for instance, ILO, UNICEF, and UNWOMEN in Ortiz et al. 2017). 1. Increasing tax revenues: This is the principal channel for generating resources, achieved by altering different types of tax rates – e.g., on consumption, corporate profits, financial activities, property, imports/exports, natural resources – or by strengthening the efficiency of tax collection methods and compliance. Many countries are increasing taxes for social investments, not only on consumption, which is generally regressive and counter to social progress, but also on other areas. For example, Bolivia, Mongolia, and Zambia are financing universal pensions, child benefits, and other schemes from mining and gas taxes; Ghana, Liberia, and the Maldives introduced taxes on tourism to support social programs; and Brazil introduced a tax on financial transactions to expand social protection coverage. Wealth taxes are also being proposed in many countries to cope with the COVID-19 pandemic; even

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the IMF supports that high earners and companies that prospered in the coronavirus crisis should pay additional tax to show solidarity with those who were hit hardest by the pandemic.3 2. For social protection, expanding social security coverage and contributory revenues: Increasing coverage and therefore collection of social insurance contributions is a reliable way to finance social protection, freeing fiscal space for other social expenditures. Social protection benefits linked to employment-based contributions also encourage formalization of the informal economy. A remarkable example can be found in Uruguay’s Monotax.4 Argentina, Brazil, Tunisia, and many other countries have demonstrated the possibility of broadening both coverage and contributions by formalizing and protecting workers in the informal economy. 3. Borrowing or restructuring existing debt: This involves active exploration of domestic and foreign borrowing options at low cost, including concessional, following careful assessment of debt sustainability. For example, South Africa issued municipal bonds to finance basic services and urban infrastructure. For countries under high debt distress, restructuring existing debt may be possible and justifiable if the legitimacy of the debt is questionable and/or the opportunity cost in terms of worsening deprivations of the population is high. In recent years, more than 60 countries have successfully renegotiated debts, and more than 20 have defaulted/repudiated public debt, such as Ecuador, Iceland, and Iraq, directing debt servicing savings to social programs. 4. Eliminating illicit financial flows: Estimated at more than ten times the size of all ODA received, a titanic number of resources illegally escapes developing countries each year. To date, little progress has been achieved, but policymakers should devote greater attention to cracking down on money laundering, bribery, tax evasion, trade mispricing and other financial crimes that are both illegal and deprive governments of revenues needed for social and economic development. 5. Reallocating public expenditures: This is the most orthodox approach, which includes assessing ongoing budget allocations through Public Expenditure Reviews (PERs) and other types of thematic budget analyses, replacing high-cost, low-impact investments with those with larger socioeconomic impacts, eliminating spending inefficiencies, and/or tackling corruption. For example, Egypt created an Economic Justice Unit in the Ministry of Finance to review expenditure priorities, while Costa Rica and Thailand shifted military spending to finance universal health services. 6. Using fiscal and central bank foreign exchange reserves: This includes drawing down fiscal savings and other state revenues stored in special funds, such as sovereign wealth funds, and/or using excess foreign exchange reserves in the central bank for domestic and regional development. Chile, Norway, and Venezuela, among others, are tapping into fiscal reserves for social investments.

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7. Lobbying for aid and transfers: This requires either engaging with different donor governments or international organizations to ramp up North–South or South–South transfers. Despite being much smaller than traditional volumes of ODA, bilateral and regional South–South transfers can also support social investments and warrant attention. 8. Adopting a more accommodating macroeconomic framework: This entails allowing for higher budget deficit paths and/or higher levels of inflation without jeopardizing macroeconomic stability. A significant number of developing countries have used deficit spending and more accommodative macroeconomic frameworks during the global recession to attend to pressing demands at a time of low growth and to support socioeconomic recovery. Many governments around the world have been applying these options for decades, showing a wide variety of revenue choices as well as creativity to address critical investment gaps. Each country is unique, and all options should be carefully examined, including the potential risks and trade-offs, and considered in national social dialogue. National tripartite dialogue, with government, employers, and workers as well as civil society, academics, Parliaments, United Nations agencies, and others, is fundamental to generate political will to exploit all possible fiscal space options in a country and to adopt the optimal mix of public policies for inclusive growth and social justice. Given the importance of public investments for human rights and inclusive development, it is imperative that governments explore all possible alternatives to expand fiscal space to finance national investments in decent work, improved health, and the fuller realization of human rights. Notes 1  “G20” refers to the Group of 20 wealthier nations in the world: Argentina, Australia, Brazil, Canada, China, France, Germany, India, Indonesia, Italy, Japan, Republic of Korea, Mexico, Russia, Saudi Arabia, South Africa, Turkey, the United Kingdom, the United States, and the European Union. See https://www.dfat. gov.au/trade/organisations/g20. 2  The categorization of countries by income levels is based on World Bank fiscal year 2021 and does not imply endorsement; it is used to

indicate that austerity is not solely a matter for higher income countries. 3  See “IMF Proposes ‘Solidarity’ Tax on Pandemic Winners and Wealthy,” Financial Times, April 7, 2021. https://www. ft.com/content/5dad2390-8a32-4908-8c966d23cd037c38. 4  Monotax is a simplified tax collection/ payment scheme for Uruguayan small contributors. People covered by the Monotax regime are entitled to the same social security benefits as salaried workers (ILO 2014b).

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AUSTERITY RERUN  |   207 austerity-exacerbated-the-crisis-by-analucia-badillo-salgado-and-andrew-m-fischer/. Bambra, Clare, Ryan Riordan, John Ford, and Fiona Matthews. 2020. “The COVID-19 Pandemic and Health Inequalities.” Journal of Epidemiology and Community Health 74 (11): 964–968. doi: 10.1136/jech-2020-214401. Casper, Brett A. 2017. “IMF Programs and the Risk of a Coup d’Etat.” Journal of Conflict Resolution 61(5): 964–996. doi: 10.1177/0022002715600759. CESR. 2018. Assessing Austerity: Monitoring the Human Rights Impacts of Fiscal Consolidation. New York: Center for Social and Economic Rights. Corkery, Allison, Andrés Chiriboga-Tejada, Jayat Ghosh, Demba Moussa, and Adrian Falco. 2020. “Austerity is Killing Ecuador. The IMF Must Help End this Disaster.” The Guardian. August 29. https://www.theguardian.com/ commentisfree/2020/aug/29/ecuadorausterity-imf-disaster. Detraz, Nicole, and Dursun Peksen. 2016. “The Effect of IMF Programs on Women’s Economic and Political Rights.” International Interactions 42(1): 81–105. doi: 10.1080/03050629.2015.1056343. Dimakou, Ourania, María Jose Romero, and Elisa Van Waeyenberge. 2020. “Never Let a Pandemic Go to Waste: How the World Bank’s COVID-19 Response is Prioritising the Private Sector.” Eurodad Briefing Paper. https://d3n8a8pro7vhmx.cloudfront. net/eurodad/pages/1101/attachments/ original/1602585821/WBG_covid_funding_ FINAL.pdf?1602585821. Eurodad. 2018. “History RePPPeated: How Public Private Partnerships are Failing.” Brussels: EURODAD. https://www.eurodad.org/ historyrepppeated. Eurodad. 2020. “Arrested Development: International Monetary Fund Lending and Austerity Post COVID-19.” Brussels: EURODAD. https://www.eurodad.org/ arrested_development. Evans, Bryan M., and Stephen McBride. 2017. Austerity: The Lived Experience. Toronto: University of Toronto Press. doi: 10.3138/9781487515584. Forster, Timon, Alexander Kentikelenis, Bernhard Reinsberg, Thomas Stubbs, and Lawrence King. 2019a. “How Structural Adjustment Programs Affect Inequality: A Disaggregated

Analysis of IMF Conditionality, 1980–2014.” Social Science Research 80: 83–113. doi: 10.1016/j.ssresearch.2019.01.001. Forster, Timon, Alexander Kentikelenis, Thomas Stubbs, and Lawrence King. 2019b. “Globalization and Health Equity: The Impact of Structural Adjustment Programs on Developing Countries.” Social Science & Medicine 267: 1–9. doi: 10.1016/j. socscimed.2019.112496. Hartzell, Caroline A., Matthew Hoddie, and Molly Bauer. 2010. “Economic Liberalization via IMF Structural Adjustment: Sowing the Seeds of Civil War?” International Organization 64(2): 339–356. doi: 10.1017/ S0020818310000068. ILO. 2014a. “World Social Protection Report 2014-15.” Geneva: International Labour Organization. https://www.ilo.org/global/ research/global-reports/world-socialsecurity-report/2014/lang–en/index.htm. ILO. 2014b. “Monotax: Promoting Formalization and Protection of Independent Workers.” Geneva: International Labour Organization. https://www.social-protection.org/gimi/ gess/RessourcePDF.action?id=48020. ILO. 2017. “World Social Protection Report 2017-19.” Geneva: International Labour Organization. https://www.ilo.org/global/ publications/books/WCMS_604882/lang–en/ index.htm. ILO. 2019. “Reversing Pension Privatization: Key Issues. Policy Brief.” Geneva, International Labour Organization. https://www. social-protection.org/gimi/RessourcePDF. action?id=55463. IMF. 2010a. “Exiting from Crisis Intervention Policies.” Washington, DC: International Monetary Fund. https://www.imf.org/ external/np/pp/eng/2010/020410.pdf. IMF. 2010b. “Strategies for Fiscal Consolidation in the Post-Crisis World.” Washington, DC: International Monetary Fund. https://www. imf.org/external/np/pp/eng/2010/020410a. pdf. IMF. 2010c. “Financial Sector Taxation, IMF’s Report to the G-20.” Washington, DC: International Monetary Fund. https://www. imf.org/external/np/seminars/eng/2010/ paris/pdf/090110.pdf. IMF. 2020. “World Economic Outlook October 2020: A Long and Difficult Ascent.” Washington, DC: International Monetary

208   |  Global Health Watch 6 Fund. https://www.imf.org/en/Publications/ WEO/Issues/2020/09/30/world-economicoutlook-october-2020. Jubilee Debt Campaign. 2020. “IMF Loans Bailing Out Private Lenders during the COVID-19 Crisis.” https://jubileedebt.org.uk/ wp-content/uploads/2020/07/IMF-bailoutsbriefing_07.20.pdf. Kentikelenis, Alexander. 2017. “Structural Adjustment and Health: A Conceptual Framework and Evidence on Pathways.” Social Science & Medicine 187: 296–305. doi: 10.1016/j.socscimed.2017.02.021. Kentikelenis, Alexander, and Amanda Shriwise. 2016. “International Organizations and Migrant Health in Europe.” Public Health Reviews 37(1): 19. doi: 10.1186/s40985-016-0033-4. Kentikelenis, Alexander, Marina Karanikolos, Aaron Reeves, Martin McKee, and David Stuckler. 2014. “Greece’s Health Crisis: From Austerity to Denialism.” The Lancet 383(9918): 748–753. doi: 10.1016/S01406736(13)62291-6. Kentikelenis, Alexander, Lawrence King, Martin McKee, and David Stuckler. 2015. “The International Monetary Fund and the Ebola Outbreak.” The Lancet Global Health 3(2): e69–e70. doi: 10.1016/S2214-109X(14)70377-8. Kentikelenis, Alexander, Thomas Stubbs, and Lawrence King. 2016. “IMF Conditionality and Development Policy Space, 1985–2014.” Review of International Political Economy 23(4): 543–582. doi: 10.1080/09692290.2016.1174953. King, Lawrence, Patrick Hamm, and David Stuckler. 2009. “Rapid Large-scale Privatization and Death Rates in Excommunist Countries: An Analysis of Stressrelated and Health System Mechanisms.” International Journal of Health Services 39(3): 461–489. doi: 10.2190/HS.39.3.c. Loopstra, Rachel, Aaron Reeves, David TaylorRobinson, Ben Barr, Martin McKee, and David Stuckler. 2015. “Austerity, Sanctions, and the Rise of Food Banks in the UK.” British Medical Journal 350: h1775. doi: 10.1136/bmj.h1775. Maresso, Anna, Philipa Mladovsky, Sarah Thomson, Anna Sagan, Marina Karanikolos, Erica Richardson, Jonathan Cylus, Tamás Evetovits, Matthew Jowett, Josep Figueras, and Hans Kluge. 2015. Economic Crisis, Health Systems and Health in Europe:

Country Experience. Observatory Studies Series. No. 41. Copenhagen: European Observatory on Health Systems and Policies. https://pubmed.ncbi.nlm.nih.gov/28837306/. Martin, Nathan, and David Brady. 2007. “Workers of the Less Developed World Unite? A Multilevel Analysis of Unionization in Less Developed Countries.” American Sociological Review 72(4): 562–584. doi: 10.1177/000312240707200404. McKee, Martin, and David Stuckler. 2020. “If the World Fails to Protect the Economy, COVID-19 will Damage Health Not Just Now but Also in the Future.” Nature Medicine 26: 640–642. doi: 10.1038/s41591-020-0863-y. OHCHR. 2013. “Report on Austerity Measures and Economic, Social and Cultural Rights.” Presented to ECOSOC, Substantive Session of 2013, Geneva, July 1–26, E/2013/82. Geneva: Office of the High Commissioner for Human Rights. Ortiz, Isabel, and Matthew Cummins. 2019. “Austerity: The New Normal – A Renewed Washington Consensus 2010–24.” New York, Brussels, London and Ferney: Initiative for Policy Dialogue, International Trade Union Confederation, EURODAD, Public Services International, Bretton Woods Project. http:// policydialogue.org/publications/workingpapers/austerity-the-new-normal/. Ortiz, Isabel, and Matthew Cummins. 2021. “Global Austerity Alert: Looming Budget Cuts in 2021–25 and Alternative Pathways.” New York, Brussels, Ferney, Beirut, London and Penang: Initiative for Policy Dialogue, International Trade Union Confederation, Public Services International, Arab Watch Coalition, Bretton Woods Project and Third World Network. https://policydialogue.org/ files/publications/papers/Global-AusterityAlert-Ortiz-Cummins-2021-final.pdf. Ortiz, Isabel, Sara Burke, Mohamed Berrada, and Hernan Cortes. 2013. “World Protests 2006– 2013.” Working paper. New York: Initiative for Policy Dialogue and Friedrich-EbertStiftung New York. http://policydialogue. org/publications/working-papers/worldprotests-2006-2013. Ortiz, Isabel, Sara Burke, Mohamed Berrada, and Hernan Cortes. 2021 forthcoming. “World Protests 2006–2020.” New York: Initiative for Policy Dialogue and Friedrich-EbertStiftung New York.

AUSTERITY RERUN  |   209 Ortiz, Isabel, Matthew Cummins, Jeronim Capaldo, and Kalaivani Karunanethy. 2015. “The Decade of Adjustment: A Review of Austerity Trends 2010–2020 in 187 Countries.” Geneva: International Labour Organization. New York: South Centre and Initiative for Policy Dialogue. http://policydialogue.org/publications/ working-papers/the-decade-of-adjustment-areview-of-austerity-trends-2010-2020-in-187countries/. Ortiz, Isabel, Matthew Cummins, and Kalaivani Karunanethy. 2017. “Fiscal Space for Social Protection: Options to Expand Social Investments in 187 Countries.” Geneva: International Labour Organization. https://www.social-protection.org/ gimi/RessourcePDF.action?ressource. ressourceId=51537. Ortiz, Isabel, Fabio Duran-Valverde, Stefan Urban, and Veronika Wodsak. 2018. Reversing Pension Privatizations. Rebuilding Public Pension Systems in Eastern Europe and Latin America. Geneva: International Labour Organization. https://www.ilo.org/ wcmsp5/groups/public/ – ed_protect/ – soc_ sec/documents/publication/wcms_648574. pdf. Oxfam. 2020. “IMF Paves Way for New Era of Austerity Post-COVID-19.” Nairobi: OXFAM. October 12, 2020. https://www.oxfam.org/ en/press-releases/imf-paves-way-new-eraausterity-post-covid-19. People’s Health Movement, Medact, Third World Network, Health Poverty Action, Medico International, and ALAMES. 2017. Global Health Watch 5: An Alternative World Health Report. London: Zed Books. https:// phmovement.org/download-full-contentsof-ghw5/. Pfeiffer, James, and Chapman, Rachel R. 2019. “NGOs, Austerity, and Universal Health Coverage in Mozambique.” Globalization and Health 15(S1): 1–6. doi: 10.1186/s12992-0190520-8. PSI. 2015. “Why PPPs Don’t Work: The Many Advantages of the Public Alternative.” University of Greenwich. https://www. world-psi.org/sites/default/files/rapport_ eng_56pages_a4_lr.pdf. Reeves, Aaron, Martin McKee, Sanjay Basu, and David Stuckler. 2014. “The Political Economy of Austerity and Healthcare:

Cross-national Analysis of Expenditure Changes in 27 European Nations 1995– 2011.” Health Policy 115: 1–8. doi: 10.1016/j. healthpol.2013.11.008. Reeves, Aaron, Martin McKee, and David Stuckler. 2015. “The Attack on Universal Health Coverage in Europe: Recession, Austerity and Unmet Needs.” European Journal of Public Health 25(3): 364–365. doi: 10.1093/eurpub/ckv040. Reinsberg, Bernhard, Alexander Kentikelenis, and Thomas Stubbs. 2019. “Creating Crony Capitalism: Neoliberal Globalization and the Fueling of Corruption.” Socio-Economic Review 19 (2): 607–634. doi: 10.1093/ser/ mwz039. Reinsberg, Bernhard, Thomas Stubbs, and Alexander Kentikelenis. 2020. “Taxing the People, Not Trade: The International Monetary Fund and the Structure of Taxation in Developing Countries.” Studies in Comparative International Development 55(3): 278–304. doi: 10.1007/s12116-02009307-4. Reinsberg, Bernhard, Alexander Kentikelenis, Thomas Stubbs, and Lawrence King. 2019a. “The World System and the Hollowing Out of State Capacity: How Structural Adjustment Programs Affect Bureaucratic Quality in Developing Countries.” American Journal of Sociology 124(4): 1222–1257. doi: 10.1086/701703. Reinsberg, Bernhard, Thomas Stubbs, Alexander Kentikelenis, and Lawrence King. 2019b. “The Political Economy of Labor Market Deregulation during IMF Interventions.” International Interactions 45(3): 532–559. doi: 10.1080/03050629.2019.1582531. Reinsberg, Bernhard, Thomas Stubbs, Alexander Kentikelenis, and Lawrence King. 2020. “Bad Governance: How Privatization Increases Corruption in the Developing World.” Regulation & Governance 14(4): 698–717. doi: 10.1111/rego.12265. Rickard, Stephanie J., and Teri L. Caraway. 2019. “International Demands for Austerity: Examining the Impact of the IMF on the Public Sector.” Review of International Organizations 14(1): 35–57. doi: 10.1007/ s11558-017-9295-y. Romero, María José. 2015. “What Lies Beneath? A Critical Assessment of PPPs and their Impact on Sustainable Development.”

210   |  Global Health Watch 6 Brussels: EURODAD. https://www.eurodad. org/what_lies_beneath. Stubbs, Thomas, and Alexander Kentikelenis. 2017. “International Financial Institutions and Human Rights: Implications for Public Health.” Public Health Reviews 38(1): 27. doi: 10.1186/s40985-017-0074-3. Stubbs, Thomas, and Alexander Kentikelenis. 2018. “Targeted Social Safeguards in the Age of Universal Social Protection: The IMF and Health Systems of Low-income Countries.” Critical Public Health 28(2): 132–139. doi: 10.1080/09581596.2017.1340589. Stubbs, Thomas, Alexander Kentikelenis, David Stuckler, Martin McKee, and Lawrence King. 2017. “The Impact of IMF Conditionality on Government Health Expenditure: A Cross-national Analysis of 16 West African Nations.” Social Science & Medicine 174: 220–227. doi: 10.1016/j.socscimed.2016.12.016. Stubbs, Thomas, William Kring, Christina Laskaridis, Alexander Kentikelenis, and Kevin Gallagher. 2021a. “Whatever it Takes? The Global Financial Safety Net, COVID-19, and Developing Countries.” World Development 137: 105171. doi: 10.1016/j. worlddev.2020.105171. Stubbs, Thomas, Alexander Kentikelenis, Rebecca Ray, and Kevin P. Gallagher. 2021b. “Poverty, Inequality, and the International Monetary Fund: How Austerity Hurts the Poor and Widens Inequality.” GEGI Working Paper. No. 46. https://www.bu.edu/gdp/ files/2021/04/GEGI_WP_046_FIN.pdf. Stubbs, Thomas, Bernhard Reinsberg, Alexander Kentikelenis, and Lawrence King. 2020. “How to Evaluate the Effects of IMF Conditionality: An Extension of Quantitative Approaches and an Empirical Application to Public Education Spending.” Review of International Organizations 15(1): 29–73. doi: 10.1007/s11558-018-9332-5. Stuckler, David, Lawrence King, and Martin McKee. 2009. “Mass Privatisation and the Post-communist Mortality Crisis:

A Cross-national Analysis.” The Lancet 373(9661): 399–407. doi: 10.1016/S01406736(09)60005–2. Thomson, Michael, Alexander Kentikelenis, and Thomas Stubbs. 2017. “Structural Adjustment Programmes Adversely Affect Vulnerable Populations: A Systematic-narrative Review of their Effect on Child and Maternal Health.” Public Health Reviews 38(1): 13. doi: 10.1186/s40985-017-0059-2. UN. 2016a. Report E/C.12/GBR/CO/6 of the UN Committee on Economic, Social and Cultural Rights (CESCR), International Covenant on Economic, Social and Cultural Rights. 58 Session. Geneva: United Nations. UN. 2016b. UN Human Rights Council Report A/HRC/34/57: Report of the Independent Expert on the Effects of Foreign Debt and Other Related International Financial Obligations of States on the Full Enjoyment of All Human Rights, Particularly Economic, Social and Cultural Rights. Geneva: United Nations. UN. 2019. UN Human Rights Council Report A/74/178. Responsibility for Complicity of International Financial Institutions in Human Rights Violations in the Context of Retrogressive Economic Reforms. Report of the Independent Expert on the effects of foreign debt and other related international financial obligations of States on the full enjoyment of all human rights, particularly economic, social and cultural rights. Geneva: United Nations. UNWOMEN. 2015. Progress of the World’s Women 2015–2016: Transforming Economies, Realizing Rights. New York: UNWOMEN. https://www.unwomen.org/en/digitallibrary/publications/2015/4/progress-of-theworlds-women-2015. World Bank. 2020. Poverty and Shared Prosperity 2020: Reversals of Fortune. Washington, DC: World Bank. doi: 10.1596/978-1-4648-1602-4.

C2  |  UNEQUAL LABOR MARKETS MEET A DISEQUALIZING PANDEMIC

Introduction

Since the 1980s, neoliberal globalization has had dramatic impacts on workers through the informalization of employment relationships and the flexibilization of labor markets (Labonté and Ruckert 2019). This restructuring had serious implications for workers’ health, as work and income are considered crucial social determinants of health (SDH) (Ruckert, Huynh, and Labonté 2017). Labor markets can contribute to higher rates of injury and psychological stress, while neoliberal reforms of the 1980s contributed to higher rates of material deprivation and poverty, heightening societal and global disparities (Labonté and Ruckert 2019, 94). Labor market trends are a crucial element in monitoring population health and, as informal and precarious work continues to grow, it becomes increasingly necessary to understand the implications this will have for health. The COVID-19 crisis is continuing this process of dramatically reshaping the world of work in ways that could have significant and long-lasting implications. Not only has it led to a material decrease in employment and hours worked; it is also reshaping how and where people work. This chapter considers some of these emerging trends to better understand how labor changes are unfolding, and what their health-related implications might be. We begin by providing some historical background on how the rise of neoliberalism reshaped labor markets. The regional impacts of the COVID-19 pandemic on employment and their variations are then considered. Following this, changes that occurred in supply chains and on production, writ large, are summarized. The growth of informal and precarious employment in the wake of the pandemic and the rise of digitization in work are then discussed. Finally, the chapter considers how these labor market trends are affecting health now, and into the future, and what countermeasures could be taken to protect worker’s health. Neoliberalism, health, and labor markets

Prior to neoliberalism, Western labor markets were characterized by the Fordist model of industrial capitalism, that is, permanent, full-time, and year-round employment that often came with various health-related benefits. The ability that labor had to sustain these arrangements was related to the strength of unions and their ability to collectively bargain. This bargaining power allowed labor to

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secure a greater proportion of gross domestic product (GDP) through rising wages and a stronger social safety net that provided more and higher quality public services (Peters 2008, 83–98). However, this reality was not shared by many of the workers in the Global South. Similarly, in the so-called “developed world,” women, marginalized groups, and self-employed contractors were often excluded from the benefits associated with this supposed “golden age of capitalism” that lasted from the 1950s into the 1970s (Quinlan, Mayhew, and Bohle 2001, 334–414). The standard employment relationship came under pressure in the late 1970s during the economic crisis of stagflation. Following this, Western states implemented economic programs characterized by austerity and neoliberal restructuring (which remain dominant in most parts of the world today). According to the neoliberal economics that succeeded the Fordist model of industrial capitalism, one of the reasons capitalism entered crisis was the rigidity of labor markets. This led to a major societal reorganization process through the weakening of labor power and strengthening of capital, a process that has been ongoing for decades and continues today. This was accompanied by a global trend towards capital liberalization in the 1990s which facilitated the rapid movement of finance across the globe to invest in areas conducive to capital accumulation, leading employers to threaten to move operations elsewhere when labor regulations and benefits were deemed too restrictive or unfriendly towards their desired profitability. Together these developments culminated in the reorganization of global production under a new international division of labor (Labonté and Ruckert 2019, 95). Over the three decades that followed, global production was restructured with acute impacts on labor markets and the health of workers. As low- and middle-income countries (LMICs) began to emerge as spaces consisting of low wages and minimal protections for workers, they became the de facto destination for many of the Fordist production activities that had been present in the West. Export Production Zones (EPZs) became a common policy to attract foreign investment in these new spaces for manufacturing, due to their weak regulation of wages and worker safety. Beyond issues of inadequate pay, various reviews of EPZs have found problems with enforcement of even basic workers’ rights, as for example in the case of derogations on health and safety standards in EPZs in Bangladesh and Kenya (Perman et al. 2004, 12; Labonté and Ruckert 2019, 102). In high-income countries (HICs), the health and well-being of workers were also facing setbacks. A decline in unionization, due partly to the outsourcing shift in manufacturing and the rise of right-to-work legislation, meant lower wages and a general decline in health and safety regulations. Union density in the Organization for Economic Cooperation and Development (OECD) declined by almost one-fifth since the 1990s, from 21% of the workforce in 1999, to roughly 17% in 2013 (Labonté and Ruckert 2019, 105). There is also a correlation between declining unionization rates and labor’s share of GDP

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Figure C2.1  Global profit and labor income share. Source: Reproduced with permission from Kevin Gallagher; UNCTAD (2017) as cited in Boston University Global Development Policy Center, “A New Multilateralism from Shared Prosperity,” 2019. https://www.bu.edu/gdp/files/2019/05/Updated-New-Graphics-NewMultilateralism-May-8-2019.pdf

(Labonté and Stuckler 2016), and between the rise in transnational corporate profits and the fall in global labor income share (Figure C2.1). In sum, the integration of global commodity chains through neoliberal restructuring has had both direct and indirect health impacts, many of which are being intensified by the COVID-19 pandemic. Impact of COVID-19 on employment

The COVID-19 pandemic has had an immediate impact on employment rates, with no corner of the globe spared from the economic collapse induced by the virus and its accompanying public health measures. The number of people employed globally experienced a steep drop alongside declining global labor incomes and working hours, with some sectors facing more severe damage than others. Globally, an OECD report suggests that working hours declined by 14% in 2020, which approximates to roughly 400 million full-time jobs, with 265 million of these losses occurring in G20 countries (OECD and ILO 2020, 12). Compared to the corresponding periods in 2019, labor income dropped by 10.7% during the first three-quarters of 2020, equivalent to $3.5 trillion (ILO 2020a, 11). Among the most impacted are those employed in high-risk sectors, which the United Nations (UN) defines as agriculture, manufacturing, wholesale

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and retail trade, and accommodation and food services; globally, 38% of the workforce, or roughly 1.25 billion workers, are employed in these sectors (United Nations 2020a, 9). Particularly affected by pandemic-related employment losses have been young people, low-skilled workers, women, and the elderly. Low-income countries so far (as of mid-2021) account for the greatest share of the loss in labor income, at 15.1%. This compares to projected labor income losses in lower-middle-income countries of 11.4%, upper-middle-income countries of 10.1%, and high-income countries of just 9.0% (ILO 2020a, 8). These variations will inevitably impact the nature of employment within different global regions. For instance, 85% of workers in African countries are informally employed, as is the reality for most workers in Asia, Latin America, and the Middle East (UN 2020a, 5). Workers in these regions will be particularly affected by pandemicrelated job insecurity due to their inability to access social protection measures.

1. COVID-19 related health risks due to impacts on employment The COVID-19 pandemic has posed health risks to workers in various ways. To begin, it is the health workers on the frontline of this pandemic that face unsafe and underpaid work, a concern that has mobilized nurses’ organizations globally (see Chapter A2). Inadequate access to personal protective equipment (PPE) has been an issue that has politicized many healthcare workers and led to various forms of political struggles and activism. For example, healthcare workers in Zimbabwe, Kenya, and South Africa organized protests over inadequate access to PPE (EQUINET and SATUCC 2021, 9). Similarly, in Canada most healthcare workers in the province of Ontario felt they were unprepared and unsafe due to a lack of PPE (Brophy et al. 2021, 268), complaining of a lack of enforcement of health regulations and laws in the context of the pandemic response. Concerns over a lack of PPE and social distancing requirements, alongside inadequate pay, have similarly caused workers in other sectors to echo these calls for safer working conditions (EQUINET and SATUCC 2021, 10). Even for those that could easily transition to working from home, the pandemic has the potential to impact their health negatively by increasing their social isolation and loneliness, in turn raising the potential for exacerbating mental health related disorders and ergonomic related physical injuries (ILO and OECD 2020, 22). Case study: garment and textile industry

The garment and textile industry provides a snapshot of the trends emerging in global labor markets due to the pandemic. One central element is the potential for much sharper regional divides in the post-COVID-19 world. Manufacturing has often been centered in Asia, the “factory of the world,” with the garment and textile sector making up large segments of exports for countries such as Bangladesh, Cambodia, Myanmar, and Vietnam (ILO 2020b, 6–7). With the collapse of supply chains due to low consumer demand and fears of Western

UNEQUAL LABOR MARKETS MEET A DISEQUALIZING PANDEMIC  |  215 Box C2.1: World Cup (of Shame) vs. the health of workers in Qatar The construction of the facilities for the World Cup in Qatar highlights the struggle of migrant workers to secure safer and more secure working conditions. For the workers of largely South Asian descent, the construction of the World Cup facilities has been characterized by death and tragedy. According to a recent report, in the ten years since Qatar was given the right from FIFA to host the world games, more than 6,500 migrant workers have died in the country (Pattisson et al. 2021). This amounts to close to 12 workers a week dying due to the conditions they are faced with. A British Broadcasting Corporation (BBC) news story reported that workers were having to work long hours in the heat without access to water, told to perform tasks that they had little training in, and were being paid less than previously agreed (Fottrell 2015). The reporters who filed this news item were arrested in Qatar in 2015 (Stephenson 2015). Qatar’s intense summer heat is likely to be significant in these workers’ deaths; however, their deaths are often misclassified to suppress this information and attributed to acute heart or respiratory failure, despite many occurring among a largely young and fit workforce (Pattisson et al. 2021). Most of these deaths by “natural causes” occurred amongst Indian, Nepali, and Bangladeshi workers. Amnesty International spoke out against these death classifications, calling for not only greater workplace safety standards but also for greater transparency and clarity (Pattisson et al. 2021). Through its World Cup of Shame campaign, Amnesty International has highlighted the plight of these migrant workers, including appalling living and working conditions, delayed or non-existent salary payments, physical confinement, and forced labor (Amnesty International 2021). Some professional football players have supported this, and similar campaigns, by staging on-field protests in World Cup qualifying matches, with Norwegian players wearing a shirt stating: “Human Rights, On and Off the Pitch.” Such campaigns, however, have had limited impact thus far, the only exception being the scrapping of the need for an employer’s permission to change jobs, something that rights activists said tied migrant workers’ presence in the country to their employers and led to abuse and exploitation (Aljazeera 2021). The deaths of Qatar’s World Cup construction workers have occurred over the course of a decade, although the COVID-19 pandemic has amplified the hazardous conditions they face. They are not alone in this, as most migrant and guest workers are confronted with unreliable contracts and unsafe workplaces. From construction workers in Qatar to temporary foreign workers in Canada, migrant workers and their generally exploitative working and living conditions continue to underpin many of the major building projects of wealthy states and developers, even as they experience higher

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rates (than non-migrants) of adverse occupational exposures and working conditions, which lead to poor health outcomes, workplace injuries, and occupational fatalities (Moyce and Schenker 2018).

states reshoring their manufacturing sector, several futures for these workers are imaginable. One possibility is that these jobs may return, but the already few benefits once associated with them may be even more limited and employment more precarious. As a recent report on the garment industry noted: 72.4% of [Bangladeshi] furloughed workers were sent home without pay. 97.3% of buyers refused to contribute to severance pay expenses of dismissed workers, also a legal entitlement in Bangladesh. 80.4% of dismissed workers were sent home without their severance pay. This is despite the fact that many brands have “responsible exit” policies, in which they commit to support factories in mitigating potential adverse impacts to workers should they decide to exit. (Anner 2020, 2)

The scale of these labor rights violations raises serious questions about how these workers will be reintegrated into this sector once the pandemic subsides and whether this new level of mass disregard for labor rights will become the new normal. When this is considered alongside the fact that women are overrepresented in this sector in Asia (ILO 2020b, 7), and that women are already suffering at a greater rate than men amidst the pandemic, the potential for a rise in (health) inequalities is significant. Alternatively, as many HIC governments consider reshoring manufacturing and protecting domestic industries in the wake of the shock to supply chains, countries that were chosen for their cheap wages and weak labor rights regimes may be further relegated to a peripheral economic status as their key industries are uprooted.

2. Impact of COVID-19 on the growth of informal and precarious employment Various organizations are already reporting the unique impact the pandemic is having on those working in informal and precarious employment. In particular, the “gig economy,” characterized by precarious jobs with flexible employment standards, had already seen rapid growth before the pandemic, as reported in Global Health Watch 5 (People’s Health Movement et al. 2017, 207). The pandemic is acting as an additional catalyst for growth in this kind of employment (Ståhl and MacEachen 2020). According to UN estimates, informal workers account for 1.6 billion worldwide with an additional 400 million of them working in precarious forms of employment such as temporary, short term, or non-standard employment (UN 2020b, 10). Workers in this sector, that is,

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Image C2.1  “Attack on labour rights.” Source: Sketch by Arun for Global Health Watch 6.

self-employed workers, those on temporary, on-call or part-time contracts, and informal economy workers, have been hit hard by this crisis as they often lack access to social benefits if they become unemployed. In the UK, for example, many workers experienced a decline in employment earnings, but the selfemployed suffered a much steeper drop than those in salaried positions (OECD 2020, 15). This finding is significant given that 40% of workers in the EU are estimated to work in this form of employment (OECD 2020, 15). Beyond the self-employed, fixed-term contract workers are also suffering unique challenges. An example of this is found in France where the bulk of unemployment claims in March and April 2020 came from fixed-term contract workers who were not having their contracts renewed, with similar patterns being identified in Italy and Spain (OECD 2020, 15). For informal workers, the situation is also dire, as staying home often means losing one’s job. According to 2020 estimates, there were 1.2 billion informal workers in G20 countries; roughly 70% were impacted by the pandemic crisis, leading to an estimated 61% decline in their earnings and 36% increase in their relative poverty (OECD 2020, 15). In terms of regional impacts, African and Latin American informal sector workers are expected to be hit particularly hard, as their earnings are expected to drop by 80%, in contrast to the global average of 60% (UN 2020a, 11). Among those most impacted by the crisis are care workers, domestic workers, young people, and refugee and migrant workers, all groups that are overrepresented in the

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informal and precarious economy and for whom job loss is likely to exacerbate their already present lack of access to health and social services (UN 2020a, 13). In terms of the gig economy, there are already indications that the COVID-19 pandemic is transforming this ongoing trend. The gig economy covers various fields, such as delivery drivers, online platform-related jobs and other, often tech-driven, jobs. Most notable during the pandemic has been an increase in delivery services, with numbers of delivery orders in Europe, as one example, rising on average by 36%, and with “35–55% of existing [European] consumers intend[ing] to continue using delivery more in the future” (Khan et al. 2020). To meet these growing demands many of the platforms that employ gig-economy workers, such as Etsy, Uber, and delivery-related services, are re-organizing their workers’ responsibilities. Etsy encouraged those who work through their platform to craft masks, while Uber encouraged their drivers to begin delivering groceries and other supplies (Alvarez et al. 2020, 3). There are promising developments and signs that gig workers are gaining the power to ensure their contracts with these corporations have some protections and permanency. One notable situation where this is taking place is the UK in the court case Uber v Aslam. This case dealt with the question of whether Uber drivers, such as Yaseen Aslam, had been self-employed, or were instead “‘workers’ with statutory rights to a minimum wage and paid holidays” (Dukes

Image C2.2  Over 2,500 years ago a message-courier ran scores of miles to proclaim Greek victory over the Persians, and then promptly died. Are gig workers our new marathon couriers? Source: Sketch by Arun for Global Health Watch 6.

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and Streeck 2021). Uber argued that its drivers were self-employed, and that Uber was simply an intermediary, and as such drivers were not entitled to the rights associated with the term “worker” as recorded in UK legal statutes. The Court, however, asserted that “It is the very fact that an employer is often in a position to dictate contract terms … that gives rise to the need for statutory protection in the first place” (Dukes and Streeck 2021). This case will likely resonate with gig-economy workers across the globe in their respective struggles to gain full employment rights. Furthermore, Spain has also reached a landmark agreement between social partners and the Spanish government on the labor rights of people working for digital platforms. The agreement not only establishes employment rights for those delivering services via a digital platform but also calls for algorithm transparency. Declaring drivers on digital platforms employees follows the decisions already made by courts of other states; however, the decision on algorithm transparency is unique. This ensures that these workers have a right to the information, such as the mathematical or algorithmic formulas determining their working conditions (Aranguiz 2021). Nevertheless, the decision is not without setbacks. Drivers only cover a small percentage of the informal economy. Furthermore, contracting arrangements will still be the mode of operation for these companies and their employees during “peak” hours, meaning that arrangements for wages during these select times will still be shaped through temporary contracts. Nonetheless, progress is occurring in ensuring better working conditions for those in the informal gig economy. Pandemic-related adaptations in the informal or precarious sectors are often designed to cater to a customer-centric approach that prioritizes customer over worker safety. The pandemic surge in home deliveries insulates the customer from exposure to COVID-19, while delivery workers who are then expected to pick up, deliver, and sometimes also return these products risk exposure instead (Alvarez et al. 2020, 3). A good example of this is San Francisco, where a “shelter in place” order required most workers to stay at home. Uber drivers, however, were deemed essential workers and remained on the frontlines of COVID-19 exposure, even while they lacked any of the worker protections if they became sick, as well as basic income security (Dubal and Whittaker 2020). Although considered “essential workers” they were simultaneously labeled as “independent contractors,” whereby employers don’t have to provide such workers “with basic protections and benefits, including the minimum wage and unemployment insurance” (Dubal and Whittaker 2020). Gig-economy jobs that occur from home, such as decentralized call centers operating through home offices, are also being intensified, with the dual demands of managing work from home and family life increasingly being laid upon the shoulders of workers employed through these platforms (Alvarez et al. 2020, 4). Carrying the burden of work and family from home amidst the current state of isolation has implications for the mental health of these workers (see Chapter B5).

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Image C2.3 “Quien sostiene la vida” / “Those who sustain life” (2020). Source: Henar Diez Villahoz, Tricontinental: Institute for Social Research, Madrid, Spain.

3. Gendered impacts on employment due to the COVID-19 crisis Women are emerging as one of the groups uniquely disadvantaged by the COVID-19 pandemic. Among the pandemic-related trends differentially impacting women are not returning to employment at the same rates as men; more likely to be employed in precarious or informal jobs; and more likely to be working in sectors that are particularly unsafe with respect to risk of infection with COVID-19 (see Chapter A2). Among the first of these trends, women are likely to emerge from this crisis in economic conditions worse than their male counterparts. An OECD report, for example, notes that women in G20 countries are experiencing a greater fall in employment and total hours worked in comparison to men, particularly so in Italy and Spain (OECD 2020, 19). The reduction in paid work has corresponded with higher rates of unpaid care work due to school and daycare closures (OECD 2020, 12). In addition, women in OECD countries (and elsewhere) are overrepresented in employment sectors

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most vulnerable to job loss, such as retail trade, hospitality and food services, arts, entertainment, and other personal services (OECD 2020, 19). Where job loss has not occurred, women’s service sector work generally cannot be done from home and often involves face-to-face contact with the public, putting those working in these jobs at a greater risk of infection. These risks become more acute when considering the precarious or informal employment status of many women. Recent OECD data find that women account for 42% of employment in informal sectors in comparison to 32% of men (OCED 2020, 19). Ultimately, the combination of women being expected to shoulder most of the burden of unpaid care work at home, and being overrepresented in dangerous and informal work, is leading to a potential trend that leaves women less secure than men in the aftermath of the pandemic. Impact of COVID-19 on the digitization of the economy

The digitization and automation of workplaces is becoming increasingly characteristic of labor market changes unfolding through the pandemic. This is likely to become a key employment trend. The most obvious example of this is in the rise of those workers whose jobs shifted online in the immediate aftermath of the pandemic, with “evidence based on surveys conducted in mid-April show[ing] a massive surge in the share of workers working from home compared to the pre-crisis numbers, ranging from around 30% in Canada to almost 70% in South Africa” (OECD 2020, 21). This growth in digital workspaces is further reflected in the strong economic performances of some e-commerce companies. In the United States, Amazon has reportedly hired an additional 100,000 workers to meet the surging demand for products that perhaps would have been purchased on-site at another company (Palmer 2020). These trends are likely to persist post-pandemic (Palmer 2020), and it is important to understand the implications this will have on health equity and its underlying social determinants. The first among these consequences is that a more digitized world will likely sharpen regional divides, particularly between the Global North and South. The UN reports that in 71 countries, mostly located within the African continent and South Asia, less than half of the population has access to the internet; in Latin America and the Caribbean, 38% of the poorest households do not have internet access (UN 2020b, 14). Unless the digital divide is greatly reduced, large numbers of workers will be unable to pivot to the digitalization of work, further compounding the regional divides already occurring due to strains on supply chains, discussed earlier. How has organized labor responded?

As the COVID-19 pandemic alters the global labor market by intensifying precariousness, workers are pushing back by organizing. Instances of rising labor activism can be found across the world. Earlier, this chapter noted that delivery drivers are making gains not only in their reclassification as employees

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but also in their demands for greater transparency between themselves and the digital transnational corporations that employ them. In Canada, the Ontario teachers’ unions have organized for greater protection in schools and the mass vaccination of all education workers (Canadian Press 2021). Globally, healthcare workers and their unions have been on the frontlines challenging the lack of PPE and other safety measures that put them directly at risk (see Chapter B3). Across North America migrant agricultural workers have been struggling to gain greater access to safer working conditions and vaccinations, as these workers, due to their unsafe (crowded) housing conditions, are at substantial risk of COVID-19 exposure (see Box C2.3). In another example of growing labor activism, workers at an Amazon facility in the US state of Alabama recently attempted (though unsuccessfully) to organize themselves into the first union at an Amazon distribution center, demanding better and safer working conditions as the company overall recorded 20,000 positive COVID-19 cases amongst its workforce (Associated Press 2020). Globally, trade unions and civil society organizations focused on the rights of workers have coordinated to protect the health, well-being, and interests of workers amidst the pandemic. Trade unions and worker rights organizations have been among those pushing governments to make available comprehensive supports for those affected directly by increased COVID-19 risks and by subsequent lockdowns associated with public health measures. Although trade unions have endorsed government efforts to support workers, such as wage subsidy programs, they have also noted the limitations of these programs, noting that such subsidies do little to address the unsafe work environments that are driving transmission among precariously employed workers in the informal economy or to limit the commodification of social services that can undermine access to healthcare, even if subsidies are made available to support access to privatized services.

Box C2.2: Associations of workers and former workers with occupational illness in Colombia Transformations in the world of labor derived from the legal, technological, and managerial changes introduced in production processes in recent decades have intensified the conditions of precarious work, bringing about profound impacts on the health and lives of workers. Our present situation recalls the working conditions surrounding the origins of the Industrial Revolution, where long and intense working hours, exposure to physicochemical, biological, and mechanical risk conditions, and the manner in which workplaces were organized produced high rates of occupational accidents, illness, and death.

UNEQUAL LABOR MARKETS MEET A DISEQUALIZING PANDEMIC  |  223 In recent decades, the workers’ movement has lost crucial achievements organized labor had achieved earlier, for example, that of “the three eights.”1 Today, employees (again) work long hours thanks to piece-rate pay schemes or temporary service contracts, among other informalized work arrangements, and thanks to new communication technologies which keep workers permanently connected to their jobs. Thus emerges an epidemic of pathologies derived from labor, serving as an expression of the conditions of overexploitation and flexibility imposed by the new global labor structures. These structures favor the new patterns of capitalist accumulation characteristic of neoliberalism, highlighting even further the contradictions between capital and labor, accumulation and injury, profits, and insecurity. These working conditions and their impacts on the health and lives of workers have historically triggered collective action by workers to preserve their health. In Colombia at the dawn of the twenty-first century, the clash between capital and labor manifested also in other ways, as evidenced by the large group of workers and former workers who became ill because of their working conditions. They were denied recognition of the labor-based origins of their pathologies, leading them to organize and form associations to demand their rights. The associations: establishing a collective actor Since 2006, there began to emerge in Colombia several associations of workers and former workers with occupational illness; as of 2019, 19 such groups exist. These associations have a broad national reach explained by the presence of productive processes in several regions of the country, linked to mining-energy, agriculture, construction, tobacco, manufacturing, maintenance, hotel, and health and safety sectors. The shared experiences of these affected workers and former workers led them to understand that the damages incurred against their health were due to their working conditions, a problem that was common among them and one that was met with responses of rejection and disregard for their illnesses. This led these workers to organize in associations. These associations in Colombia have taken many forms, including associations where there is no labor union, associations that arise with the support of a labor union, and associations in dispute with a labor union or unions which then take issue with the association. The concept of forming an “association” arose from two perspectives and one condition. First, it was to avoid the less favorable option of having the labor union serve as an organizational body, since it was believed that the labor union was not interested in the problems of sick workers. Second, the association was a broader option than discussions with the labor union,

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since it allowed the affiliation of both workers and former workers, and even of workers’ relatives. These conditions also had to do with regulations, as dismissed workers can no longer unionize, and labor unions did not have a regulatory framework to address the issues of dismissed workers and their social security. Given their collective dynamic, the creation of these associations in Colombia established a novel organizational process in terms of its more open and flexible structure in comparison with labor unions, which were historically used to organize workers. This sometimes led to conflicts, including legal disputes with company-based labor unions. The conflicts are an expression of the irrelevance of the subjects of workers’ health and the problems of sick workers within the labor union agenda. At the same time, these conflicts could also be revealing a rift between sick and “healthy” workers, the latter being the ones who primarily make up labor union membership. This issue is a problematic one, as it demonstrates the inadequacy of social class as the basis to build organizational unity. Conclusions: progress in setting up non-toxic forms of work The experience of workers and former workers with occupational illness demands that society discusses how to shape labor markets so that they generate health and well-being and not illness and death. The experience of these injured workers’ associations in Colombia reveals three realities. First, changes in the world of labor in recent decades resulting from shifts in workplace organization and management and in forms of labor ties are creating toxic work settings where the capital-labor conflict leads to the dispossession of work, health protection at work, and the body and health of the worker. Second, it reveals the failure of health protection in the world of labor, at least within Colombia, but almost certainly more broadly as well. Third, in the political competition established mainly for the control of the domain of workplace safety and health, a crucial aspect is the control and hegemony of technical and scientific information on the harmfulness of working conditions. This rests more with capital (owners) than with the knowledge of affected workers and that of independent doctors and academics. Colombian associations represent processes of identity-building, a search for support mechanisms, and development of legal actions and factual accounts. These processes exert pressure on employers, the state, and social security entities to guarantee the health, labor, and social security rights of workers. In turn, these associations can be understood as an appeal to society to discuss the ways in which people work today, given its intensified traits of insecurity, subordination, and alienation, forming a neo-slave-like way of working which must be challenged and overcome.

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Labor activism has been particularly pronounced in the Global South. In countries such as Namibia and Botswana where wage subsidy programs were implemented, employers did not use these programs and instead imposed unpaid leave on workers; this led to union activism and educational campaigns about workers’ rights to access such wage subsidies (EQUINET and SATUCC 2021, 10). In Zimbabwe, Kenya, and South Africa, healthcare workers protested their precarious working conditions amidst the pandemic (EQUINET and SATUCC 2021, 10). Additionally, healthcare workers in Mozambique have been working to build networks amongst migrant workers to ensure they receive prevention and quarantine messages and services (EQUINET and SATUCC 2021, 11). A related example is the Vula platform in South Africa which has been used to allow health workers to share advice and provide mutual support to one another (EQUINET and SATUCC 2021, 12). Mineworkers across this region, such as in the DR Congo, Zambia, and Zimbabwe, have engaged in strike action to challenge unsafe working conditions and allowances (EQUINET and SATUCC 2021, 10).

Box C2.3: Temporary migrant agricultural workers Temporary migrant agricultural workers are the backbone to many economies around the world as they compose the workforce that helps feed local populations. In Canada, they represent more than 20% of the total agricultural workforce each year. Though referred to as temporary, those migrant workers often fill long-term positions and provide crucial support to the agricultural industry around the globe. Temporary migrant agricultural workers face particular risks in the COVID-19 pandemic due to their communal living and working conditions. While health vulnerabilities faced by these workers have long been well documented, the COVID-19 pandemic exacerbated many of these and further increased the risk of labor rights violations and vulnerability to exploitation. Substandard living conditions have contributed to the rapid spread of COVID-19 amongst this workforce, while many face additional barriers and challenges accessing social and medical services. In Canada, these conditions led to the infection of over 1,000 temporary migrant agricultural workers and to the eventual deaths of three of these workers to date. A follow-up coroner’s review of the COVID-19 deaths of migrant farm workers in Ontario renewed a call for better safeguards and improved working conditions for foreign seasonal agricultural workers. The acute problems experienced during the pandemic, however, are deeply rooted in a system that consistently fails to protect these workers’ health, labor, and human rights. The COVID-19 pandemic

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highlighted these inequities that were previously easily overlooked, while also underscoring the crucial role that temporary migrant agricultural workers play in ensuring food security. It is the duty of local, national, and global authorities (the International Labor Organization (ILO), the International Organization of Migration, and the Office of the UN High Commissioner on Human Rights) to address major flaws in the structure and implementation of the Temporary Foreign Worker Programs around the world and to finally break a cycle of perpetuating injury, inequity, and exploitation (Landry et al. 2021).

Image C2.4  A group of migrant agricultural workers petition for residency status in 2016. Source: Reproduced with permission from Chris Ramsaroop; Harvesting Freedom, “Petition: Tell both the Government of Canada and the Government of Ontario farmworkers need urgent protections.” May 7, 2020. https://harvestingfreedom.org/2020/05/07/petition-tell-the-ontariogovernment-farmworkers-need-urgent-protections/

Where do we go from here?

The pandemic has made it abundantly clear that it will require a long and lasting collective effort to challenge the dominance of neoliberal policy hegemony in the fight for fair pay and secure jobs. But there are some potential policy reforms that could have a direct and immediate impact on health outcomes associated with employment and related determinants of health pathways, policies which have been promoted by a coalition of progressive NGOs and various international organizations even before the pandemic.

1. Universal basic income One solution a variety of countries utilized during the pandemic to support individuals struggling financially were direct cash transfers. A more lasting

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solution could be a permanent extension of this aid in the form of a universal basic income (UBI), as mentioned in Chapter A1. The COVID-19 crisis has exposed significant gaps in social protection coverage that a UBI program could potentially solve. First, with informal and gig-economy jobs both surging in growth, these workers are often on the frontlines of the pandemic but with little-to-no health coverage or other basic entitlements. Not only are these workers not getting benefits while working but, if they lose their unstable employment, they will also be left with little or no social security coverage. A UBI program would provide these workers with the stability that labor markets are currently not providing, guaranteeing a basic level of income security (Gentilini et al. 2020, 45). Thus, as COVID-19 intensifies the flexibility of labor markets through the growth of precarious employment, UBI could fill a gap by providing workers with crucial income protections. While better regulations on gig-economy corporations and progressive labor market reforms are also necessary, a UBI could provide immediate relief for workers struggling in the rapidly expanding precarious labor market. There is strong civil society support for the notion of UBI (see Box C2.4 below), and even some political parties, such as the Liberal Party in Canada or the Green Parties in Germany and the UK, are currently considering the role that UBI could play in social policy reform going forward. This support for UBI is also growing in LMICs. Even before the pandemic, there have been multiple experiences with UBI in LMICs, including a pilot project in 2011 in India where the state of Madhya Pradesh gave a basic income to some 6,000 Indians. The largest and longest UBI experiment in the world is currently taking place in Kenya, where the charity GiveDirectly is making payments to more than 20,000 people spread out across 245 rural villages. As part of this randomized controlled trial, which started in 2016, recipients receive roughly 75 cents per adult per day, delivered monthly for 12 years (Sigal 2020). The pandemic has only accelerated the popularity and uptake of basic income programs, in both the developed and developing world, with new (but time-bound) UBI initiatives implemented widely, including in Spain, the United States, Bolivia, Mexico, Argentina, and South Africa.

Box C2.4: Basic income – a post-pandemic quick fix Interest in basic income2 has grown steadily around the globe in recent years. When the pandemic hit, interest soared as existing programs proved inadequate to meet people’s needs in the economic fallout. When some governments responded with direct cash transfers and a lessening of conditions to receive them, the possibility of a basic income became more tangible. The pandemic has also made the stakes higher by both magnifying

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and accelerating long-standing problems, putting the virus on a collision course with the intersections of race, class, gender, and colonialist divides. The current patterns of inequality, insecurity, poverty, and societal unrest reflect chasms in public policy that are endangering people, livelihoods, and the planet. The world’s wealthiest people have gained billions from the pandemic while countless others have lost jobs, businesses, housing, health, and lives. Firms that could speed up their technological investment did so, creating more disruption for humans as workers and as citizens. This is the context for thinking about basic income: not in the abstract, but in the reality we face now and going forward. Payments that are temporary, irregular, or one-off are not a basic income. What characterizes a basic income is regular, universal, unconditional payments to individuals – no strings attached and no stigma. Benefits traditionally tied to participation in the labor market are neither universal nor unconditional; they leave people out, undermine non-market work that holds up the rest of the economy, and deepen disadvantage faced in the paid labor market. Last resort programs that stigmatize and deprive people of autonomy and dignity compound the damage. In practice, a basic income may be difficult to establish in an ideal version, at least for now. Progress and design will depend on a country’s context, including its other income programs, labor legislation, social infrastructure, and politics. The principle of universality is especially important now as it is applied to policy design. Providing an equal check to everyone may be an ultimate goal, but the extent of change required for this is daunting. Adequacy is increasingly the more urgent policy concern. In France and Canada, rigorous modeling shows that there are different ways to achieve good results. While people identify many different reasons for instituting a basic income, there is also a range of criticism which defies traditional left/right or other political categorizations. The most frequent concerns are about work disincentives, costs, and funding. Much effort has gone into finding evidence of a “work” disincentive (work here meaning paid employment) but to no avail. The deeper root of this continuing concern despite lack of evidence is likely discriminatory bias against people different than oneself and a desire of those with privilege to protect it. That is more challenging to address. The concerns about cost and how to pay for a basic income program are very important ones, and they deserve careful attention. Modeling that looks at benefit design, funding sources, and outcomes is critical. A progressive benefit can result in perverse outcomes if the funding sources are not also progressive. A narrow focus on gross rather than net costs or

UNEQUAL LABOR MARKETS MEET A DISEQUALIZING PANDEMIC  |  229 the claim that public services must be cut to afford a basic income are not constructive and undermine its healthful and solidaristic intent. Some critics identify alternatives – more services or a job guarantee for people in poverty instead of income. Aside from the practical and moral issues these ideas raise, there is little analysis and evidence showing how they could provide results equivalent to income. What the large and growing body of evidence tells us about basic income, however, is hopeful and confident. There have been unconditional cash transfer programs running successfully in some countries for years. There are many pilots around the world including those from the USA, Canada, India, Kenya, and Finland. There is evidence of basic income’s beneficial impacts from research on human behavior, neuroscience, inequality, scarcity, mental health, food security, and more. Now we can learn from the cash transfers during the pandemic. The consistent pattern across all this work is that a basic income improves lives with benefits to health, education, family, and community life. It improves all forms of work and employment, and it empowers women and marginalized groups, builds greater trust among people, and leads to less violence and crime. A basic income is not a silver bullet to the health crises created by insecure labor markets or inadequate labor incomes that pre-date the pandemic. But it is arguably the fastest, most direct, and effective way that people collectively can improve the post-pandemic distribution of income, wealth, work, health, and decision-making power that affect our lives.3

2. Social protection floor Social Protection Floor (SPF) is a global program designed to enhance social cohesion, particularly during turbulent times such as economic recessions. The SPF concept can be understood as a basic set of social rights (derived from human right treaties) including access to essential services (such as health, education, housing, water and sanitation, and others) and social transfers, in cash or in kind, to guarantee income security, food security, adequate nutrition, and access to essential services (ILO 2021). The floor is based on the idea that everyone should enjoy at least basic income security sufficient to live a healthy life, guaranteed through transfers in cash or in kind such as pensions for the elderly and persons with disabilities, child benefits, income support benefits, and/or employment guarantees and services for the unemployed and working poor. The idea behind the need for a SPF dates to a Social Protection Floor Recommendation issued in 2012 by the ILO. As many countries have responded to the pandemic by introducing, scaling up, or adapting social protection measures to protect previously uncovered or inadequately covered population

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groups, calls for implementation of a SPF are again gaining momentum (ILO 2021). While there are many potential policy structures for an SPF, some ideas include cash transfers through the global monetary system and strengthened state-level legislation to broaden social protections or state-level guarantees for certain essential services, such as health, food, and housing (as advocated for by the Social Protection Floor Coalition, http://www.socialprotectionfloorsco­ alition.org). An internationally funded SPF program could serve as one means to ensure that, during periods of global economic uncertainty, workers faced with job loss or lack of access to basic social services would be able to access an international program designed to ensure their fundamental needs are satisfied. Indeed, migrant workers unable to qualify for national programs would have guarantees through this international program to ensure that they would have either cash or a combination of guarantees for social programs that they might otherwise not have. Similarly, due to the impacts of crises often being gendered, women who are vulnerable to being dependent on a job or living situation would have increased security to provide for their safety.

3. Stronger labor regulations While the UBI and SPF are post-market reforms (distributing wealth after the market has failed to generate fair outcomes for workers), pre-market reforms are also necessary to address the health and economic fallout of the COVID-19 pandemic. As detailed throughout this chapter, the pandemic has revealed the weakness of labor protections and the lack of enforcement of existing labor rights for unionized and precarious workers alike. Stronger labor regulations must be part of a comprehensive solution to overcome the growing informalization and precarity of work, notably those regarding the right to organize trade unions, which has suffered amidst pandemic public health restrictions (EQUINET and SATUCC 2020, 12). Strengthening this basic labor right post-pandemic, alongside ensuring all countries move to ratify the full set of ILO conventions, must be key health activist demands. For as the world returns to its pre-pandemic trajectory of growing income inequities worsened by the pandemic, labor/class politics are resuming prominence in progressive social activism. This chapter has indicated that the health struggles related to informal and precarious employment are likely to intensify over the coming years, as the digitization of the economy, the explosion of the gig economy, and the pandemicrelated loss of employment by vulnerable population groups represent intensifying challenges to population health. To address these challenges will require a comprehensive policy response that acknowledges employment relationships as a key entry point for improving population health, and promotes secure and fair employment relationships that allow workers to live healthy lives and to contribute meaningfully to their communities.

UNEQUAL LABOR MARKETS MEET A DISEQUALIZING PANDEMIC  |  231 Notes 1  “Three eights” is the idea that a healthy workday should be divided into three parts: rest (eight hours), work (eight hours), and leisure (eight hours). 2  The term “basic income” is used here as a plain language, lower case description of a concept. As a policy or a proposal being advanced, basic income can go by many names, like Bolsa Familia in Brazil, or by abbreviations,

like UBI (universal basic income). Knowing some detail about how it works is more important than what it is called. 3  To learn more, the website of the Basic Income Earth Network (https://basicincome. org/) has links to the research supporting basic income’s many positive health and social impacts and links to country affiliates around the world.

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Brophy, James T., Margaret M. Keith, Michael Hurley, and Jane E. McArthur. 2021. “Sacrificed: Ontario Healthcare Workers in the Time of COVID-19.” NEW SOLUTIONS: A Journal of Environmental and Occupational Health Policy 30 (4): 267–281. doi: 10.1177/1048291120974358. Canadian Press. 2021. “Ontario Teacher Unions Call for Further Protections Against COVID-19.” Toronto: CityNews. https:// toronto.citynews.ca/2021/04/07/ontarioteacher-unions-call-for-further-protectionsagainst-COVID–19/. Cirera, Xavier, and Rajith W.D. Lakshman. 2017. “The Impact of Export Processing Zones on Employment, Wages and Labour Conditions in Developing Countries: Systematic Review.” Journal of Development Effectiveness 9 (3): 344–360. doi: 10.1080/19439342.2017.1309448. Dubal, Veena, and Meredith Whittaker. 2020. “Uber Drivers are being Forced to Choose between Risking COVID-19 or Starvation.” The Guardian. March 25. https://www. theguardian.com/technology/2020/mar/25/ uber-lyft-gig-economy-coronavirus. Dukes, Ruth, and Wolfgang Streeck. 2021. “Putting the Brakes on the Spread of Indecent Work.” March 10. https:// socialeurope.eu/putting-the-brakes-on-thespread-of-indecent-work. Equity in Health in East and Southern Africa (EQUINET) and Southern African Trade Union Co-ordination Council (SATUCC). 2021. “Pandemic Impacts on Labour – Experience and Responses January 2021.” https://www.equinetafrica.org/sites/default/ files/uploads/documents/EQUINET%20 SATUCC%20info5%20COVID19%20%20 and%20labour%202021.pdf.

232   |  Global Health Watch 6 Fottrell, Stephen. 2015. “Qatar Migrant Workers Describe ‘Pathetic’ Conditions.” BBC. May 21. https://www.bbc.com/news/world-middleeast–32822016. Gentilini, Ugo, Margaret Grosh, Jamele Rigolini, and Ruslan Yemtsov. 2020. “Exploring Universal Basic Income.” World Bank. http://documents1.worldbank.org/ curated/en/993911574784667955/pdf/ Exploring-Universal-Basic-Income-A-Guideto-Navigating-Concepts-Evidence-andPractices.pdf. ILO. 2020a. “ILO Monitor: COVID-19 and the World of Work: Sixth Edition.” International Labour Organization. September 23. https://www.ilo.org/wcmsp5/groups/ public/—dgreports/—dcomm/documents/ briefingnote/wcms_755910.pdf. ILO. 2020b. “COVID-19 and Global Supply Chains: How the Jobs Crisis Propagates across Borders.” International Labour Organization. June 29. https://www.ilo.org/ global/research/policy-briefs/WCMS_749368/ lang–en/index.htm. ILO. 2021. “Towards Solid Social Protection Floors? The Role of Non-contributory Provision during the COVID-19 Crisis and Beyond.” International Labour Organization: Geneva. January 21. https://www.ilo.org/ secsoc/information-resources/publicationsand-tools/Brochures/WCMS_766884/ lang–en/index.htm. Keohane, Mark. 2021. “Qatar 2022 … Human Lives Sacrificed in the Name of Football.” IOL News. March 27. https://www.iol.co.za/ sport/opinion/qatar-2022-human-livessacrificed-in-the-name-of-football-4dbcac3730cc-48e9-ba66-4a5f2265990f. Khan, Hamza, Franck Laizet, Jessica Moulton, and Tom Youldon. 2020. “Reimagining European Restaurants for the Next Normal.” McKinsey & Company. August 5. https:// www.mckinsey.com/industries/retail/ourinsights/reimagining-european-restaurantsfor-the-next-normal. Labonté, Ronald, and Arne Ruckert. 2019. Health Equity in a Globalizing Era: Past Challenges, Future Prospects. Health Equity in a Globalizing Era. Oxford University Press. https:// oxford.universitypressscholarship.com/ view/10.1093/oso/9780198835356.001.0001/ oso- 9780198835356.

Labonté, Ronald, and David Stuckler. 2016. “The Rise of Neoliberalism: How Bad Economics Imperils Health and What to Do about It.” Journal of Epidemiology and Community Health 70 (3): 312–318. doi: 10.1136/jech-2015206295. Landry, Vivianne, Koorosh Semsar-Kazerooni, Jessica Tjong, Alba Alj, Alison Darnley, Rachel Lipp, and Guido I. Guberman. 2021. “The Systemized Exploitation of Temporary Migrant Agricultural Workers in Canada: Exacerbation of Health Vulnerabilities during the COVID-19 Pandemic and Recommendations for the Future.” Journal of Migration and Health 3: 100035. Moyce, Sally, and Marc Schenker. 2018. “Migrant Workers and their Occupational Health and Safety.” Annual Review of Public Health 39 (1): 351–365. doi: 10.1146/annurevpublhealth-040617-013714. OECD. 2020. “The Impact of the COVID-19 Pandemic on Jobs and Incomes in G20 Economies.” ILO-OECD. https://www.ilo. org/wcmsp5/groups/public/—dgreports/— cabinet/documents/publication/ wcms_756331.pdf. Ortiz, Isabel, Christina Behrendt, Andrés Acuña-Ulate, and Quynh Anh Nguyen. 2018. “Universal Basic Income Proposals in Light of ILO Standards: Key Issues and Global Costing.” ESS Working Paper 62. International Labour Office, Geneva. https:// www.ilo.org/wcmsp5/groups/public/—ed_ protect/—soc_sec/documents/publication/ wcms_648602.pdf. Palmer, A. 2020. “Amazon to Hire 100,000 More Workers and Give Raises to Current Staff to Deal with Coronavirus Demands.” CNBC. March 16. https://www.cnbc. com/2020/03/16/amazon-to-hire-100000warehouse-and-delivery-workers.html. Pattisson, P. 2021. “Qatar has Failed to Explain up to 70% of Migrant Workers Deaths in Past 10 Years – Amnesty.” The Guardian. August 26. https://www.theguardian.com/ global-development/2021/aug/26/qatarhas-failed-to-explain-up-to-70-of-migrantworker-deaths-in-past-10-years-amnesty. People’s Health Movement, Medact, Third World Network, Health Poverty Action, Medico International, and ALAMES, eds. 2017. Global Health Watch 5. London: Zed Books.

UNEQUAL LABOR MARKETS MEET A DISEQUALIZING PANDEMIC  |  233 Perman, S., L. Duvillier, N. David, et al. 2004. “Behind the Brand Names: Working Conditions and Labour Rights in Export Processing Zones.” International Confederation of Free Trade Unions. Brussels: International Confederation of Free Trade Unions. https://www.nager-it. de/static/pdf/ICFTU_Cafod_EtAl_LR_ CapResist04.pdf. Peters, John. 2008. “Labour Market Deregulation and the Decline of Labour Power in North America and Western Europe.” Policy and Society 27 (1): 83–98. doi: 10.1016/j. polsoc.2008.07.007. Quinlan, Michael, Clair Mayhew, and Philip Bohle. 2001. “The Global Expansion of Precarious Employment, Work Disorganization, and Consequences for Occupational Health: A Review of Recent Research.” International Journal of Health Services 31: 335–414. Ruckert, A., C. Huynh, and R. Labonté. 2017. “Reducing Health Inequities: Is Universal Basic Income the Way Forward?” Journal of Public Health 40 (1): 3–7. doi: 10.1093/ pubmed/fdx006. Sigal, Samuel. 2020. “Everywhere Basic Income has been Tried, in One Map.” Vox News. October 20. https://www.vox.com/futureperfect/2020/2/19/21112570/universal-basicincome-ubi-map.

Social Europe. https://socialeurope.eu/puttingthe-brakes-on-the-spread-of-indecent-work. Ståhl, Christian, and Ellen MacEachen. 2020. “Universal Basic Income as a Policy Response to COVID-19 and Precarious Employment: Potential Impacts on Rehabilitation and Return-to-work.” Journal of Occupational Rehabilitation 31: 3–6. doi: 10.1007/s10926020-09923-w. Stephenson, Wesley. 2015. “Have 1,200 World Cup Workers Really Died in Qatar?” BBC. June 6. https://www.bbc.com/news/ magazine-33019838. UN Chief Executives Board for Co-ordination on the Social Protection Floor. 2009. “The Social Protection Floor.” Geneva. United Nations. https://www.un.org/en/ga/second/64/ socialprotection.pdf. United Nations (UN). 2020a. “Policy Brief: The World of Work and COVID-19.” United Nations. https://unsdg.un.org/resources/ policy-brief-world-work-and-covid–19. United Nations (UN). 2020b. “Special Rapporteur on Extreme Poverty. Looking Back to Looking Ahead: A Rights Based Approach to Social Protection in the PostCOVID-19 Economic Recovery.” United Nations. https://www.ohchr.org/Documents/ Issues/Poverty/covid19.pdf.

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C3  |  CONFRONTING THE COMMERCIAL DETERMINANTS OF HEALTH

Introduction

Industry-propelled health harms continue to persist. Past editions of Global Health Watch explored issues related to extractive industries, global food industries, and the growth and power of transnational corporations generally. Most attention went to what we now call unhealthy commodities: tobacco/ tobacco-related products, ultra-processed/obesogenic foods, and alcohol. Many of the earlier concerns remain, largely in corporate push-back against progressive initiatives to limit the promotion and consumption of unhealthy commodities. The particular focus in this chapter will be on both the novel and well-worn strategies companies use to shape the consumer environment and the conditions that shape government regulatory approaches. This chapter also identifies assumptions that steer governments away from regulatory measures, making it harder for public health policy actors to counter economic arguments that support continued growth in such industries. This is the case for many low- and middle-income countries (LMICs) where the drive for short-term economic growth and “development” can override longer-term health considerations. What are commercial determinants of health and why do they matter?

Transnational tobacco, food, and alcohol companies continue to produce and promote unhealthy products, shaping the policy landscape, public discourse, and consumer space. The outcome is what the World Health Organization (WHO) has called a “slow-motion disaster” for non-communicable diseases (NCDs). The commercial determinants of health (CDoH), as they are now called, have been defined as “strategies and approaches used by the private sector to promote products and choices that are detrimental to health” (Kickbusch, Allen, and Franz 2016). The CDoH lens is a direct response to the industry-manipulated framing of consumption-based NCDs as rooted in individual choice, shifting responsibility away from unhealthy product producing industries. The tobacco industry is notoriously skilled at shifting responsibility to consumers, veiling its own devious practices and products. The appeal to individual responsibility continues to resonate with ideologies that hold personal freedom as sacrosanct. The deception lies in the assumption that all conditions are held equal for all individuals. Clearly not all individuals have access to necessary

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information about options or the monetary capacity to purchase the healthiest option, particularly with respect to food. There is now widespread recognition of how these companies shape the consumer environment, making unhealthy products normalized, attractive, pervasive, and affordable. It is not simply products floating in an environment that shapes consumption, but intentional corporate actions to manipulate consumers, to produce products that induce addiction, and to influence policies in their favor, ultimately creating “toxic” consumer environments. Where industries accede to some form of control, it tends to be self-regulation whereby they position themselves as “part of the solution.” Companies often welcome self-regulation as a strategy to ward off statutory regulations. When government regulation is imposed, companies have also been relentless in using litigation. These companies have mobilized extensive resources to pursue protracted legal battles in national and sub-national courts, and in international trade and investment dispute forums. This context is also conditioned by neoliberal principles, including an overarching assumption that the freer the market, the better for everyone. This assumption has shaped the relationship between governments, markets, and individuals in ways that make it difficult to advocate for stronger regulatory measures governing production and consumption of unhealthy commodities (Lencucha and Thow 2020). Issues are also converging in dramatic ways, making the CDoH more pressing (Mialon 2020). There is growing attention on the synergy of three pandemics, namely obesity, undernutrition, and climate change. They constitute a syndemic, or synergy of epidemics, because they co-occur in time and place and interact with each other to produce complex sequelae. These pandemics share common underlying food-related societal drivers including the activities of the transglobal food industry which distort food environments and contribute to environmental degradation. Packaging materials used by the food, alcohol, and tobacco industries have a negative impact on the environment. The very process of manufacturing packaging materials contributes to climate change through depletion of natural resources and greenhouse gas emissions. For example, in Europe, only 30% of the 25 million tonnes of plastic waste generated is recycled, with 39% being incinerated and 31% dumped in landfills (Calleja 2019). Companies often also create conditions of economic precarity, such as opposing policies that seek to instate livable wages for workers (Maani et al. 2021). While unhealthy commodity industries attempt to detach themselves from such negative consequences, the syndemic approach widens the lens on health problems and puts them in the context of other diseases and the social and economic inequities that fuel them (Swinburn et al. 2019). The remainder of this chapter outlines the CDoH, including recent approaches by companies to solidify their market presence, and actions by governments and other groups to stave off this influence.

CONFRONTING THE COMMERCIAL DETERMINANTS OF HEALTH  |  237 The health burden of unhealthy commodities

1. Tobacco Tobacco products are consumed by 1.3 billion people globally. Eight million people die annually due to tobacco, and over 90% of these deaths are due to direct use (smoking) of tobacco products. Eighty percent of current tobacco users are in LMICs (WHO 2020). The emerging markets in LMICs have been the target of transnational tobacco companies as these firms look to expand their reach and to compensate for shrinking markets in high-income countries (HICs). In addition to harms caused by tobacco use, its production also places a social and economic burden on communities and has been linked to numerous environmental harms. Tobacco growing uses child labor and companies have exploitative arrangements with growers. Household debt is also common for smallholder tobacco farmers (Magati et al. 2019). 2. Alcohol Of the 3 million deaths from alcohol and alcohol-related incidents globally, 13.5% occur among young people aged 20–39 years (WHO 2018). This age group is a common target of alcohol marketing campaigns which encourage early alcohol initiation and harmful alcohol use, such as binge drinking. The surge in production and popularity of flavored alcoholic beverages (FABs) is also alcohol industry’s tactic to capture the young demographic. As with tobacco, alcohol marketing and consumption is increasingly pivoting to LMIC markets.

Image C3.1  A young boy harvests tobacco on a farm near Sampang, East Java, Indonesia. Source: Human Rights Watch, “A boy harvests tobacco on a farm near Sampang, East Java,” in “Child labour in tobacco growing, Indonesia.” Unfairtobacco. n.d. Accessed May 25, 2021. https://www.unfairtobacco.org/en/child-labour-in-tobacco-growing/child-labour-in-tobaccogrowing-indonesia/#/. Licensed under CC BY-NC-ND 3.0 US.

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3. Unhealthy food Poor quality of food consumed is linked to health challenges such as micronutrient deficiency, stunting, obesity, and other chronic conditions. While the amount of food available has increased over the decades, many diets are becoming less healthy. Consumption of fruit, vegetables, whole grains, nuts, and seeds, the key components of a nutritious diet, remains below the required daily intake level across all world regions. Recent dietary changes are most evident in the “majority world” (i.e., LMICs), where the volume of soft drink consumption increased by an average annual growth rate of 5.2% per person between 1997 and 2009 (Moodie et al. 2013). Consumption of sugary snacks and drinks is also increasing among very young children (6–23 months of age) in LMICs (Huffman et al. 2014) Industry strategies to promote unhealthy commodities

These health challenges stem from deliberate efforts by companies to influence consumption patterns and curtail regulation. We focus on the three main strategies of marketing, lobbying, and corporate social responsibility.

1. Marketing Companies consistently target new markets with existing or new products and take advantage of weak regulations and vulnerable social conditions to do so. With the increase in advertising bans and saturation of markets in many HICs, unhealthy commodity companies have found novel ways to promote their products. One of the most subtle and pervasive is the infiltration of social media. Tobacco companies have been found to sponsor parties hosted by social media influencers replete with their products and resulting in the widespread diffusion of their product images on social media (Kozinets 2019). While advertising bans force tobacco companies to use these discrete practices, the alcohol and food industry have a less restricted marketing path. Alcohol companies indiscriminately advertise during global sporting events like the FIFA World Cup, viewed by billions around the globe. Alcohol and food industry also use social media marketing initiatives including use of celebrities in advertisements, planting their products firmly in popular culture. McDonald’s, Coca-Cola, PepsiCo and a host of alcohol companies have been quick to exploit the popularity of reality TV shows by promoting their brands on recent editions of Big Brother Brazil and Nigeria, which are viewed by millions of youths. Alcohol brands are also promoted through interactive games, competitions, and user-generated content and peer endorsements on social media platforms (Atkinson et al. 2017). The ubiquitous uptake and use of smartphones has extended marketing reach beyond traditional broadcast media, with promotion through social media platforms slipping through most regulatory frameworks. The overall UK expenditure on digital advertising is twice that of traditional

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advertising (£10.3 billion vs £5.2 billion) (Orsini 2018). Although this example is not specific to unhealthy commodities, this pattern is reflected in these industries as well.

2. Lobbying Manufacturers of unhealthy commodities use different lobbying tactics to avoid strict regulation and receive favorable treatment by governments. The direct contact with government is often legitimized by companies’ purported contribution to economic growth. Tobacco remains an entrenched cash crop in some LMICs in Asia, Africa, and South America, and the industry has direct access to economic sectors of government which support tobacco as a means of economic development. Companies use this contact to shape policy and perception. Alcohol companies similarly lobby to protect their economic interests. In one instance, strong direct lobbying by the alcohol industry led the Brazilian Congress in 1996 to define alcoholic beverages for advertising purposes as those with an alcohol concentration greater than 13%, effectively eliminating advertising controls for beer and most wines (Noel et al. 2017). Increasing public health initiatives to intervene in the obesity pandemic has intensified lobbying to resist food regulations. Focal issues have been around excise taxation measures for sugar-sweetened (soda) beverages, which is proving effective in reducing consumption (Hofman 2021), menu labeling, “front-of-pack nutrition labeling” (FOPNL), and placing limits on fast food portion sizes. The food industry has resisted such measures, using domestic courts, threats of trade or investment disputes, and extensive lobbying. Between 2009 and 2015 the main producers of sugar-sweetened beverages in the US spent $100 million to fight the introduction of tax or other regulatory measures (O’Hara and Musicus 2015). The food industry also spends massive amounts attempting to shape influential dietary guidelines. Mars Incorporated alone spent $2 million in 2018–2019 lobbying US Congress, and soda makers like Coca-Cola and PepsiCo spent $24 million in 2014–2015 to resist the move by government to encourage less soda consumption (Stillerman 2019).

Image C3.2  A health food label from a Chilean product specifying that the product is “high in sugar … high in saturated fats … high in sodium … and high in calories.” Source: Ministry of Health, Government of Chile.

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Box C3.1: Front-of-pack nutrition labeling (FOPNL) Institutional structures can also influence dynamics regarding industry lobbying. The use of food labels to inform consumers and support healthier diets – including “interpretive” front-of-pack labels using symbols, colors, or words – are recommended by the WHO. Countries have adopted diverse approaches to front-of-pack labeling, informed by national context. However, the use of such labels has been contested at the World Trade Organization (WTO) as a potentially “unnecessary” barrier to trade.  The Codex Alimentarius Commission (Codex), a multilateral United Nations body responsible for work on food standards, is now developing global guidance for FOPNL. As Codex is recognized by the WTO as an international standards setting body, guidance it develops also has potential to act as a reference point for trade discussions as well as for national policy making. However, Codex has a dual mandate: to protect consumer health and to ensure fair trade practices. Industry Observers at Codex have been quick to provide their input for Codex work on front-of-pack labeling through participating in working groups and Codex meetings and lobbying Ministries of Agriculture and Industry, which often represent countries at Codex. In contrast, public health actors to date have been under-represented in these Codex discussions. There is an urgent need for balanced representation at Codex to ensure that the definition of “front-of-pack nutrition labeling” supports schemes most likely to be effective in achieving public health objectives and not, for example, industry preferred options such as the Guideline Daily Amount that aren’t backed by evidence.

3. Corporate social responsibility Corporate Social Responsibility (CSR) initiatives are actions taken by industry (voluntarily or as part of industry-wide obligations) ostensibly to contribute to social well-being, but essentially aimed at portraying themselves in good light and to leverage favorable (i.e., prevent unfavorable) government regulation. In Malawi, British American Tobacco (BAT) as part of its CSR agenda committed $2.3 million to the Eliminating Child Labour in Tobacco Growing Foundation (ECLT). This foundation has built schools, planted trees, and constructed shallow wells to address the use of child labor in tobacco farming. However, critics note that the amount committed to the Foundation does not compare to the profits made from engaging children in tobacco farming. Recent analysis of the CSR activities of Djarum, a tobacco company in Indonesia, illustrates how CSR activities are used to influence public perception and gain favor with the government (Siahaya and Smits 2020). Box C3.2 showcases the work of The

CONFRONTING THE COMMERCIAL DETERMINANTS OF HEALTH  |  241 Box C3.2: The Foundation for a Smoke-Free World The Foundation for a Smoke-Free World was created with a purported mission to end smoking in this generation. The foundation is funded by Philip Morris International and, although it places emphasis on eliminating cigarette consumption, Philip Morris has not waned in its promotion of cigarettes worldwide, still selling over 700 billion cigarettes per year. At the same time its heated tobacco product sales have skyrocketed. The Foundation has used this framing to position itself as a partner in public health and champion of “harm reduction”(Yach, 2021). The Foundation has channeled resources into tobacco growing countries building strong relationships with government. For example, the Foundation is working in Malawi, providing lucrative scholarships to young researchers to pursue graduate studies around the world. It has also established a Tobacco Transformation Index,™ where it evalutes 15 of the largest tobacco companies in the world on indicators such as harm reduction. The Foundation also produces the Global Trends in Nicotine report to identify the major players in nicotine delivery, outline each of their product organization and geographic focus, and quantify their outputs. The Foundation’s activity reflects a growing emphasis on redirecting public perception and reframing tobacco company activities under the guise of harm reduction while pursuing new addictive products.

Foundation for a Smoke-Free World which is funded by Philip Morris International (PMI), and which continues to obscure PMI’s consistent orientation towards cigarette sales (Yach 2021). The alcohol industry’s CSR activities have similarly been shown to be vehicles used to influence policy decisions, delay and offset alcohol control legislation, and indirectly market their brands. The industry’s “responsible drinking” campaigns use ambiguous language to define harmful drinking practices and often frame the problem as arising from behavioral factors (Petticrew et al. 2016), only scarcely mentioning the harmful effects of alcohol. Food industries use CSR initiatives to build a positive public image and promote their products. Through the Project Last Mile, a public–private partnership (PPP) among the Coca-Cola Company, US Agency for International Development (USAID), the Global Fund, and the Bill & Melinda Gates Foundation, Coca-Cola branded vehicles are used to deliver medical supplies to remote villages notably in Africa, along with their unhealthy product. Multinational companies like PepsiCo often sponsor education programs that promote healthy lifestyles usually targeting youth, which ultimately serve as a marketing strategy.

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PepsiCo explicitly linked their CSR initiative to product sales by successfully incentivizing purchase of specially marked PepsiCo beverages with participation in its Refresh project (Dorfman et al. 2012). Pepsi’s Refresh project, which ran from 2010 to 2012, was a $20 million initiative which sought to support social impact projects nominated and selected by their consumers (including businesses, non-profit organizations, and individuals) around the world. Unhealthy commodity industry activities during the COVID-19 pandemic

As part of the preventive measures during the COVID-19 pandemic, countries instituted lockdowns which saw businesses, including bars and restaurants, shut down for several weeks to curb the spread of the virus. These lockdowns and restrictions on socialization negatively affected food and alcohol industries that rely on on-site consumption. In response, many of these companies shifted to “pandemic-tailored” digital marketing campaigns. These campaigns helped companies to build and maintain brand loyalty by inserting themselves into the COVID-19 response through novel advertising and empathetic messages and hashtags. McDonald’s, for example, encouraged consumers to stay at home and instead used delivery services for consumers to continue accessing their products. In Mexico, Burger King modified their “#HaveItYourWay” hashtag to “#HaveItYourWayAtHome” to align with the pandemic prevention guidelines (White, Nieto, and Barquera 2020). Numerous examples exist where tobacco companies like BAT provided branded masks to social influencers to use on social media postings, or where BAT and PMI used a “stay at home” hashtag promoted by government to promote electronic cigarette devices in numerous countries in the world (Campaign for Tobacco-Free Kids 2021). The pandemic has also provided an opportunity for food and beverage industry to expand the reach of their CSR activities by fostering partnerships with governments and international agencies. PepsiCo reportedly spent $49 million in support to international organizations like Save the Children, Red Cross, and local non-profits for food relief and health system strengthening efforts in over 40 countries (PepsiCo 2020). Heineken donated €15 million to support relief efforts of the International Federation of Red Cross and Red Crescent Societies (IFRC) in Africa, Asia, and Latin America. The WHO’s COVID-19 Solidarity Response Fund received support from Coca-Cola and PepsiCo through Global Citizens, a non-governmental organization (NGO) that is working to end extreme poverty by 2030. Although the details are not known in each of these cases, corporate donations generally trigger tax savings; critics, in turn, argue that such CSR activities essentially exploit the COVID-19 pandemic for cheap marketing and profit maximization (White et al. 2020). More generally, post-pandemic rebuilding of economies needs to be safeguarded from the threat of “COVID capture,” where unhealthy commodity industries attempt to influence public health policy responses that may interfere with their vested interests (Collin 2020).

CONFRONTING THE COMMERCIAL DETERMINANTS OF HEALTH  |  243 Conditions that facilitate unhealthy commodity industry influence on consumers and governments

There are important conditions that allow industries to exert their policy and political influence. Market regulation is an uphill battle within a free-market paradigm, and the “commonsense” of de- and anti-regulation underpins the global system of economic policy. This laissez-faire orientation puts the onus on consumers rather than on governments to shape market practices, even when company products may cause harm.

1. Trade and investment regimes The market penetration in LMICs of transnational companies producing unhealthy commodities has been facilitated by liberalized trade and foreign direct investment (FDI) regimes (Lencucha and Thow 2019). As one example, the 1994 North American Free Trade Agreement (between the USA, Canada, and Mexico) increased US sugar-sweetened beverages exports and FDI, contributing to Mexico having the highest consumption of soft drinks globally. Trade agreement rules also constrict the range of public health measures governments can take, while creating new openings for industry to influence regulatory policy (Labonté 2019b). Tobacco “exceptionalism” and the recent decade of tobacco-related trade and investment disputes, however, have reinforced flexibilities within these regimes that allow for government regulation over tobacco products (Zhou and Liberman 2020). Whether such interpretations will extend to trade or investment disputes regarding food and alcohol products remains to be seen (see Chapter D2). As part of their economic development or growth strategies, governments often provide incentives for investors to promote the inflow of FDI including fiscal incentives and investor protections via international investment agreements. Such incentives often increase supply and consumption of unhealthy commodities in LMICs. Vietnam, for example, removed restrictions on FDI as a requirement for entry into the WTO. This resulted in greater investment by transnational food companies and enabled significant growth in sales of sugar-sweetened carbonated beverages from 6.7% to 23% of total beverage sales per year (Schram et al. 2015). Similarly, a comparison between Peru and Bolivia showed a 122% increase in soft drink production following Peru’s ratification of the US/Peru Free Trade Agreement, compared to minimal change in Bolivia which had no trade agreement with the US (Baker et al. 2016). In Zambia, the government offered tax incentives and infrastructure support to two cigarette plants aimed, in part, at increasing consumption within the country, despite being a signatory to the WHO Framework Convention on Tobacco Control (WHO FCTC) which explicitly prohibits incentives to the tobacco industry (Labonté et al. 2019). 2. Regulatory environments Regulatory environments are shaped not only by powerful companies, but by pervasive and entrenched ideas of government-market relationships. Ideas like

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“the market will decide” underpin government reluctance to directly regulate harmful consumer products. These ideas also rationalize challenges waged against government regulation by industry interests. Recent examples include BAT contesting the introduction of stricter tobacco control measures in Uganda and Kenya and the now famous PMI case against standardized cigarette packaging in Australia. Tobacco companies have also convinced governments to pursue legal challenges to regulations through the WTO, as witnessed in response to Australia’s standardized packaging legislation. Fortunately, these cases have resulted in decisions in favor of government regulation, but with significant monetary costs to governments for the often-lengthy process of litigation. Given the cost of the process, these cases often result in regulatory chill in which governments (both the challenged government and other countries observing the industry arguments and actions) may delay or even abandon adoption of the regulation (Kelsey 2017). Policies seeking to reduce consumption of unhealthy foods have also faced trade-related challenges. Mandatory interpretive nutrition labeling, such as a proposed requirement by the Government of Thailand for a front-of-pack label stating “children should take less,” has been challenged repeatedly at the WTO’s Technical Barriers to Trade Committee (Thow et al. 2017). In Samoa, a ban on the importation of turkey tails (a highly fatty and nutritionally poor cut of meat) in order to address obesity in the country was removed as part of the country’s requirements to join the WTO. The alcohol industry has been successful in influencing policy change to reduce regulation in a number of LMICs. In several African countries (Lesotho, Malawi, Uganda, and Botswana), the alcohol industry influenced national alcohol control policy to focus on individual behavior change rather than industry regulation. South Africa’s 2016 Liquor Amendment Bill proposed a ban on all alcohol advertising, which was strongly opposed by industry and is yet to be enacted. In Botswana, however, the main producers of alcohol unsuccessfully

Image C3.3  Health Star Rating (Australia–New Zealand). Source: Reproduced with permission from the Commonwealth of Australia; World Health Organization, “Manual to Develop and Implement Frontofpack Nutrition Labeling: Guidance for Countries on the Selection and Testing of Evidence-Informed Front-of-Pack Nutrition Labeling Systems in the WHO European Region.” Copenhagen: WHO Regional Office for Europe, 2020. https://apps.who.int/iris/bitstream/handle/10665/336988/WHO-EURO-2020-1569-4132056234-eng.pdf?sequence=1&isAllowed=y

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contested the introduction of a 30% levy on all alcoholic beverages, which has been implemented. Addressing the commercial determinants of health

Despite the uphill struggles that health activists face in attempting to control the spread of unhealthy commodities by confronting their industry purveyors, there have been cases of “success” in implementing measures to create healthpromoting environments and to reduce commercial influence in policy making.

1. Promoting healthy environments Fiscal policies that create price-based incentives are effective in reducing consumption of health-harming products. Following reforms of the excise tax structure in Thailand in 2017, the alcohol tax rate became proportionate to alcohol content while tobacco taxes increased from 20% to 40% (Phonsuk and Suphanchaimat 2019), which reduced consumption of these products. The Power of the Consumer in Mexico, ACT Health Promotion in Brazil, and Healthy Living Alliance in South Africa are activist civil society organizations (CSOs) that have helped garner public support for a sugar tax passed by their governments. Box C3.3 shows the advocacy activities of ACT Health Promotion of Brazil for promoting healthy environments. Food reformulation efforts to reduce the number of unhealthy components such as sugar, salt, and trans fats have been marked by controversy. Reformulation efforts tend to be voluntary and self-regulated, making their effectiveness questionable. Examples of reformulation include the salt reduction pledge of the UK Responsibility Bill to reduce salt content in foods. Regulation at the sub-national level has also encouraged reformulation. For example, the City of New York’s administration successfully instituted a ban on trans-unsaturated fatty acids and calorie labeling at point of sale (Kelly et al. 2016). While regulation remains a critical focus, it is also essential for activists to encourage governments to support healthy product producing companies (Lencucha et al. 2018). The incentives, subsidies, and other infrastructure supports to health-harming companies that currently exist in many (or even most) countries are unacceptable and unjustifiable from an economic perspective when the economic and social costs to society far exceed any returns received by government.

Box C3.3: ACT Health Promotion advocacy work in Brazil ACT Health Promotion (http://actbr.org.br/) in Brazil was originally a tobacco control advocacy organization. It has expanded its mission since 2014 and began to work on the prevention of other chronic non-communicable disease risk factors which, in addition to smoking control, include the promotion of healthy eating, control of alcohol abuse, and physical activity. ACT systematically monitors industry activity including tobacco, food and

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beverage, and alcohol companies. The organization uses this monitoring activity in their advocacy and activism efforts. For example, ACT recently exposed and publicly scrutinized a new partnership between Coca-Cola and the Ministry of Health in Brazil. They also organized a “happiness tent” inside Congress to mobilize support for a bill that prohibited soft drinks in schools; the bill passed. Another recent investigative initiative exposed government subsidies to the soda industry. The investigative work resulted in national press coverage and is mobilizing support to end these subsidies.

Image C3.4  A health promotion ad from Brazil that reads: “Soda has a simple formula. Syrup, water, gas, sugar, sugar, sugar, sugar, sugar, sugar and sugar.” Source: Campanhas Destaque Campanha, “Bebida açucarada. Se faz mal para a saúde, tem que ter mais imposto,” Aliança Pela Alimentação Adequada e Saudável (blog). October 20, 2020. https://alimentacaosaudavel.org.br/tributo-saudavel/

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2. Managing conflict of interest Public health advocates insist that industries’ inherent profit-making mandate means they should not have any role in design and implementation of regulations affecting their products. But they do, through various consultative and PPP arrangements. The continued growth in such partnerships makes it critically important that there are clear rules to manage the influence of private partners and to minimize any conflicts of interest. One necessary requirement to manage the CDoH is establishment and implementation of monitoring and accountability frameworks, both for the actions of industry and those (especially inactions) of government. It is particularly critical for civil society and international bodies to monitor and advocate for transparency in government-industry relations. For example, the Framework Convention Secretariat, through the adopted guidelines of Article 5.3, plays a critical role in supporting governments to separate decision-making bodies from industry influence. Governments also need to play a stronger role in managing conflicts of interest and in holding industry accountable. Governments can use a quasi-regulatory, “scaffolding” approach to managing conflicts of interest, where they take a leading role in monitoring performance of the private sector’s self-regulatory activities and imposing stronger actions when required (Kraak et al. 2014; Reeve and Magnusson 2015). 3. Alternative livelihoods In response to the economic implications of reducing consumption of tobacco and unhealthy food – and to mitigate some of the commercial concerns – there have been efforts to support alternative livelihoods (Thow et al. 2021). The FCTC actually obliges ratifying countries to support alternatives for (generally poor) tobacco farmers, and there is emerging evidence that farmers who shift away from tobacco do better as a result. The use of contract farming, however, has many tobacco-growing households trapped in debt cycles to leaf-buying companies; and only strong government support to create fair financial loan programs and alternative supply chains is likely to break this hold (Lencucha et al. 2020). Some of these challenges and opportunities are also relevant to strengthen production of healthy, nutrient-rich food. As with transitioning tobacco farmers into other crops, governments can provide incentives along the supply chain that make growing healthy food easier and economically attractive for farmers (Lencucha et al. 2020). This will require reforming agriculture subsidy programs that have been criticized to be skewed towards staple foods which provide the raw material for the manufacture of unhealthy food products. Linking local agriculture to nutritious diets through programs such as home-grown school feeding initiatives is another way to provide local markets and income for farmers. The government in Brazil successfully implemented this approach and

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requires that at least 30% of foods used in school feeding programs be sourced from family farmers and local rural enterprises (Hawkes et al. 2016). Interventions that reduce the cost barrier associated with healthy food products also increase demand for fruit and vegetables (An 2013) especially when coupled with consumer food literacy activities (Brimblecombe et al. 2017). Interventions along the food/agriculture supply chain

Agriculture policy should strengthen agriculture systems to grow nutritious food for in-country consumption as well as for export. Governments can incentivize growing of diverse nutritious foods beyond the staples to curb monocropping and its threat to food-related biodiversity. Targeted support, especially for small enterprises (small businesses and small farms) that produce healthy foods, is required as a more agroecological approach to food production shows potential to improve both availability of and access to healthy foods (SALSA

Image C3.5  “Helping British Columbians access healthy food.” Source: BC Gov Photos on flickr. https://www.flickr.com/photos/45802067@N03/28191573504. Licensed under CC BY-NC-ND 2.0.

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2020) (see Chapter C5). Support to local farmers’ markets is one example. Countries, especially LMICs, can target processing, storage, and preservation capacities to retain nutritional value and food safety, and to reduce seasonality and postharvest losses. This should extend to store and/or government agency stocking requirements to mandate or incentivize these establishments to stock a minimum percentage of locally produced fruits and vegetables. Conclusion

The CDoH play a crucial role in shaping consumer environments. The bad news is that the purveyors of unhealthy commodities remain organized in their opposition to see public health regulations as threats to their continuing global diffusion and profitable market shares. Through lobbying, marketing, litigation, and CSR activities, their corporate influences over government policy and consumer behavior persist. These efforts persisted even during the COVID-19 pandemic. The good news is that effective measures such as labeling and taxation policies continue to be implemented by governments, despite extensive opposition from various interests, and have succeeded in reducing consumption of health-harming products in many parts of the world. Activists, however, need to keep the pressure on governments, especially those in LMICs that are arguably more vulnerable economically to the influences of transnational corporations and the lure of FDI. At a deeper structural level, governments must also work to promote healthy product producing companies to ensure that healthy choices are appealing, accessible, and affordable. References An, Ruopeng. 2013. “Effectiveness of Subsidies in Promoting Healthy Food Purchases and Consumption: A Review of Field Experiments.” Public Health Nutrition 16(7): 1215–1228. doi: 10.1017/S1368980012004715. Atkinson, Amanda Marie, Kimberley May RossHoule, Emma Begley, and Harry Sumnall. 2017. “An Exploration of Alcohol Advertising on Social Networking Sites: An Analysis of Content, Interactions and Young People’s Perspectives.” Addiction Research & Theory 25(2): 91–102. Baker, Phillip, Sharon Friel, Ashley Schram, and Ron Labonté. 2016. “Trade and Investment Liberalization, Food Systems Change and Highly Processed Food Consumption: A Natural Experiment Contrasting the Soft-Drink Markets of Peru and Bolivia.” Globalization and Health 12(1): 24. doi: 10.1186/s12992-016-0161-0. Beaglehole, Robert, Ruth Bonita, Derek Yach, Judith Mackay, and K. Srinath Reddy. 2015.

“A Tobacco-Free World: A Call to Action to Phase out the Sale of Tobacco Products by 2040.” The Lancet 385(9972): 1011–1018. doi: 10.1016/S0140-6736(15)60133-7. Brimblecombe, Julie, Megan Ferguson, Mark D. Chatfield, Selma C. Liberato, Anthony Gunther, Kylie Ball, Marj Moodie, Edward Miles, Anne Magnus, Cliona Ni Mhurchu, Amanda Jane Leach, and Ross Bailie. 2017. “Effect of a Price Discount and Consumer Education Strategy on Food and Beverage Purchases in Remote Indigenous Australia: A Stepped-Wedge Randomised Controlled Trial.” The Lancet Public Health 2(2): e82–95. doi: 10.1016/S2468-2667(16)30043-3. Calleja, Daniel. 2019. “Why the ‘New Plastics Economy’ Must Be a Circular Economy.” Field Actions Science Reports. The Journal of Field Actions Special Issue 19: 22–27. Campaign for Tobacco-Free Kids. 2021. “Big Tobacco is Exploiting COVID-19 to Market its Harmful Products.” Campaign for Tobacco-

250   |  Global Health Watch 6 Free Kids. https://www.tobaccofreekids.org/ media/2020/2020_05_covid-marketing. Collin, Jeff. 2020. Signalling Virtue, Promoting Harm: Unhealthy Commodity Industries and COVID-19. NCD Alliance and SPECTRUM. Dorfman, Lori, Andrew Cheyne, Lissy C. Friedman, Asiya Wadud, and Mark Gottlieb. 2012. “Soda and Tobacco Industry Corporate Social Responsibility Campaigns: How Do They Compare?” PLoS Medicine 9(6): e1001241. doi: 10.1371/journal.pmed.1001241. Glanz, Karen, and Amy L. Yaroch. 2004. “Strategies for Increasing Fruit and Vegetable Intake in Grocery Stores and Communities: Policy, Pricing, and Environmental Change.” Preventive Medicine 39: 75–80. doi: 10.1016/j.ypmed.2004.01.004. Glasgow, Sara, and Ted Schrecker. 2016. “The Double Burden of Neoliberalism? Noncommunicable Disease Policies and the Global Political Economy of Risk.” Health & Place 39: 204–211. doi: 10.1016/j. healthplace.2016.04.003. Hawkes, Corinna, Bettina Gerken Brazil, Inês Rugani Ribeiro De Castro, and Patricia Constante Jaime. 2016. “How to Engage across Sectors: Lessons from Agriculture and Nutrition in the Brazilian School Feeding Program.” Revista de Saúde Pública 50: 47. doi: 10.1590/S1518-8787.2016050006506. Hofman, Karen. 2021. “New Research Shows South Africa’s Levy on Sugar-Sweetened Drinks Is Having an Impact.” The Conversation. https://theconversation.com/ new-research-shows-south-africas-levyon-sugar-sweetened-drinks-is-having-animpact–158320. Huffman, Sandra L., Ellen G. Piwoz, Stephen A. Vosti, and Kathryn G. Dewey. 2014. “Babies, Soft Drinks and Snacks: A Concern in Lowand Middle-Income Countries?” Maternal & Child Nutrition 10(4): 562–574. doi: 10.1111/ mcn.12126. Kelly, Paul M., Anna Davies, Alexandra J.M. Greig, and Karen K. Lee. 2016. “Obesity Prevention in a City State: Lessons from New York City during the Bloomberg Administration.” Frontiers in Public Health 4: 1–16. doi: 10.3389/fpubh.2016.00060. Kelsey, Jane. 2017. “Regulatory Chill: Learnings from New Zealand’s Plain Packaging Tobacco Law.” QUT Law Review 17: 21. Kickbusch, Ilona, Luke Allen, and Christian Franz. 2016. “The Commercial Determinants

of Health.” The Lancet Global Health 4(12): e895–896. doi: 10.1016/S2214109X(16)30217-0. Kozinets, Robert. 2019. “How Social Media Is Helping Big Tobacco Hook a New Generation of Smokers.” The Conversation. https:// theconversation.com/how-social-media-ishelping-big-tobacco-hook-a-new-generationof-smokers–112911. Kraak, Vivica I., Boyd Swinburn, Mark Lawrence, and Paul Harrison. 2014. “An Accountability Framework to Promote Healthy Food Environments.” Public Health Nutrition 17(11): 2467–2483. doi: 10.1017/ S1368980014000093. Labonté, Ronald. 2019a. “Neoliberalism 4.0: The Rise of Illiberal Capitalism.” International Journal of Health Policy and Management 9(4): 175–178. doi: 10.15171/ijhpm.2019.111. Labonté, Ronald. 2019b. “Trade, Investment and Public Health: Compiling the Evidence, Assembling the Arguments.” Globalization and Health 15(1): 1. doi: 10.1186/s12992-0180425-y. Lencucha, Raphael, and Anne Marie Thow. 2019. “How Neoliberalism Is Shaping the Supply of Unhealthy Commodities and What This Means for NCD Prevention.” International Journal of Health Policy and Management 8(9): 514–520. doi: 10.15171/ijhpm.2019.56. Lencucha, Raphael, Laurette Dubé, Chantal Blouin, Anselm Hennis, Mauricio Pardon, and Nick Drager. 2018. “Fostering the Catalyst Role of Government in Advancing Healthy Food Environments.” International Journal of Health Policy and Management 7(6): 485–490. doi: 10.15171/ijhpm.2018.10. Lencucha, Raphael, Nicole E. Pal, Adriana Appau, Anne-Marie Thow, and Jeffrey Drope. 2020. “Government Policy and Agricultural Production: A Scoping Review to Inform Research and Policy on Healthy Agricultural Commodities.” Globalization and Health 16(1): 11. doi: 10.1186/s12992-020-0542-2. Lencucha, Raphael, and Anne Marie Thow. 2020. “Intersectoral Policy on Industries That Produce Unhealthy Commodities: Governing in a New Era of the Global Economy?” BMJ Global Health 5(8): e002246. doi: 10.1136/ bmjgh-2019-002246. Liberman, Jonathan. 2013. “Plainly Constitutional: The Upholding of Plain Tobacco Packaging by the High Court of Australia.” American Journal of

CONFRONTING THE COMMERCIAL DETERMINANTS OF HEALTH  |  251 Law & Medicine 39(2–3): 361–381. doi: 10.1177/009885881303900209. Maani, Nason, May Ci Van Schalkwyk, Mark Petticrew, and Sandro Galea. 2021. “The Commercial Determinants of Three Contemporary National Crises: How Corporate Practices Intersect With the COVID-19 Pandemic, Economic Downturn, and Racial Inequity.” The Milbank Quarterly 99(2): 503–518. doi: 10.1111/1468-0009.12510. Magati, Peter, Raphael Lencucha, Qing Li, Jeffrey Drope, Ronald Labonté, Adriana Appau, Donald Makoka, Fastone Goma, and Richard Zulu. 2019. “Costs, Contracts and the Narrative of Prosperity: An Economic Analysis of Smallholder Tobacco Farming Livelihoods in Kenya.” Tobacco Control 28(3): 268. doi: 10.1136/tobaccocontrol-2017-054213. Magnusson, Roger S., Benn McGrady, Lawrence Gostin, David Patterson, and Hala Abou Taleb. 2019. “Legal Capacities Required for Prevention and Control of Noncommunicable Diseases.” Bulletin of the World Health Organization 97(2): 108–117. doi: 10.2471/BLT.18.213777. Mialon, Melissa. 2020. “An Overview of the Commercial Determinants of Health.” Globalization and Health 16(1): 74. doi: 10.1186/s12992-020-00607-x. Moodie, Rob, David Stuckler, Carlos Monteiro, Nick Sheron, Bruce Neal, Thaksaphon Thamarangsi, Paul Lincoln, and Sally Casswell. 2013. “Profits and Pandemics: Prevention of Harmful Effects of Tobacco, Alcohol, and Ultra-Processed Food and Drink Industries.” The Lancet 381(9867): 670–679. doi: 10.1016/S0140-6736(12)62089-3. Noel, Jonathan, Zita Lazzarini, Katherine Robaina, and Alan Vendrame. 2017. “Alcohol Industry Self-Regulation: Who Is It Really Protecting?” Addiction 112(S1): 57–63. doi: 10.1111/add.13433. O’Hara, Jim, and Aviva Musicus. 2015. Big Soda vs. Public Health: How the Industry Opens Its Checkbook to Defeat Health Measures. Washington, DC: Centre for Science in the Public Interest. Orsini, Patricia. 2018. UK Digital Ad Spending by Industry 2018. eMarketer. PepsiCo. 2020. “COVID-19: See How We’re Working to Ensure the Health & Safety of Consumers & Communities.” PepsiCo. https://www.pepsico.com/news/story/ covid–19.

Petticrew, Mark, Niamh Fitzgerald, Mary Alison Durand, Cécile Knai, Martin Davoren, and Ivan Perry. 2016. “Diageo’s ‘Stop Out of Control Drinking’ Campaign in Ireland: An Analysis.” PLoS One 11(9): e0160379. doi: 10.1371/journal.pone.0160379. Phonsuk, Payao, and Rapeepong Suphanchaimat. 2019. “A Report of Effective Intervention Strategies Conducted by Non-Health Sectors.” OSIR Journal 12(3): 109–116. Rayner, Geof, Corinna Hawkes, Tim Lang, and Walden Bello. 2006. “Trade Liberalization and the Diet Transition: A Public Health Response.” Health Promotion International 21(suppl. 1): 67–74. Reeve, B., and R. Magnusson. 2015. “Reprint of: Food Reformulation and the (Neo)-Liberal State: New Strategies for Strengthening Voluntary Salt Reduction Programs in the UK and USA.” Public Health 129(8): 1061–1073. doi: 10.1016/j.puhe.2015.04.021. SALSA. 2020. Small Farms, Small Food Businesses and Sustainable Food Security: Project Summary Booklet 2016–2020. Universidade de Évora. Schram, Ashley, Ronald Labonté, Phillip Baker, Sharon Friel, Aaron Reeves, and David Stuckler. 2015. “The Role of Trade and Investment Liberalization in the SugarSweetened Carbonated Beverages Market: A Natural Experiment Contrasting Vietnam and the Philippines.” Globalization and Health 11(1): 41. doi: 10.1186/s12992-015-0127-7. Schrecker, Ted. 2016. “‘Neoliberal Epidemics’ and Public Health: Sometimes the World Is Less Complicated than It Appears.” Critical Public Health 26(5): 477–480. doi: 10.1080/09581596.2016.1184229. Siahaya, Isabella Astrid, and Tim Smits. 2020. “Sport CSR as a Hidden Marketing Strategy? A Study of Djarum, an Indonesian Tobacco Company.” Sport in Society 24 (9): 1609– 1632. doi: 10.1080/17430437.2020.1764537. Stillerman, Karen Perry. 2019. “‘Big Food’ Companies Spend Big Money in Hopes of Shaping the Dietary Guidelines for Americans.” Union of Concerned Scientists. https://blog.ucsusa.org/ karen-perry-stillerman/big-food-companiesspend-big-money-in-hopes-of-shaping-thedietary-guidelines-for-americans. Swinburn, Boyd A., Vivica I. Kraak, Steven Allender, Vincent J. Atkins, Phillip I. Baker, Jessica R. Bogard, Hannah Brinsden,

252   |  Global Health Watch 6 Alejandro Calvillo, Olivier De Schutter, Raji Devarajan, Majid Ezzati, Sharon Friel, Shifalika Goenka, Ross A. Hammond, Gerard Hastings, Corinna Hawkes, Mario Herrero, Peter S. Hovmand, Mark Howden, Lindsay M. Jaacks, Ariadne B. Kapetanaki, Matt Kasman, Harriet V. Kuhnlein, Shiriki K. Kumanyika, Bagher Larijani, Tim Lobstein, Michael W. Long, Victor K.R. Matsudo, Susanna D.H. Mills, Gareth Morgan, Alexandra Morshed, Patricia M. Nece, An Pan, David W. Patterson, Gary Sacks, Meera Shekar, Geoff L. Simmons, Warren Smit, Ali Tootee, Stefanie Vandevijvere, Wilma E. Waterlander, Luke Wolfenden, and William H. Dietz. 2019. “The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission Report.” The Lancet 393(10173): 791–846. doi: 10.1016/S01406736(18)32822-8. Tangcharoensathien, Viroj, Orana Chandrasiri, Watinee Kunpeuk, Kamolphat Markchang, and Nattanicha Pangkariya. 2019. “Addressing NCDs: Challenges From Industry Market Promotion and Interferences.” International Journal of Health Policy and Management 8(5): 256–260. doi: 10.15171/ ijhpm.2019.02. Thow, Anne Marie, and Deborah Gleeson. 2017. “Advancing Public Health on the Changing Global Trade and Investment Agenda Comment on ‘The Trans-Pacific Partnership: Is It Everything We Feared for Health?’” International Journal of Health Policy and Management 6(5): 295–298. doi: 10.15171/ ijhpm.2016.129.

Thow, Anne Marie, Alexandra Jones, Corinna Hawkes, Iqra Ali, and Ronald Labonté. 2017. “Nutrition Labelling Is a Trade Policy Issue: Lessons from an Analysis of Specific Trade Concerns at the World Trade Organization.” Health Promotion International 33(4): 561–571. doi: 10.1093/heapro/daw109. Thow, Anne Marie, Raphael A. Lencucha, Kieron Rooney, Stephen Colagiuri, and Manfred Lenzen. 2021. “Implications for Farmers of Measures to Reduce Sugar Consumption.” Bulletin of the World Health Organization 99: 41–49. doi: 10.2471/BLT.19.249177 White, Mariel, Claudia Nieto, and Simon Barquera. 2020. “Good Deeds and Cheap Marketing: The Food Industry in the Time of COVID-19.” Obesity 28(9): 1578–1579. doi: 10.1002/oby.22910. WHO. 2018. “Alcohol Factsheet.” World Health Organization. https://www.who.int/newsroom/fact-sheets/detail/alcohol. WHO. 2020. “Tobacco.” https://www.who.int/ news-room/fact-sheets/detail/tobacco. Yach, Derek. 2021. “Bringing Everyone to the Tobacco Table.” Medium. https://medium. com/@Dr.DerekYach/bringing-everyone-tothe-tobacco-table-a2e235e0ea4f. Zhou, Suzanne, and Jonathan Liberman. 2020. “Public Health, Intellectual Property, and the Trade and Investment Law Challenges to Australia and Uruguay’s Tobacco Packaging Laws.” SSRN Scholarly Paper. ID 3752521. Rochester, NY: Social Science Research Network.

C4 | DEVELOPMENT MODEL, EXTRACTIVISM, AND ENVIRONMENT: KNITTING RESISTANCES GLOBALLY

Introduction Such arrogance to say that you own the land, when you are owned by it. How can you own that which outlives you? To claim a place is the birthright of everyone … And where shall we obtain life? From the land. To work the land is an obligation, not merely a right. In tilling the land you possess it. And so the land is a grace that must be nurtured. Land is sacred. Land is beloved.1

As a working group of the People’s Health Movement (PHM), contributors to this chapter have a strong critique of economic growth as the dominant paradigm of social organization. This paradigm subordinates our well-being to growth and so-called progress; inequities and poverty are reduced to economic factors, i.e., gross domestic product (GDP) and the Human Development Index (Arteaga-Cruz 2017, 909). Discussions of green energy or carbon markets that do not question the fundamental growth-centric approach will only mitigate its damage, not repair it (see Chapter A3). Thus, it is important to first address briefly the concept of development. The Alternatives to Development Permanent Working Group says development is: A device of power that reorganized the world, re-legitimizing the international division of labor in the capitalist context, through an enormous set of discourses and practices. Development became a public policy objective, budgets were allocated, and multiple institutions were created to promote development at local, national, and international levels … In countries of the North, what were previously economic policies towards the colonies were re-signified in terms of ‘international cooperation’ for development. (Lang and Mokrani 2011, 13 as cited in Arteaga-Cruz 2017, 909; author’s translation)

As the PHM Environment and Health circle, we take aim at extractivism as the system through which this development model operates. Extractivism: Is a mode of accumulation that favors extraction of natural resources (minerals such as gold, manganese, bauxite, copper, cobalt, zinc, tin, diamonds, and uranium, and fossil fuels, and commercial farming, forest, and fishing industries) from countries of the Global South who export their resources. The extractivist project began to be structured with the conquest and colonization of

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America, Africa, and Asia.(Acosta 2013, 61 as cited in Arteaga-Cruz et al. 2020, 101)

Both right- and left-wing governments across the world, especially in Latin America, are captured by the belief in this development paradigm, along with their allies in the emerging geopolitical centers of China, India, and Russia. Communities continue to experience growing displacement, the loss of social services, land, water, and livelihood, heightened militarization, violence and repression, and increased incidence of communicable diseases and health problems resulting from exposure to toxins. All of these are linked to an extractivist project, driven by global financial capital, promoting an unsustainable and inequitable development model that threatens the people’s and planet’s health. The right to health is not compatible with financing national health systems with revenues of activities that intrinsically destroy life (oil industry, mining, etc.). This chapter will demonstrate the inconsistency of development policies that fund health and the right to health with extractivism, and depict examples of resistance to extractive industries. Development serves as a fundamental organizing principle of both capitalism and its particular form of the welfare state (Arteaga-Cruz et al. 2020, 101). The extractivist status quo strives to maintain itself by displacing blame to the individual rather than addressing root causes of injustice. In a global economy predicated on the extraction of resources and the relentless pursuit of profit, systems of oppression – white supremacy, patriarchy, ableism, neoliberal capitalism – simultaneously drive health inequalities and climate change. Exacerbated by free trade agreements (instruments that increase colonial domination through unequal exchange) that protect capital mobility, this development paradigm has resulted in privatization of health services for impoverished/racialized sectors (Hardeman and Karbeah 2020) of the Global South (see also Chapters B1 and B3), with fragmented health programs for the poor population – referred to locally as salud de pobres para pobres (López Arellano et al. 2015, 287), loosely translated as “poor health services for the poor” – a “reward” for assimilation into a consumption economy while destroying territories and leaving sacrifice areas. Alternatives As a working group building a global network of solidarity, we have been learning from each other about different models with which to challenge the dominance of the extractivist development paradigm; models that promote rather than threaten collective well-being. From the group’s beginnings in Latin America (Abya Yala), we have been influenced by Indigenous philosophies critiquing global capitalism. We are also aware of alternative health models emerging in other parts of the world. There is extensive work providing an excellent overview of the various paradigms from which we can learn, such

DEVELOPMENT MODEL, EXTRACTIVISM, AND ENVIRONMENT  |  255 as ubuntu from southern Africa, or people’s medicine from South Asia. (Loewenson et al. 2020; Kothari et al. 2019)

Case study 1: Sumak Kawsay or Buen Vivir, loosely translated as “Good Living”

Sumak Kawsay/Buen Vivir, the Indigenous philosophy of Ecuador, provides a useful paradigm to challenge extractivism’s impact on people’s health. This philosophy considers nature as a living being, a subject of care and rights. Health in each world view (Kichwa/Indigenous and Capitalist/Western) is perceived differently from its origins (Table C4.1). Health in a capitalist society is a product of individual action, the submission to the medical-industrial complex, the pathologization of physiological processes such as birth, and the subsumption of people to an agribusiness dominated food system (see Chapter C5). Sumak Kawsay is tied to human beings and their relationships to their communities and lands: life processes are considered sacred connections with such territory; the philosophy is tied to food sovereignty as the expression of collective health (Arteaga-Cruz 2017, 911). The Sumak Kawsay worldview is not particular to Andean Communities (Ecuador, Bolivia); Aotearoa/New Zealand has also passed a law recognizing jurisdictional rights for the spirit that protects water, as reparation for the Indigenous Māori, the Te Awa Tupua Act (New Zealand Ministry of Justice 2017). While other Indigenous and struggling peoples hold a variety of world views, most share the understanding that development to meet human needs has been replaced by development to accumulate wealth for international capital, to the detriment of the health and well-being of people and the planet. The commune is an ancestral urban settling present in pre-colonial Ecuador; the Spanish colonizers called them Tierras de Indios (Indian lands/Indigenous reservations), and these spaces shared common identity, cultural, and social

TABLE C4.1:  Capitalism compared to Sumak Kawsay world view Capitalism

Kichwa: Sumak Kawsay

• Property is privately held, and capital privately accumulated • Individual subject (mainly economic rights – Homo economicus) • Seeks individual economic benefit • Accumulation • Market freedom • Obsession for economic growth • Private business predominance • Natural “resources” degradation • Production towards satisfying needs (wants) created by companies (new illnesses) • Based on market rules: supply and demand

• Property is held collectively or in common, familiar property (ancient commons) • Collective subject (collective rights) • Seeks community well-being • Institutions of social reciprocity/ redistribution (nature) • Market: space of exchange of surplus and to supplement needs (trueque) • Human being as a part of nature (sacred reciprocity) • Based on needs satisfaction and establishment of alliances to guarantee that all community members have equitable access to resources

Source: Maldonado 2009.

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characteristics. In the Kichwa commune we can witness principles of reciprocity, collective property, relation and coexistence with nature, social accountability to others, and the building of consensus. The commune, says Floresmilo Simbaña, an Indigenous Ecuadorian historian and movement leader, is a model that opposes/contradicts neoliberalism and the development/progress it entails (Arteaga-Cruz 2017, 911). The commune-based principles of Sumak Kawsay/Buen Vivir offer a civilization alternative. These principles are important in our struggles for health and against a colonial extractivist development model that pillages the land, fueling climate change and social inequities. Indigenous rights, however, are challenged even in the social democracies elevated as examples of equitable capitalist societies, such as Sweden (Case study 2). Women often bear the highest burden of the impacts of planetary destruction (Case study 3). Environmental defenders risk their lives (Case study 7) while hundreds of thousands of workers face death laboring in mines (Case study 8). As we collect these stories of extractivist damage around the globe, we also collect hope. For example, the Argentinian resistance to water contamination and proposals for a Green New Deal to reverse climate destruction while guaranteeing decent labor conditions. This hope is stitched together with the various threads of our work (the examples of PHM-Canada and our International Peoples Health Universities), which we must weave into a larger global patchwork of care – for ourselves, each other, and the planet. Case study 2: Teaming up with the mining companies: how Swedish law violates Indigenous rights

Sweden’s economy is based on the exploitation of natural resources (forest, hydropower, and ore). Mining is expanding, with estimates of a threefold increase through 2025, directly or indirectly creating more than 50,000 new jobs (SVEMIN 2020), generating tax revenue and economic growth (1.4% of total GDP), particularly in the rural north. Many criticize that Sweden’s minerals are given away to foreign corporations, leaving behind ruinous landscapes. Similarly, the government’s taxation argument is undercut by soft taxation schemes applied to mining companies (Af Geijerstam et al. 2011; Petersen 2013; Sámediggi 2020). Of Sweden’s total ore production, more than 96% comes from the mines in the northern region/Norrland, where 10 of 12 active mines in the country are in the traditional territory of the Sámi. The Sámi are the Indigenous people from northern Scandinavia and northwestern Russia. Traditionally, Sámi have subsisted on small-scale farming, fishing, hunting, and reindeer herding. Even though some Sámi still provide for their families through reindeer herding, those families are now a minority (10%) (Sámediggi-MAFCA 2020). Sweden has ratified the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), the International Covenant on Civil and Political Rights, and the United Nations Declaration on the Rights

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of Indigenous Peoples; however, these are not legally binding. Sweden has been heavily criticized for not signing the International Labour Organization’s Indigenous and Tribal Peoples Convention (ILO 169), which is binding on signatories (Tauli-Corpuz 2016). According to ILO 169, states commit to protect and respect the cultures and ways of life of Indigenous peoples, to recognize their rights to land and natural resources, and to define their own priorities for development. Consultation and participation constitute its cornerstone principles. While the Sámi use of land for reindeer herding is regulated and protected by law, as a central part of Sámi culture, the Sámi do not own the land. There is a conflict between the state wanting to use the land for extractive purposes and its obligation to protect the landscape and reindeer husbandry. There is evidence that mining and reindeer herding cannot coexist (Lawrence et al. 2019). Furthermore, Sámi people are systematically marginalized in land-use planning and mining-related decisions, forcing them to continually adapt their reindeer husbandry or give up their traditional way of living, depriving them of their means of sustenance and right to self-determination. The legal framework of the approval process for mining concessions only stipulates a right to information and, in the planning stage, only indirect consultation. Finally, the Environmental Code only requires assessment of environmental – not social, cultural, or health – impacts of mining projects. A recent health impact assessment has revealed adverse mental health impacts on a Sámi community, even during the planning stage of a mining project. Future social conflicts and negative health impacts were also predicted due to pressure on traditional reindeer husbandry practices (Blåhed and San Sebastián 2020). These conflicts challenge the state to fulfill its obligations to protect the rights of the Sámi to self-determination, to consent to activities on their traditional lands, and to achieve health equity. The destruction of the shared environment in every step of exploration, extraction, and processing practices affects women’s productive work and possibilities as well as their reproduction, leading to miscarriages, birth defects, and infant illness. The “man camps” established to initiate and execute extractive processes generate violence against (often indigenous) women and sex trafficking to service the camps. The climate change disasters that result from extractivist development’s death grip on our world are also gendered, affecting women differently and more severely than men.

Case study 3: Planetary destruction: gendered impacts of climate change

Climate change exacerbates the frequency and intensity of extreme weather events including floods, cyclones, storm surges, fires, and slow-onset events such as droughts and salinization of land and water resources. The ongoing loss of lives and livelihoods and decrease in the quality of life and well-being generate additional burdens for women and girls. The dominant model of disaster recovery frames suffering as a private and individual matter, as something to be “managed effectively and efficiently” (Cox and Perry 2011). The naming of widespread interpersonal violence as a

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gender/power dynamic during and in the aftermath of disasters, including during community recovery, is too often overlooked and even shunned. Women’s contributions in responding to disasters are often undervalued and their needs are rarely fully incorporated into disaster planning and response in either the Global North or the Global South. Violence against women is a well-known characteristic of post-disaster recovery globally. A systematic review of the international literature from 1976 to 2011 found “being exposed to natural disasters … increased the violence against women and girls” (Rezaeian 2013, 1105). Drawing from an Australian example, women’s accounts of the period following the devastating 2009 Victoria state fires (Parkinson 2019) described how existing violence escalated and new violence emerged. Related factors exacerbating this violence included unemployment, temporary housing arrangements, trauma, grief, rebuilding, media attention, grant entitlements, increased drug and alcohol use, and risky or “hyper-masculine” behaviors. Some health services in fire-affected communities chose to tackle the gender-based violence that emerged or increased in the post-disaster recovery. For example, Women’s Health Goulburn North East in Victoria tailored gender equity training for first responders and disaster recovery workers. They also developed localized resources to prevent and respond to gender-based violence during the COVID-19 pandemic (Women’s Health Goulburn North East 2021). More climate-related bushfires are probable, if not certain, and climate change itself is accelerated by extractivist development activities (e.g., agro-industry, open-pit mining, fracking). One key lesson from post-disaster and recovery strategies for preventing and responding to gender-based violence in Australia is that applying a gender lens to our global climate crisis is essential – not optional (Alston and Whittenbury 2013). Latin American post-dictatorship civil-military processes were characterized by systems of weak representative democracy, often subject to international corporate economic power. These wielded foreign debt as a tool for blackmail and mobilized international financial organizations to restructure regional policies. The advance of extractive models (agro-industry, open-pit mining, fracking, among others) led to a transformation of epidemiological profiles in Latin American communities, but their health systems were not prepared to address these new problems.

Case study 4: Resistance and hope: the fight for water in urban Argentina

New pathologies or unusual presentations of known diseases are part of the daily life of those who live in “sacrifice areas” (areas destined for extractivism). Mega-mining poses serious problems that result from unsafe work routines and accidents (e.g., Brumadinhos – Mina Gerais, Brazil; Veladero – San Juan, Argentina). It poisons the environment and our bodies, producing physical effects and increasing morbidity and mortality.2 Workers’ lifestyles are affected by economic vulnerability, an increase in serious accidents, modification of

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traditional ways of life, and increased substance abuse (Chenaut 2017; Christel 2018; Lombardi 2020). Popular and community resistance is born in such conditions, trying to reverse the destruction of territories and to preserve the health of Mother Earth. Such is the case in Argentina, where struggles against mining in Chubut, against fracking in Mendoza, against agribusiness in Entre Rios, and against Monsanto in Córdoba have been permanent, regardless of whether there is a progressive or right-wing government in power. In the Argentine province of Mendoza, water has been the engine of local economy and defending water has been a focus of struggle for a century (Wagner 2008). Over the previous decade the province registered the greatest drought in history. From 2009 to 2017, water reserves of the Andes Mountains in Mendoza lost an average of more than 8 cubic meters (Marianetti, Hinrich, and Rivera 2018). Yet oil extraction was allowed in 2018 by means of fracking (hydraulic fracturing) which requires an enormous amount of water, prioritizing a capitalist logic of big monopolies or “economic development” in the hands of the mega-mining companies (Svampa 2019, 9). By Christmas 2019, victory was celebrated in the streets of Mendoza with the repeal of the reform of Law 7722, the Water Law. Earlier that year, a modification to Law 7722, passed in 2007, violated the prohibition of regression in environmental and human rights matters established in the Argentinean National Constitution. A historic march began on Sunday, December 22, 2019, in San Carlos; artistic events and peaceful demonstrations were held in all the departments of the province to support the defense of water and against mining and fracking operations (Simonovich 2020). People celebrated Christmas in the streets, defending common goods. On December 26, 2019, the governor announced that he would not approve the new modification, and thus Law 7722 and the protection of water remains in place. Thanks to the organization, resistance, and creativity of the people of Mendoza, its water is NOT FOR SALE. This struggle achieved the prohibition of mega-mining through Law 7722, which stated, “the use of chemical substances such as cyanide, mercury, sulfuric acid and other similar toxic substances in the metalliferous mining processes of prospecting, exploration, exploitation and/or industrialization of metalliferous minerals obtained through any extraction method is prohibited in the territory of the Province of Mendoza.” Mining companies have filed appeals of unconstitutionality since its approval (Salamone 2017). Case study 5: PHM-Canada and transnational resistance to Canadian mining

For decades, the global mining industry has taken advantage of Canada’s tax incentives, lax regulation, pro-mining diplomacy, easy access to capital, and impediments to lawsuits brought by affected communities. The harms of the Canadian mining industry have been well documented (Schrecker et al. 2018): 1. physical and economic displacement through loss of land and livelihoods;

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2. environmental degradation, heavy metal exposure (water, air, soil contamination), water depletion/scarcity, vector-borne diseases, and food insecurity/loss of sovereignty; 3. dangerous working conditions; 4. violence against resisters by private security and state-sponsored repression, assaults, and assassination; 5. disruption of community cohesion; 6. poverty and exacerbation of social and economic inequalities; 7. loss of traditional territories and culture; and 8. associated mental health consequences. Communities’ resistance to mining addresses an array of political, economic, environmental, and societal determinants of health. In our domestic activism and transnational solidarity, we seek to infuse health dimensions into the efforts of social movements and civil society organizations contesting mining domestically and internationally, working with organizations such as Mining Watch, Mining Injustice Solidarity Network, Working Group on Mining and Human Rights in Latin America, and PHM-Ecuador. Drawing on anti-capitalist, anti-oppressive, and anti-colonial frameworks, our activities have spanned individual and collective efforts: publishing popular and academic works; organizing to respond to community requests for campaign support and appeals for urgent actions; and participating in direct action.

1. PHM-Canada’s solidarity with anti-mining resistance Our solidarity efforts have ranged from protesting the harms of the mining industry at Canada’s major mining convention (Prospectors and Developers Association of Canada-PDAC), held annually in Toronto (Image C4.1), to supporting communities in conflict with Canadian extractive firms at home and abroad, including: Indigenous activists resisting uranium mines in Saskatchewan, Canada; the Standing Rock Sioux people’s struggle to stop the Dakota Access Pipeline (DAPL) in the United States; community struggles for self-determination regarding mining projects in Azuay, Ecuador; and resistance against gold mines in Rancho Grande and Santo Domingo, Nicaragua, and Halkidiki, Greece (Mukhopadhyay and Hanson 2015; Hanson 2016; 2017; PHM-CA 2016a). 2. Research and advocacy efforts Alongside our solidarity with anti-mining resistance, we have also raised awareness through publishing, speaking truth to and about power within our own country, and partnering with academic institutions. We have, for example, published work exploring the harmful role of Canadian mining in Latin America, calling on the Canadian public health community to use their expertise to speak against these issues (Birn et al. 2018). Other published works include connecting the right to health to anti-extractive resistance globally and highlighting the role

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Image C4.1  PHM-Canada members bring messages from mining-affected communities in Ecuador to demonstrations against the Canadian transnational mining industry at PDAC, the largest mining conference in the world, held in Toronto, ON, Canada. March, 2020. Source: Photo by People’s Health Movement Canada.

of neocolonial and corporate influences on global health and resource extraction research (Brisbois et al. 2016; 2019; Arteaga-Cruz et al. 2020). We have also exercised joint pressure in the form of a petition against the University of Toronto’s promotion of health research funding from Vale, a $34 billion Brazilheadquartered transnational mining corporation with a subsidiary in Canada and which is implicated in numerous human rights violations (University Worlds 2020). Case study 6: Extractivism in the US Gulf South: everything is bigger in Texas, home of the world’s biggest industrial megaplex

Extractivism to the detriment of human and environmental well-being in the pursuit of “progress” and “development” is nowhere more evident than in the “petropolis” of Houston, Texas, and its surrounding “petro-metro.” Much of the United States’ extracted fossil fuels and natural resources are transported to Gulf South chemical refineries geared for large-scale processing and production of innumerable chemical compounds for products, chiefly in the petroleum and plastics industries. Fossil fuels are literally presented as the fuel of “progress” and incontestably essential to meet human consumption demands. “The industrial megaplex that begins on the east side of Houston and continues uninterrupted to the Gulf of Mexico, 50 miles away, is the largest

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concentration of petroleum refineries, petrochemical companies, and storage structures on earth” (Weisman 2007). Houston prides itself as the “Energy Capital of the World” due to its command of the global energy sector. The wealth from these industries accumulates in affluent white communities, businesses, and governments, while the health of communities living and working nearby is extracted. The predominantly Black and Brown fence-line communities face environmental health inequities from exposure to lead, hazardous air pollutants, landfills, and some of the most hazardous waste sites in the country. Residents living along the Houston Ship Channel experience an onslaught of toxic chemicals from leaks, flares, and explosions that occur during the production and processing of fossil fuels. “Fugitive” emissions, the unexpected release of chemicals into the community, in addition to legally permitted “regulated” emissions, have led to disproportionate health impacts (Horswell and Carroll 2007) in communities in close proximity to the production and processing of fossil fuels (Rosen 2020). In Houston, it is low-income communities of color who live alongside the industrial landscape and work the most dangerous jobs. The bodies of fence-line community residents are overburdened by cancercausing chemicals (Dellinger 2021), yet they are not provided or offered information about the same safety equipment or health insurance enjoyed by industry profiteers. They are instead expected to “get used to the smells” and accept without question and as unextraordinary recurring health ailments, such as headaches, nose bleeds, and respiratory issues. But these toxic byproducts do not go unnoticed and are cynically and commonly referred to as the “smell of money” (Owen 2003) by industry insiders. Flooding and winds from increasingly dangerous storms, caused by climate change instigated by these very industries, destroy the already inadequate safety mechanisms that fail to protect these communities’ health (Fraser 2020). This is not limited to Houston but holds true for the entire region. The petrochemical industry has taken hold in the US Gulf Coast states of Texas and Louisiana, as well as Oklahoma and New Mexico, turning much of the region into a sacrifice area for “development.” Not surprisingly, these areas include large populations of black, Indigenous, and people of color. In just the last decade, several mega-projects have been rushed past regulatory safeguards with disastrous results. From the Keystone XL pipeline (cancelled following the election of Biden) to the BP Drilling Disaster, from the fracking boom in West Texas and New Mexico to the lifting of the export ban and expansion of offshore drilling, this region has been beset by corporate efforts to feverishly extract every last drop of fossil fuel. Petrochemical and mining industries are among the most dangerous proponents of environmental destruction. They are also among the most politically reactionary transnational and local corporations on the planet. In the United States, the Trump administration championed their unimpeded ability to devastate natural resources with accountability to nothing but their owners’ profits.

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It rolled back close to 100 environmental rules (Popovich, Albeck-Ripka, and Pierre-Louis 2021), eroding the already minimal scrutiny of extractive industries. While the Biden administration promises a different approach, it remains to be seen whether these promises will be like those usually made to black, Latino, and Indigenous communities: largely unkept. Skepticism about governmental will to oppose extractive industries is based on the virtually unlimited stream of petrodollars flowing to both US political parties (OpenSecrets.org n.d.) as well as to the governments that enable extraction throughout the Global South. The ideologies of white supremacy, colonialism, and savage capitalism, expressed in the violent attack on the US Capitol in January 2021, also drive the agents of extractivism, evidenced by the harassment, imprisonment, and murder of environmental defenders, often Indigenous, throughout the world. The extractivist project is enforced by state and extrajudicial violence. In the United States, opposition to pipelines has been legally equated with terrorism in seven states and similar statutes are pending in six more (Cagle 2019). Statistics show 2019 to be the worst year ever for environmental activists with 212 murders, primarily of people opposing mining, largely in Colombia, the Philippines, Mexico and Central America. (Global Witness 2020)

Case study 7: The struggles of environmental defenders in the Philippines

The Philippines abounds in biodiverse ecosystems. Forests host over 3,000 tree species and are home to around 25 to 30 million people, almost half of whom are Indigenous peoples living in their ancestral lands. This rich biodiversity provides the people’s source of food, livelihood, and other basic needs. However, biodiversity also attracts an onslaught of neoliberal destruction. Logging, mining, corporate plantations, and other extractive activities have diminished forest cover to just 7 million hectares as of 2015, or just 23.3% of the country’s land area. Large-scale mining causes deforestation, soil erosion, watershed degradation, crop damage, and forcible displacements of Indigenous communities. According to the Kalikasan Philippine Network for Environment and the Center for Environmental Concerns, the Duterte presidency has sold off at least P773 billions ($16 billion) worth of the Philippines’ sovereign mineral, water, wildlife, and marine resources between 2016 and 2018 (Mogato 2019). The country contains huge mineral deposits, including about 20% of the world’s total nickel resources (Center for Environmental Concerns 2016), as well as extensive non-metal minerals such as limestone and marble. This is the context in which Philippine defenders of the people and environment have been struggling for years. One of the first environmental martyrs, Macliing Dulag, was murdered during the struggle to stop construction of the World Bank-funded Chico Dam on April 24, 1980 (Martial Law Museum n.d.). Since then, the violence has only intensified. In its 2018 annual report,

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Global Witness called the Philippines one of the most dangerous countries for land and environmental defenders and activists, documenting 30 murders. In 2019, the Kalikasan People’s Network for the Environment (Kalikasan PNE) recorded 46 deaths of environment defenders and many cases of trumped-up charges against activists. The Network further reported that between March 15 and May 15, 2020, 57 environmental defenders were illegally arrested, detained, and hit with Strategic Lawsuits against Public Participation (“SLAPP suits”); 48 were threatened and intimidated, 15 were physically assaulted, and one was murdered. Environmental activist Jory Porquia was shot to death at home by two gunmen in Barangay Santo Nino Norte, Iloilo City on April 30, 2020. Porquia was the city coordinator of the Bayan Muna Party and a member of the Madia-es Ecological Movement, which played a pivotal role in the passage of a mining ban in Capiz and other campaigns against large-scale mining, coal power plants, and large dams. For more than a year now, the People’s Barricade has shown the strength and resolve of the people of Dipidio, Nueva Viscaya, against the illegal operations of OceanaGold and its many violations on the people’s right to clean water and livelihood. The People’s Barricade has the support of the local government and various environmental advocacy organizations. Their opposition forced the suspension of OceanaGold operations following the expiry of its Financial and

Image C4.2  Barricade protest at the entrance of OceanaGold's mining site in Nueva Vizcaya, Philippines. Source: Reproduced with permission from Leon Dulce, Kalikasan People’s Network for the Environment. https://globalvoices.org/2020/04/10/philippine-police-dismantle-anti-miningbarricade-amid-covid-19-lockdown/

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Technical Assistance Agreement (FTAA) renewal on June 20, 2019. On April 6, 2020, OceanaGold used more than 100 police to violently remove 29 barricaders, mostly women, and arrested community leader Roland Pulido of the Dipidio Earth Savers Movement Association (Montesclaros 2020). In the face of hardships and challenges, threats and intimidation, arrests and murders, the struggle to defend people and the environment in the Philippines continues. Proponents of extractivist development say it provides needed jobs and income for impoverished communities, but their concern for the poor never extends to include their health and safety as workers. It is impossible to read the daily news without learning about yet another mining accident; there are approximately 12,000–15,000 mining deaths reported yearly (Nebahay, 2010), but the actual number is considered to be much higher; mining injuries are estimated to be in the hundreds of thousands. Even in so-called developed countries, occupational health for miners is denied. A medical program reviewing compensation cases for coal companies at the prestigious Johns Hopkins University found not a single case of black lung in more than 1,500 cases reviewed. (Mosk and Kreider 2015)

Case study 8: Workers and environment struggles in India

Occupational health and safety of informal workers is grossly neglected in India. Ninety percent of the sub-continent’s workforce comes from the informal sector, producing almost 50% of the national income (National Statistical Commission 2012). Nearly 48,000 workers in India die every year from hazards and precarious work environments (PTI 2017). Recent estimates suggest over 3 million workers are exposed to silica dust, while an additional 8.5 million are exposed to construction dust (Sharma et al. 2016). A survey by the National Institute of Miners’ Health shows a 40% prevalence of silicosis among miners equating to at least 94,000 workers who are either affected or exposed (Rajavel et al. 2020). Silicosis can manifest in several ways and is often underdiagnosed due to its similarity to tuberculosis. Although some legislation has been passed to compensate families of people who have died of silicosis, the most vulnerable workers remain unprotected. Silicosis is a notifiable disease under basic labor law, specifically the Factories Act of 1948, which intended to protect the rights of workers in the organized sector and is included in the list of diseases for which compensation can be claimed under several other laws. But significant gaps remain, addressed by the sustained work of several civil society organizations. For example, Silicosis Peedit Sangh uncovered deaths of migrant informal Adivasi (Indigenous) workers from Madhya Pradesh who contracted silicosis from quartz crushing installations in Gujarat; many of these migrant workers are employed in factories and mines that are not actually covered by legislation. In absence of evidence

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such as required identity cards, the workers could not establish proof of their employment, depriving them of relief from the employer or the state. No formal department, program, or structure accounts for occupational health in the informal sector. Civil society organizations have taken judicial action to ensure compensation and rehabilitation for silicosis victims along with continued advocacy. In its 2011 “Special Report to the Parliament of India on Silicosis,” the National Human Rights Commission (NHRC) called on the Government of India “to pass a suitable legislation having provisions for immediate relief and suitable compensation in all reported cases of silicosis” (NHRC 2016). The Supreme Court of India referenced a 2016 Silicosis Peedit Sangh report which surveyed 743 households with 1,721 silicosis-affected patients, either deceased or alive, in 105 villages across Madhya Pradesh. The report, revealing the sorry state of compensation and rehabilitation provided by the government, also highlighted the multiple layers of silicosis’s impact, including the fact that 65% of deaths were people 19 to 35 years old (Shuruwat 2016). Most families lost between two to eight members at peak productive age, becoming landless or heavily indebted as the costs of medical treatment in India’s highly privatized health system compounded the loss of income. Small children who traveled with their parents also contracted silicosis, on occasion becoming orphaned by the illness. Between 2009 and 2019, several cases relating to the harms of silicosis have been heard in the Supreme Court as well as in specific states. In 2009, the courts recognized severe violations by the industries and issued a ruling in favor of the NHRC to facilitate compensation for families impacted by silicosis. In 2016, Supreme Court passed a landmark order applicable nationally that “a compensation of Rs 3 lakh each to be awarded for 589 cases.” As of December 2020, 555 persons have received compensation according to civil society organizations. But the legislation passed to compensate affected families has not been sufficient. In 2019 the Supreme Court, responding to a report by the Central Pollution Control Board outlining significant health problems for workers and habitats, issued a show-cause notice to all states to provide compensation where these polluting industries were functioning. Death and disease due to these conditions are preventable. Specific worker health and safety issues, especially those of migrant workers, are absent from government discourse, and so is adequate recognition of silicosis as an occupational health issue. The decades-old struggle to recognize environmental health in India continues with a focus on protecting workers rights through community mobilization, policy advocacy, and judicial activism. As the example of India demonstrates, extractivism has a direct impact on the lives of people who are compelled into exposure against their will. Judicial intervention alone is not sufficient to protect them. Coordinated action from civil society is required to achieve the right to health in the face of extractivism.

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The idea of radically restructuring our economies away from fossil fuel capital by means of central planning has its roots in the nascent movement for ecological justice in the 1970s. However, it wasn’t until 2007 that the term “Green New Deal” (GND) would be coined (The Green New Deal Group 2019) (see Chapters A1 and A3). In response to the 2008 global financial crisis, the UK GND Group proposed a worker-led “just transition” that would simultaneously decarbonize and democratize the economy through the creation of millions of well-paid, secure green jobs. By 2019, the GND had reached the mainstream in the UK with endorsement from the Labour Party. In the US, the GND came to be associated with the progressive wing of the Democratic Party, with Alexandria Ocasio Cortez and Ed Markey quick to link it to President Franklin Delano Roosevelt’s “New Deal” that helped lift the country out of the 1930s Great Depression. The movement for a GND, typified by the Sunrise Movement, has captured the imaginations of many by demonstrating that it is possible for us to respond rapidly to prevent a “worst-case” climate change scenario (IPCC 2018) and fundamentally change our society and economy to prioritize justice. Among those delivering this call to action were public health experts who had borne witness to widening health inequalities. Physician and former health director of the city of Detroit Abdul El-Sayed noted that “by eliminating the local consequences of fossil fuel emissions, and lifting whole communities out of poverty, the Green New Deal will also be a Public Health New Deal” (El-Sayed 2019). Michael Marmot has called for a “bringing together” of the health inequality and climate change agendas (Marmot et al. 2020). This is even more starkly evident as we seek to respond to and recover from the injustices exacerbated by COVID-19. As Guppi Bola highlights, we need a “transition centered on health and sustainability; which addresses the root causes of wealth, power and income inequalities; and pursues a democratic economy that prioritises self-determination” (Bola 2020, 3). At first the GND, with its promise of green jobs and infrastructure, seems like the solution to our ills. This thinking risks overlooking a key tenet of “climate justice.” Without a firm grounding in the principles of global solidarity, a GND for the wealthier former colonial powers of the Global North will reproduce many of the same injustices we face today. An increase in mining for the raw materials needed for new “green” technologies, as many activists and Indigenous communities have pointed out, would mean maintaining high rates of ill health for those on the frontlines as well as perpetuating the denial of sovereignty to those least responsible for the climate crisis. As we continue to navigate the COVID-19 pandemic, we must place health and well-being at the heart of the social policies that will help us build anew, and build differently. A transformative GND offers us the chance to reverse the ever-widening health inequalities of the last few decades. Large-scale investment

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in jobs and infrastructure, while simultaneously decarbonizing our economy, will help us tackle a range of social ills, from the mental health crisis exacerbated by precarious, poorly paid work to the physical impacts of polluting emissions and a lack of services. Our transition must be just globally as well as domestically. We must call for climate reparations from industrialized former colonial powers as much as we campaign for green jobs (Burkett 2009). We must also seek to understand and build a platform for Indigenous traditions and theories that address the interconnectedness of human life and the rest of the natural world. It is our responsibility, regardless of where we are in the world, to ensure that internationalism is compatible with our vision of an ecologically sound future. Final thoughts

The reports from specific places and struggles presented in this chapter are not unique, rather they are representative of hundreds of other stories that could (and should) be told. They demonstrate how extractivism harms our health, which is tied to the health of the planet, by destroying Indigenous livelihoods, polluting and depleting water sources, increasing violence against women, violating people’s human and political rights murdering those who oppose it), and denying safe and decent employment to workers. They illustrate how those who are physically closest to and economically benefit least from the extractivist project are those who bear the harm most intensely, whose health and lives are confined to “sacrifice areas.” This inversion of benefit and harm is the reality of capitalist development in today’s world. This sharply contrasts with the paradigm of Sumak Kawsay/Buen Vivir, which strives instead for reinstitution of the commons, recognition of collective rights and community well-being, redistribution of wealth and health, and respect of the sacredness of relations among people and between people and the earth we inhabit. Honoring the peoples’ ancestral knowledge, and our own belonging to the territory, is the way to counter climate change and build a society we want to live in. The urgent question the People’s Health Movement (PHM) Environment and Health circle hopes to contribute to answering is: how can we get there from here? PHM-Canada shows how international solidarity is a necessary component of that transition, and so is a Green New Deal that emphasizes a redistribution of power as well as the decarbonization of power production. As the Mendoza water defenders demonstrate, a unified, uncompromising, and steadfast confrontation with power can stop the extractivist project in its tracks. When we defend health and connect our struggles nationally and internationally into a respectful movement of equals, we can change the world. In trying to connect these disparate struggles in this chapter, we have amplified the silenced voices of women and sewn together stories from eight territories and most continents. We need more voices from Africa and Asia, and we acknowledge this limitation as we look forward to working in collective and horizontal ways,

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using opportunities such as this chapter contribution to strengthen our outreach and capacity for resistance. At the PHM Extractive Industries Circle, we have promoted an International People’s Health University, partnering with the Training School of the SocioEnvironmental Health Institute at Universidad Nacional del Rosario (Argentina). Attended by 240 health workers (nurses, doctors, auxiliary personnel) from 13 Latin American countries, we used a participatory process designed to understand the impact of extractivism on health services in sacrifice areas. This training generated a Latin American network of exchange among resistances in Venezuela (Observatorio de Ecología Política), Ecuador, Argentina, and the Environmental Network of ALAMES, among others. PHM-North America is promoting a series of webinars focusing on extractivism, and Medact (PHM-UK) has co-organized a People’s Health Hearing in the People’s Summit lead-up to the 2021 United Nations Climate Change Conference (COP26). Testimonies have been presented that bear witness to the public health impacts of extractive industries and the systems driving climate breakdown and health inequities. The hearing created a space to connect people’s struggles and construct a vision for intersectional, transformative climate justice. As we completed this chapter, the Intergovernmental Panel on Climate Change (IPCC) 2021 report was launched, stating that the future is not promising (IPCC 2021). PHM’s and similar efforts must help build an urgent understanding of why structural changes in the way development is carried out are needed at national and global levels to protect the rights of Indigenous peoples, and the health of us all and the planet we share. We are running out of time. We must challenge and jettison the “development” myth and its components: progress, economic growth, and modernization. Notes 1  This quote is from Macliing Dulag, a Butbut tribe Elder, in addressing the struggle against the Chico Dam Project in the Philippines. See https://www.wowcordillera.com/2017/05/thegreat-macli-ing-dulag-cordilleran.html.

2 See Mapa del cuerpo territorio, “Map of the Body Territory.” https://rosalux-ba.org/ wp-content/uploads/2021/03/Poster-Cuerpoterritorio.pdf.

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DEVELOPMENT MODEL, EXTRACTIVISM, AND ENVIRONMENT  |  273 People’s Health Movement Canada (PHM-CA). 2016b. “Submission to the Expert Panel Review of Environmental Assessment Processes.” People’s Health Movement North America. https://phm-na.org/ wp-content/uploads/2018/09/ PHMCEAAReviewWhyWe NeedtoRememberHealthin ThisConversation.docx.pdf. Petersen, Åsa. 2013. “En efterlängtad gruvdebatt.” Dagens Arena. http://www. dagensarena.se/opinion/en-efterlangtadgruvdebatt/. Popovich, Nadia, Livia Albeck-Ripka, and Kendra Pierre-Louis. 2021. “The Trump Administration Rolled Back more than 100 Environmental Rules.” New York Times. January 20. https://www.nytimes. com/interactive/2020/climate/trumpenvironment-rollbacks-list.html. PTI. 2017. “48,000 Die due to Occupational Accidents Yearly.” Times of India. November 20. https://timesofindia.indiatimes.com/ business/india-business/48000-die-dueto-occupational-accidents-yearly-study/ articleshow/61725283.cms. Rajavel, S., P. Raghav, M.K. Gupta, and V. Muralidhar. 2020. “Silico-tuberculosis, Silicosis and Other Respiratory Morbidities among Sandstone Mine Workers in Rajasthan – a Cross-sectional Study.” PLoS One 15 (4): e0230574. doi: 10.1371/journal. pone.0230574. Rezaeian, Mohsen. 2013. “The Association between Natural Disasters and Violence: A Systematic Review of the Literature and a Call for More Epidemiological Studies.” Journal of Research in Medical Sciences 18: 1103–1107. Rivera, Juan A., Olga Penalba, Ricardo Villalba, and Diego C. Araneo. 2017. “Spatio-Temporal Patterns of the 2010–2015 Extreme Hydrological Drought across the Central Andes, Argentina.” Water 9 (9): 652. doi: 10.3390/w9090652. Rosen, Julia. 2020. “Study Links Gas Flares to Preterm Births, with Hispanic Women at High Risk.” New York Times. July 22. https:// www.nytimes.com/2020/07/22/climate/gasflares-premature-babies.html. Salamone, Mariano. 2017. “Un impasse en medio de la tormenta. La defensa del agua en Mendoza al reparo de un fallo judicial.” Terceras Jornadas de Sociología

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C5 | TRANSFORMING FOOD SYSTEMS FOR HEALTHY PEOPLE AND A HEALTHY PLANET

Introduction

Food is a central part of our lives, if not the essence of it. However, the direct linkages between persisting structural and systemic inequalities and today’s rising hunger make it clear that the matter of food and nutrition needs to be recognized as part of the broader “equation” towards more just and equal societies, including the realization of the human right to adequate food and nutrition for all. This is where the concept of food systems comes in and becomes a central part of the questions of why, what, and how changes are needed to ensure the health and well-being of today’s populations, as well as that of future generations. There are multiple forms of food systems, best understood as dynamic, heterogeneous, and complex assemblages of people, resources, places, interactions, relationships, practices, and politics. A holistic food systems approach, the focus of this chapter, reaches beyond the linear understanding of food supply chains and considers food systems in their totality, considering all the elements, their relationships, and related effects (Food and Agriculture Organization 2018). It recognizes the role of power, gender, and generational relationships as well as the complex inter-relatedness of food systems with other sectors (such as health, agriculture, environment, and culture) and systems (such as ecosystems, economic systems, social-cultural systems, energy systems) (High Level Panel of Experts 2020). Fundamentally, a holistic food systems approach recognizes how food systems can combine, serve, and support multiple public objectives within all domains of life, and individual and collective well-being. Although there has not been a single and unique historical food system, but rather a plurality of coexisting food systems, over the past 60 to 70 years a few powerful actors have been pushing for a standardization of food systems across regions. Based on a model that is referred to as the agro-industrial production model, these standardized food systems consist of increasingly globalized “food” or “value” chains,1 supported by liberalized global trade and investment agreements, and constitute in sum a global dominant food system. Their growth coincided with corporate concentration that works in and for the interest of powerful countries and large companies, while simultaneously marginalizing other food systems. This industrialized corporate-dominated food system, however, is today failing to accomplish its claimed function to nourish people and ensure their well-being.

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After two decades of a decline in undernourishment (1990–2013), in 2014 the number of people affected by hunger began to increase again and continues to rise. In 2020, the COVID-19 pandemic exacerbated the pre-existing food crisis. Up to 811 million people were suffering from hunger in 2020, as many as 161 million more people than in 2019 (Food and Agriculture Organization et al. 2021). Alongside hunger, all forms of malnutrition, including undernutrition, micronutrient deficiencies, overweight, and obesity were a persistent and growing challenge even before the COVID-19 pandemic (High Level Panel of Experts 2020). The highly likely pandemic-related increase in malnutrition (United Nations Standing Committee 2020) is associated with the consequent economic crisis that is depleting the financial resources of many. The absence of coordination and direction across government sectors over containment measures to counter the rapid spread of the coronavirus and the near collapse of already enfeebled public health systems reflected the lack of awareness of ground and people’s realities, particularly those of small-scale food producers, local vendors, workers, and the landless (Civil Society and Indigenous 2020). Local and rural market activities were restrained or even forbidden to operate in multiple countries, despite them being the main means of subsistence for many food producers and one of the most important ways that households access healthy and seasonal produce (Civil Society and Indigenous 2020). Instead, distribution channels controlled by powerful corporations and selling “convenient and safe” ultra-processed edibles2 were kept working (La Vía Campesina 2020), revealing how corporate profit was prioritized over the work, well-being, and dignity of millions, aggravating already existing inequalities within and across countries. Border closures and other COVID-19 containment measures harshly affected agricultural workers’ income and livelihoods, while the inadequacy of many food workers’ living and working conditions were exposed, especially those of individuals working in industrial meat production (FIAN International 2020). For many regions of the world this was particularly the case of migrant workers, either temporary or permanent.3 Moreover, gender inequalities and inequities intensified through increased burden of care work, loss of employment, reduction of economic opportunities disproportionately affecting women, reduction in women’s reproductive and health services, and increased gender-based violence due to the confinement measures and economic closures in the pandemic’s context (Duncan and Claeys 2020) (see Chapter A2). These facts are only part of a broader picture that shows how the pandemic exacerbated the already imminent food crisis, and clearly exposes the pandemic and its responses’ deep linkages with agro-industrial and globalized food systems. These intersections can even be traced back to the very origin of the COVID-19 pandemic, indicating that they are all part of the same “syndemic,” where the usual determinants of an epidemic mesh with unconventional determinants related to poverty, in turn related to economic systems and social inequality, all converging to create a major social crisis (Salcedo Fidalgo 2020a).

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Although there have been frequent calls for a transformation of food systems at the global level, these are often ignored or, at best, fall into simplistic and siloed answers far from the holistic food systems approach needed. A holistic transformation requires coordination among different policy domains and must tackle structural drivers such as power asymmetries. This is particularly relevant for today’s dominant food system which prioritizes corporate profits over people’s needs and in which food is understood as an object for sale (a commodity) to extract private gain. In this agro-industrial system access to healthy and sustainably produced food depends on purchasing power. A holistic transformation of this system requires food to be considered as an essential resource that requires management, with a social mandate to guarantee the right to adequate food for all not as a commodity, but as a commons (Vivero-Pol et al. 2018).4 Likewise, healthy, just, and sustainable food systems should be based on the recognition and fulfillment of the human right to adequate food and nutrition and all other interrelated, indivisible, and interdependent human rights. They should foster sovereignty, preserve the environment and traditional knowledge, protect and increase biodiversity, and strengthen sustainable smallholder food production. Food systems based on agroecology as a science, movement, and practice have proven to best align with these objectives. Agroecology draws on social, economic, political, and biological/ecological dimensions and integrates these with ancestral and customary knowledge and practices of peasants, smallscale food producers, and Indigenous peoples. Anchored in food sovereignty, it fully grasps diets as a matter of public interest and, therefore, is able to address the interconnections between food, health, societies, culture, and the environment in an equitable way, and is increasingly recognized for its promising results in responding to challenges such as climate change, soil erosion, water scarcity, and loss of biodiversity. It is, moreover, highlighted as a distinct approach to truly transform food systems, rather than a tweaking of the practices of unsustainable agricultural systems (Food and Agriculture Organization 2018). This chapter explores past and current failures of the agro-industrialized model of the dominant food system. It reveals how such a model hinders our understanding of food systems’ multiple dimensions and connectedness, and how it leads to the marginalization and food insecurity of millions of people and the destruction of the global ecosystem. The chapter also identifies some of the diverse structural reforms needed by food systems to reclaim their full potential to provide for the interconnected food and health needs of people; those which are consistent with principles of social justice and human rights while respecting and protecting the natural ecosystems on which all life depends. The current food system and health: what is at stake?

1. A system that pollutes and fails to feed The COVID-19 pandemic and related governmental measures have reinforced imaginaries and narratives that portray distribution on a big scale as “safe” channels for access to food, while reducing and limiting the channels

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that actually provide people with nutritious, healthy, and adequate food and generate economies that support the territories. “Territories” are understood as a set that includes both material territories – ecosystems, water, soil, land, seeds, or biodiversity – and “immaterial territories” – knowledge, care, ties, or cultures (Rosset and Martinez Torres 2016). In such a view, nutritious food is replaced with mere edibles that substantially reduce the nutritional value and directly relate to production and distribution models that deplete the planet’s natural resources and biodiversity. Production systems and dynamics have suffered a standardization process since the rise of the industrial era. This has led to an exponential increase of agricultural practices that prioritize uniformity, intensiveness, and extension that often challenge planetary boundaries. These systems and dynamics are the ones that shape the corporatized agro-industrial production model based on an artificialization of land and specialization in monocultures to supply the large, and in many cases transnational, food distribution chains. This production model requires numerous external inputs, often locking producers in vicious circles of dependency without any improvement of their livelihoods. Moreover, it invades, destroys, and replaces production models that require far fewer resources and that respect, protect, and ensure the well-being of people. According to the ETC Group, which monitors the impact of emerging technologies and corporate strategies on biodiversity, agriculture, and human rights, the agro-industrial model provides food to less than 30% of the world’s people while using at least 75% of the world’s agricultural resources (ETC Group 2017). The majority of the world’s population relies on food produced by peasants and small-scale food producers – most of it “organic” – requiring less (often much less) than 25% of available agricultural resources – including land, water, and fossil fuels. The production model of today’s dominant food system has highly negative impacts on the environment and is one of the main contributors to climate change. In 2017, agriculture represented 20% of the world’s CO2 emissions of all human activities (Food and Agriculture Organization 2020). Under the agro-industrial model, agriculture and livestock farming, both supposedly energy producers, become energy deficit activities. While a diversified agroecological activity invests ten calories to produce one calorie, an agro-industrial model requires up to 40 calories to produce the same quantity (Porcuna and Gonzálvez 2001). Much of the energy in question comes from fossil fuels and generally produces crops with a low nutritional value due to being grown on poor quality soils that require significant quantities of chemical fertilizers. Studies show that as the use of chemical fertilizers increases, the proportion of water in the food also increases, thus decreasing the concentration of nutrients (Raigón 2020). This phenomenon is aggravated when food is harvested before its optimum ripening point, a necessary practice to distribute the products thousands of kilometers away from the actual harvesting location that is routinely used in today’s global food chains.

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The past 60 years have also seen a 70% loss of biodiversity (ETC Group 2017). While peasants have cultivated 2.1 million varieties of plants from more than 7,000 species of domesticated plants in the world, the agro-industrial chain relies on 137 crop species and receives 45% of private investment in research and development for only a single crop, namely maize (ETC Group 2017). Similarly, in the case of livestock farming, while the peasantry breeds and reproduces more than 8,000 breeds, of which 774 are rare, the agro-industrial chain works with fewer than 100 commercial breeds of only 5 species (ETC Group 2017). In the case of industrial livestock farming large groups of animals are enclosed and packed into reduced spaces, leading to a threefold effect. First, high animal waste production is a consequence of industrialized livestock and is often disposed of in far greater amounts than land can absorb (Kraham 2017). Second, as no such equivalent grazing land exists for such high livestock densities, there is an increased demand for feed crops, such as high energy grains or transgenic soy for concentrate feed, requiring an intensification of the agricultural land which often involves large processes of deforestation, resulting in high environmental costs (Kraham 2017). In the case of beef, pastoral approaches and grass-fed animals result in meat with higher nutritional value than “feed-lot” produced beef (Daley et al. 2010). Third, an increasing concern is with the rise of antimicrobial resistance (AMR), partly due to the use of antibiotics for livestock growth promotion (due to suboptimum growth caused by unsanitary conditions) and routine antibiotic use for prevention or treatment of disease outbreaks. This has led to a rise in the spread of resistant bacteria not only through food derived directly from intensive livestock but also through soil, water, and crops due to their irrigation with contaminated water (Laxminarayan et al. 2013). For years, social movements have been warning about the serious consequences of overexploitation of the land and oceans, deforestation, and mega-urbanization, and how this whole “assault” on biodiversity would come at a cost. In 2020 we saw one of these costs in the form of the COVID-19 syndemic, the emergence of which has been linked to zoonotic processes (animal–human interactions) directly related to biodiversity loss (Salcedo Fidalgo 2020a).

2. Deterioration of people’s health The agro-industrial production model affects people’s health unequally: peasants and agricultural workers are directly exposed to agrochemicals in the production process and their families, who often live near these production sites, also pay the price of exposure. Ultimately, agrochemical residues end up affecting consumers’ health. As already mentioned, agricultural and livestock products derived from this model have lesser nutritional values at source than those obtained from agroecological production practices. Moreover, food processing and ultra-processing to supply longer chains and/or to create “fast food” products all contribute to the reduction of nutrients, while increasing the content of sugar and other additives

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along the “chain” until the food arrives on people’s plates (see Chapter C3). In Europe, for instance, unhealthy diets are associated with risks that are three times higher than the risks associated with the second highest public health threat, namely tobacco consumption. In other words, for every day of good health lost to tobacco consumption, unhealthy eating creates a loss of three days (VSF Justicia Alimentaria Global 2015). Notwithstanding, the food industry tries to primp itself by using adjectives like “natural” and “super-food” to describe edibles, manipulating the collective imagination. Actual healthy and nutritious food becomes something exceptional, with the cheapest and most accessible products being the least healthy. This situation locks persons with fewer resources and lower purchasing power into loops of malnutrition and poor health, increasing the rates of hunger, diabetes, and obesity among these populations (ibid.). In countries without public health systems, this translates into additional individual costs, as people need to cover high expenditures on medical care, thus suffering an even greater loss of income. Their health deterioration leads to further problems such as poor access to employment, adding to their already inadequate level of income and further impacting their access to adequate food and the health resources they may need (Álvarez et al. 2020). In cases where people lack the minimum resources to obtain food, access is often provided by food assistance programs whose supplies are sourced from the surplus of large agro-industrial production units. Such assistance usually lacks fresh produce. This reality is not limited to just regions in the Global South, as the polarizations between the “North” and “South” are entrenched within every country and city today. Throughout the entire food system, the agro-industrial model is particularly damaging for women. Women participating in production as peasants or agricultural workers in many cases are the main harvesting laborers and are exposed to crops highly contaminated by chemicals which weaken their health. Due to the unequal sexual division of labor within households, women as consumers are also usually responsible for food-related tasks. They are constrained to double working hours with no space or time for self-care (see Chapter A2). The food chain model has not questioned these patriarchal dynamics but rather has reinforced the status quo, interiorizing it only to make ever greater profit by massively marketing and selling labor-saving and timesaving “options” targeted uniquely at women. These so-called “solutions” include such things as ultra-processed, pre-prepared meals that claim to reduce household food preparation and time (for women). Beyond the negative impacts of these ultra-processed “edibles” on health, they more deeply immure women within the sexual division of labor by emphasizing their domestic roles rather than their social rights. Moreover, the different stages of women’s lives fall into medicalized “solutions” and become the source of niche markets for the food industry. Throughout the lifecycle, from breastfeeding to childhood to menopause, products are specifically

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Image C5.1  Imagining a nutritious meal is the only way out for some. Source: Sketch by Kriti Shukla for Global Health Watch 6.

aimed at women. Women, particularly young ones, are also the focus of campaigns promoting unrealistic body images, often leading to multiple eating disorders (Álvarez Vispo 2018). While women in some parts of the world die of hunger or malnutrition because of their lack of access to food, in others they starve themselves to respond to dominant systemic gendered parameters.

Box C5.1: Women in the COVID-19 crisis The COVID-19 pandemic crisis is exacerbating inequities within our globalizing and neoliberal capitalist system while uncovering weaknesses in our present food systems. The result is the increasing erosion of our material territories, natural assets, biodiversity, and the bonds and relationships that comprise our immaterial territory, namely the community. Today, unrecognized and unpaid care work is what sustains lives. It is carried out predominantly by women through the unjust sexual division of labor. Despite women being the ones who feed the world, they are invisible within the food system both as food producers and in their (unequal) role as caregivers responsible for food-related tasks in the household. The current crisis has highlighted the importance of care work but paradoxically multiplied the tasks of many women. In return, confinement measures across

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countries have deprived many women of their ability to make a living, due to the limitations either of the informal economy or of peasant markets. Moreover, people were often required to possess a title deed of land to be able to go to the countryside during the pandemic, including to tend to allotments for personal consumption; most women lack such title deeds. In other cases, the restrictions to movements of migrant laborers led to them being replaced by rural women workers in the fields to guarantee the harvest of crops. Yet women hardly appear in major analyses of COVID-19 impacts, or in the reporting of the consequences of this crisis regarding food systems. They continue to remain invisible to many, even though they are the ones who have once again provided the essential care work that sustains lives. In such a context, women are not inactive; they organize mutual support and mobilization networks to fight against the inequalities that this corporate agro-industrial model imposes on them.

How did our food system break?

1. The history of a production model Today’s global environmental, health, and food-related crises had their origins in the vision promoted by the Green Revolution for increased agricultural and livestock production. After both World Wars, practices and systems were reoriented and promoted to build a model that would “improve” food, gradually shifting from the needs of the land to an artificialization of the territory and high levels of energy consumption. These were rapidly expanded as, back then, petroleum seemed to be available in abundance and planetary limits were not a consideration. This model was inspired by the Fordist vision and applied to the food systems it had co-opted or “engineered,” resulting in agro-industrial food systems that would claim to produce large quantities of food at low prices to feed the world. Doing so, however, would leave control of these systems to international markets and their powerful intermediaries with little regard for prioritizing people and their right to adequate food. Driven by a firm belief that unregulated markets would efficiently allocate economic resources in a way that maximizes overall well-being, and in order to receive support from international institutions such as World Bank and the International Monetary Fund, governments had to implement a package of neoliberal economic policies (Sonkin 2020). As earlier editions of Global Health Watch (GHW) have noted (e.g., GHW4, Chapter A1), these “structural adjustment” reforms included fiscal consolidation (austerity), reduction of cross-border capital controls, trade liberalization, elimination of agricultural subsidies, privatization of public services such as water supply or agricultural inputs/infrastructure

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provision, and other measures such as allowing foreign investors’ ownership of natural resources. A new push for austerity and privatization of previously public services gained even more strength following the 2008 global financial crisis (see Chapter C1). Over these neoliberalizing decades, food was increasingly reduced to a mere commodity linked to other financial products, and the territory and plant genetic resources fragmented into assets that could be privatized. Natural assets have become tradeable commodities and subjected to speculation, while peasants were progressively forced to leave their territories. This forced the migration of small-scale food producers to urban areas where development projects were the key focus. Thus, the industrialization of food production became linked to the mega-urbanization process and changed models of consumption. These models were shaped by the decoupling of food and nutrition from food production, contributing equally to the medicalization of nutrition to the point where certain sectors understood nutrition as something merely prescriptive and, in a mechanistic way, as the simple sum of different nutrients. Market-led reforms included policy changes that opened new markets for genetically modified seeds, facilitating the approval of chemical pesticides and fertilizers, and changing countries’ land tenure arrangements to enable buying or leasing by international investors to “enhance productivity of land use” (Sonkin 2020). This implied food production trending towards high specialization and monocultures and against practices that would work in harmony with ecosystems. This increased the need for chemical inputs for production, that forced producers who transitioned to this model to become more and more dependent on external input providers, increasing their indebtedness (The Oakland Institute 2017). The parallel replacement of farmers’ seeds with a few uniform industrial varieties led to the rapid erosion of global seed diversity (The Oakland Institute 2017), contributing to the previously mentioned 70% loss of biodiversity that has taken place over the last 60 years (ETC Group 2017). This “financialization of food and agriculture” – or, in other words, the increasing role played by financial actors (from private equity and pension funds to commercial banks) and markets within food systems (Sonkin 2020) – resulted in a model that is mainly accessible to large corporations. The high amounts of resources and inputs required for the model to expand, in both quantity of land and money, mean that small-scale producers are not able to access this type of production, even if they wanted to do so.

2. Public policies The agro-industrial model can only be sustained with the support of and promotion by public policies at different levels, from local to global. It is almost a century since the world began establishing the pillars for human rights intended to serve as rules of the game to protect and guarantee the rights of all people. Today, however, we are fully immersed in a neoliberal model of globalization

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with a more unequal and hungrier world than ever. Public policies have played a central role throughout, simultaneously promoting human rights while enabling a form of economic globalization that deepens inequalities and thus severely hinders human rights protection (FIAN International 2009). The privatization of natural assets has been accompanied by policies that support the supply of international markets controlled by large and highly polluting corporations. Today, the globalized and corporate agro-industrial model not only prevails in politics and has transformed social narratives, portraying itself as the only possible option, but its interests are the driving force behind public policy making. One of the factors abetting the expansion of this model are trade agreements, which are aimed at increasing international commerce and ignore or marginalize people’s human rights concerns. Specifically, the Agreement on Agriculture (AoA), which came into force as part of the World Trade Organization (WTO) in 1995, has been a barrier to fully realizing the right to food because it focuses only on creating a fair and market-based agricultural trading system without prioritizing non-trade concerns such as food security or the environment. Trade liberalization and domestic policies in the wealthiest countries increased the market power of transnational commodity traders and processors, and thus contributed to the consolidation of corporate power by ignoring the dominant role that a handful of large companies play at all levels of the food system (Fakhri 2020). Tight restrictions for agricultural subsidies within socalled developing countries that are party to the WTO AoA, and the subsequent WTO-mandated trade liberalization, caused agriculture in these countries to become “non-competitive” (Bello 2007), which had (and continues to have) a devastating impact on many countries’ local economies. Competitive pressures induced by trade liberalization led to the expansion of commercial plantations at the expense of smallholders (Bello 2007), not only wrecking the livelihoods of the peasant communities but also advancing a model of “development” that makes the practices that do sustain those livelihoods invisible (see Chapter C4), reducing them at best to museum objects or elements of folklore. The extent to which agro-industrial food corporations have grown in size and power in recent decades pushed governments to invite them to the table of policy making, often through so-called multistakeholder platforms and/or public–private partnerships, to develop solutions to the problems they are largely responsible for, while granting corporations more and more influence over government policies and practices. This growing governance tendency is inconsistent with human rights frameworks, as governments fail to clarify roles of the different parties. These governance spaces often lack effective policies to protect against conflicts of interest and power imbalances and disregard those most affected by hunger and malnutrition, who are the real rights holders, often seeing them as people in need of protection but without the knowledge or evidence of workable food systems, thus legitimizing a paternalistic approach. Even when these

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spaces have, in their perspective, condescended to accept the participation of civil society in decision-making processes, the manner in which this is done is too often merely choreographic or it consists only of consultation without the possibility of genuinely influencing decision-making processes. The COVID-19 pandemic is aggravating and polarizing this reality even further. The few existing participatory spaces for public policy building have been reduced to purely virtual modalities. Policy making and consultation through digital means is portrayed and even promoted as inclusive governance, when in fact these governance modalities limit access for people from many communities and key sectors that lack the necessary technologies.

3. A crisis with multiple dimensions The processes described above have resulted in a crisis that manifests in many ways. The struggle for access to resources required for minimum survival is deeply contributing to multiple conflicts, many of which subsequently turn into chronic and prolonged crises. The current climatic and environmental context further aggravates the situation, as it contributes both to the displacement of peasant populations and to corporate attempts to increasingly hoard resources related to food production for the purpose of large-scale land investments by new financial actors and speculation over food commodities (Sonkin 2020). In this sense, crises such as the current health emergency become opportunities for large corporations, as they expand the playing field for implementing measures in emergency situations that, far from providing solutions, worsen the very causes of the problem.

Box C5.2: False solutions to ending hunger and malnutrition and achieving sustainable food systems Big food corporations have managed to design “solutions” for hunger and malnutrition that will only protect their interests. One of these “solutions” is reformulated and fortified food: the industry fortifies food that is already unhealthy and, through marketing, makes it appear healthy, all in the effort to keep food systems centered around the promotion of ultra-processed foods. Evidence demonstrates that such foods contribute to diet-related diseases (VSF Justicia Alimentaria Global 2015). Furthermore, by disassociating hunger and malnutrition from poverty and inequality, consumers are blamed for their bad choices, a strategy allowing corporations to deflect attention away from their responsibility of promoting unhealthy food. Additionally, food aid based on fortified food – which can be an appropriate short-term solution to treat severe micronutrient deficiencies – has become a core strategy used by many states to address hunger and malnutrition,

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thus creating further dependence on corporate diets instead of local and diverse diets. Likewise, agri-food companies offer “green solutions” to agriculture – often based on digital technologies – which ultimately profit them and do not allow a systemic and structural transformation towards sustainable and just food systems. Precision agriculture is one of these digital solutions on offer, which allows farmers to optimize their costs by tailoring input applications (High Level Panel of Experts 2019). While this can contribute to more sustainable practices, precision agriculture is essentially promoted and controlled by large agricultural inputs companies and is focused on increased yield rather than an interest in the fundamental shifts required to phase out fertilizers and pesticides (IPES-Food 2016; Carolan 2017). Digital technologies are also contested because of unequal access for all food system actors, creating food producers’ dependence on the owners of those technologies, something that is often associated with debt (High Level Panel of Experts 2019). Today, many states’ narratives and proposals go hand in hand with this digitalization of food, a term that refers to the increasingly automated, delocalized, and computerized process of food production and commercialization. As researchers have commented, “ … while this process might have been initiated by scientists genuinely concerned with safeguarding biodiversity by creating virtual genetic material which might be transplanted to future territories, it has now been captured by global corporations aiming to patent nature and acquire control of the production process by controlling the market in agricultural inputs” (Prato et al. 2018). The use of big data is not only limited to on-farm input management but also entails the collection of data sets from consumers. This can be used to influence consumer choices in line with the interests of food industry companies (Carolan 2018). In this sense, digital technologies raise key questions on governance, access, and rights to information, as large companies are the ones who mainly own the platforms and equipment to control the data (Carolan 2017; 2018, Higgins et al. 2017) (see Chapter B2).

The urgent need to transform food systems: how can we build a resilient food system?

1. Agroecology as the answer The current environmental and social crises in which we find ourselves did not evolve naturally but are the consequences of an economic model that, when transferred to food systems, results in hunger and malnutrition, separating food from the needs of people and the planet. Agroecology exists as a genuine alternative model.

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The agroecological model is based on common fundamental pillars (Nyeleni Center 2015) that reach well beyond a simple technological approach. Agroecology is a science, a set of practices, and a social movement aimed at producing healthy and nutritious food while responding to people’s needs by respecting and protecting both material and immaterial territories. It is closely linked to food sovereignty and has proven itself to be a resilient model, as its practices promote biodiversity and therefore greater adaptation to climate change. According to the Food and Agriculture Organization’s “10 Elements of Agroecology” (2018), a key element is that of social and economic change as represented in the principles of social solidarity economy. Furthermore, in reducing reliance on external resources, it empowers producers by increasing their autonomy and resilience to natural or economic shocks (Food and Agriculture Organization 2018). Agroecology is based on the prioritization of local contexts and realities in social, cultural, economic, and environmental dimensions, and seeks to offer food systems that enable communities to be autonomous. This ultimately leads to independence from external inputs for production by adopting a circular approach that takes advantage of the symbiotic relationships between the different animal and vegetal species and their metabolisms in food production. This preserves or even increases biodiversity even as it converts the soil into a carbon sink, thereby contributing to cooling the planet. Thus, the agroecological model incorporates a broad view that reaches beyond the techniques or management of soils. It considers the ecosystem as a whole, analyzing both land management and socioeconomic models and the political decision-making capacity of people within the food system. In other words, it works to preserve and sustain the territory. Although the current economic paradigm is clearly not built on these principles, during the COVID-19 pandemic many practices and models of mutual support and solidarity emerged or were strengthened at the territorial level that were based on solidarity economy. This holds even more validation for their continuation and expansion in the post-pandemic period as global attention returns to climate change. The agroecological model offers a holistic and integrated view that responds to the complexities of the food system and results in healthy and sustainable diets. In this model, small-scale food production is given a leading role alongside the ancestral knowledge that has fed populations for centuries, generating “knowledge dialogues” (diálogo de saberes) that lead to innovations adapted to the needs and health of both the territory and the people. Under this holistic view, a feminist approach is emerging which increasingly incorporates and emphasizes the role of women. This approach equally regards the inequalities faced by women as a pending, essential task, since no model based on inequality will result in an equitable impact (Civil Society and Indigenous 2019).

2. Alternative models, other forms of governance COVID-19 has provoked a renewed examination of today’s food systems, including local food system alternatives that have proven that they work better

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Box C5.3: Agroecology and sustainable development programs in the dry land of Chile. Case study of the Pajal Community In this case study, Mrs. Rosa Cueva’s work around her house on a 600 square meter piece of land using an agroecological approach with high diversity was compared with another production site, that of her husband, Mr. Miguel Romero, who farmed a 4.5 hectare (ha) hilled area, growing lentils, wheat, and pasture using conventional practices. Both systems were closely monitored for one year and the results compared, both in terms of yield (in kilograms of available feed) and income. This comparison showed that the 4.5 ha hilly system was highly degraded and its productivity was much lower than that of the diversified system. Also, the average production cost was higher and the number of calories obtained was much lower. This was in part due to the large harvest having to be shared with the landowner and part of it not being destined for local food distribution and consumption but, rather, for other markets. As a consequence of this study, Mr. Romero soon joined his wife’s work, and both decided to form a micro-company of organic horticultural products. The transformation was impressive. What originally was an average, not very functional area with stationary diversity and depleted soils was transformed into a very high agro-diversity area, managed by a majority of women, that realized a better income for the surrounding families. The transformation began in the small organic gardens, and gradually spread throughout the community, implementing a proposal with a strong emphasis on food production and recovery of natural resources. In this way, crops would be adapted and diversified, even taking advantage of soils that were not useful for commercial varieties but suitable for more rustic crops. This, in turn, would regenerate soil and biodiversity. In this way, not only was there a more diverse ecosystem, but also an economy was developed based on the integration of women’s knowledge and skills. The agroecological system ultimately proved to be more autonomous and resilient and, over time, this system has become a learning space for other communities (Infante 2013).

Box C5.4: Agroecology and COVID-19 The COVID-19 pandemic led to public policies prioritizing large distribution chains, even presenting them as “safe spaces,” while open-air farmers’ markets were being closed. These and further measures, such as the closure of schools that often represent the spaces where children from low-income

TRANSFORMING FOOD SYSTEMS FOR HEALTHY PEOPLE AND PLANET  |  289 contexts receive their daily meals, increased hunger rates in many cities. Meanwhile, organized local groups that consume through collective initiatives such as cooperative markets or Community Supported Agriculture (CSA), which is based on a mutual collaboration between producers and consumers, have seen their demands increase. This shows that agroecology and solidarity movements are able to respond to people’s real needs in many places, even during acute crises. In the same way, while large production was affected by global markets grinding to a halt or the impossibility of harvesting their monoculture, agroecological production, despite the limitations imposed for some of their marketing channels, has been able to adapt to the circumstances of the crisis. Moreover, consumers in many places increased their demand for products coming from agroecological chains and solidarity-based agriculture, while different actors called for the availability of healthy, quality food for all. This clearly demonstrated the rise of a wider claim for a right to food perspective within food systems (Urgenci 2021). The fact that agroecological movements are collectively organized has facilitated their adaptation to the new situation and even their articulation with other local movements, by sharing work and logistics. In many places, this situation has succeeded in reinstating spaces and relationships that had weakened over time. It has also resulted in developing support for local production and markets. In return, producers have been able to adapt to mobility restrictions that had to be followed by many consumers through collectivizing tasks with others.

than the dominant one, even in times of crises. The lessons so far learned must now be incorporated into the construction of agroecological transitions that move away from the agro-industrial model. Such a transition requires other forms of governance. If the agro-industrial system has been supported by public policies over the past 70 years, transformation of the food system must necessarily involve the redirecting of both the modalities and content of such policies. Inclusive spaces based on human rights that clearly distinguish duty bearers and rights-holders are needed to enable the fundamental dialogues between states and civil society. The UN Committee on World Food Security (CFS) is a multilateral space and includes the Civil Society and Indigenous Peoples Mechanism (CSM) as one of the main participants. The CSM has proven to be a space that can incorporate the voices of the different groups or constituencies that are key agents of agroecological food systems. After the food and financial crises in 2009, the CFS underwent a reform that was guided by the following principles: inclusiveness, strong linkages to the field to ensure the process was based on the

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reality on the ground, and flexibility in implementation. It still stands by the vision of being the most inclusive international and intergovernmental platform to eliminate hunger and ensure food security and nutrition for all human beings (CFS 2009). Although this was a major achievement for social movements, the CFS principles must be further reflected upon with the aim to preserve the public common good over the multiple interests that may converge. If food systems governance is to be anchored in a human rights-based approach, those groups most affected by hunger and malnutrition (“rights holders”) must be able to participate meaningfully in the determination of public priorities and the development of strategies, policies, legislation, and other measures that affect food systems. Democratic, inclusive, and participatory processes and institutions must be supported (High Level Panel of Experts 2020). These should recognize, respect, and support the self-organization and autonomy of movements and collectives as key contributors to food systems policy making (for an example of how this might be done, see Box C5.6). The immense power imbalances within society and, more specifically, within food systems (e.g., between groups affected by malnutrition and large agri-food corporations) must be recognized. Consequently, it is crucial that states adopt policy frameworks that recognize such power imbalances and clearly distinguish and ensure appropriate roles for different actors in public policy making and program implementation. A key element in this approach is the adoption of robust safeguards to protect against conflicts of interest resulting from inappropriate relationships with and influence of the corporate sector, and that uphold the public interest and human rights orientation of public policy. Likewise, a crucial condition for a democratic and human rights-based governance is accountability. States must ensure transparency in their actions and establish clear frameworks and mechanisms whereby they can be held accountable for decisions and actions taken in relation to food systems. At the same time, they should establish clear regulations and accountability frameworks for holding private actors, including corporations, accountable for actions that undermine human rights (see Chapter D5).

Box C5.5: Construction of the CSM’s vision document on Food Systems and Nutrition A good example of an autonomous, self-organized, and participatory process for paving the way to transform food systems is the construction of the vision document (Civil Society and Indigenous 2021) by the Working Group on Food Systems and Nutrition of the Civil Society and Indigenous Peoples Mechanism (CSM) for relations with the UN Committee on Food

TRANSFORMING FOOD SYSTEMS FOR HEALTHY PEOPLE AND PLANET  |  291 Security (CFS). When the CFS embarked on the process of elaborating the Voluntary Guidelines on Food Systems and Nutrition in 2018, the CSM Working Group started a parallel process of building its own vision document for Guidelines to transform food systems. Its construction has since evolved, and it remains open as a living document. The organizations and movements of the people most affected by food insecurity and malnutrition are prioritized, recognizing that they are the organizations of the rights-holders that are the subjects of their own development. Furthermore, they are the most important contributors to food security and nutrition worldwide and must therefore remain at the center of developing such guidance. The process started with a Working Group meeting with all 11 of the CSM constituencies,5 followed by a public briefing in Rome. Different popular struggles for food security and sovereignty were discussed, with requests for their representation in the document to ensure that all concerns were adequately addressed. This dialogical process was strengthened through the CFS regional consultations in 2019 whose objective was to receive important inputs from the different regional and local realities. The result entails the multiplicity of public objectives that food systems serve within all domains, from livelihoods to health, socio-cultural, and ecological ones. The vision document’s structure aims to address this systemic perspective by offering a definition of healthy and sustainable diets and proposing a set of guiding principles that should be observed to reshape food systems in order to make them healthy, sustainable, and just. The document then provides a series of policy interventions in five key domains of food systems: governance; protection and regeneration of nature; health and well-being; modes of food production, exchange, and employment; and culture, social relations, and knowledge. Finally, it indicates a series of connected systems and policy domains in which structural changes and transformation are necessary to ensure policy coherence. For more information visit: http://www.csm4cfs.org/.

The way forward

The analysis with which this chapter began argued how, if changes do not occur, the future will be increasingly difficult and inequitable, particularly when considering the impact of the COVID-19 pandemic. Paradoxically, we already possess enough tools and answers to generate a resilient and just food system that can feed and nourish both the planet and people. The transformation from our dominant but unsustainable agro-industrial model to an agroecological model can succeed, but only if alliances are cultivated and networks that incorporate

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its vision and principles are generated. Health, ecosystems, and food must be regarded as interconnected commons, not as commodities for financial profit; and public policies must be based on a human rights framework, clearly differentiating needs and rights from mere private interests.

Box C5.6: Building networks for food sovereignty: the University Chairs Network in Argentina and Paraguay The Network of Independent University Chairs in Food Sovereignty and Related Collectives (known as Calisas Network) links 50 entities in Argentina and Paraguay into one network that promotes public discourse on the agribusiness model imposed on the Southern Cone of Latin America. Calisas connects networks for the collective construction of food sovereignty.6

Origins and foundation The possibility of creating Independent Chairs to promote areas of culture and knowledge, which do not have specific places in the curriculum of university careers otherwise, originates with Argentina’s University Reform of 1918. Inspired by the principles of the Reform and after the World Food Summit of 1996, in which Vía Campesina (the International Peasants’ Movement) introduced for the first time the Food Sovereignty Paradigm, the first Independent Chair on Food Sovereignty was created in 2003 under the Universidad Nacional de La Plata (National University of La Plata), to which all other entities would eventually be added. Constantly growing, the Calisas Network today consists of: a. Independent Chairs on Food Sovereignty found in national public universities which have been approved by the boards of directors or university superiors; b. University Chairs that are not specifically geared towards food sovereignty but that address the Food Sovereignty Paradigm as their main objective; c. Collectives, associations, and organizations that seek to establish themselves as Independent Chairs within national universities, and d. Social organizations that develop workspaces and/or discussions on food sovereignty, though these are not always within universities. There is great diversity and heterogeneity between the entities within the Calisas Network, derived from the different academic units of the universities and the social sectors involved. The decision on a university chair structure by many of the entities within the Network is not arbitrary, since the title

TRANSFORMING FOOD SYSTEMS FOR HEALTHY PEOPLE AND PLANET  |  293 guarantees the greatest freedom of decisions and criteria, doctrines, and philosophical orientations, while it also serves as the adequate framework to develop teaching, research, outreach, and liaison activities with different scientific, technical, and cultural institutions of all educational levels.

Common traits Although the entities of the Calisas Network are autonomous and freely define their own approaches, they all generally share the following features: 1. They question the agribusiness model, hypermarketism, as the dominant form of food distribution, and the circulation of food as mere commodities in a capitalist economy. 2. They promote food sovereignty as an antithetical paradigm that opposes and surpasses the agribusiness model. 3. They are part of and/or associated with social movements, peasants, and native peoples, with family, peasant, and Indigenous agriculture, and with the social and popular economy; 4. Regardless of their proposals, the entities are not intended exclusively for university students and are open to the community as a whole, and they promote an exchange of knowledge with the community. 5. They develop teaching, research, and outreach activities such as fairs, workshops, local work opportunities in neighborhoods, Participatory Guarantee Systems (local forms of guaranteeing organic production), agroecological food production, and community communications, among other things. 6. They are composed of interdisciplinary and transdisciplinary teams. 7. They are composed of graduates, students, and professors who are all of the same standing, promoting a horizontal and assembly-based internal structure. 8. They may or may not be embedded in the university curriculum. 9. In most cases, they lack specific funding, relying on volunteer work and their members’ commitment to the cause. 10. They seek to influence public policies and, in this regard, they are increasingly becoming reference and consultation actors in the discussion of agri-food public policies in the country.

Permanent exchange, pronouncements, and Annual Assemblies The entities that make up the Network are in constant communication and frequently issue public statements and/or collectively draw up advocacy strategies on current issues. Once a year, the Calisas Network holds its Annual Assembly in one of the different regions where it is present, decided on a rotating basis. This meeting becomes a space for gathering,

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discussion, and friendly exchange and a possibility for taking a stance as a Network on different topics.

The South: A Latin American Network of Independent Chairs on Food Sovereignty and Related Collectives Although the Calisas Network was born in Argentina, beyond the spaces it permanently inhabits, it is planting the seed that is the Independent Chairs and Related Collectives in other countries of Latin America. Recently, the first Calisa of Paraguay joined the Network, thus opening the door to the future formation of a Latin American Network, an objective to which the different Network entities collectively aspire. The Calisas Network’s fundamental contribution lies in weaving and building networks in the regions where it is present for the collective construction of the food sovereignty of peoples. For more information, visit: http://redcalisas.org/. Download the book about the Network’s experience: http://www.biodiversidadla.org/Documentos/ Argentina_-RED_CALISAS_Tejiendo_redes_para_la_Soberania_Alimentaria.

Notes 1  References to the agro-industrial model and/or food or value chains allude to the linear sequence of links running from production, including its inputs, to consumption outcomes. The different links involve crop and livestock genomics; pesticides, veterinary medicines, fertilizers, and farm machinery; transportation, storage, milling, processing, and packaging; wholesaling, retailing, and ultimately delivery to homes or restaurants. These different links cannot be understood as different from the market economy and are deeply connected to the financial and political system (ETC Group 2017). 2  We refer to “edibles” as the source of worldwide pseudo-food consumption. It is possible to distinguish edibles from real food by their degree of processing. Industrially processed edibles have high concentrations of critical nutrients such as glucose, trans fats and sodium, preservatives, colorings, sweeteners, and genetically modified organisms. Scientific evidence shows that obesity is directly linked to the consumption of highly processed edibles (Salcedo Fidalgo 2020a; 2020b).

3  For case studies, see for instance: https:// focusweb.org/publications/farm-workers-duringcovid-biggest-casualty-of-neoliberal-foodsystems/. 4  Commons and public goods are often used as interchangeable terms, but in different domains. The notion of commons is not about the nature of a good but rather the way in which societies organize around it. Commons can therefore be understood as “self-regulated social arrangements to govern material and immaterial resources deemed essential for all” (Vivero-Pol et al. 2018, 8). 5  The CSM is composed by 11 constituencies, namely smallholder farmers, pastoralists, fisherfolks, Indigenous peoples, agricultural and food workers, landless, women, youth, consumers, urban food insecure, and nongovernmental organizations (NGOs). 6  For more information on the Calisas Network, see http://redcalisas.org/. Download the book about the Network’s experience at http://www.biodiversidadla.org/Documentos/ Argentina_-_RED_CALISAS_Tejiendo_redes_para_ la_Soberania_Alimentaria.

TRANSFORMING FOOD SYSTEMS FOR HEALTHY PEOPLE AND PLANET  |  295 References Álvarez, Isa, Mari Fidalgo, Ruth L. Herrero, and Lucia Shaw. 2020. ¿Qué Comen las que Malcomen? Malaga: Zambra/Baladre. Álvarez Vispo, Isabel. 2018. “Salud y Alimentación desde la Mirada Feminista.” In Salud y derecho a la alimentación. Bienestar, equidad y sostenibilidad a través de las políticas alimentarias locales, 35–39. Valladolid, Spain: Fundación Entretantos. http://www.ciudadesagroecologicas.eu/ wp-content/uploads/2018/12/InformeSalud_ Definitivo_Web.pdf. Bello, Walden. 2007. “Free Trade vs. Small Farmers.” https://www.tni.org/es/node/11368. Carolan, Michael. 2017. “Publicising Food: Big Data, Precision Agriculture, and CoExperimental Techniques of Addition.” Sociologia Ruralis 57 (2): 135–154. Carolan, Michael. 2018. “Big Data and Food Retail: Nudging out Citizens by Creating Dependent Consumers.” Geoforum 90: 142–150. doi: 10.1016/j.geoforum.2018.02.006. CFS [Committee on World Food Security]. 2009. “Final Version of the ‘Reform of the Committee on World Food Security.’” CFS Thirty-Fifth Session, October 14, 15, and 17. Rome: UN Committee on World Food Security. http://www.fao.org/tempref/ docrep/fao/meeting/018/k7197e.pdf. Civil Society and Indigenous Peoples Mechanism. 2019. “Without Feminism there is no Agroecology. Towards Healthy, Sustainable and Just Food Systems. An Input and Vision Paper of the CSM Working Group of Women.” http://www.csm4cfs.org/wpcontent/uploads/2019/10/CSM-Agroecologyand-Feminism-September-2019_compressed. pdf. Civil Society and Indigenous Peoples Mechanism. 2020. “Voices from the Ground – From COVID-19 to Radical Transformation of our Food Systems.” Working Group on Global Food Governance of the Civil Society and Indigenous Peoples’ Mechanism (CSM) for Relations with the UN Committee on World Food Security (CFS). http://www. csm4cfs.org/wp-content/uploads/2020/12/ EN-COVID_FULL_REPORT-2020.pdf. Civil Society and Indigenous Peoples Mechanism. 2021. “Vision Document on Food Systems and Nutrition. An Alternative to the CFS Voluntary Guidelines on Food Systems

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www.ipes-food.org/_img/upload/files/ UniformityToDiversity_FULL.pdf. IPES-Food. 2020. “COVID-19 and the Crisis in Food Systems: Symptoms, Causes, and Potential Solutions.” Communiqué. April. http://www.ipesfood.org/_img/upload/files/ COVID-19_CommuniqueEN%283%29.pdf. Kraham, Susan J. 2017. “Environmental Impacts of Industrial Livestock Production.” In International Farm Animal, Wildlife and Food Safety Law, edited by Gabriela Steier and Kiran Patel, 3–40. Switzerland: Springer. doi: 10.1007/978-3-319-18002-1_1. La Vía Campesina. 2020. “The Corona Crisis Harms Those Who Feed Us.” Op-ed. https:// viacampesina.org/en/the-corona-crisisharms-those-who-feed-us/. Laxminarayan, Ramanan, Adriano Duse, Chand Wattal, Anita K.M. Zaiti, Heiman F.L. Wertheim, Nithima Sumpradit, et al. 2013. “Antibiotic Resistance – the Need for Global Solutions.” The Lancet Infectious Diseases Commission 13 (12): 1057–1098. doi: 10.1016/ S1473-3099(13)70318-9. Nyeleni Center. 2015. “Declaration of the International Forum on Agroecology.” https://viacampesina.org/en/declaration-ofthe-international-forum-for-agroecology/. The Oakland Institute 2017. “Down on the Seed: The World Bank Enables Corporate Takeover of Seeds.” Report. https://www. oaklandinstitute.org/sites/oaklandinstitute. org/files/down-on-the-seed.pdf. Porcuna, José Luis, and Victor Gonzálvez. 2001. “La Alternativa Agroecológica.” Summer course. El Escorial: RIESGO TÓXICO. Protección Ambiental, Salud Laboral y Seguridad Alimentaria. http://istas.net/ descargas/escorial/ponen/ponen05.pdf. Prato, Stefano, Elenito Daño, Trudi Zundel, Lim Li Ching, and Chee Yoke Ling. 2018. “Policies that Strengthen the Nexus between Food, Health, Ecology, Livelihoods and Identities.” Spotlight on Sustainable Development. https://www.2030spotlight.org/sites/ default/files/spot2018/chaps/Spotlight_ Innenteil_2018_chapter2_prato.pdf. Raigón Jiménez, María Dolores. 2020. Manual de la Nutrición Ecológica. De la Molécula al Plato. Valencia: Sociedad Española de Agricultura Ecológica. Rosset, Peter, and María Elena Martinez Torres. 2016. “Agroecología, Territorio,

TRANSFORMING FOOD SYSTEMS FOR HEALTHY PEOPLE AND PLANET  |  297 Recampesinización y Movimientos Sociales.” Estudios Sociales: Revista de Alimentación Contemporánea y Desarrollo Regional 25 (47): 273–299. https://dialnet.unirioja.es/ servlet/articulo?codigo=5831955. Salcedo Fidalgo, Hernando. 2020a. “Corporate Food Paradigms and Health Crisis: The Image of a Syndemic Crash.” Development 63: 205–208. doi: 10.1057/s41301-020-00265-x. Salcedo Fidalgo, Hernando. 2020b. “The Coronavirus Pandemic: A Critical Reflection on Corporate Food Patterns.” In Right to Food and Nutrition Watch 2020: Climate, Environment and the Human Right to Adequate Food and Nutrition, Issue 12, by Global Network for the Right to Food and Nutrition. Germany: Brot für die Welt and FIAN International. Sonkin, Fora. 2020. “Recipe for Disaster: The IMF and World Bank’s Role in the Financialisation of Food and Agriculture.” Bretton Woods Project Spring Observer 2020. https:// www.brettonwoodsproject.org/wp-content/ uploads/2020/04/IMF-and-World-Bank-rolein-financialisation-of-food-and-agricultureAt-Issue-Spring-2020.pdf.

United Nations Standing Committee on Nutrition. 2020. “Strengthened Action on Nutrition in the COVID-19 Response: Putting Healthy, Affordable and Sustainable Diets at the Heart of a Human-rights Based Response to COVID-19.” https://www.unscn. org/19?idnews=2096. Urgenci. 2021. “Enacting Resilience: The Response of Local Solidarity-based Partnerships for Agroecology to the Covid-19 Crisis.” https://urgenci.net/wp-content/ uploads/2021/01/Urgenci-rapport-EnactingResilienceFINAL-FINAL.pdf. Vivero-Pol, Jose Luis, Tomaso Ferrando, Oliver De Schutter, and Ugo Mattei. 2018. “Introduction. The Food Commons are Coming.” In Routledge Handbook of Food as a Commons. New York: Taylor & Francis. VSF Justicia Alimentaria Global. 2015. “Viaje al Centro de la Alimentación que nos Enferma.” https://defiendeme.org/wp-content/ uploads/2018/09/informe-damevenenoFINAL-BAJA.pdf.

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C6  |  CONFLICT AND HEALTH IN THE ERA OF CORONAVIRUS

Introduction

The indicators of positive peace1 and the social determinants of health are closely linked, making it logical to examine the interactions between peace and health – especially at a time when both face significant new threats around the world. This chapter analyzes the global relationship between peace and health: from the top-down agenda of the Sustainable Development Goals (SDGs) to grassroots peace and health initiatives “from below.” Case studies explore the health impacts of two of the most devastating ongoing conflicts in the world today, in Yemen and Syria, and examine how COVID-19 has compounded their pre-existing crises. The weaponization of the coronavirus by state powers for repressive purposes is also surveyed. A gendered analysis of the impacts of conflict, and women’s leadership in many grassroots initiatives for peace and health, runs as a thread throughout the chapter. The global peace agenda

1. The SDG agenda and global partnerships in health and peacebuilding Described as a sweeping and ambitious blueprint for improvements on a wide variety of economic, social, and environmental issues (United Nations 2020), and developed through an extensive consultation process that included UN (United Nations) agencies, civil society organizations, national governments, and private sector actors, the 17 interconnected SDGs envision a broad global partnership for sustainable development (see also Chapter D3). Peacebuilding and health figure prominently in the SDGs as individual goals (SDG3: Good Health and Well-Being, SDG16: Peace, Justice and Strong Institutions) and as cross-cutting themes. The inclusion of peace as a specific goal, and the conceptualization of the SDGs as a single “whole” comprised of interconnected and mutually reinforcing goals, are based on learning from the Millennium Development Goals and informed by feminist approaches to peace, including the Women, Peace, and Security Agenda, which see peacebuilding and sustainable development not as separate processes but as fundamentally connected (Women’s International League 2020). SDG16 emphasizes the need for “effective, accountable and inclusive” institutions at all levels. This vision recognizes “the connection between the structures of power and the people that they should serve” (Whaites 2016, 2) or, in other

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words, the ways that government and governance can affect the day-to-day realities of human lives. The entire SDG agenda promotes an understanding of security that is grounded in human (and humanitarian), rather than nationstate, considerations; reflecting an international consensus that we must strive for societies which are not simply conflict-free, but which also have all the attributes of positive peace. The goals are intended to be universal, applying equally to all countries. They carry internal and external responsibilities: “countries are obligated to uphold their extraterritorial obligations, which means that they can be held accountable for the effects of their actions abroad” (Women’s International League 2020). This offers an important opportunity to link health and peacebuilding efforts around the world. Using the frame of the SDGs to address health issues could perhaps also reverse a problematic trend towards treating health as a security issue (see Global Health Watch 5 Chapter D6), which has led to a blinkered, narrowly national response to COVID-19 on the part of some countries, without regard for the global human cost of doing so. The SDGs encourage cross-sectoral partnership working towards shared goals, such as global health diplomacy being used as a tool of peace, or health workers learning to act as community peace builders through the inclusion of peacebuilding in medical curricula. However, despite its positive potential, the SDG agenda also faces legitimate criticism, particularly for its focus on the national-institutional level.

2. Criticisms of the SDG agenda for peace and health A general critique of the SDG agenda focuses on its top-down approach, driven by governments and institutions, and its continued reliance on the doctrine of economic growth as the route to development (see Global Health Watch 5 Chapter A1 for a detailed critique). For peacebuilding and health, a central question is whether the SDG agenda can effectively link national and international efforts to local grassroots initiatives. The UN and its agencies work primarily on a national level and, in the case of the SDGs, focus on strengthening institutions. Yet, as Arifeen and Semul (2019, 240) point out, “it is debatable whether institutions alone can mitigate marginalization and alienation among citizens.” Despite its cross-sectoral aspirations, and the principle that each goal reinforces the others, governments report on their SDG progress within the framework of each goal. This means that lessons learned about peacebuilding through health risk being lost. For example, efforts by health workers to provide non-partisan care to parties in conflict, and bring them together through mutual health needs, is a crucial form of “soft peacebuilding” which falls outside the institutional SDG peace agenda. The mutually reinforcing work of health and peacebuilding, including the contribution of health workers towards SDG16 and the overall SDG agenda, needs to be given much more emphasis.

CONFLICT AND HEALTH IN THE ERA OF CORONAVIRUS  |  301 Box C6.1: The Treaty on the Prohibition of Nuclear Weapons Following several years of international humanitarian dialogue, the UN negotiated the Treaty on the Prohibition of Nuclear Weapons (TPNW) in 2017. Supported by more than 130 countries, it entered into force on January 22, 2021, making nuclear weapons illegal under international humanitarian law. Signatory countries are prohibited from producing or using nuclear weapons, or assisting in any related activities (financing, research, etc.), and have positive duties towards victims and the environment. Although non-signatories are not bound by the Treaty, they are still affected by it. For example, a growing number of international financial institutions are choosing to divest from nuclear weapons (Don’t Bank on the Bomb 2019) as these become increasingly stigmatized. The treaty complements and strengthens the SDG agenda. Any use of nuclear weapons, deliberate or accidental, would have catastrophic consequences. Even a “limited” nuclear war would cause massive fires, dramatically changed weather patterns, and widespread crop failure (Toon et al. 2019). The resulting famine would affect more than 2 billion people, causing mass displacement on an unprecedented scale. SDGs relating to food security, water and sanitation, and climate change would be immediately and enduringly reversed. Nuclear war is a fundamental threat to health and well-being. Innumerable deaths and injuries, and extensive destruction of public services, would follow a nuclear attack – so much so that the International Committee of the Red Cross (2013) has warned there would be no viable humanitarian response. This Treaty is the first of its kind to explicitly recognize that women and girls are disproportionately affected by nuclear attacks, both in terms of direct health consequences and stigma about reproductive choices. SDGs relating to gender equality and reducing inequality are thus interwoven in the treaty. The hope of a world without nuclear weapons must be tempered with recognition of the challenges that remain. Growing militarization among nuclear-armed states – most recently, the UK government’s decision to increase its nuclear stockpile, in clear contravention of its international obligations – contribute to increasing international tensions. Massive, ongoing investment in nuclear weapons represents a failure to prioritize spending appropriately, especially so at a time when urgent investment in health, social care, and climate action is needed more than ever. Yet despite huge uncertainty about increasing risk of nuclear war and global pandemics, the implementation of the TPNW has real transformative potential and offers hope for a better future.

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Peace and health “from below”

1. The promise of peace and health from below Even while ostensibly supporting the SDGs, many powerful states undermine its global peace agenda by licensing arms sales to parties in conflict. The UK, Canada, and Sweden continue to arm Saudi Arabia, contributing to the crisis in Yemen discussed later in this chapter. The UN Secretary-General’s March 2020 appeal for a global ceasefire in the wake of the COVID-19 pandemic appears somewhat naïve in the geopolitical context of declining multilateralism and falling support for the UN (see Chapter D3), whose peacekeeping interventions are increasingly seen as a form of neo-imperialism (Dorussen 2020). Moreover, since the “motivations and interests” at the root of most conflicts are contextspecific and linked to local issues and grievances, ceasefires tend only to work if implemented locally, ideally “build[ing] on pre-existing structures” born of “inclusive negotiations” involving those “most affected by the conflict” – who are best placed to understand relevant dynamics – and “driven by political will, from the ground up” (Chetcuti et al. 2020). This demonstrates the disconnect between high-level calls for action and the realities of regional and community-level work. However, there is a contemporary turn towards the “local” in peacebuilding in response to growing debate about the need to move beyond state-centric models (Minde 2018), owing a huge debt to feminist peacebuilding work (Basu, Kirby, and Shepherd 2020). This shift is “a clear rejection of the interventionist approach” to peace-making and of top-down models which “rely exclusively on the knowhow of the elite both local and international” and which “[reduce] the rest of the population into passive recipients of peace conceived elsewhere” (Kasonga Mbombo 2018). Decentralization, local capacity, and agency are becoming key components of peacebuilding efficacy, with growing recognition that the involvement of civil society actors, including women’s organizations, correlates with more durable peace settlements (Nilsson 2012). The trust and legitimacy enjoyed by community health workers may be particularly important in enabling health to serve as peacebuilding efforts in contexts where trust in the state is low. It is noteworthy that women make up the majority of frontline health workers and have overwhelmingly fronted grassroots “mutual aid” responses to COVID-19, arguably another form of “soft peacebuilding” at the nexus of health and peace. In contexts where the state is failing to provide for people’s basic needs, these community-led efforts by health workers and others – such as volunteers in India refilling oxygen cylinders – plug gaps in fragmented public service provision. 2. Criticisms of initiatives from below: linking top-down and bottom-up approaches Peacebuilding is a notoriously complex and fluid field. Predictably, the turn towards the local and peace initiatives “from below” has given rise to criticisms and counterpoints. Rather than dismissing the worth of local initiatives altogether, critics ask whether such a re-focusing of peace work can offer general and

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universally applicable solutions for peacebuilding efforts. Particular concerns are that (1) prioritizing local agency above all can lead to the reinforcement of exclusionary local practices, particularly on the basis of gender (BarguésPedreny and Mathieu 2018), (2) there is no such thing as a “pure” local context which exists independently of outside influences (Simons and Zanker 2014), (3) locally focused initiatives may remain artificially insular and detached from wider peacebuilding efforts (Piccolino 2019), and (4) local initiatives fail to address the structural determinants of war and conflict, such as the political economy of the arms trade (see Box C6.3 below). Building links between health and peacebuilding initiatives at local levels with national- and international-level peace work can thus be considered a promising way forward. Acknowledging the importance of local contributions does not necessitate a dismissal of “external involvement, resources, and support, nor does it presume that local traditions are not in need of refinement” (Funk 2012, 401). Within the SDGs’ peacebuilding agenda, core considerations such as gender equality (SDG5), the need for universal healthcare access (SDG3), and inclusivity and non-discrimination in all peacebuilding efforts (SDG16) can provide important cornerstones of a framework for essential community-level peace work carried out by health professionals. Conflict and coronavirus

The indivisibility of peace and health has been illustrated starkly by the impact of COVID-19 in countries affected by conflict. Such states, where “long periods of fighting [have led] to the destruction of infrastructure, health systems and trust in government and state institutions,” comprise the bulk of those most vulnerable to the pandemic (Clugston and Spearing 2020). From Afghanistan to South Sudan, coronavirus is worsening pre-existing dynamics and jeopardizing fragile peace processes, while pandemic responses are hampered by “fragmented authority, political violence, low state capacity, high levels of civilian displacement, and low citizen trust in leadership” (Brown and Blanc 2020). International responses to the conflicts themselves are frequently absent, ineffective, or contradictory.

1. Yemen The World Health Organization has called the situation in Yemen a “perfect storm.” Even before the intensification of long-standing low-level conflict in the country in 2015, Yemen was one of the poorest countries in the Middle East, ranking 147th in life expectancy, with half of the population (two-thirds in rural areas) lacking access to healthcare services (United Nations Development Programme 2019). The civil war involves a complex array of actors – with Saudi Arabian air strikes in support of the government, Iranian backing for the Houthis, and the Southern Transitional Council backed by the United Arab Emirates – as well

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as a range of underlying, unaddressed grievances going back many years. The impact of the war has been devastating, leading the United Nations Development Program to label it “among the most destructive conflicts since the end of the Cold War” and “one of the greatest preventable disasters facing humanity” (United Nations Development Programme 2019). As well as direct casualties resulting from armed conflict, indirect mortality from diseases and famine has been vast, with the UN estimating indirect casualties totaling 233,000 in December 2020. The war and siege have damaged every sector, from agriculture, irrigation, and food production, to healthcare, water infrastructure, sanitation, and social services. Airstrikes have destroyed and damaged at least 278 health facilities, leaving less than half functioning; and those are struggling with shortages of workers, essential medicines and supplies, safe water, and power. With water weaponized, food imports still not recovered from a 2017 blockade, and aid underfunded, politicized, and often impeded (Chetcuti et al. 2020), the humanitarian consequences have been catastrophic. Poor sanitation has contributed to the “largest [cholera] outbreak in epidemiologically recorded history” (United Nations Development Programme 2019, 12), with more than 1.3 million suspected cases. Food insecurity has left parts of Yemen on the brink of famine, with malnutrition a contributing factor in 45% of deaths amongst children under the age of five (El Bcheraoui et al. 2018). Children have suffered disproportionately due to food insecurity, and the impact of the conflict has also been gendered. Over two million Yemenis have been internally displaced and most of the displaced are women (United Nations Development Programme 2019). The challenges posed to reproductive, maternal, and newborn health are “formidable” (Tappis et al. 2020), with maternal mortality increasing to a national average of 213 deaths per 100,000 live births in 2016 (El Bcheraoui et al. 2018). Conflict is consistently associated with higher rates of sexual and gender-based violence and Yemen has been no exception, with additional COVID-19 lockdown measures apparently driving rates even higher (Searle, Spearing, and Yeyha 2020). In sum, COVID-19 inevitably compounded Yemen’s already deep crisis. While calls for a ceasefire were initially welcomed, the Saudi-led coalition’s announcement of a two-week ceasefire in spring 2020 was not sustained. The true extent of the pandemic remains unclear. But as the ongoing cholera epidemic shows, infectious diseases spread easily in Yemen. Most people, especially those in camps, live in overcrowded conditions, making physical distancing impossible, whilst poor access to water makes handwashing and hygiene difficult, and illiteracy restricts access to information about effective infection control. Women have again been hardest hit, being overwhelmingly expected to care for the sick (Clugston and Spearing 2020) and facing heightened barriers to sexual and reproductive health services as resources are redirected and movement restrictions tightened. The Women, Peace, and Security agenda, expressed in UN Security Council Resolution 1325, is intended to tackle the exclusion of women from peacebuilding

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and humanitarian efforts. Grassroots actors like the Yemeni Women’s Union (YWU) are already at the forefront of this work, providing lifesaving support to the Yemeni population. Their work on the ground also allows YWU members to monitor emerging trends in violence against women (Searle, Spearing, and Yeyha 2020). Local actors like these are becoming even more important as international organizations withdraw from Yemen in the wake of COVID-19. We are seeing international donors increasingly turn inwards and direct resources towards domestic efforts to tackle COVID-19, affecting funding for grassroots women’s organizations for peace and health. This threatens hopes for peace, will have a long-term impact on health and development, and may also make COVID-19 eradication difficult given that – even with vaccines – infectious diseases are hardest to eradicate in conflict zones. The international community has not only failed to mediate the conflict, but some parties have actively contributed to prolonging it, particularly by licensing arms sales to Saudi Arabia. The hypocrisy of offering humanitarian assistance and calling for a ceasefire, whilst profiting from commercial trading of arms in a context marked by grave violations of international law, runs counter to the holistic logic of the SDGs, which recognizes that health is impossible without peace. The deleterious consequences for both peace and health cannot be overstated.

2. Syria The past ten years have been marked by unrelenting war in Syria. The conflict is complex, with multiple warring parties including government forces, government-backed militias, and various opposition forces. External actors are also heavily involved: it is thought that countries including Turkey, Israel, Iran, the United States, and Russia are waging their own discrete but interlocking conflicts in and through Syria (Yacoubian 2020). Additional countries are invested in the war through arms sales to various parties. A decade of violence has taken a vast toll on the lives of the Syrian people. In a country of 17 million people, over 5.5 million Syrians are registered as refugees; 6.2 million are displaced; and 6.5 million are facing critical levels of food insecurity (ReliefWeb 2020). The UN Commission of Inquiry on Syria (2020) found “continuing violations and abuses by nearly every conflict actor controlling territory in Syria [including] an increase in patterns of targeted abuse, such as assassinations, sexual and gender-based violence against women and girls, and looting or appropriation of private property.” The ongoing war has undermined much of Syria’s previous social and economic development, making it harder to recover from the conflict and to deal with other shocks, such as COVID-19. The Syrian population has lost many of the basic building blocks needed to live healthy, peaceful lives: amongst them a secure food supply, reliable sanitation and waste infrastructure, and access to housing (Commission of Inquiry on Syria 2020).

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To the warring parties, lack of civilian access to healthcare is little more than collateral damage (Commission of Inquiry on Syria 2020). Worse yet, health services have often been purposefully targeted with violence. Repeated attacks on at least 350 healthcare facilities have been documented, leaving less than half functioning (Syria Public Health Network 2020). Despite the impact of COVID-19, attacks on healthcare provision have continued into 2020 (World Health Organization 2020). The conflict itself is waged in ways which are exceptionally and directly damaging to human health. Multiple chemical weapons attacks have taken place (Arms Control Association 2020). The UN Commission of Inquiry (2020) “has reasonable grounds to believe that the Government of Syria … has continued to perpetrate the crimes against humanity of enforced disappearance, murder, torture, sexual violence and imprisonment.” International organizations report “rape as a ‘prominent and disturbing feature’ in the Syrian war” (Women’s International League 2016). An effective public health response to COVID-19 is all but impossible in conflict settings. The conflict in Syria has seen the fragmentation and politicization of the health system, with at least four discrete systems operating in different parts of Syria (Syria Public Health Network 2020). Each one put in place different response plans at the start of the pandemic, further stretching already limited resources. Emergency responses are also blurring the line between “peace” and suppression: on one hand, “the regime of Bashar al-Assad … is working with some of its international backers to push for ‘normalisation’” and the lifting of sanctions (Yahya 2020), while “U.S. foreign policy during the pandemic appears, if anything, more committed to severe sanctions implementation and variants of its ‘maximum pressure’ efforts against particular regimes” (Brown and Blanc 2020). Despite the conflict, there are grassroots women’s organizations which continue providing Syrian women with “much-needed services, and carrying their voices to the international fora” (Women’s International League 2016). These organizations, and others like them, represent hope for a just and lasting peace through community-led activism and voluntary service dedicated to relieving human suffering. But even before the pandemic, these organizations “face[d] devastating threats and challenges every day,” with activists being “subjected to various forms of abuse, including arbitrary arrests, abduction and torture” (Women’s International League 2016). Repression and arbitrary detention of activists continue to be a feature of the Syrian conflict (Commission of Inquiry on Syria 2020), with little or no improvement in the prospect of building an enduring peace beyond the pandemic.

3. Weaponizing the coronavirus Many of the world’s governments have used the pandemic as an excuse to weaken human rights, advance authoritarian goals, and undermine the integrity

CONFLICT AND HEALTH IN THE ERA OF CORONAVIRUS  |  307 Box C6.2: Islamophobia and genocide The twenty-first century has seen genocidal campaigns directed against Muslim minority populations across the globe. These demonstrate a vast disparity between the peace- and health-building aspirations of the SDGs and the actions of states. In Myanmar, the predominantly Muslim Rohingya people have been subjected to a “textbook example of ethnic cleansing,” with “progressive intensification of discrimination over the past 55 years” (UN Human Rights Council 2017). Denied citizenship since 1982, the Rohingya have fled waves of persecution since the 1990s, with the largest wave of forced migration happening in August 2017. The military-led campaign resulted in an estimated 11,400 deaths in just one month (Médecins Sans Frontières 2018), and the partial or total destruction of hundreds of villages. More than 700,000 Rohingya fled for their lives to Bangladesh that year (High Commissioner for Refugees n.d.). A military coup in Myanmar in February 2021, and a massive fire that broke out in March 2021 in Kutupalong refugee camp in Bangladesh, destroying thousands of shelters and vital services, mean that the Rohingya community’s plight is likely to worsen. Those remaining in Myanmar face increased risk of persecution because of the newly installed military regime, while those in refugee camps in Bangladesh are at greater risk of poor health, including COVID-19 infection, due to their poor living conditions. In China, the government has conducted an intensifying campaign of mass internment, intrusive surveillance, political indoctrination and forced cultural assimilation of the Uyghur Muslim population since 2017. The government is believed to have built hundreds of internment camps, where an estimated one million Uyghur Muslims are being detained without trial or charge (Human Rights Watch 2021a). Uyghurs inside and outside the camps face severe travel restrictions and confiscation of passports, and those abroad are tracked and threatened for speaking out about the oppression in Xinjiang (Amnesty International n.d.). The abuses which the Uyghur Muslim population continues to suffer at the hands of the Chinese government have led activists and scholars to describe this, the “largest mass internment of an ethnic-religious minority since World War II” (Alecci 2019), as a genocide. In India, the far-right Bharatiya Janata Party (BJP) government passed the controversial Citizenship Amendment Act (CAA) and introduced the National Register of Citizens (NRC) in Assam, both widely considered to deliberately target Muslims (International Commission of Jurists 2020). The CAA refuses asylum to Muslims from Afghanistan, Pakistan, and Bangladesh whilst affording protection to other religious groups, and the NRC is

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suspected to be a mechanism to allow the identification and expulsion of Muslims from India. The BJP government also abrogated article 370 of the Indian constitution in 2019, revoking the constitutional autonomy of the Kashmir region, a disputed territory with a Muslim majority population. Tens of thousands of extra troops were deployed in the region, with about 4,000 people reported to have been detained (Ghoshal and Pal 2019) and reports of beatings, torture, pellet gun injuries, and deaths of Kashmiri civilians at the hands of the Indian military (Hashmi 2019). The global response to these atrocities has been overwhelmingly disappointing. These crimes against humanity demand the immediate attention of the global community to alleviate the suffering of targeted populations, whatever the political or economic cost.

of democratic institutions. Freedom House (2020) reports that democracy has weakened in 80 of the 192 countries it examined, while Viva Salud (2020) found that state actions to control COVID-19 have jeopardized human rights and compromised the work of social movements. In the USA, voting rights were compromised by confusing and contradictory measures during the state-by-state primary elections in spring and summer 2020 (Freedom House 2020). Measures to reduce crowding at polling stations during the November 2020 presidential election, such as early voting and postal voting, were exploited by the losing candidate to question the legitimacy of the result (Van Voris et al. 2020). The virus was also used in the USA to justify increasingly restrictive immigration and asylum policies. Delays and restrictions on formal processes worsened insecurity among already vulnerable populations (Loweree, Reichlin-Melnick, and Ewing 2020). Continued confinement of asylum seekers in overcrowded detention centers heightened their risk of exposure to COVID-19, while the ongoing operation of deportation flights meant that thousands of people were deported to countries with less resilient health infrastructure, with many testing positive for COVID-19 on arrival (Gonzalez 2020). COVID-19 has been “weaponized” to further increase authoritarian states’ control of public life. In Turkey, antiterrorism laws have been used to intimidate or arrest individuals who criticize the government’s handling of the pandemic, furthering its hostile stance towards social media (Amnesty International 2020). Freedom of expression has been curtailed in several other countries, through censorship measures as well as arbitrary arrests and detentions, under the pretext of curbing the spread of misinformation (Office of the High Commissioner for Human Rights 2020). The security of minority or vulnerable populations has also become more precarious during the pandemic. Sri Lanka used a militarized approach to

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Image C6.1  “Militarization of quarantine/lockdown.” Source: Sketch by Arun for Global Health Watch 6.

control the virus, resulting in large numbers of arrests, an intensified military presence at checkpoints, and contact tracing run by intelligence agencies (Human Rights Watch 2020a). Across the Americas and Europe, incidents of racial discrimination, harassment, threats, and physical violence against people of Asian descent have increased (Human Rights Watch 2020b), sometimes stoked by government officials and politicians blaming Asian immigrants for the spread of the virus. The global pandemic also distracted international attention from repressive measures enacted by a number of states against populations under their control, such as the decision by China to disqualify four pro-democracy legislators from Hong Kong’s Legislative Council, advancing Beijing’s ambition to gain full control of the territory (Human Rights Watch 2020c). In the Middle East, Israel has used COVID-19 as the pretext to tighten its control over and increase violence against Palestinians (Human Rights Watch 2021b). In addition, despite a world-leading vaccination campaign, only in March 2021 did Israel start offering vaccination to Palestinians who work in Israeli controlled lands or illegal Israeli settlements in the West Bank (see Chapter B4). The statement issued by the UN High Commissioner for Human Rights, emphasizing Israel’s responsibility to provide equal access to COVID-19 vaccine in the West Bank and Gaza, did not result in the international community enforcing binding obligations on Israel to comply (Office of the High Commissioner for Human

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Image C6.2  “Vaccine apartheid.” Source: Sketch by Arun for Global Health Watch 6.

Rights 2021). Although broadly ignored, these geopolitical shifts could foment future instability and international conflict. But the use and abuse of measures to control COVID-19 has not been without grassroots resistance. Some have attempted to enhance social solidarity and support in the face of restrictions on normal life. For example, mutual aid networks have developed in which neighbors organize to help each other cope with the economic, social, and psychological impacts of the pandemic and associated public health restrictions, regardless of immigration status or other markers of difference (Mutual Aid Hub 2020). Despite increased repression and arrests, pro-democracy activities in Hong Kong continue (Pomfret and Pang 2020). In Sri Lanka, the militarized response to COVID-19 has been met with peaceful resistance and community solidarity. However, acts of resistance have not been wholly benign. For example, anti-lockdown protests have taken place worldwide. These protests sought to assert the liberty of participants in the face of repressive government measures. Such protests have been widely viewed as dangerous and irresponsible. This polarization has been compounded by the conflation of anti-lockdown campaigns with conspiracy theories and “anti-vaxxers.” It is therefore important to assess the exact nature of acts of resistance against the rise in government control in the context of COVID-19. Restrictions must also be understood in the whole

CONFLICT AND HEALTH IN THE ERA OF CORONAVIRUS  |  311 Box C6.3: Spending comparison: pandemic preparedness versus preparation for war Military conflicts and uncontrolled pandemics both result in massive loss of life and long-term casualties, together with vast social and economic disruption and costs. It is instructive to compare global spending on the military with the amount invested in pandemic preparedness around the world. Stockholm International Peace Research Institute (2021) estimates that global military expenditure reached USD $1,960 billion in 2020, with the US alone responsible for nearly 40% of that spending. By contrast, in 2019 – the year COVID-19 emerged – countries allocated just $0.374 billion in development assistance for pandemic preparedness (Stutzman, Micah, and Dieleman 2020). The amount allocated to warfare was over 5,000 times greater than this investment in protecting global health. Investing in disaster resilience and pandemic preparedness is crucial to help alleviate poverty, as infectious diseases tend to disproportionately affect the poor (Global Preparedness Monitoring Board 2020). The Commission on Global Health Risk Framework for the Future (2016) estimated that an investment of $4.5 billion per year (just 0.2% of global military spending each year) would make a significant impact on global health security by

Image C6.3  “Funding on arms trade and health.” Source: Sketch by Arun for Global Health Watch 6.

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strengthening national public health systems, funding research and development, and financing global coordination and contingency efforts. Failure to invest in prevention has led to countries facing substantial costs resulting from COVID-19. The global response is estimated to have costed around $11,000 billion so far – meaning that, at current rates of spending, it would take 500 years to spend as much on pandemic preparedness as the world has lost in just 12 months due to COVID-19 (Global Preparedness Monitoring Board 2020). Global investment in militarism and the arms trade is several orders of magnitude greater than global investment in health systems and pandemic preparedness, despite the overwhelming human and economic cost of COVID-19. The impact of the pandemic demands a complete reprioritization of national and international expenditure, with a focus on the foundations of health and peace.

socio-political context in which they occur, recognizing the conflictual consequences of such acts on global peace and security. Conclusion

The work of building health and peace cannot be imposed exclusively through top-down initiatives, nor achieved solely through action “from below.” A complementary relationship is essential: one in which local actors can lead, informed by their rich understanding of local context and dynamics but integrated within a broader strategy, incorporating international perspectives and institutional support where these can strengthen the response. The cases of Yemen and Syria exemplify how far top-down agendas can fall short in practice, showing the devastating impact on peace and health when international actors pay lip service to ceasefires while selling arms for war, despite the best efforts of grassroots peace activists. In conflict zones around the world, COVID-19 has exacerbated pre-existing dynamics and worsened health outcomes, while further eroding the foundations of potential peace. The pandemic has plunged the entire world into a health crisis. It has necessitated the top-down imposition of social distancing restrictions but also served as a pretext for repression far beyond measures warranted by public health. While women remain under-represented in the highest echelons of power, they disproportionately carry out the frontline health and care work that the pandemic has required. As state governments increasingly turn inwards to confront domestic COVID-19 outbreaks, it is local, grassroots initiatives, frequently driven by women’s labor, that will play a vital role in sustaining efforts for health through peace amidst the pandemic chaos.

CONFLICT AND HEALTH IN THE ERA OF CORONAVIRUS  |  313 Note 1  A term commonly used to describe policies and activities that aim to build conditions for peace and social coherence. Such policies and

activities focus on sustainable economic and social development to address roots of conflicts rather than their triggers.

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314   |  Global Health Watch 6 Crackdown, Official Data Reveals.” Reuters. September 12. https://www.reuters.com/ article/us-india-kashmir-detentions/ thousands-detained-in-indian-kashmircrackdown-official-data-revealsidUSKCN1VX142. Gonzalez, Daniel. 2020. “‘They were sending the virus’: Guatemala Reels after U.S. Deports Hundreds of Deportees with COVID-19.” AZcentral. https://eu.azcentral.com/story/ news/politics/immigration/2020/10/28/ hundreds-deported-by-us-to-guatemaladuring-pandemic-had-covid-19/5902239002/. Global Preparedness Monitoring Board. 2020. A World in Disorder: Global Preparedness Monitoring Board Annual Report 2020. Geneva: World Health Organisation. Hashmi, Sameer. 2019. “‘Don’t Beat Us, Just Shoot Us’: Kashmiris Allege Violent Army Crackdown.” BBC. August 29. https://www. bbc.co.uk/news/world-asia-india-49481180 Human Rights Watch. 2020a. “Sri Lanka: Increasing Suppression of Dissent.” August 8. https://www.hrw.org/news/2020/08/08/ sri-lanka-increasing-suppression-dissent. Human Rights Watch. 2020b. “Human Rights Dimensions of COVID-19 Response.” March 19. https://www.hrw.org/news/2020/03/19/ human-rights-dimensions-covid-19-response. Human Rights Watch. 2020c. “China: Beijing Forces Out Hong Kong Opposition Lawmakers.” November 12. https://www.hrw. org/news/2020/11/12/china-beijing-forcesout-hong-kong-opposition-lawmakers. Human Rights Watch. 2021a. “Break Their Lineage, Break Their Roots: China’s Crimes Against Humanity Targeting Uyghurs and Other Turkic Muslims.” April 19. https:// www.hrw.org/report/2021/04/19/break-theirlineage-break-their-roots/chinas-crimesagainst-humanity-targeting. Human Rights Watch. 2021b. “Israel and Palestine: Events of 2020.” https://www.hrw. org/world-report/2021/country-chapters/ israel/palestine. International Commission of Jurists. 2020. “India: Citizenship Amendment Act Violates International Law.” March 10. https://www. icj.org/hrc43indiacaa/. International Committee of the Red Cross. 2013. “No Way to Deliver Assistance in the Event of a Nuclear Explosion.” https://www.

icrc.org/en/doc/resources/documents/ interview/2013/03-04-nuclear-weaponshumanitarian-assistance.htm. Kasonga, Mbombo, Jean-Marie. 2018. “Making a Case for Human Peace Model from Below.” Ibadan Journal of Peace and Development 8(1): 65–77. Loweree, Jorge, Aaron Reichlin-Melnick, and Walter Ewing. 2020. “The Impact of COVID-19 on Noncitizens and Across the U.S. Immigration System.” American Immigration Council. September 30. https:// www.americanimmigrationcouncil.org/ research/impact-covid-19-us-immigrationsystem. Minde, Nicodemus. 2018. “The Fabric of Peace in Africa: Looking beyond the State.” Journal of Contemporary African Studies 36: 416–418. Médecins Sans Frontières. 2018. “Rohingya Crisis in Bangladesh: A Summary of Findings from Six Pooled Surveys.” https://web. archive.org/web/20180131213206/https:// www.doctorswithoutborders.org/sites/usa/ files/summary_of_findings_-_msf_mortality_ surveys_-_coxs_bazar.pdf. Mutual Aid Hub. 2020. “Find a Network near You.” https://www.mutualaidhub.org/. Nilsson, Desiree. 2012. “Anchoring the Peace: Civil Society Actors in Peace Accords and Durable Peace.” International Interactions 38 (2): 243–266. Office of the High Commissioner for Human Rights. 2020. “Asia: Bachelet Alarmed by Clampdown on Freedom of Expression during COVID-19.” June 3. https://www. ohchr.org/EN/NewsEvents/Pages/ DisplayNews.aspx?NewsID=25920&LangID=E. Office of the High Commissioner for Human Rights. 2021. “Israel/OPT: UN Experts Call on Israel to Ensure Equal Access to COVID-19 Vaccines for Palestinians.” January 14. https://www.ohchr.org/EN/NewsEvents/ Pages/DisplayNews.aspx?NewsID=26655. Piccolino, Giulia. 2019. “Local Peacebuilding in a Victor’s Peace. Why Local Peace Fails without National Reconciliation.” International Peacekeeping 26 (3): 354–379. Pomfret, James, and Jessie Pang. 2020. “Democracy Darkens.” Reuters. November 30. https://www.reuters.com/investigates/ special-report/hongkong-democracyactivists.

CONFLICT AND HEALTH IN THE ERA OF CORONAVIRUS  |  315 ReliefWeb. 2020. “Syrian Arab Republic – Humanitarian Situation.” https://reliefweb. int/country/syr?figures=all#key-figures. Searle, Laura M., Michelle Spearing, and Noha Yeyha. 2020. “Women Leaders COVID-19 Response from the Grassroots to Government: Perspectives from Yemen.” London School of Economics. June 2. https://blogs.lse.ac.uk/wps/2020/06/02/ women-leaders-covid-19-response-fromthe-grassroots-to-government-perspectivesfrom-yemen/. Simons, Claudia, and Franzisca Zanker. 2014. “Questioning the Local in Peacebuilding.” Working Paper Series No. 10. Leipzig and Halle: German Research Foundation. Stockholm International Peace Research Institute. 2021. “SIPRI Military Expenditure Database.” https://www.sipri.org/databases/ milex. Syria Public Health Network. 2020. “Policy Report: COVID-19 Situation in Syria and Possible Policy Responses.” http:// syriahealthnetwork.org/attachments/ article/36/PolicyBrief-%20COVID19Syria_29.4.2020_FINAL.pdf. Stutzman, Hayley, Angela E. Micah, and Joseph L. Dieleman. 2020. “Funding Pandemic Preparedness: A Global Public Good. https:// www.thinkglobalhealth.org/article/fundingpandemic-preparedness-global-public-good. Tappis, Hannah, Sarah Elaraby, Shatha Elnakib, Nagiba A.A. AlShawafi, Huda BaSaleem, Iman A.S. Al-Gawfi, Fouad Othman, Fouzia Shafique, Eman Al-Kubati, Nuzhat Rafique, and Paul Spiegel. 2020. “Reproductive, Maternal, Newborn and Child Health Service Delivery during Conflict in Yemen: A Case Study.” Conflict and Health 14: 30. doi: 10.1186/s13031-020-00269-x. Toon, Owen B., Charles G. Bardeen, Alan Robock, Lili Xia, Hans Kristensen, Matthew Mckinzie, R.J. Peterson, Cheryl S. Harrison, Nicole Lovenduski, and Richard Turco. 2019. “Rapidly Expanding Nuclear Arsenals in Pakistan and India Portend Regional and Global Catastrophe.” Science Advances 5: 10. UN Commission of Inquiry on Syria. 2020. “UN Commission of Inquiry on Syria: No Clean Hands – Behind the Frontlines and the Headlines, Armed Actors Continue to Subject Civilians to Horrific and Increasingly Targeted Abuse.” https://www.ohchr.org/

EN/HRBodies/HRC/Pages/NewsDetail. aspx?NewsID=26237&LangID=E. United Nations Development Programme. 2019. “Assessing the Impact of War on Development of Yemen.” April 22. https:// www.ye.undp.org/content/yemen/en/home/ library/assesing-the-impact-of–war-ondevelopment-in-yemen.html. UN High Commissioner for Refugees. n.d. “Rohingya Refugee Crisis.” US for UNCHR. Accessed June 2, 2021. https://www. unrefugees.org/emergencies/rohingya. UN Human Rights Council. 2017. “Human Rights Council Opens Special Session on the Situation of Human Rights of the Rohingya and Other Minorities in Rakhine State in Myanmar.” Office of the High Commissioner. December 5. https://www.ohchr.org/ en/NewsEvents/Pages/DisplayNews. aspx?NewsID=22491&LangID=E. United Nations. 2020. “Goal 16: Promote Just, Peaceful and Inclusive Societies.” https:// www.un.org/sustainabledevelopment/peacejustice/. Van Voris, Bob, Mark Niquette, and Patricia Hurtado. 2020. “Trump’s Challenge to the 2020 Vote: A State-by-State Guide.” Bloomberg. November 10. https://www. bloomberg.com/news/articles/2020-11-10/ trump-s-challenge-to-the-2020-vote-a-stateby-state-guide. Viva Salud. 2020. “Campaign Paper: All Heroes for Health.” September 17. https://www. vivasalud.be/en/all-heroes-for-health/. Whaites, Alan. 2016. “Achieving the Impossible: Can We be SDG16 Believers?” GovNet Background Paper No. 2. Organization for Economic Cooperation and Development. World Health Organization. 2020. “Attacks on Healthcare in Syria: 1 Jan–31 Oct 2020.” https://reliefweb.int/sites/reliefweb.int/ files/resources/wos_attacks_on_health_care_ october_2020_v1_final.pdf. Women’s International League for Peace & Freedom. 2016. “Violations Against Women in Syria and the Disproportionate Impact of the Conflict on Them: NGO Summary Report – Universal Periodic Review of the Syrian Arab Republic – November 2016.” https:// www.wilpf.org/wp-content/uploads/2016/06/ WILPF_VAW_HC-2016_WEB-ONEPAGE.pdf. Women’s International League for Peace and Freedom. 2020. “A WILPF Guide to

316   |  Global Health Watch 6 Leveraging the SDGs for Feminist Peace.” https://www.wilpf.org/wp-content/ uploads/2020/07/WILPF_WPS-SDGsGuide_Web.pdf. World Bank Group. 2019. “Pandemic Preparedness Financing Status Update.” https://apps.who.int/gpmb/assets/thematic_ papers/tr-4.pdf.

Yacoubian, Mona. 2020. “After Nine Years, Syria’s Conflict Has Only Become More Complicated.” United States Institute of Peace. https://www.usip.org/ publications/2020/03/after-nine-years-syriasconflict-has-only-become-more-complicated. Yahya, Maha. 2020. “Syria and Coronavirus.” https://carnegieendowment.org/2020/04/14/ syria-and-coronavirus-pub-81547.

D1  |  WHO AND THE POLITICS OF PANDEMICS

Introduction

The global management of the COVID-19 pandemic has been torn by self-interest and resentment but has also showcased inspiring leadership and solidarity. The search for new technologies has blended “warp speed” science with a grasping refusal by Pharma and high-income countries (HICs) to share. While wealth and power have not guaranteed an effective national response, the vulnerabilities associated with poverty and marginalization have been all too predictable. Many of the experiences of the COVID-19 pandemic point to deep flaws in the prevailing institutions of global health governance in relation to emergency preparedness. However, the pandemic also provides an opportunity to examine the forces, structures, and dynamics at the root of such flaws. This chapter explores these underlying factors with a focus on the political economy of prevention, preparedness, and response. In so doing, it locates the project of creating more effective management of such crises in the broader context of neoliberal globalization and the converging struggles of people’s movements around the globe for an equitable and environmentally sustainable future. The global COVID-19 experience

The early international response to the pandemic was shaped by the response in China. The speed with which the Wuhan outbreak was controlled was impressive although it involved a huge cost in terms of the burden on hospitals and healthcare workers and a very tight lockdown. Even as the epidemic in China was controlled, case numbers in the rest of the world started to rise from mid-March before declining, then again rising as second and later third waves occurred in differing parts of the world. As with many diseases (communicable or otherwise), COVID-19 mortality has been unevenly distributed in many countries. Healthcare workers have carried a disproportionate burden: around 7.2 million healthcare workers had been infected as of April 2021 with perhaps 70,000 deaths (WHO 2021a). Shortages of personal protective equipment (PPE), testing resources, ventilators, and oxygen were universal early in the pandemic and accounted for many of the health worker casualties. They remain a challenge for poorer countries. During the April 2021 second wave surge in India a lack of medical oxygen in most cities contributed to many avoidable deaths. There have been wide variations in countries’ performance in managing the pandemic. Vietnam and Taiwan stand out for their success in preventing the

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spread of the coronavirus. China and New Zealand stand out for their success in controlling outbreaks. By contrast, the USA, the UK and other European countries, Brazil, and India stand out for their failures to control the pandemic. Ironically, the USA and UK were identified as the best prepared countries in the 2019 Global Health Security Index (Global Health Security Index 2019) but were among the worst hit; politics appeared to trump public health. The World Health Organization’s COVID-19 response: the political tensions

The World Health Organization’s (WHO) response to the pandemic is framed by the International Health Regulations (IHRs), which trace their genealogy to the periodic international sanitary conferences which were held from 1851 onwards. One of the principal drivers of these meetings was the tensions around the use of quarantine and border control in the event of a cholera outbreak. Countries hosting a cholera outbreak were concerned not to have trade disrupted, while countries not yet affected might seek to gain commercial advantage by restricting trade in the name of protecting their population. The IHRs, adopted by WHO in 1969, created an agreed framework for managing the tensions between trade and disease control. Contradictions between trade and health, however, returned to the fore in 2003 in the context of the Severe Acute Respiratory Syndrome (SARS) outbreak when both China and Canada were accused of covering up the severity of the epidemic to protect tourism and trade. The SARS experience highlighted the dependence of the IHRs on prompt and full disclosure by countries experiencing an outbreak; but this was not always forthcoming. This led to a revision of IHRs in 2005, including a provision empowering the Director-General to draw on informal and media sources beyond the reports of the affected government. States party to the IHRs are obligated to put in place certain “core capacities” including surveillance, laboratory capacity, and border controls. However, many low- and middle-income countries (LMICs) have been slow to come up to the required standard. For countries facing heavy disease burdens associated with lack of clean water and sanitation, child malnutrition, and maternal mortality, the opportunity costs of investing in core capacities may be very high. The pressures on such countries to put in place the required core capacities have been significant including repeated deadlines, various forms of naming and shaming, increasing pressure of external assessments, and threats of International Monetary Fund (IMF) sanctions. Such pressures have been driven in large part by the rich countries, including a network of countries, corporations, and philanthropies coming together in multistakeholder partnerships such as the US-sponsored Global Health Security Agenda. The 2005 revised IHRs also replaced the previous requirements for countries to notify the WHO of specific disease outbreaks with a more generic category: a “public health emergency of international concern” (PHEIC), understood as any potential international threat to health.

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1. To PHEIC or not to PHEIC The IHRs authorize the WHO Director-General (DG) to convene a multinational emergency committee to advise the DG on whether to declare a PHEIC and, if declared, to issue advice to the DG, the states party to the IHRs, and to the global health community. The Emergency Committee for the COVID-19 outbreak met first on January 20, 2020 but was unable to agree on the need for a PHEIC (WHO 2020a; Director-General 2021). The difficulty in issuing one at that time was a delay in acknowledging person-to-person transmission. Although Chinese public health officials had clear evidence that person-to-person spread was occurring, its political leaders kept repeating that there was “no clear evidence of human-to-human transmission.” Political concerns about public panic in China may have shaped this official line although it also generated serious anger among China’s netizens (internet users) (Gonglei 2020), exposed the Chinese leadership to international criticism, and likely contributed to delays in countries outside China putting in place appropriate pandemic plans. The politicians were finally forced to acknowledge person-to-person transmission (Li et al. 2020), and the Emergency Committee reconvened on January 30 and declared a PHEIC (WHO 2020b). 2. Trade, travel, and the IHRs Another limitation in WHO’s early pandemic response derives from the historic tension between trade facilitation and public health containment. In the first month of the epidemic, WHO advised repeatedly against the application of any travel restrictions on China. Similar advice was issued over the succeeding months, although it became progressively more qualified. Notwithstanding WHO’s advice against travel restrictions, by July 10, 2020, 192 countries, territories, and areas had implemented “additional measures” (beyond those recommended under the IHRs) that significantly interfered with international traffic (WHO 2020c). Interrupting transmission through restrictions on people’s movement is a fundamental principle of disease control. Countries which controlled transmission effectively (including through travel restrictions) were able to open up their economies more quickly and have suffered less aggregate economic loss than those countries which experienced prolonged outbreaks (Nixon 2020). 3. To mask or not to mask Respiratory transmission of the SARS-CoV-2 virus is not in question but the role of droplet only versus droplet plus aerosol transmission was initially controversial. Droplet only theory focuses attention on symptomatic cases who are coughing and sneezing and suggests that relatively short spatial separation (1–2 m) will be protective, focusing on source control (masking and isolation of cases). Aerosol theory suggests that pre-symptomatic and asymptomatic people can be infectious, and that transmission can take place across longer distances.

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It therefore supports greater spatial distancing, universal masking in community settings, and closer attention to air flow and ventilation. WHO’s experts came to the view quite early that droplet transmission was the main route for community spread (WHO 2020d) and that accordingly a mask mandate in open settings was not necessary (WHO 2020e). Meanwhile, anecdotal evidence was accumulating suggesting aerosol transmission could contribute to spread in multiple closed environmental settings, as did evidence of the effectiveness of community masking in preventing community transmission (Duong 2020). WHO’s February 2020 advice that questioned the need for widespread use of masks appears to have been motivated by a concern to ensure the availability of masks (then in short supply) for frontline healthcare workers. However, this concern had the effect of locking WHO into a policy path (in which asymptomatic transmission is considered rare) that ran counter to emerging evidence.

4. Staff and funding shortfalls Following widespread criticism of WHO’s 2014 Ebola response, member states agreed in 2016 to establish a unified emergency capacity that would cut across its three institutional levels (country, region, and headquarters) and would be subject to the operational management of the director of the Health Emergency Program (WHE). Another 2016 innovation was the establishment of the Contingency Fund for Emergencies (CFE). This was designed as a floating fund of $100 million dollars to be drawn from as needed, to ensure rapid emergency response, topped up by WHO donors as necessary. Over the four years to 2020, the WHE gained field experience from contributing to many health emergencies in different parts of the world. The reluctance of donors to fully fund the WHE and the CFE, however, meant that at the outset of the COVID-19 response the WHE was several hundred staff short and the CFE was nowhere near its $100 million target. On April 14, 2020, in the midst of the pandemic, the US Trump administration announced its suspension of its assessed financial contributions to WHO ($900m in 2018–2019) pending a review of WHO’s response to the pandemic (Gearan 2020). The WHO’s apparent acceptance of China’s advice regarding the lack of evidence for human-to-human transmission was central to the US critique. On July 8, 2020 President Trump announced that the USA was proceeding with the withdrawal (Cohen et al. 2020). On the same day, Joseph Biden pledged that he would reverse the decision on day one if he won the presidential election (BBC 2020); he won, and he did (Ravelo 2021). Although the US withdrawal from WHO reflected two arms of Trump policy – first, the rejection of multilateralism and, second, the economic and strategic containment of China – it was not supported in Europe. Several European countries responded by increasing their funding to WHO, as did other member states (WHO 2020f; Fletcher 2020).

WHO AND THE POLITICS OF PANDEMICS  |  321 The Independent Panel and the “origins story”

In May 2020, the World Health Assembly (WHA) commissioned an independent review of the global health response to COVID-19 to make recommendations to improve capacities for the future (WHO 2020g). The Independent Panel for Pandemic Preparedness and Response (IPPPR) presented its final report to the WHA in May 2021 (IPPPR 2021a). The panel argued that the initial outbreak became a pandemic due to gaps and failings at every critical juncture of preparedness for, and response to, a global health emergency. It linked these to the structural weakness of the WHO, stating that “Member States had underpowered the agency to do the job demanded of it” (ibid.). The absence of coordinated global leadership and worsening international geopolitical tensions had undermined multilateral institutions and cooperative action, leading to a WHO response that was “too little, too late.” Amongst its recommendations: a call to create a Pandemic Framework Convention (a new pandemic treaty), discussed later in this chapter. In May 2020 the WHA also requested the DG to undertake studies “to identify the zoonotic source of the virus and the route of introduction to the human population, including the possible role of intermediate hosts” (WHO 2020h). The planned site visit to Wuhan did not proceed until January 2021 owing to visa delays and further negotiations about process. The joint international/ Chinese team concluded that the path from bats to humans mediated by a wild animal was the most likely “origins story” and that escape from a lab was very unlikely (Joint WHO–China Study Team 2021). From a public health point of view sorting out the route of emergence is vital, particularly sorting out the ecological connections. There is already a large body of evidence suggesting that human encroachment into natural ecosystems may be contributing to an increasing frequency of novel pandemics. The prevention and early detection of future pandemics depends on clarifying this pathway in detail (see Box D1.1: The ecology of zoonotic disease).

Box D1.1: The ecology of zoonotic disease The ecological dimension of emerging infectious diseases is widely acknowledged but the political economy of these ecological pathways is less widely recognized. The epicenter of the SARS epidemic in February 2003 was Guangdong. The virus appears to have evolved from horseshoe bats via civets (and/or other small mammals) sourced (farmed or captured from the wild) from Yunnan, Vietnam, and Laos, and then transported to the wet markets of Guandong. Human encroachment into wild places may be accelerating the transfer of the virus from bats to civets. Close proximity

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of civets and humans through the wildlife trade sets the conditions for the adaptation of the virus to humans. Highly pathogenic avian influenza (H5N1) also emerged in southern China. The first outbreak was in Hong Kong in 1997. The epidemic emerged in poultry but there were a handful of human cases and several deaths. After a massive cull of poultry, the epidemic was contained. Over the next several years the disease was confined to birds but emerged again in humans in Hong Kong in 2002. Over the next six years H5N1 infected 440 people, killing 262. Most of these infections were people living closely with poultry but there have been documented cases of human-to-human transmission (Wallace 2009). The 2009 H1N1 pandemic came to attention in February 2009 through several small outbreaks of an influenza-like illness in different parts of Mexico. The H1N1 virus appears to have evolved from an avian adapted ancestor which gave rise to the “Spanish flu” in 1918 and to classic H1N1 swine flu (first isolated in 1930). Pigs, confined together in huge feedlots, including breeding stock flown around the world, provide an ideal vessel for assortment of viral genomes and the production of novel microbes capable of producing pandemics. Middle East respiratory syndrome (MERS) was first identified in Saudi Arabia in 2012 and has grumbled along since then with occasional flare ups. It has a case fatality rate of around 34% (Eastern Mediterranean Regional Office 2020). The disease is caused by the MERS coronavirus (MERS-CoV) which originated in bats, with dromedary camels being a major reservoir host. One study estimates that 12% of cases in Saudi Arabia are direct infections from camels and the rest are human-to-human transmission (Cauchemez et al. 2016). In the lead-up to the 2014 West Africa Ebola epidemic, deforestation and monocultures of palm oil attracted the fruit bats from Central Africa to move to West Africa, where they live in close proximity with monkeys in the shrinking forests. Local people depend increasingly on bush meat as their lands are appropriated by loggers, miners, and international agribusiness monocropping including maize, soybean, rubber, and palm oil (Wallace and Wallace 2016). Liberia, Guinea, and Sierra Leone were then (and still are) three of the poorest countries in the world. Subject to ruthless exploitation of the region’s natural resources, they have also suffered from IMF structural adjustment programs which proscribed public spending on healthcare. Their health systems were bleeding health workers North (Sanders et al. 2015). COVID-19 appears to have emerged in ways very similar to those described above for SARS. The WHO “origins story” investigation concluded that transmission of the virus to humans was mediated by a yet unidentified

WHO AND THE POLITICS OF PANDEMICS  |  323 intermediate species (presumably a small mammal) being traded in the supply lines and wet markets of the wildlife trade which may have acquired the virus from bats in the forests of South China, Vietnam and/or Laos. The recurring pandemics of the twenty-first century and the wider acknowledgement of their ecological origins has seen the concept of “One Health” gain in political currency. Until recently, the One Health initiative focused primarily on bringing together human, animal, and plant health experts, but this will be insufficient unless informed by a strong sociological and political economy analysis (which is now developing) and commitments to conserving biodiversity, curbing global warming, and containing the growth in the material throughput economy. Media coverage of the ecological encroachment story, still the most likely “origins story,” has been minimal. The coverage of the origins investigation in the Western media has been dominated by allegations of a Chinese cover-up and of laboratory escape. Lack of trust in the thoroughness of the Wuhan site visit has since led to a call for a renewed investigation of the accidental lab story.

What are some of the key lessons for WHO so far gleaned from the pandemic?

1. Adequate, assured, flexible funding for WHO WHO is grossly underfunded, including the WHE and the CFE. “WHO’s overall budget with roughly 5 billion USD per biennium equals the funding of a larger sub-regional hospital” (Germany and France 2020). The CFE is undersubscribed and there are hundreds of WHE positions vacant due to lack of funding (Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme 2020). The Access to COVID Tools Accelerator (ACT-A), the lead multistakeholder mechanism financing and coordinating the global pandemic response where WHO is a member, but not the leader (see Box D1.2), was facing a funding gap of $16 billion for the 2020–2021 period (WHO 2021b) and the UN’s Global Humanitarian Response plan is likewise grossly underfunded (Office for the Coordination of Humanitarian Affairs 2020). The WHO response has not been able to raise needed revenues through funds paid by its member states. Rather, it has been forced to reach out to the private sector for donations with the launch in December 2020 of the WHO Foundation. This Foundation aims to raise one billion US dollars of capital to support grants to WHO and other agencies from the earnings of the fund (Hacker 2020). Assuming 10% return on investments (a rather optimistic assumption) this would yield perhaps $100 million per year, some of which would go to WHO. The Foundation has appointed Anil Soni as its CEO. An

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ex-pharma executive and ex-senior advisor with the Gates Foundation (Hinnant 2020), Soni is explicit that he will be looking for partnerships with pharma, and he cites support for WHO’s work for pre-qualification of medicines1 as an area of which pharma is supportive (Ravelo 2020). The relationship between Bill Gates, his Foundation, and the private monopoly interests of pharma are well known and have been particularly vexing in efforts to obtain a temporary waiver on TRIPS intellectual property rights for COVID-related vaccines, treatments, diagnostics, and other health goods (see Chapter B4 and Box D1.2). The only long-term solution which preserves WHO’s integrity and guarantees sufficient funds for emergency preparedness and response will be for a substantial increase in assessed contributions (ACs) and of untied donor support (Germany and France 2020).

Box D1.2: Philanthrocapitalism and the big pandemic binge At the earliest stage of the SARS-CoV-2 outbreak, when the official pronouncement of the pandemic was still to come, the public health and scientific community summoned at the WHO in Geneva had mobilized enough international intelligence to strike a collective sense of concern for what was coming. The outcome agreement affirmed the concept of an “R&D Blueprint” (Research and Development) for the world, first mooted by the WHO in 2017. Medical knowledge could not be gated; only collaboration and information-sharing would reduce duplications, provide the best science, and accelerate development of any essential remedy against the rapidly spreading disease. Oxford University evidently had in mind a similar approach when it took the world by surprise in April 2020 with the announcement that it would shun Big Pharma involvement and give away the rights of its coronavirus vaccine to any drug producer to expedite access to COVID-19-related intellectual property (IP). The virus by then was raging on a planetary scale and the Oxford scientists were unhappy with the level of global access. Their idea was to ensure the provision of tools for preventing or treating the new coronavirus at a low cost or free of charge, insisting that nobody should profit from this unprecedented global health crisis (Oxford University Innovation n.d.[b]). This commitment was enthusiastically endorsed by global health activists but was short-lived. Following pressure from the Bill & Melinda Gates Foundation (BMGF) (Hancock 2020), the Oxford team (Gilbert 2020) sealed an exclusive vaccine agreement with AstraZeneca, a giant drug maker which had hardly any experience with vaccine development, except for a little-known nasal-spray vaccine for the flu (Electronic Medicines Compendium 2003). The deal gave the pharma

WHO AND THE POLITICS OF PANDEMICS  |  325 company exclusive rights and gave the public no guarantee of low prices. In several interviews following criticism for having discouraged Oxford from the open-source strategy, Bill and Melinda Gates argued that Oxford had to partner with a pharmaceutical company to manufacture its vaccine, and that it would be their Foundation’s role to ensure the AstraZeneca vaccine’s affordability (Melinda Gates 2021). In March 2020, the BMGF had already launched a bold bid to manage the world’s scientific response to the COVID-19 pandemic with the design of the COVID-19 Therapeutics Accelerator, together with Wellcome Trust and Mastercard (Bill & Melinda Gates Foundation 2020a). A few weeks later came the announcement that 15 players in the life sciences industry would collaborate directly with the BMGF and contribute a range of assets, resources, and expertise needed to identify effective and scalable solutions to the pandemic (Bill & Melinda Gates Foundation 2020b). BMGF went on to co-host the launch of the ACT-A which established the status quo vision for organizing global efforts aimed at the research, development, manufacture, and distribution of much-needed vaccines and treatments. Like all other BMGF-driven organizations in the global health arena, the Accelerator was engineered as a public – private partnership based on charity and industry enticement (see Chapter B3). In sharp contrast to the WHO’s inspiration for scientific sharing, which led to the Solidarity Call to Action and launch of the COVID-19 Technology Access Pool (C-TAP) in May 2020 (WHO n.d.[b]), the ACT-A perfectly embodies Bill Gates’s long-standing commitment to protect intellectual property monopolies in the pharmaceutical field. The Accelerator’s implicit arguments are that intellectual property rights do not represent an obstacle for responding to global health needs and must be safeguarded even during a pandemic. This is further evidence of just how influential Bill Gates has come to be, and how plutocratic change agents like him have been allowed to sell their partial and self-preserving recipes to pass for real cooperation and solidarity deeds. Gates’s philanthropic activism in the COVID-19 pandemic further institutionalizes his dominance via the role played by the BMGF. In the official narrative of multilateral development circles, the BMGF is firmly positioned next to the European Commission, the WHO (or at least its Secretariat), and the World Bank in the driving seats of the ACT-A initiative. The operational scaffolding of the Accelerator relies on the multistakeholder entities created in the last two decades with much of BMGF’s transformational and financial direction. It is GAVI (Global Alliance for Vaccines and Immunization) and CEPI (Coalition for Epidemic Preparedness Innovations) that run the ACT-A vaccines pillar, with lateral

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support from the Global Fund, UNITAID, and other hybrid players. It imposes the primacy of public–private partnerships (PPPs) in the management of the first pandemic crisis of globalization. It also embodies the decision of HIC governments (notably the EU and members of the G7) to entrust such PPPs, with their alliances with the pharmaceutical and the financial sectors, to deal with a global emergency (Gleckman 2021). In the pursuit of international cooperation against COVID-19, the outcome is an acceptance of control over responses to the pandemic by elites with the money and power to assume it. This is a political choice, one that now contributes to deepening unhealthy inequalities as we witness with the current vaccine “apartheid” (Winning 2021) that leaves much of the world on the losing side (Zaitchik 2021) and that furthers the weakening and almost infantilization of the WHO (Dentico 2020). People with the most to lose from genuine social transformation have positioned themselves in charge of the development agenda, often with the passive assent of those most in need of social change: Within the narrative of charity, this immanent tension in the relation between the privileged and the marginalized is obscured. The conditions that serve the interests of the privileged are portrayed as if they are delinked from the conditions that deprive the marginalized. The inherent tension between the two as a structural necessity is obscured, and their relation is recast with the gaze of charity or moral responsibility. The privileged are now exempt from the causal process underlying the deprivation of the marginalized. The privileged are then offered a sense of relief and redemption … Ideology operates at this implicit level. (Kim 2021) Bill Gates is not alone in this ideological function. The COVID-19 outbreak has played an instrumental role in ushering Ted Turner’s UN (United Nations) Foundation model (Adams and Martens 2018) into the Geneva health arena, somewhat unexpectedly, through the establishment of the WHO Foundation at the end of May 2020 as part of the WHO transformation process (WHO 2020i). The explicit aim of the Foundation, which is presented as an independent entity, is to simplify the transiting of philanthropic support and expand the WHO contributors’ pool, seeking donations from ordinary citizens, high net worth individuals, and corporations. The only sources of funding excluded by the Foundation are the tobacco and arms industries (Maani et al. 2021). The Foundation is tasked with the purpose “to maximize net financial contributions,” and to this end it favors donors’ participation in the design of their engagement with the WHO and interaction with the implementing partners they support.

WHO AND THE POLITICS OF PANDEMICS  |  327 But it would be naïve to consider this operation a mere WHO funding issue. In its constitutive relation with Ted Turner’s UN Foundation, the WHO Foundation seems to serve the purpose of shaping a parallel fasttrack diplomacy that escapes the intricacies of intergovernmental tensions while speeding up a clear geopolitical end from Geneva. As hinted by Dr. Tedros quite openly (WHO 2021c), it is through the interaction between the UN and the WHO Foundations that the WHO relationship with the US government was kindled throughout 2020, despite the Trump presidency. It is through these philanthropic foundations that vaccine equity is being sought, pushing for donation schemes from wealthier countries to poorer ones. Yes, this means that the crumbs on the table of the wealthy countries that have hoarded the pandemic vaccines should trickle down to the poor ones, making sure that no established economic or power structures are destabilized in the process. With the establishment of the WHO Foundation, it is the WHO Director-General asking for a new private-driven management system led by philanthrocapitalists, drug companies with their vested interests (Ravelo 2020), and their complicit or accommodating governments to govern global health. UN agencies are growing more and more dysfunctional in this scenario, being starved of funding by increasingly nationalistic governments. But putting plutocrats into a leadership position on public problem-solving means increasing their power to thwart solutions that might threaten them, even in the context of a pandemic. This is by no means the global governance we want or need.

2. National preparedness and accountability The Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme (IOAC) interim report on the WHO’s response to COVID-19 noted that, while most countries appeared ill-prepared for the pandemic, the orthodox metrics of preparedness (the “core capacities”) and the evaluations of preparedness (using the Joint External Evaluation Tool, JEET) had no clear relationship with country performance (Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme 2020). Rather, more recent research finds that the preconditions for effective policy responses include coherent whole-of-government responses, female leadership, transparency, effective public communication, and accountability of decisionmakers. “Trust between governments and their constituencies,” the study’s authors note, “has contributed to effective containment, particularly reciprocal trust – both horizontally among people and vertically between people and their governments” (Tangcharoensathien et al. 2021).

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Political culture also profoundly shaped the effectiveness of national pandemic responses. A culture of individualism and distrust of politicians and experts contributed to mask, lockdown, and social distancing refusals. Wide pre-existing social inequality contributed to a lower acceptance of solidaristic responses (Ford et al. 2020). The design of political institutions, and the level of support they provide for inter-sectoral coordination, intergovernmental coherence, and tight management of disease control, has also played a major role in shaping national performance in COVID-19 containment.

3. Research development and production The importance of a planned approach to research and development (R&D) was an important lesson from the 2014 Ebola response and led to the extension of the R&D “blueprint” concept to emergency preparedness and response (WHO 2016). However, it is not clear how much influence WHO planning had on the explosion of R&D funding from the beginning of the COVID-19 pandemic. The ACT-A was deliberately created outside WHO and the development and main provisions of the various deals between the vaccine manufacturers and the global funders remain quite opaque. However, it is apparent that price points have been generous and there have been no provisions for open licensing of government-funded IP. National production capacity is also critical. Thailand and Brazil both have publicly owned production capacity that is well placed to negotiate voluntary licenses and/or to ramp up local production for domestic consumption and export if the TRIPS IP rules were temporarily waived. As publicly owned manufacturers, they also have the credible threat of issuing government compulsory licenses, which may have encouraged the originators to sublicense aspects of their vaccine production. A key lesson from the COVID-19 experience would be for more middle-income countries to invest in public sector R&D and in production capacity. The African Centre for Disease Control aims to extend this continentally, reducing its current near-complete reliance on imports for its vaccine supplies (Irwin 2021). Such efforts would be greatly facilitated by an organized program to support technology transfer. Pharma’s reluctance to enable wider production capacity by refusing to join the C-TAP (intended to allow open-sharing of vaccine research and development) and by limiting its bilateral licensing was directly aimed at maintaining prices and profits in the medium to longer term. This reluctance was indirectly supported by HIC governments which chose not to include such obligations in direct R&D grant funding, who supported pharma’s refusal to join C-TAP (Boseley 2020), and who (at least initially and for 8 months) opposed the TRIPS waiver proposal (the Biden administration’s May 2021 decision to consider negotiations for a waiver has most countries now falling in line, although not yet the European Union). The restriction of the COVAX facility (the vaccine pillar of ACT-A) to supplying only 20% of funded countries’ national vaccine

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requirements was an implicit refusal to commit to herd immunity in these countries (see Chapter B4). This decision served to prevent the emergence of a single monopsonic purchaser (the COVAX facility) with the implications that this would have had for price negotiations. The role of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), a founding partner in the ACT-A, in this decision has not been disclosed. Private pharma’s preferencing of profit over access could be addressed by a combination of open licensing, expansion of public sector vaccine production capacity in LMICs, and organized technology transfer. Pharma and its supporters will fight fiercely against any proposed restrictions on their IP privileges, but LMICs have much to gain from such reforms, and the political will for such public interest policies has grown via strong civil society campaigning. Where to next for the WHO and pandemic preparedness?

At present, the WHO is poised between two sets of considerations (not necessarily mutually exclusive): revising the IHRs or negotiating a new Pandemic Treaty.

1. Reforming the IHRs The declaration of a PHEIC under the IHRs is presently an all or nothing step and there has been talk for several years of the desirability of making provision for a graded emergency declaration with a stepped level of alerts. The possibility of introducing an international public health alert (IPHA) has been suggested as a declaration short of a PHEIC. However, it is not clear that introducing an IPHA would require authorization in revised IHRs. Instead, the WHO DG might simply convene an Emergency Committee and invite them to consider advising on whether to declare an international public health alert. The successes and failures of national COVID-19 responses invite questions about the core capacities specified in the IHRs and the metrics embedded in tools such as the Joint External Evaluation Tool. The importance of surveillance and laboratories and the monitoring of traffic at borders is not in dispute. However, the IHRs say nothing about communicating the science, building public trust, cultivating policy coherence across sectors and levels of government, intensive research and evaluation into response and outcomes, inclusive decision-making, or burden sharing. These factors have been very influential as the drivers of successful outcomes, perhaps more so than the core capacities specified in the IHRs. It would be useful to have these political and cultural “capacities” recognized in the IHRs, even if they do not lend themselves to inspection and certification. The provisions for monitoring and encouraging national compliance with the advice of the IHR Emergency Committee, in particular the provisions around “additional measures” beyond those recommended by the DG, are weak and

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without sanctions. A further issue concerns on-the-spot investigation. There is a case for giving WHO the authority to undertake on-the-spot investigations in assessing international risk without the approval of the host nation but the likelihood of powerful sovereign nations agreeing to this is small. However, if “after action” accountability was strengthened (perhaps through a proposed Pandemic Treaty) attention could be directed to political failures in emergency management, an irresponsible imposition of additional measures, and a lack of national transparency.

2. Pandemic treaty In recent years there have been various calls to strengthen WHO’s power vis-à-vis member states. On March 30, 2021, 20 global leaders (centered on UK, Germany, and France, and including WHO DG Dr. Tedros but not including Russia, China, or the USA) issued a call for a new pandemic treaty (Tomlinson 2021): The main objective of this treaty would be to promote a nationwide and societal approach that strengthens national, regional and global capacities and resilience to future pandemics. This includes … measures in the field of medicine and public health, e.g. vaccines, drugs, diagnostics and personal protective equipment. … In addition, such a treaty would lead to more mutual accountability and shared responsibility, transparency and cooperation in the international system in accordance with its rules and norms. (Heads of State 2021)

The Independent Panel on Pandemic Preparedness and Response has expressed support for some form of treaty, specifically calling for a Framework Convention to “address gaps in the international response, clarify responsibilities between States and international organizations, and establish and reinforce legal obligations and norms. Mechanisms for financing, research and development, technology transfer, and capacity building could also be enshrined in the Convention” (IPPPR 2021b, 46). The IHR Review Committee appointed to assess the functioning of the IHRs during the COVID-19 response also recommended a Global Convention and listed in detail some of the issues which might usefully be included (IHR Review Committee 2021, 50). Many observers have been perplexed by the urgency which treaty supporters have exhibited in progressing the proposal, notwithstanding the lack of agreement about what it might contain and whether it would be a “framework convention” (an agreement in principle to be supplemented by more specific “protocols”), as proposed by the Independent Panel, or a unitary agreement. SKeptics have speculated that it is a smokescreen to distract attention from the TRIPS waiver controversy and the vaccine supply failure more generally. Nonetheless, there would be scope for a treaty (or a framework convention) to serve a number of useful purposes, including:

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1. Strengthening national accountability (“after action reviews”) for prevention, preparedness, and response. 2. Creating a link between the declaration of a PHEIC and the triggering of a mandatory open licensing regime. 3. Reversing the ecological degradation contributing to the emergence of new infectious diseases. The WHO’s inability to hold nation states accountable for pandemic planning, implementation, and outcomes is a major weakness. “After action reviews” conducted in public, led by independent experts, and organized at the regional level would be valuable learning opportunities and would hold governments to account for their preparedness, transparency, solidarity, and response. A range of mechanisms for this “institutionalization of praise and shame” exist, such as the committees of experts under the International Labour Organization (ILO), the trade policy reviews under the World Trade Organization (WTO), the review committees of human rights conventions, and similar mechanisms under the Organization for Economic Co-operation and Development (OECD) and IMF (Braithwaite and Drahos 2000). A second possible objective of the proposed treaty could be to ensure the rapid scale up of research and development and production for tests, medicines, and vaccines. One way of addressing this goal would be to secure a global commitment to mandatory open licensing through a mechanism such as C-TAP. This would be mandated through agreed conditions to be imposed by granting agencies and to be included in advanced purchase agreements. Finally, a pandemic treaty should also include commitments to reverse the ecological degradation associated with extractivism and the capitalist growth fetish which is contributing to the increasing frequency of emerging infectious diseases, including pandemics (see Chapters A3 and C4). One option would be to authorize WHO to establish an international independent expert capacity to identify, characterize, and publicize high-risk industries and other developments that increase the likelihood of novel zoonoses and subsequent pandemic risk, and to mandate member states to develop and implement plans for mitigating such risks. However, rushing into treaty negotiations, focused on the next pandemic, when member states are still coping with the current one and are in close negotiations regarding the proposed waiver, would place a significant burden on the diplomatic capacity of many LMICs. This may be its purpose. Nonetheless, the May 2021 WHA approved going forward with a follow-up meeting in November 2021 to discuss in broad outline what such a treaty might look like. Coincidentally, this is also the month the DG of the World Trade Organization is hoping to reach consensus on TRIPS revisions to accommodate a COVID-19 TRIPS waiver, but one that might also extend to resolving IPR issues that could affect rapid and equitable vaccine access in future pandemics (see Chapter B4).2

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Political economy of pandemic prevention, preparedness, and response

The economic relationships of imperialism under contemporary globalization include unfair trade, tax avoidance, debt entanglement, and restriction of LMICs to the supply of raw materials and cheap labor in global value chains. The consequences of these dynamics include fragile health systems, conflict and migration, insufficiency of indigenous pharmaceutical capacity, and lack of fiscal capacity to buy vaccines. All these consequences have been evident in the COVID-19 pandemic. The structures and dynamics of imperialism are complicated in the present era by the US determination to contain a rising China and to open the country up to Western liberal democratic capitalism. The US–China rivalry has been evident in former US President Trump’s bullying of WHO and in the increasing hostility of anti-Chinese propaganda in political and media commentary in the West. It has also been evident in the ebbs and flows of vaccine diplomacy. Because of its success in controlling the epidemic in China, the Chinese leadership has prioritized the export and gifting of its vaccines while initially going slow on domestic vaccination. The US leadership has been limited in its response because of its commitment to support the US vaccine manufacturers who have insisted on controlling supply to maintain prices and profits. This is somewhat now in flux, as the dangers of COVID-19 variants and an approaching vaccine herd immunity in the USA and other HICs is sparking a wave of new funding for, or donations of, vaccines for LMICs. As of writing (June 2021) the surge in new supply will still be insufficient (too little, too late) and the commanding role of patent-holding vaccine manufacturers remains firmly in place. The global economy is in the midst of one of capitalism’s episodic crises of over-production. Fewer factories and fewer people are needed to make things. Profits which no longer find their ways to investment in building productive capacity flow, instead, into the financial sector, where they support consumption through debt and “wealth creation” through speculation (see Chapter A1). The overhang of productive capacity contributes to unemployment, underemployment, and precarious employment. It weakens trade unions and deepens the exploitation of workers (see Chapter C2). In the post-pandemic short-term, the pandemic collapse in supply chains is leading to an excess in pent-up consumer demand that (for now) exceeds present supply (at least in HICs). This could temporarily increase employment in low-wage sectors. But the longer-term crises of contemporary capitalism roll across populations (hunger, displacement, conflict), ecosystems (forests, oceans, rivers), and global homeostasis (biodiversity, global warming). As COVID-19 has made abundantly clear, poor people and stigmatized minorities face greater exposure and lesser protection in outbreaks and pandemics. People living in poorer countries also suffer more because of weaker institutions (including lacking the core capacities of the IHRs and inability to access vaccine supplies).

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Capitalism depends on growth. Growth means increased profit and space for investment. The addiction to growth drives the escalating invention of new and increasingly elaborated commodities and converts social functions into commodities. The need for growth drives the industrial scale farming of pigs and poultry and drives extractivism and the continuing human encroachment into natural ecosystems (see Chapter C4). Philanthrocapitalism plays a critical role in this regime. A major function of philanthropic spending is re-legitimation. When the perceived legitimacy of the neoliberal program is challenged, philanthrocapitalism steps forward to fund good works and demonstrate that neoliberalism is not so bad after all. A particular feature of the re-legitimation dynamic in the global health policy space is the focus on the narrow technical fix, including vertical disease programs (polio, malaria, tuberculosis, and AIDS/HIV) which serve to ameliorate the disease problem but without addressing the structural and social determinants of those problems. This chapter points to a range of institutional reforms to strengthen public health emergency management, both nationally and internationally. However, it remains important to recognize how the failures of pandemic response are embedded in a broader system and reflect the macro structures, forces, and dynamics of that broader system. Effective strategies are those which address the more immediate institutional flaws and the structural forces which reproduce those flaws. Notes 1  Pre-qualification of medicines by WHO is aimed at ensuring that medicines supplied by procurement agencies (such as UNICEF, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and UNITAID) for distribution in resource-limited countries meet acceptable standards of quality, safety, and efficacy. WHO’s list of prequalified medicinal products is used by international procurement agencies

and increasingly by countries to guide bulk purchasing of medicines. 2  The November 2021 WHA special assembly did agree to begin negotiations on a treaty in March 2022, with an outcome to be presented to the WHA in 2024. The Omicron variant of the coronavirus postponed the WTO Ministerial Conference in November, with negotiations over the TRIPS waiver dragging on into 2022.

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who-a-plug-for-major-funding-gap-left-byunited-states/. Ford, Tiffany, Sarah Reber, and Richard V. Reeves. 2020. “Race Gaps in COVID-19 Deaths are Even Bigger than They Appear.” Brookings Institution. June 16. https://www. brookings.edu/blog/up-front/2020/06/16/ race-gaps-in-covid-19-deaths-are-evenbigger-than-they-appear/. Gearan, Anne. 2020. “Trump Announces Cutoff of New Funding for the World Health Organization over Pandemic Response.” Washington Post. April 14. https://www.washingtonpost.com/ politics/trump-announces-cutoff-of-newfunding-for-the-world-health-organizationover-pandemic-response/2020/04/14/ f1df101e-7e9f-11ea-a3ee-13e1ae0a3571_story. html. Germany and France. 2020. “Non-Paper on Strengthening WHO’s Leading and Coordinating Role in Global Health with a Specific View on WHO’s Work in Health Emergencies and Improving IHR Implementation.” http://g2h2.org/wpcontent/uploads/2020/08/Non-paper-1.pdf. Gilbert, Sarah. 2020. “Covid Vaccine Front-Runner is Months Ahead of Her Competition.” Bloomberg. July 25. https://www.bloomberg.com/news/ features/2020-07-15/oxford-s-covid-19vaccine-is-the-coronavirus-front-runner. Gleckman, Harris. 2021. “COVAX, a Global Multistakeholder Group that Poses Political and HEALTH RISKS to Developing Countries and Multilateralism.” Amsterdam: Transnational Institute and Friends of the Earth International. https://longreads.tni. org/covax. Global Health Security Index. 2019. “Welcome to the 2019 Global Health Security Index.” https://www.ghsindex.org/#l-section–map. Gonglei, Gu. 2020. “China CDC Head: Hero or villain?” Think China. February 1. https:// www.thinkchina.sg/china-cdc-head-hero-orvillain. Hacker, J. 2020. “Sights Set on Private Funding as Pharma Exec Appointed to Head New WHO Foundation.” Health Policy Watch. December 7. https://healthpolicy-watch. news/private-funding-who-foundation-newceo/. Hancock, Jay. “They Pledged to Donate Rights to their COVID Vaccines, Then Sold Them

WHO AND THE POLITICS OF PANDEMICS  |  335 to Pharma.” Keiser Health News. August 25. https://khn.org/news/rather-than-give-awayits-covid-vaccine-oxford-makes-a-deal-withdrugmaker/. Heads of State. 2021. “A Great Deal to Fight Pandemics.” Frankfurter Allgemeine. March 29. https://www.faz.net/aktuell/ politik/inland/nach-corona-vertragzur-bekaempfung-von-pandemiengefordert-17269543.html. Hinnant, Lori. 2020. “WHO Tries to Bolster Fragile Funding with New Foundation CEO.” Associated Press. December 8. https:// apnews.com/article/pandemics-coronaviruspandemic-united-nations-united-states-cf301 cdf3a2f9d3394c1bae4805e7537. Holmes, Edward C., and Yong-Zhen Zhang. 2020. “Novel 2019 Coronavirus Genome.” Virological. January 10. https://virological. org/t/novel-2019-coronavirus-genome/319. IHR Review Committee [Review Committee on the Functioning of the International Health Regulations]. 2021. “WHO’s Work in Health Emergencies, Strengthening Preparedness for Health Emergencies: Implementation of the International Health Regulations (2005).” A74/9 Add.1. May 5. https://apps.who.int/gb/ ebwha/pdf_files/WHA74/A74_9Add1-en.pdf. Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme. 2020. “Looking Back to Move Forward (A73/10).” Geneva: World Health Organization. https://apps.who.int/gb/ ebwha/pdf_files/WHA73/A73_10-en.pdf. IPPPR [Independent Panel for Pandemic Preparedness and Response]. 2021a. “Second Report on Progress.” January 19. https:// theindependentpanel.org/wp-content/ uploads/2021/01/Independent-Panel_SecondReport-on-Progress_Final-15-Jan-2021.pdf. IPPPR [The Independent Panel on Pandemic Preparedness and Response]. 2021b. “COVID-19: Make it the Last Pandemic.” https://theindependentpanel.org/wpcontent/uploads/2021/05/COVID-19-Make-itthe-Last-Pandemic_final.pdf. Irwin, Aisling. 2021. “How COVID Spurred Africa to Plot a Vaccines Revolution.” Nature. April 21. https://www.nature.com/articles/d41586021-01048-1. Joint WHO–China Study Team. 2021. “WHOconvened Global Study of Origins of SARS-CoV-2: China Part.” World Health

Organization. https://www.who.int/docs/ default-source/coronaviruse/who-convenedglobal-study-of-origins-of-sars-cov-2-chinapart-joint-report.pdf. Kim, Hani. 2021. “The Implicit Ideological Function of the Global Health Field and its Role in Maintaining Relations of Power.” British Medical Journal Global Health 6 (4). https://gh.bmj.com/content/6/4/e005620. Li, Qun, Xuhua Guan, Peng Wu, Xiaoye Wang, Lei Zhou, Yeqing Tong, Ruiqi Ren, Kathy S.M. Leung, et al. 2020. “Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia.” New England Journal of Medicine 382: 1199–1207. https://www.nejm.org/doi/full/10.1056/ NEJMoa2001316. Maani, Nason, May CI Van Schalkwyk, et al. 2021 “The New WHO Foundation – Global Health Deserves Better.” British Medical Journal Global Health 6: 1–3. https://gh.bmj.com/ content/6/2/e004950. Melinda Gates. 2021. “Melinda Gates on Whether Oxford Should’ve Allowed their Vaccine to Be Open Sourced.” Interview by Washington Post. https://www.washingtonpost.com/ video/washington-post-live/wplive/ melinda-gates-on-whether-oxfordshouldve-allowed-their-vaccine-to-be-opensourced/2021/01/27/7475d269-1ae8-4d7b8cd6-66476dd8f538_video.html. Nixon, Stewart. 2020. “Handling COVID-19 isn’t a Trade-off between Health and Economy.” East Asia Forum. November 2. https://www. eastasiaforum.org/2020/11/02/handlingcovid-19-isnt-a-trade-off-between-healthand-economy/. Office for the Coordination of Humanitarian Affairs. 2020. “Global Humanitarian Overview 2020 Monthly Funding Update.” United Nations. reliefweb.int/report/ world/global-humanitarian-overview-2020monthly-funding-update-31-december-2020. Oxford University Innovation. n.d. “Expedited Access for COVID-19 Related IP.” Oxford University Innovation. Accessed June 8, 2021. https://innovation.ox.ac.uk/technologiesavailable/technology-licensing/expeditedaccess-covid-19-related-ip/. Ravelo, Jenny Lei. 2020. “Q&A: New CEO Anil Soni on the Future of the WHO Foundation.” Devex. December 7. https://www.devex.com/

336   |  Global Health Watch 6 news/q-a-new-ceo-anil-soni-on-the-futureof-the-who-foundation-98717. Ravelo, Jenny Lei. 2021. “On his First Day in Office, Biden Retracts US Withdrawal from WHO.” Devex. January 21. https:// www.devex.com/news/on-his-first-day-inoffice-biden-retracts-us-withdrawal-fromwho-98961. Sanders, David, Amit Sengupta, and Vera Scott. 2015. “Ebola Epidemic Exposes the Pathology of the Global Economic and Political System.” International Journal of Health Services 45 (4): 643–656. doi: 10.1177/0020731415606554. Tangcharoensathien, Viroj, Poonam Singh, and Anne Mills. 2021. “COVID-19 Response and Mitigation: A Call for Action.” Bulletin of the WHO 99 (78–78A). http://www.who.int/ bulletin/volumes/99/2/20-285322. Tomlinson, Catherine. 2021. “Analysis: The Politics and Promise Behind a Proposed Pandemic Treaty.” Spotlight. April 13. https:// www.spotlightnsp.co.za/2021/04/13/analysisthe-politics-and-promise-behind-a-proposedpandemic-treaty/. Torjesen, Ingrid. 2020 “Covid-19: One in 10 Cases in England Occurred in Frontline Health and Social Care Staff.” British Medical Journal 370: m2717. doi: 10.1136/bmj.m2717. Wallace, Robert G. 2009. “Breeding Influenza: The Political Virology of Offshore Farming.” Antipode 41 (5): 916–951. https:// onlinelibrary.wiley.com/doi/full/10.1111/j.14678330.2009.00702.x. Wallace, Robert G., and Rodrick Wallace, eds. 2016. Neoliberal Ebola: Modeling Disease Emergence from Finance to Forest and Farm. New York: Springer. WHO. 2016. “WHO Research and Development Blueprint: Evaluation of Ideas for Potential Platforms to Support Development and Production of Health Technologies for Priority Infectious Diseases with Epidemic Potential.” WHO/EMP/RHT/TSN/2016.02. World Health Organization. https://apps. who.int/iris/rest/bitstreams/1134708/ retrieve. WHO. 2020a. “Statement on the First Meeting of the International Health Regulations (2005) Emergency Committee regarding the Outbreak of Novel Coronavirus (2019-nCoV).” World Health Organization. https://www.who.int/news/item/23-012020-statement-on-the-meeting-of-the-

international-health-regulations--(2005)emergency-committee-regarding-theoutbreak-of-novel-coronavirus-(2019-ncov). WHO. 2020b. “Statement on the Second Meeting of the International Health Regulations (2005) Emergency Committee Regarding the Outbreak of Novel Coronavirus (2019-nCoV).” World Health Organization. https://www.who.int/ news/item/30-01-2020-statement-onthe-second-meeting-of-the-internationalhealth-regulations-(2005)-emergencycommittee-regarding-the-outbreak-of-novelcoronavirus-(2019-ncov). WHO. 2020c. “Coronavirus Disease 2-19 (COVID-19) Situation Report – 179.” World Health Organization. https://www.who.int/ docs/default-source/coronaviruse/situationreports/20200717-covid-19-sitrep-179. pdf?sfvrsn=2f1599fa_2. WHO. 2020d. “Novel Coronavirus (2019nCoV): Situation Report – 12.” World Health Organization. https://www.who. int/docs/default-source/coronaviruse/ situation-reports/20200201-sitrep-12-ncov. pdf?sfvrsn=273c5d35_2. WHO. 2020e. “Advice on the Use of Masks in the Context of COVID-19: Interim Guidance.” World Health Organization. https://apps. who.int/iris/bitstream/handle/10665/331693/ WHO-2019-nCov-IPC_Masks-2020.3-eng. pdf?sequence=1&isAllowed=y. WHO. 2020f. “Coronavirus Disease 2-19 (COVID-19) Situation Report – 85.” World Health Organization. https://www.who.int/ docs/default-source/coronaviruse/situationreports/20200414-sitrep-85-covid-19. pdf?sfvrsn=7b8629bb_4. WHO. 2020g. “Independent Evaluation of Global COVID-19 Response Announced.” World Health Organization. https://www.who. int/news/item/09-07-2020-independentevaluation-of-global-covid-19-responseannounced. WHO. 2020h. “COVID-19 Response (WHA73.1).” World Health Organization. https://apps. who.int/gb/ebwha/pdf_files/WHA73/A73_R1en.pdf. WHO. 2020i. “WHO Foundation Established to Support Critical Global Health Needs.” May 27. https://www.who.int/news/item/2705-2020-who-foundation-established-tosupport-critical-global-health-needs.

WHO AND THE POLITICS OF PANDEMICS  |  337 WHO. 2021a. “Covid-19 and Health Workers.” In “COVID-19 Weekly Epidemiological Update.” February 2. https://www. who.int/publications/m/item/weeklyepidemiological-update—2-february-2021. WHO. 2021b. “The ACT Accelerator Partnership Welcomes Commitment of 870 Million Vaccine Doses and Calls for More Investment in all Tools to End the Pandemic.” Joint News Release. https://www.who.int/ news/item/13-06-2021-the-act-acceleratorpartnership-welcomes-commitment-of-870million-vaccine-doses-and-calls-for-moreinvestment-in-all-tools-to-end-the-pandemic. WHO. 2021c. “WHO Director-General’s Opening Remarks at the Meeting with UN Foundation Board of Directors.” April 8. https://www. who.int/director-general/speeches/detail/ who-director-general-s-opening-remarks-atthe-meeting-with-un-foundation-board-ofdirectors.

WHO. n.d.[a]. “R&D Blueprint and COVID-19.” Accessed June 8, 2021. https://www.who.int/ teams/blueprint/covid-19. WHO. n.d.[b]. “COVID-19 Technology Access Pool.” Accessed June 8, 2021. https://www. who.int/initiatives/covid-19-technologyaccess-pool. Winning, Alexander. “Ramaphosa Warns of ‘Vaccine Apartheid’ If Rich Nations Hoard Shots.” Business Day. May 10. https://www. businesslive.co.za/bd/national/2021-05-10ramaphosa-warns-of-vaccine-apartheid-ifrich-nations-hoard-shots/. Zaitchik, Alexander. 2021. “How Bill Gates Impeded Global Access to Covid Vaccines.” The New Republic. April 12. https:// newrepublic.com/article/162000/bill-gatesimpeded-global-access-covid-vaccines.

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D2 | SHIFTING PLAYING FIELDS: HOW NEW TRADE TREATIES GOVERN GOVERNMENTS

Introduction

Trade has been on the health activist agenda for many years, accelerating since the birth of the World Trade Organization (WTO) in 1995 which began re-making the global economy in ways that advantaged the world’s high-income countries (HICs) and their transnational corporations (Chang 2002). Much of this attention continues to focus on the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and how this affects access to essential medicines. Ironically, whereas most WTO agreements are about liberalizing trade, TRIPS is protectionist since it provides for extended monopolies on patents and copyrights, “intellectual property” being amongst the new “goldmines” of postindustrial capitalism (see Chapter B4). But there are few aspects of contemporary life (and health) that are not directly or indirectly affected by trade; and trade itself has been an element of human societies for millennia. To the extent that the exchange of goods and services between nations increases consumption levels beyond the limits of our planet (described in Chapters A1 and A3) global trade could pose an existential health risk. But health concerns with trade are generally less about trade itself than with the health equity impacts of specific and enforceable rules that governments have agreed on to govern such trade, or, more precisely, to govern what public policies governments might pursue to ensure that they do not “unnecessarily” restrict trade (we return to this point later in this chapter). The WTO represents the largest set of such agreements amongst the largest number of global nations, comprising 164 members and another 25 observer countries. There is little in its founding statement of purpose with which health activists might find fault: The field of trade and economic endeavour should be conducted with a view to raising standards of living, ensuring full employment and a large and steadily growing volume of real income and effective demand, and expanding the production of and trade in goods and services, while allowing for the optimal use of the world’s resources in accordance with the objective of sustainable development. (World Trade Organization 1994b)

Such statements, however, unlike trade agreement rules themselves, are unenforceable and little more than window dressing to make such rules more politically marketable. And it did not take long for cracks in the ability of WTO agreements to deliver on this promise to develop, with civil society organizations,

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academic researchers, and WTO member states representing low- and middleincome countries (LMICs) pointing out the power and economic asymmetries embedded in the WTO system. Facing criticism from within (its LMIC member countries, notably African) the WTO launched the so-called Doha Development Round in 2001, focusing on “developing countries’ needs and interests” (World Trade Organization, 2001). In the 20 years since, however, little progress on this agenda has been made. Even if completed, most of the economic benefits would go to the world’s wealthier countries (Polaski 2006), and WTO observers have long questioned the organization’s very survival (Vaughan 2018). This condition was not helped with the election of Donald Trump, with threats from the USA to withdraw from the organization while undermining the WTO’s enforcement system by refusing to accept new nominations to the Appellate Body that oversees final dispute settlements between member countries. For many health activists, a potential death of the WTO may be appealing. But we need to be careful what we wish for. In an anarchic (no rules-bound) global trading system there is no check or balance on the power of some nations to overpower any opposition. Although the current WTO and its many agreements skew in favor of the already mighty (the USA, EU, and other HICs which, after all, wrote many of the trade rules) there have been some health-positive developments within the WTO, notably the increasing acknowledgement of the importance of public health regulation in arbitrating trade disputes. The most notable one was the WTO’s 2020 decision that upheld Australia’s regulations on plain packaging of tobacco products. It is also important that health activists concerned with trade and health intersections do not focus their criticism exclusively on the WTO itself. The WTO is an intergovernmental organization designed to facilitate ongoing trade negotiations and administer disagreements amongst member states. Officially “neutral” on matters of trade liberalization, institutionally it is heavily steeped in liberalized trade theory’s argument that “freer” trade is important in generating economic activities that reduce poverty and improve economic growth (Gopinathan et al. 2018). But the abiding power in trade rests with the member states, notably the most powerful amongst them. If we take exception to trade or investment rules that directly or indirectly harm health, health equity, or the underlying social/structural determinants of health, our complaints need first to be made with our own national governments that created these rules or to which they initially felt compelled to agree with. From multilateral trade to bilateral/regional power-brokering

There is a new WTO Director-General, Dr. Ngozi Okonjo-Iweala, the first female and first African head of the organization. Whether she can revitalize work on the unfinished “development” agenda is another matter. Multilateral negotiations at the WTO stalled even before the Doha Development Round was initiated, precipitated by the refusal by HICs to reduce their domestic agricultural subsidies to facilitate competition with agricultural imports from LMICs. Trade

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negotiations quickly shifted to bilateral (two country) treaty-making, driven largely by the USA and the EU. These treaties introduce new rules or enhance existing liberalization measures that go beyond the WTO; hence, they are often described as “WTO+.” The USA currently has bilateral treaties with 12 countries (United States Trade Representative 2021a); the EU has 44 such agreements with 76 countries (European Union 2020, 2–3). Many of these bilateral agreements are with LMICs, where the rich countries’ “divide and conquer” strategy is simple. By negotiating with one country at a time, the more powerful nation can influence the new trade rules to their benefit, something no longer possible in the multilateral, developing country-dominated WTO. In parallel with the growth of bilateral treaties has been the rapid rise in regional trade agreements, more commonly referred to as free trade agreements (FTAs). The WTO, which allows its member states to make these preferential agreements amongst themselves if they are more liberalizing, estimates that there are 339 such agreements in force as of February 2021 (World Trade Organization 2021a). The result of these surging number of WTO+ treaties has been likened to a “spaghetti bowl” that can make it hard to assess fully what any one country’s overlapping trade obligations are and to whom. FTAs, because they involve more countries and usually include an investment chapter (on which more later), have received the greatest civil society and public health activist attention. Some of the major FTAs are described in Table D2.1; most of them include one or more dominant (HIC) members that, as with bilateral treaties, give them a powerful edge in negotiating new trade rules.

Figure D2.1  Cumulative number of free trade agreements 1948–2020. Source: WTO, “RTAs Currently in Force (by Year of Entry into Force), 1948–2021,” RTA Tracker: Regional Trade Agreements Information System (RTA-IS), (n.d.). https://rtais.wto.org/UI/ PublicMaintainRTAHome.aspx

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Figure D2.2  The spaghetti bowl of free trade agreements. Source: Reproduced with permission from Scott L. Baier et al., “Do Economic Integration Agreements Actually Work? Issues in Understanding the Causes and Consequences of the Growth of Regionalism,” The World Economy 31 (4) (2008): 461–497

TABLE D2.1:  Recent free trade agreements FTA

Key notes

Comprehensive Economic and Trade Agreement (CETA)

An FTA between Canada and the European Union signed in 2016. The Agreement is still subject to ratification by the EU and national legislatures, but most provisions are provisionally in force, including its TRIPS+ rules. It is widely regarded as the template for an eventual US/EU Transatlantic Trade and Investment Partnership (TTIP) agreement, negotiations on which have been on hold since 2017.

Comprehensive and Progressive Agreement for Trans-Pacific Partnership (CPTPP)

An FTA between Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, and Vietnam, in force since 2018. The CPTPP evolved from the Trans-Pacific Partnership (TPP). The TPP was the first “mega-regional” FTA, originally accounting for over 40% of the global economy, before the USA withdrew in 2017. The CPTPP then suspended several controversial US-driven TRIPS rules governing pharmaceuticals. Several other Pacific Rim nations and even the post-BREXIT UK have indicated interest in joining. The US Biden administration may also be encouraged to rejoin.

SHIFTING PLAYING FIELDS  |   343 United States/Mexico/Canada Agreement (USMCA)

Agreed in October 2018 and ratified in 2020, the USMCA represents a renegotiation of the 1994 North American Free Trade Agreement (NAFTA). It incorporates many of the provisions in the CPTPP from which the USA withdrew. In December 2019, a “Protocol of Amendment” to the Agreement was made, involving four key and contentious areas: pharmaceuticals, labor, environment, and dispute resolution. The USMCA eliminates investor-state dispute settlement (ISDS) between the USA and Canada (apart from legacy disputes filed within three years), and significantly narrows ISDS scope between the USA and Mexico.

Regional Comprehensive Economic Partnership (RCEP)

Signed in November 2020, this Asia-Pacific Region FTA first involved 16 countries, including the Association of Southeast Asian Nations (ASEAN) members and the six countries that have existing trade agreements with ASEAN (Australia, China, India, Japan, the Republic of Korea, and New Zealand). India opted out of RCEP in November 2019. RCEP is often portrayed as competition to the more American-centric original TPP and was intended to reflect the diverse needs of its member states, which include a significant number of LMICs. More recently, the RCEP has reportedly grown to more closely resemble the CPTPP; as of May 2021, it awaits full ratification before entering into force.

Trade in Services Agreement (TiSA)

A proposed FTA covering trade in services (such as banking, healthcare, and transport), currently involving 50 mostly high- or middle-income countries. Negotiations were initiated in 2013 by a handful of countries responsible for over half of all global services trade (primarily the USA, the EU, and Australia), which were unhappy with lack of progress under the WTO General Agreement on Trade in Services. Leaked drafts show that TiSA is a complex agreement that applies to all sectors except those which governments explicitly exclude and includes multiple annexes, all intended to create an ambitious treaty that could pose risks to public services, especially if governments decide to rescind privatization experiments that prove to be too costly or inequitable. TiSA negotiations have been stalled since 2016.

Source: Adapted from McNamara et al. (2021a) and Gleeson and Labonté (2020).

WTO+ and weaker government regulatory powers

Trade rules are commercial rules, aimed at promoting economic exchanges between countries. For the past 40 years of neoliberal policy dominance, the rationale for deeper trade liberalization has been the pursuit of continuous economic growth and trickle-down poverty reduction, neither of which have produced equitable or environmentally sustainable outcomes. In this pursuit, trade rules aim to prevent government policies and regulations from becoming “unnecessary obstacles to international trade” (Gleeson and Labonté 2020). Apart from TRIPS (and TRIPS+) agreements (see Chapter B4), several WTO agreements that have been WTO-plussed in recent FTAs could challenge new public health measures. The WTO Agreement on Sanitary and Phytosanitary Measures (SPS) sounds like a health agreement, but it is not. Its intent is to ensure that government

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health regulations do not interfere “unnecessarily” with trade. It does so by requiring that such regulations be consistent with the WHO/FAO-managed Alimentarius Commission (“Codex”). Countries can exceed the Codex standard only if they have a scientific justification, but with some allowance for the “precautionary principle” to err on the side of health when there are new hazards with only limited scientific evidence. FTAs are toughening up this provision, requiring governments to provide “documented and objective scientific evidence” for any new regulation exceeding an international standard. This weakens the precautionary principle, something usually invoked by the EU and which the USA has never liked. The United States/Mexico/Canada Agreement (USMCA) goes further, calling on parties to strive to achieve the same standards and to provide detailed information on any new regulation that could impede trade. The WTO Technical Barriers to Trade Agreement (TBT) already requires governments to implement only those measures that are “less trade restrictive”; it is the agreement that has been the source of most health-related trade challenges or formal disputes at the WTO. The TBT defers to international standards, such as Codex, meaning that if a country’s new regulation uses that standard it would be considered in compliance with the TBT. Apart from criticisms that Codex is dominated by industry, the Comprehensive and Progressive Agreement for Trans-Pacific Partnership’s (CPTPP) and USMCA’s TBT+ requires countries to cooperate to ensure that any new international standard does not become a possible trade barrier, before being agreed upon. This will likely have a chilling effect on new health and environmental standard setting. Both the CPTPP and USMCA also open the door to more private corporate involvement in setting new health or environmental regulations, risking “regulatory capture” by vested economic interests (McNamara et al. 2021a). Trade in services was already important with the birth of the WTO and its General Agreement on Trade in Services (GATS). The health concern with GATS is the extent to which decisions to liberalize certain sectors overlap with government policies to increase privatization (notably in healthcare, social protection, and environmental services such as water), making it extremely difficult for governments to reverse privatization decisions if they prove inequitable or unpopular. This is of particular concern given the extent of initiatives to increase private sector participation in many government-provided services (see Chapters B1 and B3). The WTO’s GATS used a “positive” approach to liberalization: only those sectors that governments chose to liberalize fell under the agreement. Many countries have chosen not to commit their health, education, or social services under GATS. GATS+ in FTAs, however, use a “negative” approach, where all services are considered liberalized except those which governments specifically exclude. Negative listing increases the risk that negotiators inadvertently fail to exclude a service they did not intend to liberalize. With the rise in e-commerce, FTAs also prohibit localization policies requiring digital data to be stored within the country of origin, something considered to be important

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in terms of privacy protection. Although government-collected data may be excluded from this requirement, most other digital data is not. With tech giants moving increasingly into health services commerce and personalized healthcare it is likely that such firms will “harvest” non-excluded health records from other countries for commercial purposes (see Chapter B2). Although much of the trade and health policy attention has shifted to the proliferation of bilateral and regional FTAs, the WTO is far from being left out. Rather, developed country WTO members began negotiating voluntary “plurilateral” agreements covering many of the liberalizing issues (services, investment, e-commerce) initially opposed by many developing country WTO members. The game plan here, as with new bilateral and regional FTAs, is for these plurilateral agreements to become part of the multilateral WTO system, eventually binding on all WTO members (apart from some transition periods for developing and least developed countries). The scope of these new agreements, and their health equity implications, are potentially troubling (see Box D2.1).

Box D2.1: Health implications of WTO plurilateral negotiations A number of WTO member countries have begun plurilateral negotiations at the WTO on a range of topics, without any legal mandate and without releasing the negotiating text to the public. Below are highlights of some of the main plurilateral proposals in leaked negotiating texts that can harm health.1 The services domestic regulation disciplines (DRD) plurilateral negotiations involves 64 members. The text is largely concluded and members are now deciding which service sectors the DRD will apply to. The aim is to have concluded the negotiations by the 12th WTO Ministerial Conference (MC12) which will be held from November 30 to December 3, 2021.2 The services DRD agreed text to date3 applies to the service sectors the participating members have liberalized at the WTO4 and possibly additional sectors, and includes: • Restrictions on authorization/licensing fees which can be charged in the service sectors covered by the rules to those that are reasonable, transparent, and do not restrict the supply of the service. Governments (including at the municipal or provincial level) may use annual authorization fees (e.g., for casinos) for revenue to fund public health clinics or other public services. Such cross-subsidization may no longer be possible for countries in the plurilateral DRD negotiations because doing so could be seen as restricting the supply of the service. • To the extent practicable and in a way consistent with its legal system, participating members must: a) allow companies (including foreign

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companies) a reasonable opportunity to comment on proposed laws and regulations and b) consider those comments. There is no specific exception in the DRD text to keep certain companies at arm’s length (e.g., alcohol/junk food/tobacco companies). How this might affect countries wanting to abide by recommendations under Art 5.3 of the WHO’s Framework Convention on Tobacco Control (FCTC) to restrict interactions with the tobacco industry only to the extent necessary for effective regulation is unknown (WHO Framework Convention 2008). • Laws and regulations for services licensing must be based on objective and transparent criteria. The WTO jurisprudence could mean fixed requirements such as maximum prices for water or tobacco/alcohol control requirements are not permitted and subjective regulations such as “affordable” prices for health insurance may also not be permitted (Smith 2017a). A footnote tries to clarify that health and similar regulatory requirements would be allowed, but it is not clear whether affordable water would be a “health” requirement. • A health exception would apply to these rules; however, it is part of the General Agreement on Tariffs and Trade/General Agreements on Trade in Services (GATT/GATS) exception which requires so many tests to be passed that governments involved in a WTO dispute have only succeeded once in 44 attempts to invoke it (Public Citizen 2015). The investment facilitation (IF) plurilateral negotiations involve about 106 members. There is already a consolidated negotiating text and a substantive outcome is expected by MC12 (WTO Investment Facilitation for Development 2021). The proposed IF rules (World Trade Organization 2021b) would apply to all service sectors as well as to non-service sectors like manufacturing and agriculture. Equivalent rules have been proposed to DRD to: • restrict authorization fees • require investment authorization laws and regulations to be based on objective and transparent criteria • allow and consider comments by all companies and • incorporate the general health exception in GATT/GATS. Eighty-six members are involved in the e-commerce plurilateral negotiations and they have already reached agreement on some aspects of the consolidated text like e-signatures (World Trade Organization 2021c). The proposed plurilateral e-commerce rules include (World Trade Organization 2020a): • Complete liberalization of advertising services. This would mean that participating countries could not ban or restrict tobacco, alcohol, guns,

SHIFTING PLAYING FIELDS  |   347 prescription medicine, and junk food advertising, as some countries did when liberalizing advertising under the WTO GATS. The requirement for full advertising liberalization is also contrary to the FCTC requirement to ban tobacco advertising (World Health Organization 2003, art. 13). • Participating members must allow data (including personal health data) out of their countries. Since countries like the USA do not adequately protect the privacy of personal data including health records, once health data is in the USA health insurers can buy records from pharmacies to find out which are the sickest 5% of the population (who are responsible for almost half of health costs) to avoid insuring them, or instead use that information to charge them more for coverage.5 Australia, among other countries, does not allow health records to leave the country so that its stronger domestic privacy law applies (Smith 2017b). • Restrictions on checking source code (software), e.g., in cars which have fatal crashes, or hackable pacemakers/insulin pumps (Smith 2017c). • Deregulating e-signature provisions, leaving it up to health insurers and hospitals whether their IT systems should be interoperable. This means that requirements in US laws that the same system should be used to reduce paperwork and save time and money would not be allowed (Smith 2018). As with the other plurilateral agreements, incorporating the challenging general health exception in GATT/GATS. Countries wishing to join the WTO must obtain the consent of all existing WTO members. Acceding countries are usually asked to agree to more than the standard WTO rules require (e.g., increased intellectual property [IP] protection on medicines), and joining “voluntary” WTO plurilaterals. Based on past WTO accessions, (World Trade Organization n.d.) the 23 countries in the process of joining the WTO are likely to be asked for a variety of commitments that can harm health, such as greater IP protection on medicines, tougher restrictions on services regulation, as well as possibly liberalizing advertising services.

Beyond WTO+: new trade regimes

Some bilateral and FTAs are introducing new regimes outside of the multilateral WTO, with chapters covering labor, environment, and regulatory cooperation. The first two are usually marketed as progressive improvements in trade treaties, while the third poses the risk of regulatory capture. In 1995, only three FTAs had labor provisions; by 2016, the number had reached 77 with the major proponents being the USA and EU. US-dominated FTAs rely upon reference to the International Labor Organization (ILO) 1998 Declaration on Fundamental Principles and Rights at Work. A limitation is

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that the Declaration concerns only “respect” for its core principles, whereas the ILO’s eight Core Conventions have legally binding obligations (see Global Health Watch 5, Chapter C4, for an early discussion of this issue). The CPTPP does add that each signatory country “shall adopt and maintain statutes and regulations … governing acceptable conditions of work with respect to minimum wages, hours of work, and occupational safety and health” (Global Affairs Canada 2017, 19.3.2). But there is no minimum requirement; it is up to each country to set the levels they think appropriate. In theory this creates a “floor” below which a country’s labor standards should not fall, protecting trade from becoming a “race to the bottom.” But there are no incentives to improve working conditions, and even the USA is not abiding by several of the labor rights in the ILO Declaration (Cimino-Isaacs and Villarreal 2020). Moreover, labor obligations are only violated if a country, in failing to uphold its existing laws, affects trade or investment between FTA member countries. Labor measures in EU-led FTAs go beyond the ILO Declaration and refer to the Core Conventions. Disputes over labor violations, however, rely on cooperative mechanisms regarded as largely ineffective (McNamara et al. 2021b, 2). There is some evidence that labor chapters in FTAs may improve minimum wage levels for workers, but the findings are mixed. The USMCA requires Mexico to allow independent trade unions which could strengthen the bargaining power of organized labor and subsequent wage rates. Three complaints have so far been lodged under an enforceable “rapid response labor mechanism.” The first was by Mexican women migrants who filed a complaint that the US government was failing to enforce gender discrimination provisions in the labor chapter (DiCaro and Macdonald 2021). In May 2021, unions and labor activist groups in the USA and Mexico initiated and were successful in a second complaint over a US auto parts company in Mexico that was interfering with independent union organizing (Stone and Verdi 2021). A third complaint led to Mexican workers at a General Motors truck plant voting against an earlier imposed agreement, paving the way for independent union organizing (Solomon 2021). Whether these labor victories translate into better pay and working conditions remains to be seen. The USMCA, however, is also unique in being the first trade agreement to include a minimum wage obligation. It stipulates that at least 40% of auto components traded between the three countries (the USA, Mexico, and Canada) must be made in factories paying at least $16/hour to qualify for duty-free treatment (Harrison 2019), which is three times the average wage currently paid in Mexican factories. Some observers think the requirement is more to appease US labor than to improve Mexican working conditions, and exports to the USA that do not comply with this standard will be subject to a 2.5% tariff, negligible compared to the cost of meeting the treaty’s hourly wage minimum (Labonté et al. 2019). Similar weaknesses exist in FTA environment chapters, which, like labor chapters, began popping up in FTAs in the 1990s with politicians celebrating

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their inclusion as evidence that international trade was becoming more responsive to social concerns and civil society criticism. FTAs generally refer to existing multilateral environmental agreements (MEAs). The main provision to which governments must commit is to uphold their existing MEA commitments and not to lower them in a way that affects trade or investment. In the CPTPP, even if they are found to do so, there is no formal dispute settlement, only consultation. The USMCA does allow for formal disputes but only if lowering a standard affects trade. A post-signing “Protocol” did clarify that if there is a conflict in obligations under a MEA and any provision in the USMCA, the MEA obligations prevail, which puts a bit of a floor in some countries’ push to deregulate environmental standards. Remarkably, environment provisions in most FTAs are silent on climate change and greenhouse gas emissions. An Organization for Economic Co-operation and Development (OECD) study found no statistically significant improvement in air pollution measures in countries with environmental chapters in their trade agreements compared to those without (Yamaguchi 2018), begging the question: how good are they? But there has been one positive development: some FTAs require bans on subsidies to fishing fleets that work in overfished waters – something the WTO has been unable to reach multilateral agreement on after 20 years of trying (International Institute for Sustainable Development 2021a). One could view labor and environment provisions in FTAs as baby steps forward (where giant strides are needed), or as window dressing to make new trade treaties more politically palatable, or as simply the wrong place to create rules governing how economies should function with respect to workers’ right or protection of the environmental commons. At best, they do no (or little) health harm. There is now even momentum to introduce gender relations as a trade policy issue, under the banner of ensuring that trade improves gender equality and women’s economic empowerment (see Box D2.2).

Box D2.2: Trade treaties and women’s economic empowerment: a healthy gain or just more window dressing? Trade and investment rules and agreements normally contain no reference to gender inequities. And, until recently, there was little consideration of how trade relations might affect men and women differently. But, just like the economy, trade is gendered – trade has an impact on gender relations, often working to exacerbate existing differences, and forms of inequity and exclusion. Trade liberalization, the reduction of barriers to imports and exports, has been a key element of globalization, which has often had a negative effect on women, although in an uneven fashion. In recent years, various actors – states, international organizations, academics, and civil society groups – have begun to examine the ways in which

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trade may affect gender relations, and how these effects can be mitigated or overcome. For example, over 120 WTO members have signed on to the Buenos Aires Declaration on Women and Trade, which was launched in 2017 at the eleventh WTO Ministerial Conference. The declaration acknowledges “the importance of incorporating a gender perspective into the promotion of inclusive economic growth, and the key role that gender-responsive policies can play in achieving sustainable socioeconomic development” and that “inclusive trade policies can contribute to advancing gender equality and women’s economic empowerment, which has a positive impact on economic growth and helps to reduce poverty” (World Trade Organization 2017). The relationship between trade liberalization and gender inequalities is complex, and difficult to pin down using the standard macroeconomic tools used by policymakers, particularly when there is insufficient genderdisaggregated data available. The difficulty in evaluating trade impacts is compounded by the importance of examining this issue in an intersectional fashion – looking at how gender, race, ethnicity, sexual orientation and gender expression, age, ability, location, and other dimensions of inequality interact (see Chapter A2). Feminist economists, however, argue that there are several ways in which women and other marginalized groups may be disproportionately and negatively affected by trade liberalization. First, opening markets to liberalized trade benefits sectors that export, while often disadvantaging economic sectors that produce primarily for the local or national markets. In general, women-owned businesses are much less likely to export than male-owned businesses or male-operated businesses. Secondly, women are affected as workers in the formal and informal sectors. Globalization has been associated with an increase in women’s participation in waged work, which might be expected to benefit them and increase their power and status within the household. Countries like Mexico, Haiti, Morocco, Colombia, Kenya, Bangladesh, China, and Vietnam recruited large numbers of women workers in labor-intensive export sectors like electronics, textiles, and agriculture, in part because firms could pay women less than men, and because they were expected to behave in a more docile fashion because of their traditional socially constructed gender roles. Workers in these sectors often receive low wages and benefits and are subjected to sexual discrimination, harassment, and violence. Beyond the impact of trade on women’s employment, other aspects of women’s lives may be affected by changes in trade policy. Trade liberalization may disrupt sectors and markets where women are active, thus jeopardizing their employment and pushing them into unregulated and poorly compensated jobs in the informal sector. The rollback of public services as

SHIFTING PLAYING FIELDS  |   351 a result of liberalization of services trade can also add to women’s workload, who traditionally are responsible for much of this service provision. It is important to note that these policies have a more pronounced impact on the most vulnerable women: women of color, Indigenous women, (im)migrant women, and women with disabilities. Agreements to open up economies to greater levels of foreign investment can negatively affect Indigenous women through the increase in investment in the mining sector, since women are less likely to gain employment in this sector, and their health can be affected by pollution of water sources as a result of the use of chemicals like sodium cyanide to refine minerals (see Chapter C4). The potential negative impacts of trade liberalization on gender relations are now commonly recognized, but there are profound differences about how to reduce the negative impacts and increase the positive ones. Many governments try to promote greater access of women-owned businesses to trade opportunities through training, networking, and provision of export credits. While such measures may help individual businesses, they do not have a significant impact on the situation of most women. One newer approach adopted by the Canadian government is the inclusion of separate gender chapters in new trade agreements. These chapters promote the development of cooperation and sharing of best practices to promote women’s economic empowerment and participation in the benefits of trade. Canada has included such chapters in recent agreements with Chile and Israel. Feminists have criticized these agreements, however, arguing that the objectives expressed in these chapters are purely aspirational, and that they lack the ability to enforce compliance through sanctions, as is common in most provisions in trade agreements. Other measures that have been considered and promoted are improved consultation with women and feminist organizations, improved evaluation of the gender impact of trade, especially through greater availability of genderdisaggregated data. The Canadian government has also begun mainstreaming gender-related provisions in other sections of trade agreements, including labor chapters. Here, the Trudeau government has pushed for inclusion of ILO core labor standards, including prohibition of gender discrimination in the workplace. This type of provision may be more effective in reaching less privileged women than many other policies that have been adopted so far but will neither reach women working in the informal sector nor unwaged women performing essential care work. Feminist organizations around the world have rejected the dominant approach adopted by governments and international organizations like the WTO. In 2018, the Gender and Trade Coalition, made up of over 200 feminist organizations, networks, and allies, including many based in the

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Global South, issued a critique of the impact of the Buenos Aires Declaration at the one-year mark: … since the issuance of the Buenos Aires Declaration, there has been a series of WTO-organised events which have … failed to ensure the meaningful participation of women’s rights organisations and civil society. Here it is key to remember that current trade policy impacts not just the women entrepreneurs on whom there seems to be overwhelming emphasis, but women as farmers, workers, patients, caregivers, environmental defenders, and so on. We do not see any attempt to understand the varied and complex impacts they face, most often unknowingly, from the current trade regime or to include them in these discussions.6 Doing the difficult work of incorporating gender concerns into trade agreements and trade relations has just begun. It is crucial that such efforts not act as a fig leaf on otherwise harmful trade agreements but serve as an entry point into serious consideration of how trade can be made more beneficial to women, men, gender-diverse people, and the planet.

The same cannot be said for the intrusion of new rules on regulatory coherence. TBT/TBT+ and SPS/SPS+ agreements, as noted earlier, already impinge upon governments’ regulatory space to prevent “unnecessary” obstacles to trade. A recent innovation has been the inclusion of whole chapters in FTAs governing “regulatory coherence,” with the CPTPP and the USMCA having the most detailed provisions. The CPTPP sets out a long list of requirements on how governments develop, publicize, or inform about new regulations they are considering. These requirements are likely to slow down regulatory development, perhaps “chilling” such efforts as being too troublesome. But they are not enforceable under dispute settlement rules, and so are more statements of parties’ intent to reduce differences in their regulatory standards to prevent such standards getting in the way of trade. The USMCA regulatory chapter’s commitments are more extensive and enforceable through state-to-state dispute settlement. The intent of these new chapters is to harmonize possible regulations between countries that are party to the trade agreement, but the issue then becomes: which country’s regulations should set the harmonized standard? Will this lead to improved, or lowered, standards across harmonizing countries? Already the US plastics industry is lobbying against Canada’s intention to ban plastics, which the industry believes may be contrary to the USMCA’s regulatory chapter. Similarly, the US processed food industry is using both the WTO TBT and the USMCA regulatory chapter to lobby against Mexico’s front-of-pack

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food labeling (see Chapter C3). The processed meat industry in Canada and the USA is making the same argument in opposing Canada’s proposed frontof-pack food labeling.7 International investment agreements (IIAs)

The USMCA surprisingly eliminated one of the North American Free Trade Agreement’s (NAFTA) more controversial provisions: its investment chapter. This applies only for disputes involving Canada and the USA, while limiting its scope for disputes involving Mexico. The (still untested) scope of the agreement’s regulatory chapter may become the new means by which foreign companies, via their governments in state-to-state disputes, challenge new regulations affecting the value of their investments. NAFTA’s 1994 investment chapter was the first one in an FTA and became the model for many others that followed. But it was far from the first such treaty covering foreign investment. Between 1959 and 1989, 386 bilateral investment treaties (BITs) were concluded, approximately one per month worldwide, expanding rapidly in the early 1990s (the peak decade of neoliberal expansionism) to four per week. As of early 2021, an astonishing 2,336 BITs are in force and a further 323 treaties (FTAs, such as the CPTPP and USMCA) that contain investment provisions (United Nations Conference on Trade and Development (UNCTAD) 2021a), collectively referred to as IIAs (UNCTAD n.d.). The surge in IIAs follows capital’s (investment’s) need for continued expansion (profitmaking). In turn, as many of the West’s former colonies in Africa, Asia, the Pacific, and the Caribbean became independent states, their desire to industrialize and develop their domestic economies needed capital in the form of foreign investment. But HIC investors were wary that these fledgling governments might choose to nationalize the industries in which they invested (mostly in mining and fossil fuel), and that their national courts may be prone to political capture denying foreign investors just settlement. These may be reasonable concerns but are hardly unique to “developing” countries. Nonetheless, to address this concern, IIAs created a system whereby foreign investors could directly sue governments for direct expropriation of their assets (seizure with or without compensation) and indirect expropriation (where government measures destroy the value of the investment or the ability of the investor to manage, use, or control it). A third provision in most IIAs obliges governments to treat foreign investors “fairly and equitably.”8 Investor-state disputes settlements (ISDS) are decided upon by specialized tribunals, panels generally comprised of three investment lawyers representing the investor, the country being challenged, and a third “chair” selected by the other two. Because there is no precise or consistent definition for many of the IIA provisions, especially of the fair and equitable treatment (FET) obligation, interpretation is largely a matter of tribunal discretion. Tribunal meetings are confidential, and decisions are final, although the amount of awards can be challenged. Although

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there have been some procedural improvements made in recent treaties, there are major concerns over lack of transparency and conflicts of interest among tribunal members who can – and do – work on both sides of the fence. IIAs and their ISDS system have been extremely controversial as foreign investors have increasingly used the system to challenge a wide array of public policy measures, including measures on taxation, chemical and mining bans, environmental restrictions, transportation and disposal of hazardous waste, health insurance, the price and delivery of water, and regulations to improve the economic situation of minority populations (Bernasconi-Osterwalder et al. 2012). Since ISDS was first discussed in Global Health Watch 5 (Chapter D2), the number of disputes continued to rise and only began to decline slightly in 2019. The value of awards granted by tribunals, however, continues its upward trajectory, with two multibillion awards made in 2019 ($5.9 billion in Tethyan Copper v. Pakistan, and $8.4 billion in ConocoPhillips v. Venezuela). In the Pakistan case, the tribunal’s finding was based on the country’s denial of a mining license following the company’s preliminary explorations. The denial was considered to be an indirect expropriation. An example of one the main criticisms of ISDS, the award was not based on the actual loss of the mining company’s original investment (around $150 million) but on its “legitimate, investment-backed expectations” of the profits that the mine would earn. Pakistan is seeking relief from the award, which would consume almost the entire amount of a $6 billion IMF stabilization loan the country received in 2019. Billion-dollar ISDS awards are rare, but the UNCTAD estimates the average award at $522 million (Labonté 2020). Other recent ISDS cases raise the health activist alarm. Some involve the Energy Charter Treaty, an agreement with investment provisions, which is the most frequently used agreement within the ISDS system with a massive 131 cases initiated related to energy and climate policy. Most recently, a German coal operator has initiated a €1.4 billion ISDS lawsuit against the Dutch government over a plan to phase out coal power, a decision compelled by the Dutch Supreme Court to protect Dutch citizens from climate change. Pulling out of the Energy Charter Treaty is a long-term solution, as the agreement will remain in force for 20 years, known as a sunset clause. This case is quickly becoming a focal point for civil society activism, much as the Philip Morris cases attempting (unsuccessfully) to sue Australia and Uruguay over tobacco control regulations did (People’s Health Movement et al. 2017). In recent years there has been a disturbing uptick in third-party financing of ISDS claims, especially in the wake of the 2008 global financial crisis and the search by speculative finance for new investment vehicles. Under “no win-no pay” agreements, speculators offer to finance ISDS claimants’ legal costs in return for 30% to 50% of the final award. Given that awards frequently dwarf the cost of litigation, even if many such cases rule in favor of the state, the returns to speculators can be significant. In one case, Burford Capital, which

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specializes in “litigation finance,” earned $140 million on a $13 million investment in financing a successful ISDS case involving Argentina’s renationalization of two previously privatized airlines (Dayen 2017). Contingency fee arrangements, whereby investment lawyers are only paid if they are successful in a case and on a percentage of award basis, are also becoming more common. The incentiveto-litigate nature of such financing arrangements is argued to be in conflict with the United Nations’ goal of promoting equal access to justice. Litigation investment firms have already identified the pandemic as “the beginning of a boom” with such firms receiving “a significant uptick in inquiries” from potential claimants (see Box D2.3) (Labonté 2020).

Box D2.3: Trade and the pandemic With borders closing and people locked down, it is not surprising that global trade took a nosedive. The WTO early in the pandemic estimated a 13% to 32% decline in overall trade in 2020 (McNamara et al. 2021b), although it later revised this upwards to a drop in merchandise trade of just over 9% (International Institute for Sustainable Development 2020). Much of the decline was a result of collapsing supply chains and a reduced consumer demand for finished goods. Services trade took a much sharper plunge, down by over 20% compared to 2019 and expected to continue worsening (World Trade Organization 2020b). For most LMICs, the recessionary impacts of such steep declines, alongside their own public health lockdown measures, have more direct and negative health effects than in HICs, where governments’ fiscal capacities could prop up affected workers and businesses, even if only partially. Although there are signs in early 2021 that trade volumes are on a slow uptick, global economic (and trade) recovery is expected to be “weak” with a long period of stagnant economic growth, especially if global COVID-19 vaccine herd immunity remains unattainable for several years (see Chapter B4). As earlier Global Health Watch 6 chapters argue, however, such growth (weak or strong) needs to be radically redistributive in favor of LMICs, and within global environmental limits. Trade is also likely to be dampened by a 42% drop in global foreign direct investment (FDI) in 2020, with a predicted ongoing decline of 5%–10% in 2021 (United Nations Conference on Trade and Development 2021b). To the extent that FDI in LMICs creates decent employment (a questionable assumption) the decline in capital flows will negatively affect their economies. So, too, will be an estimated 14% decline in remittances (the money foreign workers send home) between the start of the pandemic and the end of 2021 and likely beyond (Ong 2020). The most direct trade-related health impact of the pandemic was in its early months when

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shortages in medical supplies and personal protective equipment (from face masks to ventilators) led many countries to impose export bans or restrictions. Such temporary measures are allowed under WTO rules, and most were relaxed by late 2020 when supplies improved. Conversely, many countries also introduced measures to reduce existing and allowable trade barriers, such as lowering tariffs on medical imports or suspending excise or value-added taxes on such goods (World Trade Organization 2020c). The pandemic is also incentivizing many countries to “re-shore” (or shorten) global supply chains for essential goods, notably medical supplies, drug treatments, and vaccine production. Some WTO member states are suggesting that amendments should be made to trade agreements to limit future export or import barriers on medical and other essential goods in future pandemics or other health crises. While not inherently unreasonable, the proposals make no mention of the temporary TRIPS waiver request initiated by WTO developing country members to increase global supplies of COVID-19 vaccines, drugs, and medical supplies, and are being promoted by countries that are opposed to the waiver (World Trade Organization, General Council 2020) (see Chapter B4). A festering pandemic issue concerns FDI, specifically the likelihood of ISDS challenges to many of the pandemic actions taken by governments. Although only one has been initiated (as of April 2021), a suit for compensation to Santiago airport investors for losses due to pandemic-related decline in international travel (International Institute for Sustainable Development 2021b), over 60 corporate law firms have sent circulars advising their clients to consider suing governments over pandemic policies that may have lowered the value of their foreign investments, or even just investors’ expectations of that value. Many governments COVID-19 measures are potentially at risk of an investment dispute, ranging from travel bans, requisitioning hotels or facilities, mandating medical supply production, regulating prices of essential goods, suspending payments (rents, mortgages, utilities), tax measures, and even lockdown rules (Labonté 2020). This risk is aggravated by the recent entry of hedge funds (speculators) as third-party funders willing to pay the hefty corporate legal fees for investors who launch such suits, in return for half the financial award if the suit is successful (ibid.). Hundreds of non-governmental organizations (NGOs), scores of leading economists, and several UN organizations are calling for a moratorium on all ISDS activities during the pandemic, and an intergovernmental declaration exempting all future ISDS claims related to the pandemic. That such a risk nonetheless exists buried in the legal texts and procedural shortcomings of many investment treaties is one more reason why international investment law needs a thorough overhaul, as discussed elsewhere in this chapter.

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Efforts from advocacy groups across the globe, particularly in relation to ISDS, have helped put the international investment system under the microscope and initiated a comprehensive process of reform under the auspices of the United Nations Conference on Trade and Investment Law (UNCITRAL). While reforms started with a narrower focus on matters of procedure and arbitration (such as the introduction of the more transparent “Investment Court System” in the Comprehensive Economic and Trade Agreement (CETA)), the agenda has been expanding, and states are increasingly advocating for more substantive rule reform (Roberts and St. John 2019). Widespread disapproval of the use of ISDS to challenge legitimate public policy in the Australia and Uruguay tobacco cases has been instrumental in the reform process. The CPTPP, for example, includes an optional “carve-out” of tobacco measures from ISDS. Ultimately, this is a narrow protection that applies only to tobacco and only under this one agreement (leaving all previous agreements between members in play). More ambitiously, the Peru–Australia Free Trade Agreement, which entered into force in 2020, includes a provision in its investment chapter, stating that “No claim may be brought under this Section [ISDS] in relation to a measure that is designed and implemented to protect or promote public health” (Australian Government 2020). The EU and Canada, building on their (not yet ratified) Investment Court System, are pushing for a new plurilateral and then multilateral investment agreement under the aegis of the WTO. While such an agreement could prevent “treaty shopping” by investors, their lawyers, and their third-party funders, it would need to exclude all non-discriminatory government measures related to health, social, fiscal, and environmental conditions, and allow governments to require new investments to conform to their country’s economic, human, and sustainable development goals. Given that an increasing number of LMICs are notifying their intent to withdraw from (or not renew) investment treaties under the present system (they are not gaining much by way of increased FDI and risk losing considerably in disputes) such a paradigmatic shift in IIA rules in the near future is imaginable. In the UNCITRAL reforms some countries have been very ambitious in their attempts to rebalance public and private interest in the investment system. For example, in its submission to the reforms, South Africa noted that “Promoting and attracting investment should not be an end in itself, but a step toward realizing the broader objectives of the SDGs and human rights obligations, such as reducing poverty and hunger, empowerment of Indigenous peoples, promoting decent work, and reversing environmental degradation and climate change” (Government of South Africa 2019). Geopolitics of trade and investment

What of the post-pandemic future of trade and investment treaties? Any answer to this question rests on the dynamic changes occurring in the geopolitics of global

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power. Mercantilism (the centuries-old practice of states actively promoting the interests of their own industries in international trade) still largely defines how nations engage in trade and investment rule making. This largely unacknowledged practice was brought into media glare with the Trump administration’s “America First” policy, which intensified the US shift away from multilateral trade negotiations to bilateral trade agreements. When Trump withdrew the USA from the TPP and ceased trade talks with the EU, his administration instead focused on increasing tariffs on imports from several US trade partners (trade rivals) on goods such as solar panels, steel, and aluminum. Much of this targeted China, instigating an escalating tariffs “trade-war” between the two countries. Econometric analysis of the impacts of the US tariff exchange with China indicated a reduction in US trade income and a significant cost to US consumers (Amiti et al. 2019). The new Biden administration quickly wound back some of Trump’s “America First” policies by re-joining multilateral negotiations and agreements, including the United Nations Paris Climate Agreement and World Health Organization. The US approach to trade policy is still unclear; however, the Biden administration has indicated favoring trade deals which promote domestic US growth and which counter China’s rising influence (Lawder 2020). In keeping with its climate change emphasis, the administration is also arguing how trade and trade treaties need to strengthen environmental protections and not simply prevent an environmental “race to the bottom” (United States Trade Representative 2021b). The risk of a US/China trade war becoming something other than a spat about tariffs remains a critical global security concern with the pandemic providing cover for both countries (though now lifting in the USA) to pursue more aggressive and authoritarian nationalist politics. The Asia-Pacific region is likely to be a new geopolitical flashpoint with trade playing a part in the unfolding drama, especially if the USA rejoins the CPTPP. Two mega-treaties: one, the CPTPP, perhaps again dominated by USA and a few other HIC liberal democracies; and another, the Regional Comprehensive Economic Partnership (RCEP), overshadowed by the USA’s Chinese hegemonic rival. Several AsiaPacific countries are parties to both agreements, making for a potentially very messy “spaghetti bowl.” China is forecast to scoop up over 50% of the RCEP’s projected increased export earnings, though it may also feel competition from RCEP HICs (Japan, Australia) that are exporting high-end products, and from RCEP LMICs with their low labor-cost advantages (Nian 2021). This, and competition from the CPTPP, is likely to incentivize China’s “Belt and Road” initiative’s move further west, where its trade and investments already reach many Middle East and African countries. China’s use of “vaccine diplomacy” in the pandemic era is one more element in its efforts to enhance its geopolitical influence, although a January 2021 survey indicates that most ASEAN country respondents would still favor the USA over China if they had to pick sides in their ongoing trade and economic rivalry (Shotaro Tani 2021).

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The EU exercises its geopolitical power primarily through its trade policy focus on bilateral agreements. It signed the world’s largest bilateral agreement with Japan in 2018, doubled its agricultural exports to Latin American countries, and doubled its trade with sub-Saharan African countries through its regionally based “economic partnership agreements” (EPA) (European Union 2020, 17). Intended to include ambitious trade and services liberalization commitments, only one region (the Caribbean) saw all members ratify their EPAs. Under the threat of losing preferential access to the EU market, several low-income African countries ratified bilateral EPAs with the EU. West African countries also agreed as a region in 2014, but Nigeria (the largest country in the group) has so far refused to sign. Overall, only 13 African countries are implementing an EPA, 12 are not, and the group of “least developed countries” are still exempt from pressures to do so. Similarly, only 3 of 14 countries in the Pacific Island group have ratified an EPA (“EU-ACP EPAs” 2020). The reason for such enduring hesitancy is acknowledged in a European Parliament brief: “[EPAs] are the first attempt to liberalize trade between economies with such a disparate level of development, which … possibly explains the difficulties encountered during the negotiations” (Zamfir 2018). Civil society development organizations and trade unions have long opposed the EPAs, which modeling suggests will disproportionately benefit EU exporters with only much longer-term industrialized benefits flowing to LMICs (Marí 2018). Some view the agreements as little more than a new form of colonialism, given that all the EPA countries are former European or British colonies. The African Union, in the process of implementing its own continental free trade agreement, is now positioning itself to be the main player in overhauling EPAs for the entire continent to give greater export and industrial development benefit to is member states. Some EU countries, such as Germany, believe the EPAs should be re-opened or scrapped entirely (Fox 2021). The world-as-geopolitics has transitioned from bipolar (the Cold War years) to unipolar (the brief period of the touted history-ending triumph of (neo) liberal global capitalism) to a fluctuating multipolar world (the USA, Russia and its satellites, China, the EU). India’s geopolitical positioning in this group is less obvious. Its decision to withdraw from RCEP de facto increases China’s dominance in intra-regional trade and, like other powerful nations, it is focusing on an “India first” economic strategy in which bilateral trade and investment treaties are regarded as more flexible for protecting their domestic manufacturers (Roy Choudhury 2020). The price of that may be a loss in its economic and strategic influence in the region, although its role as “pharmacy of the world,” in addition to COVID-19 vaccine diplomacy, is increasing its presence globally, notably in Africa where China already has significant sway (Banik and Modi 2021). All geopolitical actors in the multipolar world face human rights and domestically divisive challenges intersecting with trade and investment. The USA is

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still recovering from the Trump era and remains politically polarized. Russia’s Crimean expansionism has increased tensions with the EU, its main trading partner, while the country is experiencing its highest level of internal dissent since the dismantling of the USSR (European Commission 2021). China is facing sanctions from many of its HIC investors and trading partners over its treatment of its Uyghur minority (Wintour 2021). India is experiencing opposition from its farmers over policies to create foreign-invested and industrialized agriculture9 (Huang 2021), while its swerve towards Hindu nationalism is increasing domestic division and risks escalating conflict with its Muslim neighbors (Bandow 2019). Reforming the agenda

Geopolitics are hard to avoid when considering how trade and investment rules might be reformed for equitable global health benefit. As with many progressive global reforms of past decades, however, such reforms are more likely to rise from civil society activism (see Box D2.4), groups of like-minded “middle power” nations, and organized LMIC advocacy, than from the world’s mega-powers. From wherever they emanate, they will need to advance reform agendas that include: • Fuller transparency and public/political participation in negotiations as they proceed (and not simply in the run-up to new treaty initiatives). • Assessing health, social, environmental, and labor market impacts of treaties before they are signed or ratified. • Full carve-outs from all treaty provisions for all non-discriminatory government measures affecting economic or health equity outcomes, food security, and occupational and environmental protection, and for services that are wholly or partially publicly funded or provided. • No TRIPS+ provisions and a critical review of how effective or necessary to innovation in the health sciences (research and development) is the current TRIPS regime of patent protection. • No ISDS provisions apart from those affecting direct expropriation of investors’ assets without reasonable compensation, and only if it can be demonstrated that domestic courts are unable to effect a fair ruling. • Required ratification of the Paris Accord on Climate Change and all new multilateral environmental agreements. • Required ratification of the eight core ILO conventions with incentives for upwards harmonization of domestic labor laws. • Flexibilities for governments to impose performance requirements in their contracts with foreign investors, or for foreign bids on government procurement contracts (Labonté and Ruckert 2019).

SHIFTING PLAYING FIELDS  |   361 Box D2.4: Public health activism Health activists have long joined with other civil society organizations (CSO) pushing back against trade and investment agreements whose rules could imperil health. One of the first of these challenged the attempt by members of the OECD, the club of rich nations, to create a binding Multilateral Agreement on Investment (MAI) granting corporations and investors unconditional rights to engage in financial operations worldwide. The MAI would allow foreign investors the right to sue governments for policy changes that affected the value of their investment – a right that existed in earlier bilateral investment treaties and can now be found in most FTAs. MAI negotiations were abandoned in 1978 after fierce CSO opposition. More recently, with the number of bilateral and FTAs increasing, health activists began focusing on new treaties as they were being negotiated. This posed challenges, as trade negotiations are not public and CSOs must rely upon leaked documents, reports, and potential contents of new treaties based on recently completed ones. Many public health groups began undertaking health impact assessments (HIAs) of new FTAs, focusing on the potential impacts of WTO+ rules related to “technical barriers to trade,” “sanitary and phytosanitary measures,” “TRIPS+,” “investor-state dispute settlement,” and wholly new agreements on “regulatory coherence,” “labor,” and “environment” (McNamara et al. 2021a; 2021b). In undertaking these HIAs, a paramount concern has been the extent to which WTO and newer WTO+ provisions could limit governments’ “policy space” to introduce regulations to protect public health. A key area of interest has been “unhealthy commodities” – tobacco, alcohol, and obesogenic (highly processed) foods (Friel et al. 2013) (see Chapter C3) – but also more systemic issues related to economic development (who benefits, effects on employment) and environmental impacts. In many cases, such as with the CPTPP and the USMCA, preliminary HIAs based on leaked documents were amended once final signed agreements were publicly released. Activism on trade issues also shifted from earlier street protests of general opposition (though these still exist) to media campaigns and formalized advocacy in efforts to have new treaty rules be more health protective. Some examples include: • CPTPP optional exclusion of any tobacco control measures from ISDS rules, following successful opposition to efforts by Philip Morris to sue Australia over its plain-packaging law. • CPTPP suspension of many TRIPS+ provisions after the USA (which had insisted on these provisions) withdrew from the agreement.

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• CETA changes to its ISDS rules in response to criticisms and procedural weaknesses in the dispute panel arbitration system (although still regarded as imperfect and yet to be ratified by all EU member states). • US withdrawal of its demand to ban front-of-pack nutrition labeling in the USMCA when information of this demand was leaked, generating immediate public health outrage in all three negotiating countries. • USMCA elimination or weakening of ISDS rules (notwithstanding a three-year period for new “legacy claims” to be made) following two decades of public health and CSO criticism. • Weakening of some agreed upon TRIPS+ measures following CSO and political criticism by the Democrat-controlled US Congress prior to USMCA ratification. • Absence of most draft TRIPS+ rules in the final RCEP agreement, following regional public health advocacy campaigns (Third World Network 2016) and a deferral of any decision on ISDS rules allowing for now only state-to-state investment disputes (Ewing-Chow 2020). The RCEP agreement was a catalyst for civil society networking and social movement mobilization, both within countries and within the wider Indo-Pacific region. Movements played a key role in India’s withdrawal from the agreement in late 2019, and in pushing several governments to allow civil society and public health presentations to the negotiators later in the negotiations, although this was limited and significantly less than industry access to negotiators facilitated from the beginning of the negotiations. Mobilization continues now against ratification in the member countries. Six ASEAN parties and three non-ASEAN parties must ratify the agreement before it enters into force. The above efforts represent small but important activist gains. Despite some of the downward changes in trade and investment flows due to the pandemic, new treaty-making continues and, with it, more public health attention to how such rules should be generically overhauled or temporarily re-worded to protect health now and into the future.

Fundamentally, new trade and investment treaties must be able to defend rigorously how their rules will improve health and well-being in an equitable way whilst preserving (indeed, remediating past damages to) the environmental commons. Liberalization and economic growth are no longer appropriate metrics by which such treaties should be adjudicated.

SHIFTING PLAYING FIELDS  |   363 Notes 1  The leaked negotiating texts for some of these plurilaterals can be found at https://www. bilaterals.org/?-other-292-. 2  The 12th WTO Ministerial Conference was postponed due to the outbreak of the Omicron variant of the coronavirus, that led several governments to impose travel restrictions. No date has been set for the rescheduling of the Conference at the time of writing. 3  See the draft text of the service DRD as of December 18, 2020 at https://www.bilaterals. org/?wto-plurilateral-services-domestic. 4  See which service sectors each country has already liberalized at the WTO in the schedules of commitments at https:// www.wto.org/english/tratop_e/serv_e/ serv_commitments_e.htm. 5  Frank Pasquale, The Black Box Society: The Secret Algorithms that Control Money and Information. Cambridge, MA: Harvard University Press, 2015.

6  Gender and Trade Network, “Letter on the Buenos Aires Declaration Anniversary.” n.d. Accessed May 31, 2021. https://sites.google.com/ regionsrefocus.org/gtc/letter-on-the-buenosaires-declaration-anniversary. 7  To obtain this information, consult https:// www.regulations.gov/docket/OMB-2018-0006/ document to request access to the relevant docket pertaining to Canada’s Regulatory Cooperation Council (RCC). 8  For a more detailed discussion of these and other IIA provisions, see Global Health Watch 5, Chapter D5, “Investment Treaties: Holding Governments to Ransom.” See: https:// phmovement.org/wp-content/uploads/2018/07/ D5.pdf. 9  In November 2021, following a yearlong protest by Indian farmers nationally, and internationally, the Modi government retracted its legislation. Committed and persistent activism can work.

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SHIFTING PLAYING FIELDS  |   367 World Trade Organization. 1994b. “Marrakesh Agreement Establishing the World Trade Organization.” https://www.wto.org/english/ docs_e/legal_e/04-wto_e.htm. World Trade Organization. 2001. “Doha Declaration on TRIPS and Public Health.” https://www.wto.org/english/thewto_e/ minist_e/min01_e/mindecl_e.htm. World Trade Organization. 2017. “Buenos Aires Declaration on Women and Trade Outlines Actions to Empower Women.” https:// www.wto.org/english/news_e/news17_e/ mc11_12dec17_e.htm. World Trade Organization. 2020a. “WTO Electronic Commerce Negotiations.” INF/ ECOM/52/Rev.1. World Trade Organization. https://www.bilaterals.org/IMG/pdf/wto_ plurilateral_ecommerce_draft_consolidated_ text.pdf. World Trade Organization. 2020b. “Trade Shows Signs of Rebound from COVID-19, Recovery Still Uncertain.” October 6. https://www. wto.org/english/news_e/pres20_e/pr862_e. htm. World Trade Organization. 2020c. “Standards, Regulations and COVID-19 – What Actions Taken by WTO Members?” World Trade Organization. https://www.wto.org/ english/tratop_e/covid19_e/standards_ report_e.pdf. World Trade Organization. 2021. “Regional Trade Agreements.” World Trade OrganizationWOrld Tr. https://www.wto.org/ english/tratop_e/region_e/region_e.htm. World Trade Organization. 2021a. “WTO Structured Discussions on Investment

Facilitation for Development.” INF/ IFD/RD/74. World Trade Organization. https://www.bilaterals.org/IMG/pdf/ wto_plurilateral_investment_facilitation_ draft_consolidated_easter_text.pdf. World Trade Organization. 2021b. “Joint Statement on E-Commerce: Further Progress Cited in E-Commerce Negotiations.” July 22. https://www.wto.org/english/news_e/ news21_e/jsec_22jul21_e.htm. World Trade Organization. n.d. “Protocols of Accession for New Members since 1995, Including Commitments in Goods and Services.” Accessed September 16, 2021. https://www.wto.org/english/thewto_e/ acc_e/completeacc_e.htm. WTO Investment Facilitation for Development. 2021. “DG Okonjo-Iweala Welcomes Progress on Investment Facilitation.” July 13. https:// www.wto.org/english/news_e/news21_e/ infac_13jul21_e.htm. Yamaguchi, Shunta. 2018. “Regional Trade Agreements and the Environment.” Presented at the OECD Workshop on Regional Trade Agreements and the Environment, Santiago, Chile, January 23. https://www.slideshare.net/OECD_ENV/ session-1-yamaguchi-oecd-regional-tradeagreements-and-the-environment. Zamfir, Ionel. 2018. “An Overview of the EU-ACP Countries’ Economic Partnership Agreements.” Briefing PE625.102. European Parliamentary Research Service. https:// www.europarl.europa.eu/RegData/etudes/ BRIE/2018/625102/EPRS_BRI(2018)625102_ EN.pdf.

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D3  |  THE UNITED NATIONS, GLOBAL GOVERNANCE, AND THE TOLL OF FUNDING FAILURES

Introduction

The United Nations (UN) is thought to be a huge organization with a system of funds, programs, and agencies to match its global role that spans the imperatives and pillars of peace and security, human rights, and sustainable development. However, it is surprisingly under-resourced for the work its member states mandate it to do. This chapter explores the nature and consequences of that misfit, as well as the power dynamics that perpetuate it. The chapter highlights the influence and impact of funding imbalances on governance, the distortion of delivery across the UN pillars, and the engagement of civil society and public interest groups. Funding: you get what you pay for

In 2019, the total funding of the UN system – including the UN Organization proper, the Secretariat, as well as its programs, funds, and specialized agencies – was $56.9 billion, approximately $7.60 per person on the planet. This investment in global “peace architecture” is dwarfed by global military expenditure, $1,917 billion in 2019, or $252 per person. Not only is the volume of UN funding inadequate, but the aggregate figure also disguises many profound imbalances that distort governance and accountability. These imbalances can be seen across the different revenue types (assessed, voluntary, core, non-core, in-kind) and in the fact that nearly half of total funding was contributed by three major donors (USA, UK, Germany). Furthermore, in 2019 funding for humanitarian activities overtook that for development operations; and one of the UN pillars – human rights – received barely 4% of the total budget. Member states’ funding for the UN system comes from two main sources: assessed and voluntary. Assessed contributions are obligatory for all UN member states and are intended to provide reliable funding to core functions of the UN Secretariat as well as to UN specialized agencies (World Health Organization [WHO], United Nations Educational, Scientific, and Cultural Organization [UNESCO], International Labour Organization [ILO], etc.). Voluntary contributions, which are not obligatory, nor exclusively from governments, are vital to the work of the UN’s humanitarian and development agencies – which do not have assessed budgets. Some specialized agencies also receive voluntary contributions in addition to their assessments, as does the UN Secretariat in the form of trust funds. Most voluntary contributions are channeled to and

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earmarked for non-core operations and programs, not to the core programs of the UN system entities. In 2019, assessed contributions accounted for just over 25% and voluntary non-core (earmarked) contributions over 50% of UN revenues (see Figure D3.1). The UN reports a steady increase of total funding over the period of 2010– 2019. However, both assessed and voluntary core contributions have stagnated, and the increase is accounted for by voluntary earmarked contributions and revenue from other activities (Figure D3.2). The adoption of the 2030 Agenda for Sustainable Development in 2015 reinforced the importance of a system-wide and integrated approach to sustainable development, but the promises by member states, especially by the traditional donors, have not been matched with action. Member states have acknowledged repeatedly in UN General Assembly resolutions that the lack of core funding undermines the ability of the UN development system to deliver on its multilateral mandates, emphasizing “the need to address the imbalance between core and non-core resources.” In 2018, they agreed to a funding compact, in which they “commit to bringing core resources to a level of at least 30 percent in the next five years” (General Assembly 2019).

Figure D3.1  Revenue by type of financing instrument funding the UN system. Source: UN System Chief Executives Board for Coordination, “Revenue by Financing Instrument.” 2019. https://unsceb.org/fs-revenue-type

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Figure D3.2  Types of financing instruments by year funding the UN system. Source: UN System Chief Executives Board for Coordination, “Revenue by Financing Instrument.” 2019 https://unsceb.org/fs-revenue-type.

Assessed contributions: who contributes the most, who receives the most

The size of the member state assessed contributions is determined by a complex formula which takes into account a member state’s gross national income (GNI) per capita, and several other economic indicators. In 2019, the four largest contributors to the United Nations – the USA (22% of the UN budget), China (12.005%), Japan (8.564%) and Germany (6.090%) – together financed some 49% of the entire UN regular budget. The main recipient is the Department of Peacekeeping Operations (DPKO), which receives approximately half of the total amount, followed by the UN Secretariat (UN System Chief Executives Board for Coordination 2019). This pattern is also at play in the funding of the UN development system that accounts for most of the resources received (71% of all UN system-wide activities in 2019) (UNDESA/OISC 2019). However, all contributions are of a voluntary nature and mainly earmarked by the donor. The top three contributors (USA, Germany, and UK) account for nearly half of the total funding from governments and the top 10 for almost three-quarters. The USA has consistently been the largest funder and contributes via each of the four different revenue types. In 2020–2021, it contributed the maximum

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assessment rate (capped at 22%) to the UN regular budget and 27.89% to UN DPKO. US funding dominance has caused widespread concern, especially when the country de-funds, withdraws from, or denigrates UN agencies and affiliated institutions, as it has done, for example, with UNESCO, United Nations Population Fund (UNFPA), United Nations Relief and Works Agency (UNWRA), and WHO. Additionally, late payments have caused severe cash flow problems and, while most concerns expressed are about budget shortfalls, the resulting constraints are leveraged in decision-making processes. UN decision-making is often compared (favorably) to the weighted voting set-up of the International Monetary Fund (IMF) and the World Bank, with the UN having one country, one vote as opposed to something closer to one dollar, one vote. This overlooks that fact that decision-making in the UN is exercised in a variety of different, often indirect, ways such as through senior appointments, funding flows (especially to non-core), threats and self-censorship, or acquiescence on the part of other member states. In 1985 Prime Minister Olaf Palme of Sweden proposed a ceiling of 10% on the assessed contribution of any member state. In addressing the UN General Assembly to commemorate its 40th anniversary, he said: “a more even distribution of assessed contributions would better reflect the fact that this Organization is the instrument of all nations” (Childers and Urquhart 1994, 153). While this statement garnered some support, it exposed resistance in many US circles, aware that it would reduce US political power and leverage at the UN. As US Ambassador Stephanie Power stated clearly in April 2014: “Our ability to exercise leadership in the UN – to protect our core national security interests–is directly tied to meeting our financial obligations” (Yeo 2014). Recent threats of US withdrawal from the WHO make stark the fragility of the organization’s public health mandate. Were the USA to withdraw, the almost entirely private Bill & Melinda Gates Foundation would replace it as top donor, using the 2018–2019 budget cycle, the latest available at time of writing. As well as heavy concentration and imbalance on the revenue side, the majority of resources flow unevenly to UN entities, with a heavy emphasis on peacekeeping (DPKO) and humanitarian operations (World Food Programme [WFP]). There is comparatively little financial support for lead UN entities addressing most of the Sustainable Development Goals (SDGs), including public health and education and gender equality (WHO, UNESCO, and UN Women respectively) as shown in Figure D3.3. Moreover, multilateral funding to tackle the global crises of health and climate has favored public–private blended responses (see also Chapters B1 and B3). In addition to being an expensive use of public resources, blended finance, involving for-profit entities, is making it more difficult to monitor and hold initiatives accountable to the public good (see Chapter D4 on World Bank Pandemic Bonds). As foundations fill the funding gap, the existing governance and accountability gap among governments will be widened. The increased use of institution specific foundations obscures transparency and public accountability. A funding vehicle

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Figure D3.3  Revenue by financing instrument, by entity, funding the UN system. Source: UN System Chief Executives Board for Coordination. “Revenue by Financing Instrument.” 2019. https://unsceb.org/fs-revenue-type

spearheaded by the UN Foundation, a US non-profit foundation established in 1998 by media entrepreneur Ted Turner, is becoming the new “business model” for UN entities with the recent establishment of the WHO Foundation (see chapter D1). Funding and governance: the evolution of development cooperation

The lack of healthy global governance is driven not only by the dominant funding share of a limited number of donors but also by the source of funding. Since its establishment, development cooperation and official development assistance (ODA) have played a major role in UN funding. In the immediate post-World War II period, UN activities focused on addressing the problem of refugees, mainly in Europe, and rebuilding the economies – also in Europe – devastated by the war, like the US Marshall Plan. With the onset of East/West tensions and the Cold War, geopolitical considerations moved to the forefront with an emphasis on Big Power spheres of influence. The superpower rivalry also shaped the mandates and institutions of the UN system. Throughout the UN Development Decades of the 1960s, 1970s, and 1980s, development support was largely related to strengthening national capacity to participate in the global economy. Development was viewed as primarily an economics agenda and the development model was essentially one based on economic growth and trickle-down (neoliberal) economics (see Chapter A1 and earlier editions of Global Health Watch). North/South tensions dominated negotiations and strongly focused on the desired rate of economic growth for so-called “developing” countries,1 compared with the estimates and proposals of financial centers in the Global North and the international financial institutions (IFIs). The dominant theory of change held that for developing countries to grow the overall economy, it was necessary to increase the economic pie as it was not politically feasible to redistribute the existing pie. This was accompanied by a belief that policies and strategies for economic growth and liberalized trade

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and finance were neutral, and that the distribution of their income benefits was a national issue, not a global one. As globalization took hold, the macroeconomic advice, policy prescriptions, and loan conditions for developing countries from the IFIs mandated a shift from producing for domestic markets via import substitution to producing for external markets, via export specialization, thereby enhancing their comparative advantage in the global economy. Development cooperation and assistance followed suit, accelerating these countries’ dependence on external markets and resource flows, over many of which they had little or no influence. The disconnect between trade and investment policies and agreements and domestic development needs had many critics. Women’s movements, environment movements, and feminist and heterodox economists steadfastly campaigned against these neoliberal policy nostrums, bringing their critical analyses to the UN which they saw as an alternative policy space. These activist groups emphasized the need to focus on the quality of aid and finance (not just the quantity) and the distortions of tied aid which required aid recipients to use funding to purchase donor providers of goods, services, and expertise. Critiques also addressed the misuse of ODA for structural adjustment programming, requiring recipient countries to implement austerity measures, and the undermining or ignoring accountability to human rights. The 1990s – and the end of the Cold War – represented a “breakthrough” decade, as it opened space for member state agreements at the UN no longer heavily dominated by superpower politics centered on the nuclear threat. The world conferences of the 1990s covered the full range of social, economic, and environmental issues; they put “quality of development” and non-military threats onto the UN agenda with new agreements and programs of action (see Box D3.1). Global and national mobilizing gave rise to a “people-centered” approach to development.

Box D3.1: “Development Decade” of the 1990s 1992: UN Conference on Environment and Development (Earth Summit), Rio de Janeiro 1993: World Conference on Human Rights, Vienna 1994: International Conference on Population and Development, Cairo 1995: World Summit on Social Development, Copenhagen 1995: Fourth World Conference on Women: Equality, Development and Peace, Beijing 1996: HABITAT II – Second United Nations Conference on Human Settlements, Istanbul 1997: Kyoto Protocol, United National Framework on Climate Change 2001: UN Special Session on HIV and AIDS, New York City

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As donors began to re-evaluate the benefits of ODA, backtracking on their commitment to a target of 0.7% of gross domestic product (GDP) to sustain it, the UN and the Organisation for Economic Co-operation and Development (OECD) shaped a more limited agenda with the Millennium Development Goals (MDGs) which slowly became the UN development agenda. The narrow focus of the MDGs on eight development goals failed to capture the ambitions and agreements of the 1990s conferences. While they brought welcome attention to social sectors that had been ignored or neglected with the emphasis on economic growth, they were one-sided, emphasizing domestic policies and programs of developing countries and shifting the “external enabling environment” away from a broad agenda that included trade and finance policies to the provision of development assistance. The pushback from some developing countries, as well as from many civil society organizations (CSOs), was evident in the post-2015 deliberations as the MDGs expired and in the articulation of the 2030 Agenda for Sustainable Development and the Sustainable Development Goals (SDGs). The three years of intense negotiations to shape and adopt the 2030 Agenda – from 2012 to 2015 – rekindled the energy and commitment of CSOs, and the impact of their advocacy efforts on the outcome was unquestioned. SDG10 on inequalities owes its existence and then survival to the sustained and sophisticated work of CSOs, including that of the Women’s Major Group (WMG), a network of between 500 and 1,000 feminist organizations worldwide. Formed in 1995, the WMG is rooted in all regions, supporting grassroots women leaders on issues ranging from violence against women to the malfunctioning and discriminatory nature of the global economic system.2 In addition to the social sector specific goals and their CSO advocates, the SDG process also drew in activists from the climate crisis and the UN Framework Convention on Climate Change process (SDG 13) and those focused on peace and security and conflict-affected countries (SDG 16). The 2030 Agenda is a universal agenda to which all UN member states are accountable in terms of domestic policy, including those of the Global North, but does not overcome the fragmentation and neoliberal orientation of the policy directives that shape those of the IFIs and the World Trade Organization (WTO). Although there are cogent criticisms of the 2030 Agenda (see Box D3.2), it nonetheless represents a fuller and more integrated approach than the MDGs to sustainable development, which is totally lacking in the MDGs. Its achievement requires significant changes in macroeconomic policy and substantial development cooperation, alongside commitments to tackle the structural and systemic barriers to its fulfillment. Post-2015 and the 2030 Agenda

While the 2030 Agenda and its goals and targets broke the donor-driven minimizing trend of the previous decade, its adoption was not accompanied by a robust accountability framework at global or national levels. Additionally, it

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Box D3.2: The contradictory SDGs The SDGs, or Agenda 2030, are the first set of post-colonial development goals to be universally applicable to all countries. Unlike the MDGs, the SDGs apply to all the world’s countries, with implications for the fulfillment of the goals within their own borders as well as for their international (cross-border) responsibilities. There are goals to reduce inequalities within and among countries (about time!) and environmental sustainability goals and targets that run throughout Agenda 2030. But as Chapter A1 of Global Health Watch 5 argued, the SDGs remain problematic if not contradictory. First, there is the problem of the lack of ambition in achieving some goals, notably the target to eliminate extreme poverty by 2030. As Chapter A1 in this volume points out, if other poverty benchmarks are used rather than the paltry “extreme” cut-off one, most of the world would wake up still poor on January 1, 2030. Second, the inequality goal is based on disproportionately increasing incomes for the bottom 40% but says nothing of reducing incomes of the top 10, 1, or even 0.1%. Do the math: a 100% increase in income for someone earning $2,000 a year would bring the total income to a value of $4,000. A disproportionately modest 10% increase on $1,000,000 would raise the total income by $100,000 – in real (rather than relative) terms – making the millionaire $98,000 richer than the person in this example stuck in the world’s bottom 40%. Yet, we could check off “success” in reaching the reducing inequality target. Also, the SDGs fail to have a target to address inequalities among countries. Fundamentally, the SDGs fail to tackle the power imbalances that ensure the same economic paradigm prevails, one that has brought us to the point of extreme inequality and collapsing ecosystems. A 2017 modeling study of this “sustainable development oxymoron” measured the inconsistencies between the SDGs’ economic assumptions and environmental sustainability. It depressingly, if unsurprisingly, concluded that “the SDG agenda will fail as a whole if we continue with business as usual … [and] that the focus on economic growth and consumption as a means for development underlies the inconsistency” (Spaiser et al. 2017). The 2017 modeling study did have some good news: SDG targets relating to health, education, and government investment did not conflict with the environmental goals or targets (ibid.).

failed to demand the long-term quality financing required for implementation and to distinguish public goods and human rights from market-based solutions. The SDGs are regularly marketed as a catalogue of win-win investment opportunities and many in the business and investment sectors and institutions

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have positioned themselves as champions in their achievement. Thus SDG17, “Strengthen the means of implementation and revitalize the global partnership for sustainable development,” has been reinterpreted from a global partnership among member states to a host of self-selected initiatives and partnerships, all claiming to be essential for the achievement of the goal. With inadequate indicators to measure progress and a lack of robust accountability, the quantity of funding has become the dominant measure of progress towards this goal along with partnerships promoted to engage the business and corporate sector and philanthropy in financing the SDGs. The enumeration of partnerships, promoted as the key modality in the achievement of the SDGs, has steadily become viewed as the primary means of their implementation. This has impacted the work across the UN system, for some entities more than others, and spurred a host of fundraising initiatives including more recently the appeal to wealthy individuals. This engagement with nongovernment funders has not been accompanied by the related/required principles, guidelines, and accountability mechanisms. The lack of rigor in ex-ante reporting and requirements has furthered the dangerous shift away from core funding and undermined transparent and democratic multilateralism. Indeed, to date there is only one instance of a member state-led process to set terms and accountability for engagement with non-government actors, namely the Framework for Engagement with Non-State Actors (FENSA) created for the WHO. However, FENSA has been criticized by CSOs for putting private sector entities on an equal footing with other non-state actors, failing to recognize their fundamentally different nature and roles (see Global Health Watch 5, chapter D1). The predominant approach to engagement with the business sector is on a voluntary basis, loosely steered by guidelines, principles, and advisory groups and lacking independent or member state oversight and accountability. Two reports by the UN’s Joint Inspection Unit (JIU) of 2017 analyzed the UN system’s mechanisms and policies on ethics and integrity, as well as on partnerships with the private sector, in the context of the 2030 Agenda. Its “Review of Mechanisms and Policies Addressing Conflict of Interest in the United Nations System” observed that, while the topic of personal conflict of interest is well covered, hardly any organizational conflict of interest policy exists among UN system organizations (Sukayri 2017). The WHO FENSA, in contrast, contains specific if still inadequate provisions on the management of conflicts of interest, both institutional and individual, stating: In actively managing institutional conflict of interest … WHO aims to avoid allowing the conflicting interests of a non-State actor to exert, or be reasonably perceived to exert, undue influence over the Organization’s decision-making process or to prevail over its interests. (Sixty-Ninth World Health Assembly 2016, 10)

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The JIU Report “United Nations System – Private Sector Partnerships Arrangements in the Context of the 2030 Agenda for Sustainable Development” addressed the inadequate UN system attention to due diligence procedures and called for urgent action: The Secretary-General of the United Nations and all the executive heads of participating organizations should identify and agree on a minimum set of common standard procedures and safeguards for an efficient and flexible due diligence process, to be applied system-wide in a transparent way by the United Nations operational staff engaged in the initiation and implementation of partnerships with the private sector. (Dumitriu 2017, vii–viii)

Corporate and business intermediaries, access, and influence

Corporate influence in the UN system operates in diverse ways, from (limited) direct funding to (over)representation on high-level panels and “networking” facilitated by platforms such as the World Economic Forum (WEF) and the Global Compact. These vehicles are structured in different ways, have different membership set-ups, and vary in their accountability requirements (either to the UN leadership or to member states). While their status, access, and stance differ, they may be making the case for legitimizing the importance of the business and corporate sector in international decision-making, committed to bringing business closer to the values of the UN. There is a growing concern among CSOs of the reverse: that is, the risk of these forms of interaction infusing business values within the UN. To date, attention to and advocacy on this “multistakeholderism” trend has tended to be entity specific and often causerelated, but some patterns are becoming more transparent from advocacy work across the climate crisis, COVID-19, and the 2030 Agenda. This is exposing the high degree of corporate engagement and interests and the lack of attention to the influence of corporate actors in the UN.

1. Global Compact Originating as a UN Secretary-General (S-G) initiative in 1999, the UN Global Compact (UNGC) has steadily repositioned itself, with support from key member states, to become a main gateway for business engagement with the UN. From its origins as a S-G initiative, it is now recognized by member states in a biennial UN General Assembly partnership resolution and has steadily positioned itself as focal point to UN agencies on engagement with the private sector. The Compact’s 12,765 participating companies span the globe and range in size from small and medium size enterprises (SMEs) to foundations to multinational corporations (MNCs).3 The Compact leverages influence through a number of affiliated local networks which are involved at local, national, and regional levels. Recently, the Compact has been embraced

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as a premier partner in the UN development system at the program country level, giving it privileged access to UN entities and program country governments. Its work in connection with the 2030 Agenda illustrates an approach weighted towards bringing corporate political influence into government and governmental agency processes. The Global Compact’s mission is to “mobilize a global movement of sustainable companies and stakeholders to create the world we want” (UN Global Impact n.d.). Self-described as the world’s largest corporate social responsibility entity, its operating framework is based on its “Ten Principles” which call on members to align their businesses in the areas of human rights, labor, environment, and anti-corruption, though there is no or limited accountability to the principles.4 The current UN Secretary-General, António Guterres, has reaffirmed the Compact’s premier role, stating in his preface to the UN Global Compact Strategy 2021–2023: “Now is the time to scale up the global business community’s contributions to the 2030 Agenda and the implementation of the Paris Agreement on climate change” (United Nations Global Compact 2021). The main sources of finance for the Global Compact and its office are contributions from member states and membership fees from the private sector members, as well as additional support by way of secondments from member states and from private corporations. In addition to limited UN funding, it is supported by the US-based Foundation for the Global Compact, established in 2006. The co-mingling of UN and private sector funding, staffing, programming, and reporting has made it increasingly difficult to assess its impact and monitor accountability to the UN and its mandates. This was addressed in a 2010 report by the UN JIU that drew attention to the lack of government representatives on the Global Compact Board, calling it highly unusual for an intergovernmental organization such as the UN. It added that this weak government oversight is duplicated in the Global Compact Government Group, which is formally entrusted with overseeing the use of government resources (Fall and Zahran 2010, v). The JIU also concluded that the General Assembly Partnership resolutions do not close the governance gap, failing to address and guide the self-set objectives of the Global Compact to promote responsible corporate citizenship, nor its business-led advocacy in policy processes. The 2017 JIU Report reiterated these concerns and recommended a revised mandate for the Global Compact, to include an: • Enhanced role for member states in its governance structure; • Updated definition of the relationship between the Global Compact office and the Foundation for the Global Compact, with an emphasis on the transparency of the Foundation’s fundraising activities; • Clear definition of the relationship between the Global Compact headquarters and the Global Compact Local Networks (Dumitriu 2017, viii).

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2. World Economic Forum The World Economic Forum (WEF) is a prominent network that defines itself as “the International Organization for Public–Private Cooperation” and asserts: “The Forum engages the foremost political, business, cultural and other leaders of society to shape global, regional and industry agendas” (World Economic Forum n.d.). While not part of the UN system, the WEF has enhanced its influence through a memorandum of understanding (MOU) with the UN. Signed by UN S-G in 2019, the MOU highlights multiple areas of cooperation on activities that the WEF describes as “shaped by a unique institutional culture founded on the stakeholder theory, which asserts that an organization is accountable to all parts of society.” It adds: “The institution carefully blends and balances the best of many kinds of organizations, from both the public and private sectors, international organizations and academic institutions” (ibid.) (see Chapter D5). The agreement frames a new form of strategic partnership. The MOU contains commitments that the UN S-G will be invited to deliver a keynote address at the WEF annual Davos gatherings. His senior staff and the heads of the UN programs, funds, and agencies will also be invited to participate in regional level meetings hosted by the WEF. It also contains a promise that the UN’s individual country representatives will explore ways to work with WEF’s national Forum Hubs. The agreement could foretell an exclusive place for multinational corporations inside the UN. The MOU has raised deep concern among many CSOs. In a letter to the S-G, 300 civil society organizations called on the UN S-G to “terminate the UN-World Economic Forum agreement.” Calling it a “form of corporate capture,” the letter states that: We are very concerned that this WEF-UN partnership agreement will de-legitimize the United Nations and provide transnational corporations preferential and deferential access to the UN System. The UN system is already under a big threat from the US Government and those who question a democratic multilateral world. However, this corporatization of the UN poses a much deeper long-term threat, as it will reduce public support for the UN system in the South and the North. (“Corporate capture of global governance” n.d.)

Concerns with the growth in these partnerships have intensified with the plans for the UN Food Systems Summit, to be held in September 2021, and the appointment by the S-G of the President of the Alliance for a Green Revolution in Africa (AGRA) as Special Envoy to the 2021 UN Food Systems Summit. AGRA, founded in 2006 with support from the Bill & Melinda Gates and Rockefeller Foundations, intends to increase the continent’s agricultural output through support to commercial farming practices by financing technological inputs (seeds, fertilizers, etc.) and building market outputs (African Centre for Biosafety n.d.). The billion-dollar funded program has so far failed to decrease

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hunger or reduce farm-household poverty (as promised) with activist demands that it be repositioned to promote agroecological farming practices instead (Malkan 2020) (see also Chapter C5). CSOs worldwide, including the People’s Health Movement (PHM), are organizing a parallel “Global People’s Summit” to advocate for an agroecological approach to farming, rather than one based on technological interventions and commercialization (Global People’s Summit 2021). State of play at UN – partnerships

UN decisions to strengthen ties with the corporate sector, such as partnering with the WEF, parallel its declining core support from member states and traditional donors. This decline was initially from core to non-core contributions, then taken further by tightly earmarking contributions to entities and projects. This pattern opened the door to non-state funding and the promotion of the role of the private sector initially for resources and, in some instances, for their expertise and business model. For UN Women, for example, in 2018 private sector corporations, foundations, and individual donations through UN Women’s National Committees provided 5% of total contributions, with a 29% increase from $17.9 million in 2017 to $23 million in 2018 (Soria et al. 2019, 4). This upward trend is drawing on funding from non-governmental sources such as the Foundation Chanel, Alwaleed Bin Talal Foundation, Bill & Melinda Gates Foundation, BNP Paribas, and BHP Billiton Foundation to such an extent that BHP Billiton now ranks in the top 20 contributors to UN Women (ibid., 9). The partnership with BHP was signed despite numerous reports of BHP’s involvement as co-owner with mining companies Samarco and Vale/SA in the 2015 collapse of a mine tailings dam in Brazil which killed 19 people and left hundreds homeless. At the time of signing, ongoing litigation included a 2018 lawsuit by Australian shareholders against BHP Billiton, alleging that the company misled them as it was aware of the safety risks prior to the disaster, but failed to take any action to prevent it (Business & Human Rights Resource Centre 2015). In August 2018, the company settled a similar lawsuit filed by US shareholders, agreeing to pay $67 million in compensation without admitting liability (Gray 2018). In a private sector promotional brochure, UNESCO similarly lists various incentives for companies to partner with the agency, including “image transfer” through association with a prestigious UN entity, access to the agency’s wide and diverse private networks, and nameless benefits from the agency’s role as a neutral and multistakeholder broker (United Nations Educational Scientific and Cultural Organization 2014, 9). These potential benefits for companies apply generally to all UN funds, programs, and agencies; so, it is worth asking: what does “image transfer” mean for the reputation of the UN? Is there not the risk that the cooperation with controversial corporations (e.g., Shell-BP, CocaCola, Microsoft, and BHP Billiton) adversely affects the image of the UN as a

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neutral broker and undermines its reputation? The UN Food and Agricultural Organization (FAO) referred to this risk in a 2005 assessment of its partnership projects, stating that non-state entities with interests that differ from the FAO mission may bring “undue influence” or “reduce the Organization’s credibility by damaging its image of impartiality” (Sauvinet-Bedouin et al. 2005, para. 189). This reliance on non-state funders exacerbates the issues regarding earmarked funding, including fragmentation, competition, and overlap among entities, disregard of UN program priorities, and high transaction costs, all of which create obstacles to progress for a UN system-wide and coherent re-positioning to achieve the SDGs (mandated by Resolution A/RES/72/279).5 Despite these risks, many UN funds, programs, and agencies plan to increase private funding for their operational activities. In general, they follow a multi-layer fundraising strategy which includes sustaining core contributions from governments and increasing those from emerging economies; exploring “core-like” funding modalities, including pooling resources in multi-donor trust funds; expanding contributions from the private sector, civil society, and philanthropic foundations; and participating in global multistakeholder partnerships. UN organizations are devoting staff and resources to analyzing potential private sector and wealthy individual donors to position themselves as an attractive brand. In 2017, the JIU analysis listed among the “most cited motivational factors” with the UN system: “Build brand image and higher visibility among civil society, including consumers, other business groups and the media” (Dumitriu 2017). Recent strategies have expanded as some UN entities have dedicated staff capacity to the pursuit of individual giving as well as to developing partnerships with corporations (see Box D3.3).

Box D3.3: Appeal to individual giving The World Food Programme’s (WFP) Strategy for Partnership and Engagement with Non-governmental Entities (2020–2025) details its plans for individual giving and brand strengthening as well as market analysis: Individual giving is the largest source of donations among non-governmental entities in the global fundraising market, and it continues to grow … The goal is to create a model that becomes self-financing within five years and delivers a significant level of flexible income to WFP … This is based on a belief that the overall individual giving market is limited. However, analysis conducted by a number of peer organizations with large individual fundraising operations shows that the market is both large and growing significantly increasing the opportunities for all organizations. (Executive Board of the World Food Programme 2019)

The UN, Global Governance, and Funding Failures  |  383 While the WFP addresses the possible tension with important partners, it ignores the distortion of accountability away from member states to individuals and downplays the important and unique role a UN agency could and should play with governments. In 2019, UNICEF redoubled efforts to grow private sector fundraising, particularly from individuals. Through the Supporter Engagement Strategy, UNICEF enhances supporter relationships with a view to reducing donor attrition and increasing donor acquisition. Continuing the current level of investment funds will be critical to support ongoing growth, particularly in individual giving. UNICEF regular resources grew in 2018, “comprising $66.1 million by National Committees and $0.8 million by country offices. Individual giving remained the primary source of contributions to regular resources” (United Nations Children’s Fund 2019, para. 9). The appeal of individual giving is evident when one recognizes that such resources are virtually always core resources; in addition to this flexibility, they require very little reporting of who may be the donors (most giving is anonymous). In 2014, 92% of the total amount of individual contributions were remitted as core funding. The United Nations High Commissioner for Refugees (UNHCR) in the last few years has successfully developed and invested in its private sector fundraising. Refugees and internally displaced persons (IDPs), like children, are appealing images for individuals. Such contributions have increased and become a key financial source for UNHCR, and they are likely to continue growing. In 2017, UNHCR mobilized $276 million from individual contributors, nearly doubling in four years ($137 million in 2014). The number of individuals giving to UNHCR in 2014 was close to one million, and in 2017 this number grew to over 1.92 million for refugees (UNHCR 2018a, 42). The UNHCR anticipates that by the end of 2018, there will be a total of 2.5 million individuals contributing a total of $500 million (UNCHR 2018b, fig. 5).

Unequal players – human rights and business

Much engagement of the UN funds, programs, and agencies with the private sector, while adhering to entity due diligence procedures, lack measures of accountability in line with member state decisions in the UN Human Rights Council (UNHRC), such as those laid out in the Guiding Principles on Business and Human Rights (UNGPs) (Office of the UN High Commissioner 2011). The UNGPs, adopted by consensus in 2011 by the UNHRC through A/HRC/ RES/17/4 (Human Rights Council 2011), provide a roadmap to both governments and businesses and are structured on three pillars: government duty to protect human rights, the corporate responsibility to respect human rights, and access to remedy. Additionally, the Human Rights Council’s A/HRC/RES/26/9

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has “establish(ed) an open-ended intergovernmental working group [IGWG] on transnational corporations and other business enterprises with respect to human rights … to elaborate an international legally binding instrument to regulate, in international human rights law, the activities of transnational corporations and other business enterprises” (Human Rights Council 2014, 2). From its inception this initiative has been developed and promoted by an alliance of social movements, CSOs, and experts from around the world. This Treaty Alliance is campaigning for a UN treaty to end corporate impunity and regulate corporate activities that violate human rights and contribute to environmental destruction (see Chapter D5). As the negotiations to elaborate this treaty progress, many member states, primarily in the Global North, have resisted its development by tying up progress through questioning on procedural and budgetary grounds. Furthermore, business associations have been active against the initiative. For example, during its deliberations in October 2017, the IGWG received a joint submission from Business at OECD, the Foreign Trade Association, the International Chamber of Commerce, and the Global Voice of Business “which collectively represent millions of companies around the world [and] have been constructively engaged in the business and human rights agenda for many years.” This submission stated: “We underscore our opposition to impose direct international human rights obligations on transnational corporations (TNCs) and other business enterprises (OBEs), which takes the debate back to the politically-charged era of the UN norms” (Business and Industry Advisory Committee et al. 2017), a reference to earlier UN attempts to create a code of conduct for transnational corporations. The tension between the promotion of unregulated economic growth and that of human rights has been addressed in depth by many UN Human Rights Council appointed Independent Experts and Special Rapporteurs, both in individual annual reports and some that are occasionally issued collectively (see Box D3.4). Their report recommendations have ranged from calling on mining companies to respect the rights of indigenous peoples to a joint call to eliminate the investor-state dispute systems (ISDS) that tie countries to arbitration over trade and investment provisions (see Chapter D2).

Box D3.4: Selected list of UN human rights reports addressing the issue of unregulated economic growth • Olivier De Schutter (Special Rapporteur on Extreme Poverty). 2020. “Looking Back to Look Ahead: A Rights-Based Approach to Social Protection in the Post-COVID-19 Economic Recovery.” September 2020. (https://www.ohchr.org/Documents/Issues/Poverty/covid19.pdf • Philip Alston. 2019. “The Parlous State of Poverty Eradication, Report of the Special Rapporteur on Extreme Poverty and Human Rights.” (A/ HRC/44/40), July 2020.

The UN, Global Governance, and Funding Failures  |  385 • Philip Alston. 2019. “The Digital Welfare State, Report of the Special Rapporteur on Extreme Poverty and Human Rights.” (A/74/48037), October 2019. • David Kaye. 2017. “Special Rapporteur on the Right to Freedom of Opinion and Expression.” (A/72/350). • Victoria Tauli-Corpuz. 2014. “Report of the Special Rapporteur on the Rights of Indigenous Peoples.” (A/HRC/27/52), August 2014. • Victoria Tauli-Corpuz. 2016. “The Impact of International Investment and Free Trade on the Human Rights of Indigenous Peoples.” (A/ HRC/33/42), August 2016. • Juan Pablo Bohoslavsky. 2018. “Guiding Principles on Human Rights Impact Assessments of Economic Reform on the Full Enjoyment of Human Rights Particularly Economic, Social and Cultural Rights.” (A/ HRC/40/57), December 2018.

The UN special procedures mandate holders and other human rights experts have repeatedly highlighted the risks these agreements pose to the regulatory space required by states to comply with their international human rights obligations as well as to achieve the SDGs. In 2019, in a remarkable letter to the S-G, seven human rights experts expressed concerns about international investment agreements (IIAs) and their ISDS mechanism, noting that these have often proved to be incompatible with international human rights and the rule of law. This letter states: The inherently asymmetric nature of the ISDS system, lack of investors’ human rights obligations, exorbitant costs associated with the ISDS proceedings and extremely high amount of arbitral awards are some of the elements that lead to undue restrictions of States’ fiscal space and undermine their ability to regulate economic activities and to realize economic, social, cultural and environmental rights. … Therefore, the current ISDS reform presents a critical opportunity to seek systemic structural changes to the architecture of ISDS. While addressing the procedural concerns identified during the previous sessions would contribute to improving the efficacy of the ISDS system, it would not remedy the power imbalance between investors and States, which is so deeply entrenched in the architecture of the ISDS system … We believe what is necessary is a fundamental, systemic change, which entails moving towards a fairer and more transparent multilateral system … (Deva et al. 2019)

Philip Alston, in the final report concluding his term as Special Rapporteur on Extreme Poverty and Human Rights, laid out the futility of relying on the business sector to achieve the SDGs and the impact of this action on human

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rights. Noting the critical importance of adequate funding to achieving the SDGs, it states: The response of the international community has been to rely ever more heavily on private sector funding, which is increasingly presented as the only viable way forward. The Secretary-General has called on business to “move further and faster … to meet the global goals” and has argued that “corporate leadership can make all the difference to creating a future of peace, stability and prosperity on a healthy planet.” Corporations have been enthusiastic in demonstrating their embrace of the SDGs, though much of this has been superficial such as boasting of female workforce participation. (Alston 2020, 12)

Alston points out that the central strategy is “to use public funds more sparingly” and use them to better leverage private capital. However, he identifies several fault lines with this strategy: First, it begs the crucial question as to whether privatization in its various forms is capable of achieving many of the SDGs, especially for the most vulnerable whose inclusion may not be profitable. There are powerful reasons to doubt this. Second, it recasts the overall SDG enterprise as one focused largely on the building of infrastructure and prioritizes an enabling business environment over empowering people. Third, the role of governments is downplayed, often relegated to insuring private investments. Fourth, all too little is done to promote domestic revenue mobilization, leaving in place destructive fiscal policies, systematic tax avoidance strategies, and illicit outflows that entrench poverty and inequality. Fifth, the commitment to “a revitalized Global Partnership,” promoting “solidarity with the poorest and with people in vulnerable situations,” is lost in the fog of an overriding focus on Public-Private Partnerships with troubling track records. (ibid.)

In recent years, there has been growing acknowledgement by scholars and researchers as well as by some member states that engagement with the for-profit sector and the promotion of unregulated partnerships carries risks for the UN and distorts its purpose and mandate. An article in the British journal Lancet details several consequences: The move towards the partnership model in global health and voluntary contributions … allows donors to finance and deliver assistance in ways that they can more closely control and monitor at every stage … away from traditional government-centered representation and decision-making; and towards narrower mandates or problem-focused vertical initiatives and away from broader systemic goals sought through multilateral cooperation. … Over time, the rearrangement of WHO’s priorities to align with funds was inevitable, with donors earmarking 93% of voluntary funds in the 2014–15 budget. Influence is heavily concentrated among the top donors. Undeniably then, a direct link exists between financial contributions and WHO focus. (Clinton and Sridhar 2017)

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The former WHO Director-General Margaret Chan reaffirmed the importance of public interest safeguards in a speech at the 8th Global Conference on Health Promotion in June 2013, emphasizing that “In the view of WHO, the formulation of health policies must be protected from distortion by commercial or vested interests” (Endal 2013). Need for a new funding compact

Healthy global governance requires a new funding compact to break the relationship between funding and governance. While not sufficient to address inequalities and pursue policies of rights and sustainability, creating such a compact is an essential first step. People’s organizations committed to human rights, sustainable livelihoods, and a livable planet have sounded the alarm for decades on the perils of unregulated corporate practices and inadequate accountability. A number of these have also challenged the governments’ multilateral policies and international organizations for their compliance/acquiescence and failures. Many have resulted in institutional changes and guidelines from the International Code of Marketing of Breastmilk Substitutes to the UNGPs. However, many measures such as the principles of Environmental, Social, and Corporate Governance (ESG) necessary for responsible investment are voluntary. Meanwhile, the institutions and monitoring and accountability mechanisms such as the UN human rights machinery suffer from the neglect or distortions illustrated in this chapter. This constitutes a perverse pattern of undermining democratic governance by inadequate funding – quantity and quality – either by accident or by design. Work needs to be strengthened and counter strategies developed to challenge the malfeasance of governance control through funding. That will be one of the critical areas for activist efforts as we emerge (inequitably and all too slowly) from the shadow of the pandemic. Notes 1 Although Global Health Watch prefers to designate countries by their per capita income level (according to the World Bank’s low- to high-income categories), the usage of “developing countries” or the more common “low- and middle-income countries,” or LMIC, are both problematic. See Chapter C1, note 2. 2  See the Women’s Major Group’s website: https://www.wecf.org/womens-major-group/.

3  For a list of the UN Global Impact initiative’s participants, see https://www. unglobalcompact.org/what-is-gc/participants. 4  To see the ten principles of the UN Global Compact, visit https://www.unglobalcompact. org/what-is-gc/mission/principles. 5  See the “Resolution adopted by the General Assembly on May 31, 2018” (A/ RES/72/279) at https://undocs.org/A/RES/72/279.

References African Centre for Biosafety. n.d. “Giving with One Hand and Taking with Two: A Critique of AGRA’s African Agriculture Status Report 2013.” African Centre for Biosafety. Accessed June 20, 2021. https://www.twn.my/title2/ susagri/2013/susagri307.htm.

Alston, Philip. 2020. “The Parlous State of Poverty Eradication.” A/HRC/44/40. United Nations Human Rights Council. https://chrgj. org/wp-content/uploads/2020/07/AlstonPoverty-Report-FINAL.pdf. Business & Human Rights Resource Centre. 2015. “BHP Billiton & Vale lawsuit (re dam

388   |  Global Health Watch 6 collapse in Brazil).” Business & Human Rights Resource Centre. https://www. business-humanrights.org/en/bhp-billitonvale-lawsuit-re-dam-collapse-in-brazil. Business and Industry Advisory Committee, Foreign Trade Association, International Chamer of Commerce, and International Organisation of Employers. 2017. “UN Treaty Process on Business and Human Rights: Response of the International Business Community to the ‘Elements’ for a Draft Legally Binding Instrument on Transnational Corporations and Other Business Enterprises with Respect to Human Rights.” October 20. https://www.business-humanrights.org/ sites/default/files/documents/Joint%20 business%20response%20to%20IGWG%20 elements%20paper%20-%2020.10.2017%20 -%20FINAL.pdf. Childers, Erskine, and Brian Urquhart. 1994. Renewing the UN System. Sweden: Dag Hammarskjöld Foundation. Clinton, Chelsea, and Devi Sridhar. 2017. “Who Pays for Cooperation in Global Health? A Comparative Analysis of WHO, the World Bank, the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, and Gavi, the Vaccine Alliance.” Lancet 390 (10091): 324–332. Deva, Surya, Saad Alfarargi, David R. Boyd, Juan Pablo Bohoslavsky, Victoria Lucia Tauli-Corpuz, and Livingstone Sewanyana. 2019. “Reference: OL ARM 1/2019,” March 7. https://www.ohchr.org/ Documents/Issues/Development/IEDebt/ OL_ARM_07.03.19_1.2019.pdf. “Corporate Capture of Global Governance: The World Economic Forum (WEF)-UN Partnership Agreement is a Dangerous Threat to UN System.” n.d. Open Letter to Secretary-General of the United Nations (António Guterres). Accessed June 20, 2021. https://www.cognitoforms.com/ MultistakeholderismActionGroup/Corporate CaptureOfGlobalGovernanceTheWorldEcon omicForumWEFUNPartnershipAgreementIs ADangerousThreatToUN?fbclid=IwAR0jaqd 3fdz2Nl3ndlSl-fbR1mlMwMESKTDX5SlwtNkwY3eLfQAFq71ujM. Dumitriu, Petru. 2017. “The United Nations System – Private Sector Partnerships Arrangements in the Context of the 2030 Agenda for Sustainable Development.” Report of the Joint Inspection Unit.

JIU/REP/2017/8. Geneva: United Nations. https://www.unjiu.org/news/ united-nations-system-%E2%80%93private-sector-partnership-arrangementscontext-2030-agenda-sustainable. Endal, Dag. 2013. “Who Director General Dr. Chan Warns Again Against Vested Interests.” ADD [Alcohol, Drugs and Development] Resources. June 14. http:// www.add-resources.org/who-directorgeneral-dr-chan-warns-again-against-vestedinterests.5218033-315750.html. Executive Board of the World Food Programme. 2019. “Private-Sector Partnerships and Fundraising Strategy (2020–2025): Cooperation with the Private Sector, Foundations and Individuals for the Achievement of Zero Hunger.” WFP/ EB.2/2019/4-A/Rev.1. Second Regular Session. Rome: World Food Programme. https://docs. wfp.org/api/documents/WFP-0000108549/ download/. Fall, Papa Louis, and Mohamed Mounir Zahran. 2010. “United Nations Corporate Partnerships: The Role and Functioning of the Global Compact.” Report of the Joint Inspection Unit. JIU/REP/2010/9. General Assembly. 2019. “Implementation of General Assembly Resolution 71/243 on the Quadrennial Comprehensive Policy Review of Operational Activities for Development of the United Nations System, 2019: Funding Compact.” Report of the Secretary-General. A/74/73/Add.1. United Nations Economic and Social Council. https://digitallibrary.un.org/ record/3803210?ln=en. Global People’s Summit on Food Systems. 2021. “People’s Movements Launch Global People’s Summit on Food Systems to Counter UN Summit.” https://www.kractivist.org/ peoples-movements-launch-global-peoplessummit-on-food-systems-to-counter-unsummit/. Gray, Darren. 2018. “BHP Settles US Class Action over Samarco Dam Failure for $67 Million.” The Sydney Morning Herald. August 9. doi: 10.1016/S0140-6736(16)32402–3. Human Rights Council. 2011. “Human Rights and Transnational Corporations and Other Business Enterprises.” A/HRC/RES/17/4. United Nations General Assembly. Human Rights Council. 2014. “Elaboration of an International Legally Binding Instrument

The UN, Global Governance, and Funding Failures  |  389 on Transnational Corporations and Other Business Enterprises with Respect to Human Rights.” A/HRC/RES/26/9. United Nations General Assembly. https://ap.ohchr. org/documents/dpage_e.aspx?si=A/HRC/ RES/26/9. Malkan, Stacy. 2020. “Gates Foundation’s ‘Failing’ Green Revolution in Africa.” U.S. Right to Know. July 29. https://usrtk.org/ our-investigations/gates-foundations-failinggreen-revolution-in-africa-new-report/. Office of the UN High Commissioner for Human Rights. 2011. Guiding Principles on Business and Human Rights. New York and Geneva: United Nations. Sauvinet-Bedouin, Rachel, et al. 2005. Evaluation of FAO’s Cross-Organizational Strategy Broadening Partnerships and Alliance. Rome: Food and Agriculture Organization of the United Nations. Sixty-Ninth World Health Assembly. 2016. “Framework of Engagement with Non-State Actors.” WHA69.10. https://www.who.int/ about/collaborations/non-state-actors/ A69_R10-FENSA-en.pdf. Soria, Nuria Felipe, Leona Barusya, Beatrix Senoner, and Leonie Felora Nazemi. 2019. Compendium of Financial Partners Contributions 2018. Geneva: UN Women. Spaiser, Viktoria, Shyam Ranganathan, Ranjula Bali Swain, and David J.T. Sumpter. 2017. “The Sustainable Development Oxymoron: Quantifying and Modelling the Incompatibility of Sustainable Development Goals.” International Journal of Sustainable Development & World Ecology 24 (6): 457–470. doi: 10.1080/13504509.2016.1235624. Sukayri, Rajab M. 2017. “Review of Mechanisms and Policies Addressing Conflict of Interest in the United Nations System.” Report of the Joint Inspection Unit. JIU/REP/2017/9. Geneva: United Nations. UN Global Impact. n.d. “Our Mission.” UN Global Compact. Accessed June 29, 2021. https://unglobalcompact.org/what-is-gc/ mission. UN System Chief Executives Board for Coordination. 2019. “Revenue by Financing

Instrument.” https://unsceb.org/fs-revenuetype. UNDESA/OISC. 2019. “Figure IX: Top Contributors’ Share of Total Member State Contributions, 2008 to 2018.” In “UN System Chief Executives Board for Coordination,” by UN System Chief Executives Board for Coordination. https://unsceb.org/fs-revenuetype. UNHCR [United Nations High Commissioner for Refugees]. 2018a. Global Report 2017. Geneva: United Nations High Commissioner for Refugees. UNHCR [United Nations High Commissioner for Refugees]. 2018b. “UNHCR’s 2018–2019 Financial Requirements.” In UNHCR Global Appeal 2018–2019. Geneva: United Nations High Commissioner for Refugees. United Nations Children’s Fund. 2019. “Private Fundraising and Partnerships: Financial Report for the Year Ended 31 December 2018.” E/ICEF/2019/AB/L.6. United Nations Economic and Social Council. United Nations Educational Scientific and Cultural Organization. 2014. “UNESCO and the Private Sector.” https://unesdoc.unesco. org/ark:/48223/pf0000228855. United Nations Global Compact. 2021. “New UN Global Compact Strategy Aims to Accelerate Business Action to Achieve Sustainable Development Goals and More Ambitious Climate Targets.” GlobeNewswire News Room. January 19. https://www.globenewswire.com/en/ news-release/2021/01/20/2161090/0/en/ New-UN-Global-Compact-strategy-aimsto-accelerate-business-action-to-achieveSustainable-Development-Goals-and-moreambitious-climate-targets.html. World Economic Forum. n.d. “Our Mission.” World Economic Forum. Accessed June 25, 2021. https://www.weforum.org/about/ world-economic-forum/. Yeo, Peter. 2014. “Amb. Samantha Power on Capitol Hill: 5 Quotes You Can’t Miss.” United Nations Foundation. April 3. https:// unfoundation.org/blog/post/amb-samanthapower-on-capitol-hill-5-quotes-you-cantmiss/.

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D4  |  WATCHING THE INTERNATIONAL FINANCIAL INSTITUTIONS: NEW RHETORIC, OLD PRACTICE?

Introduction

Since early 2020, the world has struggled to respond to the health, social, and economic impacts of the COVID-19 pandemic. Despite the “we are all in this together” rhetoric of political leaders, the reality has been rather different, with the effects of the pandemic and the capacity to respond highly unequal within and between countries. In the UK, data show that COVID-19 impacts mirror those of general trends in health, with deprivation clearly linked to poor outcomes (Marmot and Allen 2020); the same patterns hold true in the USA (Centers for Disease Control 2020) and most other countries. Although the health consequences of SARS-CoV-2 have been less than initially feared in some poorer states (e.g., in the African continent) (Winning 2020), the fact remains that Group of 20 (G20) countries were able to announce stimulus packages of $7.6 trillion (Segal and Gerstel 2020), while poorer countries lacked a similar response capacity. The disparate capacity is evident even within the G20 grouping. Such fiscal inequities translate both directly and indirectly into health inequities, exacerbated further by the global economic downturn caused, in part, by the health measures introduced to contain the spread of the virus. As is now well known, these measures have different impacts on different global and national population groups. Informal workers, migrants, and homeless people, or those who work in the service sector, are generally unable to work from home and are also less resilient to the economic shock brought about by the pandemic. They are also less able to undertake protective measures and are thus at increased danger of exposure to the virus (see Chapter C2). In some cases, it is likely that efforts to reduce the risk of infection from COVID-19 create more immediate health risks than does ignoring recommendations for confinement in order to ensure income and daily sustenance (Alcántara-Ayala et al. 2021). The world economy was performing badly prior to the pandemic with declining growth rates subsequent to the 2008 global financial crisis (United Nations Conference on Trade and Development 2020). Growth declined for low- and middle-income countries (LMICs, or so-called “developing countries”) from 7.9% in 2010 to 3.5% in 2019 (ibid.). The International Monetary Fund (IMF) stressed that the low-income countries “entered the COVID-19 crisis in an already vulnerable position” (Gurara, Fabrizio, and Wiegang 2020), with half of them suffering high public debt levels. Since March 2020, these countries were hit by an exceptional confluence of external shocks: “a sharp contraction in

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real exports, lower export prices, especially for oil, less capital and remittances inflows, and reduced tourism receipts” (Gurara, Fabrizio, and Wiegang 2020). They also experienced capital outflows of about $103 billion from January to mid-May 2020 (OECD 2020), as investors retreated to the relative safety of markets in the Global North, thus putting pressure on local currencies and potentially increasing already problematic pre-pandemic debt repayments (Murawski 2020). Future access to capital markets, which in the context of decreased overseas development assistance and insufficient multilateral lending remains an important source of finance, is by no means assured as fears of debt crises remain. The share of foreign debt held by private creditors in low- and lower-middle-income countries rose from 25% in 2010 to 47% in 2018, with asset manager BlackRock holding close to $1 billion of “Eurobonds” in Ghana, Kenya, Nigeria, Senegal, and Zambia through a number of funds (Jubilee Debt Campaign et al. 2020). The IMF considers eight advanced economies at high risk of falling into financial crisis (up from three prior to the pandemic), while the number amongst emerging markets rose from 15 to 35 (Wheatley and Romei 2020). Despite the depth and extent of the crises triggered by the pandemic, calls made by over 200 organizations for debt cancellation (JDC 2020) to enable countries to focus on adequate response to the health and social crises have gone unanswered. LMICs and their citizens have instead been left to manage with the G20’s Debt Service Suspension Initiative (DSSI), which has been criticized for being insufficient and for merely postponing onerous debt servicing rather than addressing underlying debt sustainability and questions about the legitimacy of the debt (Fresnillo 2020). The DSSI, announced by the G20 in April 2020, provides a suspension of principal and interest payments on debt due by the poorest developing countries to bilateral government lenders. While the initial suspension ran to December 2020, it was extended to December 2021 at the April 2021 World Bank (often referred to in this chapter as simply “the Bank”) and IMF Spring Meetings. Although 73 countries were deemed eligible for participation in the DSSI, only 43 have taken up the offer, as countries fear the negative impact that doing so would have on their credit ratings and access to the capital markets (Bolton et al. 2020). As underscored in a July 2020 civil society coalition report, “all 73 countries must still repay up to $33.7 billion worth of debt this year, which is $2.8 billion per month. This figure is double the amount that Uganda, Malawi, and Zambia combined spend on their annual health budget” (Oxfam et al. 2020). The publication also stressed that the World Bank’s and IMF’s refusal to participate in the debt suspension adds to the fiscal pressure on states struggling to cope with the crisis, particularly middle-income countries. Despite continued pressure from civil society and academics, neither institution is participating in the DSSI. The unwillingness of private sector creditors to voluntarily join the DSSI creates additional problems, as resources made available by the DSSI for pandemic response continue to be used instead to service debt to private creditors (Bolton et al. 2020).

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It is within this context that discussions about the World Bank and IMF responses to the COVID-19 crisis must be examined, as both institutions remain pivotal in shaping the capacity of states to respond to the urgent health, social, and economic consequences of the pandemic. The current crisis is testing the assertion that they have changed their neoliberal policies and, as some of their rhetoric proclaims, are now enlightened supporters of human rights (Bretton Woods Project 2016). The past that needs redeeming

Critiques of the negative impact of past IMF and World Bank structural adjustment programs (SAPs) on state capacity to meet their international human rights obligations, including the right to health, have a long history (Skogly 1993). The 1990 United Nations Economic Commission for Africa’s (UNECA) “African Alternative Framework to Structural Adjustment Programmes for Socio-economic Recovery and Transformation” report stressed that in many cases not only did the promised economic growth fail to materialize, but the implementation of these programs has entailed “significant reduction of expenditures in social sectors, especially education and primary health care, as well as in the size of the public sector and para-statals with negative consequences on employment” (UNECA 1989). The use of SAPs also raised significant issues about the level of state, and indeed, citizen involvement in their design, as conditions were generally imposed by the Bank and Fund. As noted by Skogly, while Article 21 of the Universal Declaration on Human Rights and Article 25 of the International Covenant on Civil and Political Rights state “that [e]very citizen shall have the right and the opportunity … to take part in the conduct of public affairs, directly or through freely chosen representative” (Skogly 1993), lack of participation of those mostly likely to be negatively impacted by IMF and World Bank programs remains a key constraint in ensuring that the health outcomes of these programs are consistent with human rights law and obligations. This lack of participation in their design historically exacerbated frustrations with the uneven distribution of adjustment costs, contributing to ethnic and other social tensions (Kaiser 1996). The World Bank and IMF have changed considerably since the days of SAPs, as exemplified by the IMF’s questioning in 2016 whether neoliberalism had been oversold (Ostry, Loungani, and Furceri 2016). In 2018, former IMF Managing Director Christine Lagarde highlighted the need for a new multilateralism, noting that it must “be more inclusive – open to diverse views and voices. It must be more people-oriented – putting human needs first. And it must be more effective and accountable – delivering results for all” (Lagarde 2018). The World Bank’s adoption of its twin goals in 2013 (reduce global extreme poverty to 3% by 2030 and share prosperity by fostering income growth of the bottom 40% of the population) also demonstrated a change. While the second goal has been criticized for ignoring the important relationship of relative income growth

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between the bottom 40% and the top 10% of the population (Galasso 2015), it does represent an acknowledgement by the World Bank that the distribution of benefits of economic growth matters. But not so fast: enter the Human Capital Project

In 2018, noting that “Governments have long invested in economic growth by focusing on physical capital … But … often under-invested in their people” (World Bank Group 2018), the World Bank announced its new Human Capital Project (HCP). The HCP is accompanied by a Human Capital Index (modeled on the much-criticized “Ease of doing business report”1) (Ortiz and Baunach 2020) and has three principal objectives: “first, to build demand for more and better investments in people; second, to help countries strengthen their human capital strategies and investments for rapid improvements in outcomes; and third, to improve how we measure human capital” (World Bank Group 2018). Perhaps sensitive to long-standing critiques of the institution’s role in undermining public services such as health and education (Stubbs and Kentikelenis 2017), the World Bank has sought to present the index as a progressive development tool with potentially wide appeal to those concerned with improvements in health and education outcomes. The concept and initiative, however, are not without detractors. Human capital theory itself has been criticized for its commodification of people underlying the notion of “capitalizable humans” and its disregard for structural constraints inherent in the development of effective health and education programs (Allais 2012). Related social capital theories, in turn, “tend to reduce complex conflictual and contextual economic and social phenomena to more or less (im)perfectly working markets” (Fine 2010). Further, the Bank’s HCP coheres closely with its International Finance Corporation (IFC) Strategy 3.0, “Creating Markets” (IFC 2019), and the Bank’s 2017 “Maximizing Finance for Development” (MFD) paradigm (Brunswijck 2019). The HCP, IFC 3.0, and MFD are complementary efforts by the Bank to push market-based solutions to complex social and class issues. They present health and education as necessary “investments” in the “capital” of individuals and families and define the state’s role as maximizing human capital’s value in domestic or international markets. This creates a discourse that instrumentalizes the concept, isolating it from considerations of structural issues, human rights, and state obligations. This is unsurprising given that the World Bank and IMF have historically energetically rejected efforts to integrate a human rights perspective into their consideration and operations (OHCHR 2017). Old wine, new bottle?

Hopes that the pandemic and its devastating impacts would bring about a radical reformulation of World Bank and IMF policies have thus far been dashed. IFC Interim Managing Director and Executive Vice President Stephanie von

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Friedeburg left this in little doubt when she stressed, during the virtual townhall meeting with civil society organizations during the 2020 IMF and World Bank joint Annual Meetings, that efforts to “maximize finance for development” through energetic support for the private sector – including in the social service sectors – is “potentially more important now than ever,” adding, “it is the right approach so we will continue to push” (von Friedeburg 2020). Referring to the World Bank’s budget support through its policy finance lending, which is premised on compliance with “prior conditions,” that is, conditionalities, such as “enhancing the role of the private sector” through privatizations and targeting of social protection spending (Brunswijck 2019), Von Friedeburg stressed that the Bank would use the leverage created by this instrument, regardless of the context created by the pandemic, to “increase the role of the private sector” and to “pull private capital back to emerging markets” (von Friedeburg 2020). These statements seem to contradict the Bank’s HCP and indeed the discourse prevalent at the 2020 World Bank and IMF Annual Meetings, where “investing in people” received a great deal of attention. The expansion of IFC investments, with support from World Bank Group policies aimed at creating a business-friendly environment with a strong focus on deregulation, seems hardly surprising given the potential financial benefits of this strategy for IFC (which receives payments on its loans) and its clients (who benefit financially from the businesses the IFC finances). IFC-financed healthcare companies, for example, report having 142 million healthcare users, with the IFC aiming to increase this number eightfold by 2030; and health is one of the IFC’s best performing sectors in terms of returns on investment (Hunter and Murray 2019). In that regard, concerns have been raised by IFC’s reliance on profitable investments in middle-income countries to safeguard its own credit rating and subsidize its activities in riskier low-income settings (Kenny, Kalow, and Ramachandran n.d.). Questions about the degree to which the IFC’s investments have had a positive development within the context of the Bank’s response to the COVID-19 pandemic have also been raised by an April 2021 report by the European Network on Debt and Development (Eurodad) (Bayliss and Romero 2021). The IFC and the World Bank Group’s support of the financialization of the health sector is consistent with what Gabor has termed the Wall Street Consensus (Gabor 2020), in which the state transitions from its role of addressing market failures under the post-Washington Consensus,2 to de-risking private investments in increasingly uncertain times, such as a worldwide pandemic. According to Gabor: Across Sub Saharan Africa, 50% of healthcare is provided by the private sector, with financing provided by investment platforms and fund managers promoting the development of healthcare asset classes. Enter digital healthcare, with its promise of better diagnostics through advanced technologies, and a complex ecosystem ripe for ‘health as an asset class’ initiatives. (ibid.) (see Chapter B2)

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In a note particularly relevant in the light of the economic crises triggered by the COVID-19 pandemic, Gabor stresses that fiscal constraints are used to justify the “crowding in” of private investments by the creation of the abovementioned new asset classes. These include health bonds, of which the World Bank’s ill-fated Pandemic Emergency Financing Facility (PEF) bond is an example. The high-profile pandemic bond was so heavily criticized that the World Bank decided not to launch a second round. Former World Bank economist Olga Jonas from the Harvard Global Health Institute had in fact argued that PEF’s design “waits for people to die” (McVeigh 2020).

Box D4.1: Pandemic bonds and the COVID-19 pandemic The World Bank’s “pandemic bonds” form part of its PEF, which was created in response to the difficulty in financing the response to the 2014 Ebola crisis (World Bank Group 2020b). The PEF aims to provide emergency funding to the poorest countries during pandemics. PEF has two components, the cash window and the insurance window. The cash window provides financial assistance for diseases not covered by the insurance window, or for immediate use before the approved funding is released from the insurance window. The pandemic bonds are issued for the specific purpose of financing a response to specified pandemic events. Bondholders receive a high premium at beginning and are guaranteed a very high fixed interest. If the specific pandemic conditions fail to materialize prior to the bond’s maturity date, all the principle is returned to the bondholder. If the bond is triggered by a pandemic and the funds provided by the bond’s principle are used in the response, the bondholder loses the used portion of the principle. The World Bank issued $320 million of pandemic bonds in 2017 (Hodgson 2020). According to the World Bank, “as of September 30, 2020, the entire $195.84 million COVID-19 insurance payout has been transferred to support COVID-19 responses in 64 countries” (World Bank Group 2020b). While some of the resources from the bonds were eventually made available, the structure was widely criticized as ineffective due to its restrictive criteria for triggering use of the funds and the complex systems used to assess whether the criteria had been met. Even as it became evident that the pandemic was quickly spreading in early 2020, it was unclear whether the conditions would be triggered to allow the disbursement of desperately needed resources. “The coronavirus had killed almost 150,000 people in dozens of countries before the casualty rates aligned with the ‘exponential growth’ requirement set out in the bond prospectus” (Alloway and Vossos 2020). It was only more than five weeks after the World Health Organization

WATCHING THE INTERNATIONAL FINANCIAL INSTITUTIONS  |  397 (WHO) declared a global pandemic that the independent arbiter tasked with determining whether the criteria had been met issued a report confirming that to be the case, allowing the disbursement of $195.8 million from the cash and insurance windows (World Bank Group 2020b). The scheme is also expensive, with the bondholders paid high interest and premia. Investors eventually earned $95 million from interest payments of 6.5% and 11.1% on the two classes of bonds, similar to rates paid for “junk bonds” (ibid.). As Olga Jones, senior fellow at Harvard Global Health Institute who had previously worked at the Bank, noted, the Bank has access to its own development assistance resources and did not have to resort to paying high interest rates to ensure a rapid response to the pandemic (ibid.). Questions about the effectiveness of the pandemic bonds predate the COVID-19 pandemic. The bonds failed to pay during the 2018 Ebola outbreak, which caused at least 1,800 deaths while payments to investors continued (Jonas 2019). Analysis by the London School of Economics determined that the bonds would have only released funds on two occasions since 2006, leading its authors to note that the scheme seems “to be serving private investor interests more than contributing to global health security” (Bretton Woods Project 2020).

Public–private partnerships (PPPs) are not the answer

Where market discipline lives up to its name in disciplining the behavior of “emerging markets” (witness the unwillingness of countries struggling to respond to the pandemic to take up the G20’s offer of debt payment suspension), states were under pressure even prior to the pandemic to show fiscal constraint. PPPs3 are another modality presented as a win-win, where states could benefit from the presumed superior knowledge, technology, and efficiency of the private sector by “merely” entering into “risk-sharing” agreements. As the IFC highlights, “more than half of the global population resides in emerging markets, where governments are under pressure to expand health services and coverage [and where] PPPs are one mechanism to help overcome financing gaps and budget constraints that limit investments” (Stucke 2019). Unsurprisingly, as a recent report documented, “89% of World Bank [post-COVID-19] projects do not plan to support any action to remove financial barriers, including user fees, that exclude millions from lifesaving care; and two-thirds lack any plans to increase the number of healthcare workers” (Oxfam International 2020). The World Bank’s push for PPPs has been heavily criticized. Civil society has mobilized around a PPP manifesto which calls upon the World Bank, among other entities, to declare a moratorium “on funding, promoting or providing technical assessment for PPPs until an independent review into the development

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outcomes of the Bank’s PPP portfolio is completed” (Romero 2018). While the case of the Lesotho hospital PPP project became emblematic of the arrangement’s risks, with more than half the country’s entire health budget (51%) being spent on payments to the private partners (Boseley 2014) (see Global Health Watch 5, Chapter B5), the problems with PPPs run much deeper. The UK’s National Audit Office (NAO 2018) and the European Court of Auditors (European Court of Auditors 2018) both criticized PPP arrangements for their high costs and limited benefits in both contexts. The negative experiences of PPPs in states with well-developed administrative and legal capacities should give pause to those advocating similar arrangements in countries with more limited capacity. The impact of the pandemic on government resources alongside the World Bank’s commitment to integrate its “Maximizing Finance for Development” (MFD) approach in its pandemic response programs raise the possibility that heavily indebted and fiscally constrained governments will turn to PPPs to bypass their fiscal constraints. Because PPP contracts do not require upfront expenditures, they can be very attractive to debt-strapped governments. They can be seen as free money, as in many cases the liabilities are not recorded as debt (nor debated in parliament) and, therefore, also are not necessarily included in debt profiles – quite an enticing possibility in the current environment in which high debt levels and limited market access are the norm for many LMICs. The lack of transparency in PPP contracts and the way such contracts are registered, however, exposes states to the possibility of significant “hidden” contingent liabilities. They are not the win-win proponents promote, unless one happens to be one of the private partners expecting a relatively risk-free return on capital (Dolack 2021). The World Bank does highlight the need to supplement weak state capacity to oversee and manage delivery of essential social services with private sector “partnerships,” but it appears to dramatically underestimate the high levels of state capacity required to negotiate and manage complex PPP projects. To address the complexity of PPP contracts – if not the inherent power imbalances between the parties – the Bank developed a Guidance on PPP Contractual Provisions. The Heinrich Böll Foundation commissioned a study of the 2017 Guidance “to determine whether the contractual provisions recommended by the World Bank Group achieve an appropriate balance between contracting parties, and adhere to common practices and international law” (Aizawa 2017). The review found that “the Guidance does not take an equitable approach to balancing public and private interests” (ibid.). It notes that the Guidance recommends, in contradiction to international jurisprudence, “that the risks of war, civil strife, strikes, riots, and terrorism be placed on the Contracting Authority, which could require that the government compensate the private partner.” Crucially, the Guidance also recommends restrictions on “the right of sovereign governments to regulate in the public interest (e.g., to provide universal, affordable infrastructure services; reduce greenhouse gas emissions in keeping with obligations under the Paris Agreement; or protect labor and

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human rights) by recommending that governments protect private partners against costs of compliance with changes in law” (ibid.). The continuing threat of investor-state disputes

There is also the threat of suits against governments launched by private foreign investors under one of the 800+ bilateral or regional investment treaties still in force globally. The World Bank-hosted International Centre for Settlement of Investor Disputes (ICSID) is the principal arbitration forum for disputes brought by investors against states through the system of investor-state dispute settlement (ISDS) (Bretton Woods Project 2020). An open letter to governments signed by over 650 international civil society organizations called for a suspension of all ISDS cases during the pandemic (S2B network 2020). In arguing for the suspension, the letter detailed a series of state actions in response to the health and economic consequences of the pandemic that could give rise to a suit, including: securing resources for health systems by requisitioning use of private hospital facilities, putting private healthcare providers under public control, requiring manufacturers to produce ventilators, ensuring access to clean water for handwashing and sanitation by freezing utility bills and suspending disconnections, ensuring medicines, tests and vaccines are affordable, and undertaking debt restructuring (ibid.). The potential impacts of ISDS cases in the context of the COVID-19 pandemic are so significant that the African Union Trade Ministers of Trade adopted a landmark Declaration on the Risk of Investor-State Dispute Settlement with respect to COVID-19 related measures in November 2020 in an effort to secure policy space (Maina and Nikiema 2021; see also Chapter D2). The perils of the World Bank’s MFD approach and its conceptualization of the private sector as a trustworthy “development partner” becomes evident when one considers that, as of May 2020 and while amid the pandemic: … there are currently over 260 [ICSID] cases pending against African States … compared to 135 cases in May 2017. It is anticipated that many more arbitrations will be commenced in the months to come. This is especially important when considering that in the case of ICSID arbitrations alone, more than half of claims commenced against African States have resulted in a final award, and more than half of those cases have resulted in an award of full or partial damages against the State. (Goddard 2020)

The links with World Bank-supported PPPs and the structure of the contractual agreements developed by the above-mentioned Guidance note become that much more concerning. What are the international financial institutions offering to pandemicafflicted countries?

The World Bank has allocated $12 billion to assist LMICs to “finance the purchase and distribution of COVID-19 vaccines, tests, and treatments for their

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citizens” (World Bank Group 2020a), although the funding is outside of the WHO-led multilateral COVAX facility similarly working to provide access for eligible LMICs. The World Bank has further pledged $160 billion in financial support, including a high proportion of loans to already heavily indebted countries “to help developing countries fight the COVID-19 pandemic” (World Bank Group 2020a). The impact of these loans and grants under the International Development Association (IDA), the World Bank’s concessional lending and granting arm for low-income countries, will vary greatly across recipient countries. While the World Bank’s $12 billion in support for the purchase of vaccines and contributions to the assessment and development of national vaccination plans has been welcomed, the Bank has been criticized for its unwillingness to support a call by over 100 countries from the Global South at the World Trade Organization (WTO) for a waiver of some aspects of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). The proposal at the WTO, which is opposed by an alliance of countries from the Global North, argues that the waiver would be imperative to enable the production and distribution of COVID-19 vaccines in the Global South and to begin to address the great inequity in the distribution of vaccines worldwide, with nine of ten people in the poorest countries “set to miss out on the vaccine this year” (Bretton Woods Project 2021; see Chapter B4). The Bank’s wider COVID-19 response has also been criticized. In December 2020, Oxfam released a report that concluded that the Bank’s pandemic response suffers from a “fatal flaw,” as “just 8 of the 71 World Bank COVID-19 health projects include any plans to remove financial barriers to accessing health services … [and] none of the 8 specify that fee waivers will cover all health services as the WHO recommends” (Oxfam International 2020). The Oxfam report underscored that, despite a preexisting global shortage of 17.4 million health workers, “two-thirds of country projects do not include any plans to increase the number of health workers, and that the 25 projects which do, have substantial shortcomings” (ibid.). The World Bank’s response through the IFC was also brought into question by an April 2021 analysis by Eurodad that found its response to the pandemic was in keeping with its MFD approach, and that “the IFC, with its emphasis on creating markets and mobilizing private finance, has a prominent position at all stages of the Covid-19 response … including in health, suggesting that private markets will be prioritized over equitable public services” (Bayliss and Romero 2021). The report also notes that long-standing criticisms of the limited extent to which IFC investments benefit local business are transferable to the IFC’s role in the COVID-19 response, stressing that “rather than supporting local private enterprises, some IFC projects have provided finance to global chains of hotels, large conglomerates, subsidiaries of international companies and international private health providers” (ibid.). The question of the institution’s impact on the COVID-19 response, however, must be considered from a systemic as well as country-specific framework that considers the extent to which responses to the pandemic are constrained

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by prior World Bank and IMF policies and the structures of their proposed medium-term programs. The IMF’s reaction to the pandemic, particularly in terms of its rhetoric, continues the trend of presenting a softer, kindlier IMF begun under its previous Managing Director, Christine Lagarde, who stated in a speech in Latin America: “This is certainly not your grandmother’s IMF” (Lagarde 2014). In a speech on October 15, 2020, IMF Managing Director Kristalina Georgieva outlined three imperatives to address the COVID-19 pandemic: designing “the right policies,” ensuring that policies are “for the people,” and that the world must no longer disregard climate change, stressing that there is no “one size fits all solution” (Georgieva 2020a; 2020b). She has also spoken about the threat posed by rising inequality warning that, “without urgent action, we risk deepening the divide – globally – between the rich and poor … It risks reverberating throughout the world with increased inequality leading to economic and social upheaval: a lost generation in the 2020s whose after-effects will be felt for decades to come” (Georgieva 2020a). In May 2020, the IMF released a report that questioned the alleged benefits of financial deepening, highlighting how the fast-paced expansion of financial markets can result in instability and noting that “regulatory policies have a role to play in reining in excessive growth of the financial sector” (Čihák and Sahay 2020). Critics of the disequalizing health and economic impacts of past IMF programs find that, in visionary statements at least, the Fund’s response to the pandemic seems different and that its “emergency programs grant the majority of countries the flexibility to get their own houses in order without onerous oversight and conditionality” (Gallagher 2020). Separate research by Eurodad and Oxfam, however, provide ample reason to temper the initial optimistic assessment. The Eurodad study released in October 2020 found that, of the 80 IMF country staff reports reviewed, “72 countries that have received IMF financing are projected to begin a process of fiscal consolidation as early as 2021. Tax increases and expenditure cuts are to be implemented in all 80 countries by 2023” (Munevar 2020). The report calculates that consolidation will be front-loaded, will impact the most vulnerable, and that the 72 countries “will implement austerity measures worth on average 3.8 per cent of Gross Domestic Product (GDP) between 2021 and 2023.” The Oxfam study reached similarly alarming conclusions. While it acknowledges that emergency response funds have been “free of policy reform requirements” (Daar and Tamale 2020) and have focused on meeting urgent health and social protection needs, its findings support those of Eurodad. Its review of IMF loans found that fiscal consolidation measures were being promoted in 84% of the loans across 67 countries, despite an open letter call to IMF Managing Director, Kristalina Georgieva, signed by over 500 academics and civil society organizations, calling for an end to such requirements (see Chapter C1 for a more detailed account of the pandemic’s re-birth of austerity measures).

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Conclusion

The evidence thus far indicates that, despite some cosmetic and rhetorical changes, the IMF and World Bank remain substantively unwilling or unable to significantly alter their approach. As UNCTAD’s (United Nations Conference on Trade and Development) September 2020 Trade and Development Report noted with reference to the pandemic, “multilateralism has struggled to adapt and reforms, while regularly promised, have been resisted by the strongest players” (UNCTAD 2020). As Gabor’s Wall Street Consensus thesis stresses, the “strongest players” now very much include financial capital, as has been vividly demonstrated by the G20’s inability to compel private finance to participate in the (obviously inadequate) DSSI during the worst pandemic and global economic crisis in a century. The UNCTAD report further underscores how “the language of ‘free trade’ has been captured by big banks and multinational corporations to push for ‘deeper integration’ that justifies efforts to rewrite the rules of standard-setting and intellectual property protection and reducing the regulatory reach and policy space available to democratically elected governments” (ibid.). While many had noted at the start of the pandemic that a silver lining could emerge from the crisis in the shape of an increased acceptance of the essential role of the state, the opposite could also be the case as the pandemic’s economic fallout challenges states already severely fiscally constrained. This dynamic appears disturbingly likely, given the above-mentioned policies supported by the World Bank and the IMF, particularly as they relate to fiscal constraints and erosion of state capacity in the medium term. The toxic mix of a slow and uneven economic recovery coupled with anger over the devastating economic impact of state public health responses to the pandemic can have long-lasting consequences for the already fragile social contract between the state and its citizens. The IMF raised the possibility of civil unrest in its April 2020 Fiscal Monitor report; that “countries could be vulnerable to new waves of social unrest, for example, if support measures are seen as insufficient to mitigate the COVID-19 crisis and its economic fallout, or as unfair by favoring the wealthy, or when those measures are later withdrawn” (IMF 2020). The April caution was repeated in December 2020, that “based on this historical trend, the COVID-19 pandemic could pose a threat to the social fabric in many countries” (Sedik and Xu 2020). These dire warnings echo research by Verisk Maplecroft, which, before the pandemic, found that, “the number of countries rated extreme risk in the Civil Unrest Index … jumped by 66.7%; from 12 in 2019 to 20 by early 2020” (Hribernik and Haynes 2020). In a December 2020 update, the consultancy firm projected that “75 countries will likely experience an increase in protests by late 2022 … We expect the surge in instability to take place against a backdrop of a painful post-pandemic economic recovery that will likely inflame existing public dissatisfaction with governments” (Campbell and Hribernik 2020).

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Just prior to the pandemic, a January 2020 study underscored that “across the planet – from Europe to Africa, as well as Asia, Australasia, both Americas and the Middle East – the share of individuals who say they are ‘dissatisfied’ with democracy has jumped significantly since the mid-1990s: from 47.9% to 57.5%” (Lewsey 2020). This is likely to worsen as the pandemic persists. The recently ended Trump presidency, and the emboldened rule of autocrats worldwide, will only hasten a democratic tailspin, without concerted civil society activism. The present trajectory of IMF and the World Bank programming must be far bolder and more ambitious in heeding the growing calls for a system change that is able to deliver more equitable, ecologically sustainable developmental outcomes. Otherwise, it will find itself continuing to defend and promulgate an economic system that is increasingly unjust, unsustainable, and unstable. Notes 1  The World Bank’s “Ease of doing business report” and related Doing Business index have been heavily criticized for promoting a regulatory “race to the bottom” as countries compete to move up the rankings by demonstrating their willingness to easy labor and environmental regulatory “burdens” (see Flora Sonkin and Bhumika Muchhala, “It’s Time for the World Bank to Scrap its Doing Business Rankings,” Aljazeera, April 22, 2021. https:// www.aljazeera.com/opinions/2021/4/22/its-timefor-the-world-bank-to-scrap-its-doing-businessrankings). 2  The Washington Consensus (WC) which emerged in the early 1980s represented a significant shift from previous development models premised on a pivotal role of the state in the economy. In contrast, the WC assumed the primacy of the market as the driver of development and growth and criticized a claimed inefficiency of the state. This belief led to a drive toward liberalization of financial markets, privatizations, and a focus on enabling policies to attract foreign investment, as development was seen to result from the provision of the

“correct” incentives to the market. The postWashington Consensus arose out of frustrations with the WC and acknowledged that markets worked imperfectly, that “institutions matter,” and that the state therefore had an important role in creating the necessary conditions to growth by addressing market failures. See Alfredo Saad-Filho, “Growth, Poverty and Inequality: From Washington Consensus to Inclusive Growth,” DESA Working Paper No. 100 ST/ESA/2010/DWP/100, UN Department of Economic and Social Affairs, 2010. https://www. un.org/esa/desa/papers/2010/wp100_2010.pdf. 3  The World Bank in its 2017 Guidance on PPP Contractual Provisions defines a PPP project as a project which is the subject of a PPP contract. A PPP contract is defined as the long-term agreement between the Contracting Authority and the Private Partner, for providing a public asset or service, in which the Private Partner bears significant risk and management responsibility, and remuneration is linked to performance. See https://ppp.worldbank.org/ public-private-partnership/library/guidance-pppcontractual-provisions-2017-edition.

References Aizawa, Motoko. 2017. “Key Messages on the World Bank Group’s 2017 Guidance on PPP Contracts.” Heinrich Böll Stiftung (blog). December 15. https://us.boell.org/ en/2017/09/15/key-messages-world-bankgroups-2017-guidance-ppp-contracts. Alcántara-Ayala, Irasema, Ian Burton, Allan Lavell, Elizabeth Mansilla, Andrew Maskrey,

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404   |  Global Health Watch 6 Allais, Stephanie. 2012. “‘Economics Imperialism’, Education Policy and Educational Theory.” Journal of Education Policy 27 (2): 253–274. Alloway, Tracy, and Tasos Vossos. 2020. “Why World Bank’s Controversial Pandemic Bonds Didn’t Function as Hoped.” Insurance Journal, December 10. https:// www.insurancejournal.com/news/ international/2020/12/10/593490.htm. Bayliss, Kate, and María Jose Romero. 2021. “‘Rebuilding Better’, but Better for Whom?” Eurodad. https://www.eurodad.org/ rebuilding_better. Bolton, Patrick, Lee Buchheit, Pierre-Olivier Gourinchas, Mitu Gulati, Chang-Tai Hsieh, Ugo Panizza, and Beatrice Weder Di Maduro. 2020. “Sovereign Debt Standstills: An Update.” CEPR Vox EU. May 28. https://voxeu. org/article/sovereign-debt-standstills-update. Boseley, Sarah. 2014. “Half of Lesotho Health Budget Goes to Private Consortium for One Hospital.” The Guardian. April 7. https:// www.theguardian.com/world/2014/apr/07/ lesotho-health-budget-private-consortiumhospital. Bretton Woods Project. 2016. “Can the IMF Leopard Change Its Spots.” Bretton Woods Observer. June. https://www. brettonwoodsproject.org/publications/ observer-summer-2016/. Bretton Woods Project. 2020. “World Bank Pandemic Bond Instrument Fails in COVID-19 Response.” The Observer. April 7. https:// www.brettonwoodsproject.org/2020/04/ world-bank-pandemic-bond-instrument-failsin-covid-19-response/. Bretton Woods Project. 2021. “World Bank Support for Covid-19 Vaccination Fails to Ensure Equitable Access.” Observer. March 23. https://www.brettonwoodsproject. org/2021/03/world-bank-support-to-covid19-vaccination-fails-to-address-fundamentalbarriers-to-equitable-access/. Brunswijck, Gino. 2019. “Flawed Conditions: The Impact of the World Bank’s Conditionality on Developing Countries.” Eurodad (blog). April 2019. https://d3n8a8pro7vhmx.cloudfront. net/eurodad/pages/520/attachments/ original/1590688379/Flawed_conditions. pdf?1590688379. Brunswijck, Gino. 2020. “Fears of Lawsuits at World Bank’s Tribunal Constrain Efforts to Fight Pandemic.” The Observer. July 16. https://www.brettonwoodsproject.

org/2020/07/fears-of-lawsuits-at-worldbanks-tribunal-constrain-efforts-to-fightpandemic/. Campbell, Tim, and Miha Hribernik. 2020. “A Dangerous New Era of Civil Unrest Is Dawning in the United States and around the World.” Verisk Maplecroft (blog). December 11. https://www.maplecroft.com/ insights/analysis/a-dangerous-new-era-ofcivil-unrest-is-dawning-in-the-united-statesand-around-the-world/. Centers for Disease Control and Prevention. 2020. “Coronavirus Disease (Covid-19).” July 24. https://www.cdc.gov/coronavirus/2019ncov/community/health-equity/raceethnicity.html. Čihák, Martin, and Ratna Sahay. 2020. “Finance and Inequality.” IMF Staff Discussion Note. IMF. Daar, Nadia, and N. Tamale. 2020. “A Virus of Austerity? The COVID-19 Spending, Accountability, and Recovery Measures Agreed between the IMF and Your Government.” Washington: Oxfam International. https://www.oxfam.org/en/ blogs/virus-austerity-covid-19-spendingaccountability-and-recovery-measuresagreed-between-imf-and. Dolack, Peter. 2021. “Private Sector is ‘Efficient’ Only at Extracting Money from Public.” Counterpunch. January 22. https://www. counterpunch.org/2021/01/22/private-sectoris-efficient-only-at-extracting-money-frompublic/. European Court of Auditors. 2018. “Public Private Partnerships in the EU: Widespread Shortcomings and Limited Benefits.” European Court of Auditors. Fine, Ben. 2010. Theories of Social Capital: Researchers Behaving Badly. London: Pluto Press. Fresnillo, Iolanda. 2020. “Shadow Report on the Limitations of the G20 Debt Service Suspension Initiative: Draining out the Titanic with a Bucket?” European Network on Debt and Development. Friedeburg, Stephanie von. 2020. “Civil Society Townhall with WBG President David Malpass.” https://live.worldbank.org/csotownhall-annual-meetings-2020. Gabor, Daniela. 2020. “The Wall Street Consensus.” SocArXiv wab8m, Center for Open Science. https://ideas.repec.org/p/osf/ socarx/wab8m.html.

WATCHING THE INTERNATIONAL FINANCIAL INSTITUTIONS  |  405 Galasso, Nicholas. 2015. “The World Bank Is Getting ‘Shared Prosperity’ Wrong: The Bank Should Measure the Tails, not the Average.” Global Policy 6 (3): 321–324. Gallagher, Kevin P. 2020. “Why the IMF Needs to Build on Its COVID-19 Record, not Backtrack.” Brookings Institution (blog). October 13. https://www.brookings.edu/ blog/future-development/2020/10/13/ why-the-imf-needs-to-build-on-its-covid-19record-not-backtrack/. Georgieva, Kristalina. 2020a. “No Lost Generation: Can Poor Countries Avoid the Covid Trap?” The Guardian. September 29. https://www.theguardian.com/ business/2020/sep/29/covid-pandemic-imfkristalina-georgieva. Georgieva, Kristalina. 2020b. “A New Bretton Woods Moment.” IMFblog (blog). October 15. https://www.imf.org/en/News/ Articles/2020/10/15/sp101520-a-new-brettonwoods-moment. Goddard. 2020. “Investment Treaty Claims in Pandemic Times: Potential Claims and Defenses.” Addleshaw Goddard (blog). May 11. https://www.addleshawgoddard.com/ en/insights/insights-briefings/2020/africa/ investment-treaty-claims-in-pandemic-timespotential-claims-and-defences/. Gurara, Daniel, Stefania Fabrizio, and Johannes Wiegang. 2020. “COVID-19: Without Help, Low-Income Developing Countries Risk a Lost Decade.” IMFblog (blog). August 27. https://blogs.imf.org/2020/08/27/covid19-without-help-low-income-developingcountries-risk-a-lost-decade/https://blogs. imf.org/2020/08/27/covid-19-without-helplow-income-developing-countries-risk-a-lostdecade/. Hodgson, Camila. 2020. “World Bank Ditches Second Round of Pandemic Bonds.” Financial Times. July 5. Hribernik, Miha, and Sam Haynes. 2020. “Political Risk Outlook 2020: 47 Countries Witness Surge in Civil Unrest – Trend to Continue in 2020.” Verisk Maplecroft (blog). January 16. https://www.maplecroft.com/ insights/analysis/47-countries-witness-surgein-civil-unrest/. Hunter, Benjamin M., and Susan F. Murray. 2019. “Deconstructing the Financialization of Healthcare.” Development and Change 50 (5): 1263–1287.

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406   |  Global Health Watch 6 COVID-Related ISDS Risks: Why It Matters Now.” International Institute for Sustainable Development (blog). March 2. https://www. iisd.org/articles/african-union-ministerialdeclaration-covid-related-isds-risks-why-itmatters-now. Marmot, Michael, and Jessica Allen. 2020. “COVID-19: Exposing and Amplifying Inequalities.” Journal of Epidemiology and Community Health 2020 74 (July): 681–682. McVeigh, Karen. 2020. “World Bank’s $500m Pandemic Scheme Accused of ‘Waiting for People to Die.’” February 28. https://www. theguardian.com/global-development/2020/ feb/28/world-banks-500m-coronavirus-pushtoo-late-for-poor-countries-experts-say. Munevar, Daniel. 2020. “Arrested Development: International Monetary Fund Lending and Austerity Post Covid-19.” Brussels: Eurodad. https://www.eurodad.org/ arrested_development. Murawski, Sara. 2020. “Time to Resolve Debt Issues in the Global South.” April 17. https:// www.tni.org/en/article/time-to-resolve-debtissues-in-the-global-south. NAO. 2018. “PFI and PF2.” National Audit Office. OECD. 2020. “COVID-19 and Global Capital Flows.” OECD. http://www.oecd.org/ coronavirus/policy-responses/covid-19-andglobal-capital-flows-2dc69002/. OHCHR. 2017. “Report of the Independent Expert on the Promotion of a Democratic and Equitable International Order.” A/ HRC/36/40. New York: United Nations. Ortiz, Isabel, and Leo Baunach. 2020. “It Is Time to End the Controversial World Bank’s Doing Business Report.” September. http:// www.ipsnews.net/2020/09/time-endcontroversial-world-banks-business-report/. Ostry, Jonathon D., Prakash Loungani, and Davide Furceri. 2016. “Neoliberalism: Oversold?” Finance & Development 53 (2): 38–41. https://www.imf.org/external/pubs/ft/ fandd/2016/06/ostry.htm. Oxfam, Christian Aid, Global Justice Now, and Jubilee Debt Campaign. 2020. “Passing the Buck on Debt Relief.” https://www.oxfam. org/en/research/passing-buck-debt-relief. Oxfam International. 2020. “From Catastrophe to Catalyst: Can the World Bank Make COVID-19 a Turning Point for Building Universal and Fair Public Healthcare

Systems?” https://www.oxfam.org/en/ research/catastrophe-catalyst. Romero, María Jose. 2018. “Civil Society Organisations’ Open Letter to World Bank on PPPs.” April 18. https://www.eurodad.org/ ed-open-letter-ppps. S2B network. 2020. “Open Letter to Governments on ISDS and COVID-19.” http://s2bnetwork.org/sign-the-pen-letterto-governments-on-isds-and-covid-19/. Sedik, Tahsin Saadi, and Rui Xu. 2020. “When Inequality Is High, Pandemics Can Fuel Social Unrest.” IMFblog (blog). December 11. https://blogs.imf.org/2020/12/11/wheninequality-is-high-pandemics-can-fuel-socialunrest/. Segal, Stephanie, and Dylan Gerstel. 2020. “Breaking Down the G20 Covid-19 Fiscal Response: June 2020 Update.” Center for Strategic & International Studies, July 2. https://blogs.imf.org/2020/08/27/covid19-without-help-low-income-developingcountries-risk-a-lost-decade/. Skogly, Sigrun. 1993. “Structural Adjustment and Development: Human Rights – An Agenda for Change.” Human Rights Quarterly 15 (4): 751–778. Stubbs, Thomas, and Alexander Kentikelenis. 2017. “International Financial Institutions and Human Rights: Implications for Public Health.” Public Health Review 38 (27): 1–17. Stucke, Amanda. 2019. “Public-Private Partnerships for Emerging Market Health: A Briefing Paper from the IFC Public-Private Partnership (PPP) Think Tank Discussion at the 2019 Global Private Health Care Conference.” Briefing paper. International Finance Corporation. United Nations Conference on Trade and Development. 2020. “World Trade and Development Report 2020.” New York: UNCTAD. UNECA. 1989. African Alternative Framework to Structural Adjustment Programmes for Socio-Economic Recovery and Transformation (AAF-SAP). E/ECA/ CM.15/6/Rev.3. Addis Ababa: UNECA. Available at: https://digitallibrary.un.org/ record/137214?ln=fr. Wheatley, Jonathan, and Valentina Romei. 2020. “Emerging Economies Face Rising Interest Rates as Capital Flows Ebb.”

WATCHING THE INTERNATIONAL FINANCIAL INSTITUTIONS  |  407 The Financial Times. October 5. https://www. ft.com/content/99603ed2-0580-455f-823ad138685e2b4f. Winning, Alexander. 2020. “Puzzled Scientists Seek Reasons behind Africa’s Low Fatality Rates from Pandemic.” Thompson Reuters. September 29. https://uk.reuters.com/article/ us-health-coronavirus-africa-mortality-i/ puzzled-scientists-seek-reasons-behindafricas-low-fatality-rates-from-pandemicidUKKBN26K0AI. World Bank Group. 2018. “Investing in People.” https://www.worldbank.org/en/news/

immersive-story/2018/08/03/investing-inpeople-to-build-human-capital. World Bank Group. 2020a. “World Bank Approves $12 Billion for COVID-19 Vaccines.” World Bank Group (blog). October 13. https://www.worldbank.org/en/news/pressrelease/2020/10/13/world-bank-approves-12billion-for-covid-19-vaccines. World Bank Group. 2020b. “Fact Sheet: Pandemic Emergency Financing Facility.” https://www.worldbank.org/en/topic/ pandemics/brief/fact-sheet-pandemicemergency-financing-facility.

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D5  |  THE WORLD ECONOMIC FORUM’S GREAT RESET: CORPORATE AMBITIONS AND THE FUTURE OF MULTILATERALISM IN AND BEYOND GLOBAL HEALTH

The Covid-19 crisis, and the political, economic, and social disruptions it has caused, is fundamentally changing the traditional context for decision-making. (WEF 2020)

Introduction

In the face of the COVID-19 pandemic, the World Economic Forum (WEF) has thrown down the gauntlet to governments and civil society with its June 2020 call for a Great Reset. This challenge is building on the WEF Global Redesign Initiative (GRI) launched in 2010 as its response to the then financial and related global crises. Now, in addressing the impacts of the COVID-19 crisis, it is claiming the pandemic as a marker “which has fundamentally changed the basis for global decision making” (WEF 2020). With this manifesto, the WEF is returning to its focus on the flaws and failures of global multilateral governance – which it elaborated in its GRI – prescribing that corporations, not states, should position themselves at the center of the global government system. The WEF paradigm of governance is “power sharing,” where corporations set the agenda and claim decision-making with states on key areas of global policy while also deciding which governments, state institutions, and civil society organizations are invited to sit at the table. Its preferred mode is that of multistakeholder bodies – where the participant elite (whether corporate, private, or public) are brought together based on their “interests” and not on their “rights or responsibilities” (George 2016). Such multistakeholder entities have proliferated in most areas of industry and governance in the past two decades, advancing – in the words of Klaus Schwab, founder of the WEF – “stakeholder capitalism” (Schwab and Vanham 2021). This chapter reviews the rise of corporate power in its main manifestations over the last 20 years, operating within a paradigm which combines untouchable protection for corporate interests and a strategy of corporate-state partnerships taking shape within multilateral platforms. It identifies the key struggles of contestation played out by three major actors: transnational corporations (TNCs), states, and civil society social movements. It discusses the options opening at this moment for resistance to the corporate-led WEF scenarios for “Planet INC.” It finally indicates how to engage and shape an alternative roadmap towards a transformative system change that seeks, in real terms, to put health and well-being, people’s sovereignty, and the public interest at the center of global government institutions.

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Asymmetries of power: the architecture of corporate privilege and impunity

The COVID-19 pandemic has put in stark relief the current interlocking crises – economic, social, environmental, and political. What initially looked like a health crisis that could be “fixed” has become a prism for taking global stock of where humanity and the planet is headed in this era of advanced corporate-driven neoliberal globalization. Most people have seen the dual role being played by Big Pharma in the pandemic debacle, as both “vaccine savior” and “vaccine profiteer,” a pandemic exemplar of neoliberal globalization at work. The WEF is accurate, and not alone, in registering a deep sense of multiple crises in the current moment that demand critical attention to what may need “resetting” in a post-pandemic world. But we must question whether its call for a Great Reset is essentially an accelerated “Great Take Over” (Transnational Institute 2021). Is it a further entrenching of the form of corporate capture illustrated by Big Pharma in the profit-making opportunity thrown up by the pandemic? Or is it indicative of an even more ambitious design in advancing corporate capture of the democratic institutions of the multilateral system, whether at the World Health Organization (WHO), other United Nations (UN) global multilateral entities, or at the UN itself? The corporate push in this pandemic era for control of democratic multilateral institutions is building not only on decades of accumulation of corporate profits but also on the protection provided for its operations with impunity. Corporate exceptionalism is accommodated by the framework of a global architecture of the international trade and financial institutions – World Trade Organization (WTO), International Monetary Fund (IMF), and World Bank (WB) – but also in the privileges guaranteed by the terms of free trade and investments agreements. The asymmetries of power between states and corporations in this global financial, trade, and investment regime are ongoing. They become glaringly clear when viewed through a pandemic lens, notably the Trade-Related Aspects of Intellectual Property Rights (TRIPS) regime at the WTO and the investor-state dispute system (ISDS) present in hundreds of bilateral trade and investment agreements (Olivet et al. 2021) (see Chapters B4 and D2). Today’s struggles against power imbalances enacted globally reflect a longer history of opposition to this predatory corporate-led economic model (see Box D5.1).

Box D5.1: A long history of struggle raises TNC impunity on the international agenda The impacts of the protected corporate trade and investment regime are well documented, in its carbon footprint and devastations of communities in the Global South, in the territories holding the coveted natural resources (fossil fuels and precious minerals) that have driven neoliberal globalization

THE WORLD ECONOMIC FORUM’S GREAT RESET  |  411 for the past 50 years (Permanent Peoples Tribunal 2010; 2018). Struggles against this extractivist capitalism are present in every continent and the sustained demands of affected communities, farmers and workers, and other sectors for binding regulation of the operations of TNCs have again pushed the agenda of corporate impunity and access to justice onto the international human rights agenda. Some of the iconic cases cover timelines since the 1960s to the present day – as this selection highlights: Chevron-Texaco Ecuador (1960s): The Indigenous People of the Ecuadorian Amazon have sustained their struggle against the oil pits left by Texaco (now Chevron-Texaco) when it withdrew its oil operations in the 1960s. Despite the rulings on the case by the Ecuador Courts (including the Supreme Court), Chevron-Texaco has not complied either for compensation or restoration of the environment. On the contrary, the company has contested all the subsequent cases in the international courts, including the International Criminal Court, where the judgements have favored ChevronTexaco (The Global Campaign 2020a). Union Carbide-India (1984): A gas leak at a pesticide plant exposed 500,000 people to toxic chemicals, killing several thousand. After 25 years of legal challenges several company officials were found guilty of death by negligence but were released on bail after paying a fine of only $2,000. Victims and their families still pursue justice for this gas leak crime (Eckerman 2005). Ogoni People vs Shell in Nigeria (1995): The indigenous Ogoni have suffered devastation of their environment and communities from oil extraction operations since the 1950s, prompting civil unrest in the 1990s, leading to extreme suppression by Nigerian armed forces. Together with eight other community leaders, the poet Ken Saro-Wiwa was executed in relation to their protest activities. The communities continue to demand accountability and justice from Shell and an end to its ongoing oil exploitations in the region and some positive steps are developing in relation to court cases in London and The Hague (Esri n.d.). BP Deepwater Horizon-Gulf Mexico (2010): The Deepwater Horizon is the largest marine oil spill in history, causing extensive environmental damage and loss of livelihoods, especially to fishing communities and to the tourist industry. The company was found guilty of gross negligence and manslaughter (17 workers died in the explosion). There were several criminal and civil cases, although none of the individuals found responsible received prison sentences. In 2020, ten years after the disaster, the former members of the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling noted that the US Congress had failed to act on most of the recommendations in the final report (Pallardy 2021).

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No-TAP movement, Lecce, Italy (2011): The communities around Lecce, southern Italy have been protesting the destruction of their community from Trans Adriatic (gas) Pipeline (TAP), including the ancient olive gardens around Lecce. On March 19, 2021, the Lecce Court of First Instance found 67 human rights defenders from the No-TAP movement guilty on charges (among others) of unauthorized protest and damage to private property. They were issued sentences ranging from three months to three and a half years imprisonment and/or fined up to €4,280. A further 25 human rights defenders also on trial were acquitted (Front Line Defenders 2021). Marikana Massacre: Lonmin Platinum Mine PLC (2012): Thirtysix miners from the Lonmin PLC Platinum mine (on strike for a living wage) were shot dead in Marikana, South Africa on August 16, 2012. This attack on the miners was made by the South African Police Services, who intervened on the side of Lonmin. The survivors, as well as the families of the miners who died, are still pursuing justice for the great loss of life and serious injuries. A government-led Commission of Inquiry was held – but its conclusions have not yet been fully acted on almost ten years later (Tolsi 2021). The Rana Plaza Fashion Factory Collapse, Bangladesh (2013): On April 24, 2013, the eight-story building where more than 3,000 workers were housed producing well-known global fashion brands (Nike, GAP, H&M Primark, Benetton, and many others) collapsed. At least 1,134 people, mainly women, died and over 2,000 others were injured. The collapse remains one of the deadliest industrial accidents to date. In response to strong campaigning and outraged public opinion the garment corporations were obliged to sign a binding Accord on conditions of safety in the factories that continued garment production. However, eight years on, the garment supply chain model is still deeply flawed with inbuilt exploitation of workers paid poverty wages ($156 a month) and who now face the threat of a reversal of the safety Accord to non-binding status. Many are subject to job dismissal without compensation – as many brands refuse to pay for garments already produced or in production. The Clean Clothes Campaign network published a Report in August 2020 covering the first three months of the COVID-19 pandemic in seven countries, finding that the garment industry owed between $3.2 and $5.8 billion in unpaid paid wages and legally owed compensation (Barradas et al. 2020). Mariana (2015) and Brumadinho Communities vs Vale Brazil (2019): The collapse of these dams holding toxic mine waste operated by the Vale corporation in Brazil has had a major impact on the loss of life and community, destruction, and contamination of the surrounding areas and toxification of major river basins. The Movement against the Dams

THE WORLD ECONOMIC FORUM’S GREAT RESET  |  413 regards the dam collapses as evidence of ongoing socio-environmental crimes by the Vale corporation (privatized in 1990 and now co-owned by several private and international shareholders and operating in 303 countries) and the Brazilian government which further eased the requirements for dam licenses in 2018 despite the Mariana collapse in 2015. In response to sustained campaigning by the affected communities, progress is being made in the courts where Vale has been ordered to pay damages up to $7 billion in the case of the Brumadinho, with senior staff facing murder charges. Meanwhile, in June 2021, the threat of the imminent collapse of a third dam (Xingu dam at Vale’s Alegria mine) has been reported (Movement of People Affected by Dams 2019). Amazon e-commerce giant and workers’ right to unionize, Alabama (2021): There were high stakes in the recent attempt by workers at the Amazon “fulfillment” center workplace in Bessemer, Alabama, to establish their trade union. The final vote on joining the Retail, Wholesale and Department Store Union (RWDSU) was heavily defeated, with Amazon urging its employees via email text to vote No, and workers claiming livelihood insecurity and fear of job loss as their reasons for not voting for the union. The right to unionize was at the core of the demands of the Alabama workers – “to have a voice” and be able to negotiate their conditions of work. This current defeat has significance for workers not only in Amazon warehouses throughout the USA (as the US second biggest corporate employer it has a workforce of 800,000 – excluding its drivers) but also globally. The Amazon “model” of no union, relentless production targets, constant surveillance, rapid staff turnover, and robotization is being normalized for major sectors of workers (MacGillis 2021). These cases combined resistance strategies (in advocacy, public mobilization, and juridical case work) and proposals for alternative development models. Primarily, they succeeded in pushing the issue of corporate power and its systemic impunity to the top of the international policy agenda. These and countless other cases still seek access to justice even as they campaign for an international binding treaty to regulate TNCs.

The role of companies as major economic actors at national and global levels has long been readily recognized, often linked to colonial and neocolonial ambitions such as the case of the East India Company. The mercantilist connections between the governments of colonizing nations and private companies were obvious (mercantilism being the use of state power to further the economic interests of companies facing global competition or operating in foreign lands). In global companies’ recent form as TNC, direct links back to government interests are often hidden in the language of “global competition,” “global economic growth,” and the claimed benefits of open global markets supported

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by trade and investment treaties. Such argumentation even enters the traditionally “charitable” domain of official development assistance (foreign aid) (see Box D5.2). What remains constant is the potential for global companies’ mega profit-making and capital accumulation.

Box D5.2: Private companies’ involvement in bilateral foreign aid Donor countries from the Global North have long involved private companies in their foreign aid programs. Initially, these countries sought to ensure that their aid helped companies at home, including through the practice of “tied aid,” which requires that goods and services be purchased in the donor country. Many countries have abandoned that practice, but aid agencies also often provide incentives, such as subsidies or guarantees against financial losses, for national companies to invest in developing countries in ways that would potentially promote economic growth. Many donors have dedicated government-owned “development finance institutions” to promote the role of the private sector in the Global South, including the United Kingdom’s CDC Group and the United States International Development Finance Corporation. The 2007–2008 global financial crisis accelerated a new trend: the rise of large corporations as “partners” in development finance. Increasingly, bilateral donors and multilateral development agencies portray private sector companies not only as actors that can contribute to economic growth, but as key participants in poverty reduction. The adoption of the Sustainable Development Goals (SDGs) in 2015 reinforced this trend: donor countries were unwilling or unable to marshal the trillions of dollars of additional resources that would be required annually to meet the ambitious SDG targets, including the complete elimination of extreme poverty all around the world by 2030. As a result, tapping into the private sector’s massive wealth became an essential part of the global development narrative, regardless of how unrealistic those expectations may have been. A major disappointment of blending public/private finance to date is the amount of private capital that it has mobilized. Far from expectations of $10 of private funding being “leveraged” for every public dollar spent, the ratio has proved to be closer to 1:1. In fragile and conflict-affected states, the ratio is even lower. The vast majority of “blended finance” funds have been channeled to middle-income countries, which generally provide more stable and investment-friendly environments but are not the places most in need of incentives to promote international investment. Moreover, the investments are often targeted at tapping into middle-class markets, for instance in shopping malls and gated communities. Providing goods and

THE WORLD ECONOMIC FORUM’S GREAT RESET  |  415 services to poor and marginalized people, who lack disposable incomes, is unsurprisingly less attractive for those profit-seeking investments. For example, when urban slums need improved access to necessities such as drinking water, sanitation, health services, and primary education, to what extent is it reasonable to expect that a private company should be able to make a profit in providing quality services to people with very low incomes? Around the world, these services are normally provided by the public sector as public goods, not investment opportunities. Many of the goals assigned to these “innovative” financing mechanisms, including not only widespread poverty reduction but also promoting gender equality, seem more like wish lists than realistic outcomes based on past experiences. Another increasingly common form of partnership with the private sector has been to involve private companies in the more traditional development projects and programs. For-profit consulting firms and corporations have long been involved in the implementation of aid, often bidding on contracts tendered by aid agencies. However, it is becoming more common for them to seek public funding for their private development efforts, usually under the label of “corporate social responsibility,” or for aid agencies to provide incentives for non-profit civil society organizations (CSOs) to seek funding from them. Canada provides stark examples of such partnerships. In 2011, while cutting its funding to CSOs, it set aside funds specifically for CSO projects that involved collaboration with Canadian mining companies. Variously presented as support to corporate social responsibility (even when, paradoxically, public funds were providing most of the funding) and alternative forms of resource mobilization for CSOs (even when corporate contributions were relatively minor), these projects are more accurately interpreted as attempts by the Canadian government to advance Canadian corporate interests in the global mining sector, which is dominated by companies listed on Canadian stock markets. These initiatives sought to encourage local communities to accept Canadian mining companies’ activities in or near their land. As such, foreign aid provided in partnerships with mining companies provides sweeteners to pave the way for the extractive sector and erodes the ability of communities to set their own development priorities, with an uncertain impact on the reduction of poverty and inequality (see Chapter C4). Faced with numerous critical commentaries on these initiatives in the media and opposition from several CSOs in Canada and especially in host countries, the Canadian government discreetly stopped promoting the extractive route to development after the election of the Liberal government of Justin Trudeau in 2015. Nonetheless, the Canadian government under Trudeau increased its support for blended finance and private sector involvement in foreign aid, creating a Canadian development finance institution of its own and

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subsequently dedicating CAD$1.5 billion to “innovative” initiatives that would involve closer collaboration with private companies. Private companies can play an important role in generating wealth and reducing poverty. However, all too often, the involvement of aid agencies offloads investment risks (i.e., potential losses) onto public taxpayers in the Global North, while transferring most of the profits to the private sector in endeavors that may not have much actual impact on human development. In such cases, these initiatives are illegitimate uses of official development assistance, which, by definition, must focus primarily on economic development and well-being in the Global South. For many donor countries, embracing private corporations’ role in bilateral aid constitutes an abdication of their own commitments, obligations, and even moral responsibility for providing the resources required to promote international development and global justice.

But it was only in 1973, following the Chilean military coup against the democratically elected socialist government of Salvador Allende that installed the world’s first laboratory for neoliberal globalization under the Pinochet dictatorship, that explicit recognition was given to the rising political power of TNCs and its threat to democracy at both national and global levels (Alden 1972). It has taken almost 50 years since for the full ambition of corporations as political actors to be more comprehensively articulated in the WEF Great Reset. Era of corporate hegemony and corporate social responsibility

The trajectory from the 1970s to 2014, which marked the UN Human Rights Council Binding Treaty Resolution 29/6 on Transnational Corporations, has not been a linear progression, neither for the corporations nor for the governments and movements that opposed them (OHCHR 2014). Rather, it has been a period of intense contestation against corporate hegemony and the rise of the rhetoric of corporate social responsibility (CSR), acted out in multiple sites of struggle from remote rural communities to highly concentrated Export Processing Zones, and in hospitals, schools, and warehouses. This contestation has likewise been manifested in the major civil society mobilizations confronting the WTO, the IMF, and the WB. Historic breakthrough 2014 – Binding Treaty Resolution at the UNHRC

The UN Guiding Principles (UNGPs) (see Box D5.3) were challenged immediately by civil society, human rights organizations, and affected communities worldwide for falling far short of what was needed to address TNCs’ abrogation of human right obligations and to strengthen citizens’ access to justice. Already

THE WORLD ECONOMIC FORUM’S GREAT RESET  |  417 Box D5.3: The trajectory of TNCs and human rights at the UNHRC 1970–2014 From the early 1970s to the mid-2000s, the expanding power of TNCs and the impacts of their devastating extractivism on the environment have been challenged by affected communities in constant demands and campaigns to governments to regulate their operations (see Chapter C4). At the same time, several initiatives taken at the UNHRC to address the violations of TNCs encountered strong pushback from TNCs, combining forces with the International Chamber of Commerce and the International Organization of Employers (IOE) (ICC 2016), both of which have Consultative Status to the UN Economic and Social Council (ECOSOC). This corporate counter strategy was also supported by many governments of the Global North, including those of Europe and the USA who opted to protect the privileges of their “national flagship” corporations, emulating the mercantilism of earlier colonial and neocolonial eras. The main efforts addressing TNC regulation with respect to human rights at the UN until 2014 include: • UN Center on TNCs set up in 1975 to monitor their operations closed under the UN Secretary-General (S-G) Boutros Boutros-Ghali in 1992, at the insistence of the USA. • UN Draft Norms for TNCs (2003) adopted by the Sub Committee on Human Rights but defeated at the UN Human Rights Council (UNHRC) and set aside (2004). • UN Global Compact & Millennium Development Goals (MDGs), ushering in an era of corporate social responsibility (CSR) under UN S-G Kofi Anan and his Special Representative, John Ruggie (2000–2015). The Sustainable Development Goals (SDGs) replaced the MDGs in 2015 and extend to 2030. Corporations, particularly in their “multistakeholder” frameworks, frequently adopt the language of the SDGs. • UN Guiding Principles (UNGPs) (2011) endorsed by the UNHRC and calling for voluntary self-regulation of TNCs. They established a Work Group on Business and Human Rights to facilitate National Action Plans (NAPs) for UNGP promotion and implementation (2011 extended to 2030). These initiatives span close to 40 years and, despite the sustained resistance on the ground by affected communities and their strongly articulated demand for binding regulation on TNC operations, the momentum of corporate impunity and corporate voluntary social responsibility appeared unstoppable. The 2011 UNHRC endorsement of the UNGPs seemed to install a final accommodation to corporate self-regulation as the high bar of corporate accountability.

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in 2012, during the Rio Summit, more than 150 affected communities, trade unions, social movements, and human rights networks set up the Global Campaign to Reclaim Peoples Sovereignty, Dismantle Corporate Power, and Stop Impunity (The Global Campaign 2012). The Campaign carried a key demand for a legally binding treaty and developed a broad global consultation process to outline principles and specific content for such a treaty (Global Campaign 2014). Several governments had also come to recognize the need to re-open discussions on the global governance of TNCs and human rights (UNHRC 2013). The historic breakthrough came in June 2014 with the UNHRC Resolution 26/9, which mandated an Open-Ended Intergovernmental Working Group (OEIGWG) to put in place “an international legally binding instrument on transnational corporations and other business enterprises with respect to human rights” (OHCHR 2014). Although carried by a narrow vote, this Resolution emerged as the combined result of sustained historic resistance of affected communities and their insistence that the UNGPs did not challenge corporate impunity or deliver on people’s access to justice for corporate violations of human rights and environmental standards. In the current conjuncture on the binding treaty process, corporate contestation with support from governments mainly of the Global North continues to obstruct progress. Despite this, each session of the OEIGWG has brought forward movement, and a draft first text of the treaty was presented in 2018 (UNHRC 2018). This caused treaty discussions to enter negotiation mode, with the leadership of some governments mainly from the Global South. It also saw the unprecedented participation of 96 governments in the 2019 treaty session (UNHRC 2019). Unlike earlier unsuccessful efforts, a significant factor in the current advance in the building of the treaty has been the sustained participation of key actors. Except in 2020, when COVID-19 restrictions required meeting in digital mode, every session has seen the combined mobilizations of the broad social movements and affected communities. These converged each year in the coordinated initiatives of the Week of Peoples Mobilization, bringing together networks of the Global Campaign, the Treaty Alliance, and Feminists for a Binding Treaty. These mobilizations were also supported by the high-profile activities of the Global Interparliamentary Network (GIN) (GIN n.d.[a]) and the recently established Local Authorities network (GIN n.d.[b]). Since 2018, negotiations on treaty content have been constantly enriched by consultations on the ground in Africa, Asia, and Latin America, with similar inputs from movements in Europe and the USA. Specific proposals address the concrete demands made by affected communities and sectors, from inclusion of comprehensive rights protections to demands for specific social, environmental, economic, and gender issues (The Global Campaign 2017). This substantive content agenda has been a unique achievement of the Global Campaign, which now numbers 230 social movements, trade unions, and civil society organizations from all continents. Content proposals are reviewed and amended in October

THE WORLD ECONOMIC FORUM’S GREAT RESET  |  419 Box D5.4: Building a UN Treaty on TNCs and Human Rights The Global Campaign demands that the Binding Treaty address the privileged power and impunity of TNCs covering all human rights and specifically that it: • Establishes the primacy of human rights and its hierarchical superiority over trade and investment treaties and the exclusion of ISDS clauses; • Sets direct legal obligations for TNCs; • Obliges governments to act together in relation to extraterritorial obligations to address TNCs violations of human rights; • Puts in place an instrument of enforcement to implement the Treaty; • Includes the rights of affected persons and communities in terms of access to justice; and • Provides protection against corporate capture of the process from the influence and interventions of TNCs in the development of the Treaty.

Source: The Global Campaign, 2016.

each year, when they are formally presented (both written and oral) by Global Campaign members at the successive sessions of the OEIGWG, and during key interventions from the floor, as well as in organized side events (see Box D5.4). In this way, the proposals from those directly affected by the human rights violation and operations of TNCs are shaping the key demands for a robust binding treaty. Detailed textual amendments have been presented and actively advocated on during sessions discussing the first and second drafts of the treaty (The Global Campaign 2020b).1 Corporate sights on global governance – the role of the WEF

Although the binding treaty may yet be established and, with it, some oversight of TNCs’ global practices, the corporate ambition to capture global governance remains and has emerged more persistently since the introduction of the Global Compact and the MDGs in 2000. The most consistent platform for this corporate voice has been the WEF, founded by Klaus Schwab in 1971 and which convenes every year in the Swiss mountain resort of Davos. Here, the CEOs of the biggest TNCs mingle with Presidents, Prime Ministers, UN Secretary-Generals, officials of the WTO, IMF, and WB, representatives of the European Commission, and a few select invitees from civil society, all participating within a framework of what Schwab calls “stakeholders in capitalism” (see Box D5.5). This convergence of elites in the WEF has also been named “the Davos Class” by Susan George, focusing on another dimension of this elite oligarchy with their unique brand of “governance [as] the way to govern without a government” (George 2015,

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18). Indeed, the WEF, from its inception, had far greater ambitions than being a global jamboree for the rich and powerful. Perhaps we can say it was the first “multistakeholder space” where corporates and states navigated their new roles. Schwab’s stakeholder theory misleadingly promotes the idea that all stakeholders in this “Davos” space are equal, denying the obvious asymmetries of economic and political power existing even between major TNCs and states. Another key dimension is that corporations with their expertise and knowledge are invited to be at the center stage in addressing global crises in a global governance vacuum where states are perceived to be failing. The corporate actors and their modus operandi are not seriously acknowledged to have any responsibilities as major contributors to these crises. And, while the crises are acknowledged, they are not seen or analyzed as a capitalist system crisis but as fixable problems if all those concerned acted as “stakeholders” and let the corporates join them in decision-making spaces. This stakeholder framework has been at the core to the Davos thinking from the beginning. But in the last two decades (2000–2020) it has not only been aggressively promoted by the WEF, but multiple “multistakeholder” entities have been constructed and positioned in several areas of strategic policy and decision-making structures important to society and the planet (see also chapter D3). By now, multistakeholder bodies are in occupation of key institutions with sights on the multilateral system: in health (WHO), in food/agriculture

Box D5.5: The rise of stakeholder capitalism A new capitalism is stalking the halls of the 2020 World Economic Forum (WEF): “stakeholder capitalism” (Schwab 2019b). Stakeholder capitalism argues that a corporation’s role is to serve not only its shareholders but “all its stakeholders – employees, customers, suppliers, local communities, and society at large” (ibid.). This is not a new argument, with some arguing that this “managerial” approach characterized corporate practices from the early 1930s through to the late 1970s before it was displaced by an emphasis on “maximum shareholder value” (Denning 2020). This “shareholder capitalism” was consistent with the rise of neoliberal economics but also led to the rapid skewing of wealth inequalities noted in Chapter A1, risking a breakdown in social cohesion that has since arisen in many countries, and in differing ways. The return of stakeholder capitalism is partly to challenge the rise of “state capitalism” (notably China, but with wider Asian influences), seen as prone “to corruption from within” (Schwab 2019a). What most activists insist is that stakeholder capitalism is little more than a mask behind which the (still) profit-maximizing strategies and operations of transnational oligopolies and monopolies can hide while proclaiming their enlightened corporate social responsibility.

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(the UN Committee of Food Security [CFS] and the Food and Agriculture Organization [FAO]); in education (United Nations Education, Scientific and Cultural Organization [UNESCO]); in environment/climate (the Committee of Parties to the Paris Accord); and in internet and data governance (World Summit on the Information Society [WSIS]). A Multi-Sectoral Work Group on Multistakeholderism (MSI-WG) was convened in 2020 to monitor and address this dominant corporate strategy in global governance.2 WEF: from the Global Redesign Initiative to the Great Reset

In advancing corporate influences in global governance, the WEF with its Davos Manifestos on multistakeholder narratives has reinvented its strategy every decade, from initially promoting a call for state-corporate strategic partnerships, which remains a core strategy, to one of placing corporates at the center as the key actors in decision-making in global governance. In the wake of the financial and related crises of 2008, the WEF launched its Global Redesign Initiative (GRI) in 2010 (Samans 2010), an elaborate roadmap for building multistakeholderism as a major trend in governance. In the past decade, multistakeholderism has been both the mantra and action strategy of the WEF, which is likely to intensify in the coming decade as the ambitions of the current WEF Great Reset are further developed. The rationale of the Great Reset is premised on an urgent call to all “stakeholders” to grasp this new opportunity “to shape the recovery … to help all those determining the future of global relations, the direction of national economies, the priorities of societies, the nature of business models and the management of a global commons … ” (International Institute for Sustainable Development 2021). In the Great Reset, the WEF is already standing on a platform of many multistakeholder bodies and institutions, building on a momentum of their proliferation over the past two decades. With sights set on the institutions of global governance, some assessments see this WEF multistakeholder approach as an aggressive strategy of corporate capture across vital areas of society and economy and as ultimately an assault on democracy itself. This was the conclusion of the preliminary results from the joint research mapping undertaken in 2020–2021 to address the “multistakeholder governance” phenomenon (Manahan and Kumar 2021). The MSI Work Group mapped the trends and impacts of multistakeholder approaches in five areas: health, education, food, environment, and internet/ data governance. Its findings demonstrate that multistakeholderism, frequently acknowledging the language of the MDGs/SDGs and consisting of different typologies, is systemic across all sectors. Moreover, each sector is increasingly governed by unaccountable, opaque structures where the democratically accountable multilateral (intergovernmental) body is marginalized or excluded in strategic decision-making and priority agenda setting (Manahan 2011).

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Important examples include the COVID-19 Vaccines Global Access (COVAX) facility, where the WHO participates but does not have a decision-making role (see Chapters D1 and D3) and the Alliance for Affordable Internet, which ostensibly claims to fulfill a UN priority to provide affordable internet in least developed countries but which focuses primarily on neoliberal restructuring of the telecom sector. The Scaling Up on Nutrition (SUN) “Movement” is another case-in-point, with its focus on food and agriculture. According to FIAN International (2020), the SUN’s broad objective is framed in human rights language but, in practice, its recommendations and interventions advance a narrow and technical interpretation of the proximate causes of malnutrition which not only promotes risk but also fails to address structural factors. Data in the MSI Mapping study indicate that only 10% of the multistakeholder platforms studied focus on human rights and, in these, the rights-based approach to global governance co-exists with the neoliberal framework that decisively advances the corporate sector as the engine of development and economic growth. Many governments and intergovernmental organizations are complicit in this, attempting to “stablilise and further entrench their roles through the introduction and legitimation of multistakeholderism as new institutions and forms of governability” (Gleckman 2021). As one indication of this, between 2000 and 2010, 42 new multistakeholder mechanisms were established; a further 57 were added in the period 2010–2020 following the launch of the Global Redesign Initiative (GRI) and the post-MDG extension to the Sustainable Development Goals (SDGs). The WEF mantra of “multistakeholderism,” especially over the last decade, is relentlessly pushed as the corporate answer to intensifying global crises and is part of a narrative of “false corporate solutions.” In this context, the WEF has also been far-seeing and strategic in its planning, moving decisively to accelerate the proliferation of multistakeholder bodies in the wake of the global financial and related crises of 2008, including in health. The multistakeholder bodies GAVI, the Vaccine Alliance (a public–private health partnership) and the Coalition for Epidemic Preparedness Innovations (CEPI) were both positioned in the health “eco” system ahead of the current pandemic. They moved swiftly in 2020 to jointly set up with the WHO COVAX. It is one of the three pillars of the Access to COVID-19 Tools Accelerator (ACT-A) which was established by the WHO, the European Commission, and France as a new multistakeholder body claiming to deliver the peoples of the Global South from the ravages of COVID-19 (see Chapter B1) (Gleckman 2021; “Vaccine Equity the ‘Challenge of Our Time’” 2021). In addition, and contrary to the popular projection, by far the biggest percentage of funding of these multistakeholder institutions is not corporate but public via the World Bank, and is combined with a much smaller percentage from private sources, including the Bill & Melinda Gates Foundation (BMGF). Public money, which should be earmarked for the multilateral institutions themselves,

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is financing these corporate-led entities generating a base of funding which reaps high corporate profits for the participating TNCs. Pfizer, for example, is represented in CEPI by its CEO, Albert Bourla, who is also the Vice President of the “Big Pharma” International Federation of Pharmaceutical Manufactures & Associations (IFPMA). Apart from the apparent conflict of interests, there is great irony and a deep concern that the WHO itself which, although participating in COVAX, is excluded from a decision-making role, and yet is actively advocating the COVAX as the entity which will deliver “vaccine equity” globally (Schwab 2021). In relatively quick succession since 2010, then, we witnessed the global-agenda setting role of the WEF and its Davos Class in reinstalling corporate “business as usual;” first, in its launch of the Global Redesign Initiative (GRI) following the financial debacle of 2008; and now, with its Great Reset seizing on the pandemic crisis, a renewed effort to advance a corporate normal towards a “Great Take Over” of the institutions of democratic global governance. We the People vs Planet Inc – challenges beyond health and beyond 2021

In its call for the Great Reset, WEF is explicitly indicating that the COVID-19 pandemic is a game changer in decisively shifting the locus of global policy and decision-making. The WEF is not only claiming a central and crucial role for the corporates; it has acted on that in authoritatively summoning major actors to its in-person Summit, rescheduled for a second time and now due to take place in the first half of 2022. The tone of the Global Reset call to action is particularly prescriptive: To achieve a better outcome, the world must act jointly and swiftly to revamp all aspects of our societies and economies, from education to social contracts and working conditions. Every country, from the United States to China, must participate, and every industry, from oil and gas to tech, must be transformed. In short, we need a “Great Reset” of capitalism. (emphasis added) (Schwab 2020)

This is the WEF speaking – not the UN and neither the G7 nor the G77. The multilateral bodies of the UN have been starved of needed financial resources by the governments of the USA and other Global North states. Their deficits in funding are leading to a situation where the UN itself, and the UNHRC along with the WHO and other multilateral bodies, are being pressured to enter corporate partnerships that can lead to ceding strategic decision-making space to TNCs (see Chapter D3). These are the same governments that also protect the institutionalization of TNC exceptionalism and impunity in the refusal to regulate corporate operations with respect to human rights or environmental standards. These developments seriously challenge the current multilateral UN intergovernmental system. Is the WEF and its Davos Class building another privatized multilateral system where unaccountable multistakeholderism rule is

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installed as the new normal? And is this being done as a fait accompli with the legitimation of the UN itself? As the death toll from COVID-19 continues to rise globally, we are confronted with media images of acres of mass graves in Brazil and India, countries which a few years ago were heralded as emerging “developing economies” alongside South Africa and China. We see continuing gridlock at the WTO as the combined political line-up of most governments (including now even the USA) and a very broad alliance of civil society have so far failed to achieve a temporary waiver of vaccine-related intellectual property rights (IPRs). Big Pharma and corporate complicit governments, including the EU bloc, persist in staunch opposition. Perhaps this gridlock, indicative of the steep asymmetry in the current conjuncture of state and corporate power, illustrates graphically the reality of the challenges ahead in seeking to advance demands for real system change. Despite the demobilization imposed during the pandemic in global lockdowns, the voices of affected communities and sectors by corporate human rights violations (especially in strikes by farmers and protests by workers in health and education) have grown even louder. Earlier in this chapter we presented the work of the Global Campaign for the Binding Treaty on TNCs and its negotiations going forward at the UNHRC. This campaign carries the promise of significant internationally binding regulation of TNCs, addressing as it does for the first time the application of a comprehensive framework of human rights to the operations on TNCs. Similarly, the interventions of the MSI Work Group and critical analysis on the WEF Great Reset and the corporate capture of global governance is also shaping a new strategy of mobilization and engagement. These initiatives from the ground have grown out of and reflect the ongoing multiple and persistent resistance to corporate power in the spheres of both economy and politics. The next few years will see a deepening of the corporate offensive but also a stronger convergence of the sustained resistance of affected communities and sectors in the frontline of contestation. These contestations carry within them the practices and perspectives of transformative system change – articulating propositions for a democratic multilateralism that includes but goes beyond the global health system. It is a strategy of declaring unequivocally that corporate rule is not OK: instead of a corporate “Great Take Over,” we need a Democratic Reset that refuses the privatization of democracy and puts people’s sovereignty and the public good at the center of an accountable global inter-government system fit for the twenty-first century. Notes 1  To accompany Global Campaign’s “Comments and Amendments on the Second Revised Draft of the Legally Binding Instrument on Transnational Corporations and other

business Enterprises with Regard to Human Rights,” the group has also produced a “Matrix of Amendments” and a “Matrix of Comments.” Both documents can be directly downloaded

THE WORLD ECONOMIC FORUM’S GREAT RESET  |  425 from the Campaign’s website at https://www. stopcorporateimpunity.org/binding-treaty-unprocess/. 2  In mid-2020, the Multisectoral Work Group on Multistakeholderism (MSI-WG), a collaboration of several concerned movements and networks active in addressing multistakeholderism as it impacts key

areas of life such as health education, food, environment, and internet, convened to work jointly and commission a mapping across these sectors. See https://www.tni.org/en/topic/ multistakeholderism. Further information can be found online at https://www.msi-integrity.org/ test-home/history/.

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Cultural and Environmental Sovereignty of Our Peoples. End the Impunity of Transnational Corporations Now.” https:// www.stopcorporateimpunity.org/call-tointernational-action/. The Global Campaign [The Global Campaign to Reclaim Peoples Sovereignty, Dismantle Corporate Power, and Stop Impunity]. 2014. “Ideas and Proposals for Advancing the Work on the International Peoples Treaty on the Control of Transnational Corporations.” https://www.stopcorporateimpunity.org/ wp-content/uploads/2016/11/PeoplesTreatyEN-mar2015-1.pdf. The Global Campaign [The Global Campaign to Reclaim Peoples Sovereignty, Dismantle Corporate Power, and Stop Impunity]. 2017. “Treaty on Transnational Corporations and their Supply Chains with Regard to Human Rights.” https://www.stopcorporateimpunity. org/wp-content/uploads/2017/10/Treaty_ draft-EN1.pdf. The Global Campaign to Reclaim Peoples Sovereignty, Dismantle Corporate Power, and Stop Impunity. 2020a. “Chevron and Corporate Impunity.” December 10. https:// www.stopcorporateimpunity.org/chevronand-corporate-impunity/. The Global Campaign [The Global Campaign to Reclaim Peoples Sovereignty, Dismantle Corporate Power, and Stop Impunity]. 2020b. “Comments and Amendments on the Second Revised Draft of the Legally Binding Instrument on Transnational Corporations and other business Enterprises with Regard to Human Rights.” https:// www.stopcorporateimpunity.org/wpcontent/uploads/2021/06/Comments-andamendments_Global-Campaign_draft2_ENG. pdf. Global Interparliamentary Network. n.d.[a]. “Call of People’s Representatives Worldwide.” Accessed June 24, 2021.

426   |  Global Health Watch 6 https://bindingtreaty.org/gin-globalinterparliamentary-network/. Global Interparliamentary Network. n.d.[b]. “Local Authorities in Support to the UN Binding Treaty.” Accessed June 24, 2021. https://bindingtreaty.org/local-authoritiesin-support-to-the-un-binding-treaty/. ICC [International Chamber of Commerce]. 2016. “UN Treaty Process on Business and Human Rights. Further Considerations by the International Business Community on a Way Forward.” https://iccwbo.org/publication/ icc-ioe-biac-wbcsd-un-treaty-businesshuman-rights-futher-considerations/. International Institute for Sustainable Development. 2021. “World Economic Forum Annual Meeting 2021.” https://sdg.iisd. org/events/world-economic-forum-annualmeeting-2021/. Laura Gutierrez, David Hachfeld, Christie Miedema, Miriam Neale, and Johnson Yeung, eds. 2020. “Un(der)paid in the Pandemic. An Estimate of what the Garment Industry Owes its Workers.” Clean Clothes Campaign and Worker Rights Consortium. https:// cleanclothes.org/file-repository/underpaidin-the-pandemic.pdf/view. MacGillis, Alec. 2021. “The Union Battle at Amazon is Far from Over.” The New Yorker. April 13. https://www.newyorker.com/news/ news-desk/the-union-battle-at-amazon-isfar-from-over. Manahan, Mary Ann, and Madhuresh Kumar. 2021. “Multi-Sectoral Working Group on Multistakeholderism (MSI WG) The Great Takeover: A Multi-Sectoral Mapping of Multistakeholder Institutions.” Draftv1. Unpublished report. May 30. Manahan, Mary Ann. 2011. “Infographics: Mapping Multistakeholderism.” https://www. tni.org/en/article/the-corporate-capture-ofglobal-governance-and-what-we-are-doingabout-it#H3.2. Movement of People Affected by Dams. 2019. “Movement of People Affected by Dams Call Out New Crime by Vale.” The Global Campaign to Reclaim Peoples Sovereignty, Dismantle Corporate Power, and Stop Impunity. https://www. stopcorporateimpunity.org/movement-ofpeople-affected-by-dams-call-out-new-crimeby-vale-2/. OEIGWG [Open-Ended Inter Governmental Working Group]. 2016. “Building a UN Treaty

on Human Rights and TNCs. A Way Forward to Stop Corporate Impunity.” 2nd Session. https://www.stopcorporateimpunity.org/wpcontent/uploads/2016/10/SIX-points_ENG.pdf. OHCHR [Office of the United Nations High Commissioner for Human Rights]. 2014. “Elaboration of an International Legally Binding Instrument on Transnational Corporations and Other Business Enterprises with Respect to Human Rights.” A/HRC/ RES/26/9. https://ap.ohchr.org/documents/ dpage_e.aspx?si=A/HRC/RES/26/9. Olivet, Cecilia, Cecilia Olivet, Lucia Bárcena, Bettina Mueller, Luciana Ghiotto, and Sara Murawski. 2021. “Pandemic Profiteers: How Foreign Investors Could Make Billions from Crisis Measures.” https://longreads.tni.org/ pandemic-profiteers. Pallardy, Richard. 2021. “Deepwater Horizon Oil Spill.” Encyclopedia Britannica. https://www. britannica.com/event/Deepwater-Horizonoil-spill/additional-info#history-last. Permanent Peoples Tribunal. 2010. “Judgement on European Corporations in Latin America.” www.enlazandoalternativas.org/IMG/pdf/ TPP-verdict.pdf. Permanent Peoples Tribunal. 2018. “Judgement on TNCs in Southern Africa.” http://aidc. org.za/download/ppt_2018/List-of-Casespresented-in-previous-PPT-Hearings.pdf. Samans, Richard. 2010. “The Global Redesign Summit.” November 2. World Economic Forum. https://www.weforum.org/ agenda/2010/11/the-global-redesignsummit/. Schwab, Klaus, and Peter Vanham. 2021. “Stakeholder Capitalism: A Global Economy that Works for Progress, People and Planet.” 1st ed. New Jersey: John Wiley and Sons Inc. Schwab, Klaus. 2019a. “Why We Need the ‘Davos Manifesto’ for a Better Kind of Capitalism.” World Economic Forum. December 1. https:// www.weforum.org/agenda/2019/12/why-weneed-the-davos-manifesto-for-better-kind-ofcapitalism/. Schwab, Klaus. 2019b. “Davos Manifesto 2020: The Universal Purpose of a Company in the Fourth Industrial Revolution.” World Economic Forum. December 2. https:// www.weforum.org/agenda/2019/12/davosmanifesto-2020-the-universal-purpose-of-acompany-in-the-fourth-industrial-revolution. Schwab, Klaus. 2020. “Now is the Time for a ‘Great Reset.’” June 3. World Economic Forum.

THE WORLD ECONOMIC FORUM’S GREAT RESET  |  427 https://www.weforum.org/agenda/2020/06/ now-is-the-time-for-a-great-reset/. Tolsi, Niren. “Hope Faces off against Power in Marikana Trial.” Mail & Guardian. May 17. https://mg.co.za/news/2021-05-17-hopefaces-off-against-power-in-marikana-trial/. Transnational Institute. 2021. “The Great Take Over: How We Fight the Davos Capture of Global Governance.” Webinar. January 26. https://www.tni.org/en/webinar/the-greattake-over-how-we-fight-the-davos-captureof-global-governance. UNHRC [UN Human Rights Council]. 2013. “Statement on Behalf of a Group of [85] Countries at the 24rd Session of the Human Rights Council.” https://media.businesshumanrights.org/media/documents/files/ media/documents/statement-unhrc-legallybinding.pdf. UNHRC [UN Human Rights Council]. 2018. “Legally Binding Instrument to Regulate, in International Human rights Law, the

Activities of Transnational Corporations and other Business Enterprises.” https://www. ohchr.org/Documents/HRBodies/HRCouncil/ WGTransCorp/Session3/DraftLBI.pdf. UNHRC [UN Human Rights Council]. 2019. “Report on the Fourth Session of the Openended Intergovernmental Working Group on Transnational Corporations and Other Business Enterprises with Respect to Human Rights.” https://undocs.org/A/HRC/40/48. “Vaccine Equity the ‘Challenge of Our Time’, WHO Chief Declares, as Governments Call for Solidarity, Sharing.” 2021. UN News. April 16. https://news.un.org/en/ story/2021/04/1089972.Notes WEF [World Economic Forum]. 2010. “The Global Redesign Initiative.” November 2. https:// www.weforum.org/agenda/2010/11/theglobal-redesign-summit/. WEF [World Economic Forum]. 2020. “The Great Reset.” June 3, 2020. https://www.weforum. org/great-reset#articles.

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CONCLUSION: BUILDING POWER IN THE STRUGGLE FOR HEALTH ( JUSTICE): A CALL TO HEALTH ACTIVISTS

Introduction

Global Health Watch 6 is a book by and for health activists, people whose engagement in the “struggle for health” (Sanders 1985) reflects a personal commitment above and beyond any professional or institutional role. Throughout the previous chapters, we explained the motivations and needs for such activism, and showed many examples of what collective action by social movements entails and what it can achieve in transformative change towards “Health for All.” From the victories of the feminist movement to the resistance against extractivism and the push for more progressive environmental policies, to the ongoing struggle to regulate the super power of transnational corporations, we witnessed the capacity of people to both resist an unjust economic order and imagine/enact healthier ways to live together and with the planet. In this chapter, we weave these experiences together and with the wealth of previous learnings collected through the People’s Health Movement’s (PHM) 20-year history, and describe some of the practices that sustain movements resisting current systems of oppression and imagining what visions of an ecojust health look like. Resistance goes global

The idea of changing the global political and economic system, and the underlying power structures that support it, can seem like an impossible task. But, quoting Ursula Le Guin, while the power of capitalism seems inescapable, so did the divine right of kings: “Any human power can be resisted and changed by human beings” (“Ursula K. Le Guin’s Speech at National Book Awards: ‘Books Aren’t Just Commodities’” 2014). As described throughout this edition of the Watch, the current situation – which endangers the health of people and the planet, and perpetuates inequality – was not given by the laws of nature. It was created and continues to be shaped by human beings. There have long been individuals, organizations, and networks working to address the social determinants of ill health and to achieve better healthcare in many different settings and countries. Social movements, operating at local, regional, and national levels, have played and continue to play a critical role in creating the conditions for better health and access to affordable decent healthcare. Until recently, these movements were mostly local struggles addressing local factors, and the need to conceive and be part of a global movement was not so pressing. However, with the social and political pathways towards

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better health, decent healthcare, and health equity increasingly determined at the global as well as national and local levels, even the most “local” issue or struggle has at least some roots in the globalization dynamics of the past several decades. Building a global movement has become a crucial challenge for civil society health activists worldwide. Such a “global people’s health movement” does not aim to coopt the huge diversity of individuals, organizations, and networks – each with their own history, commitments, and identities. Rather, it strives to create synergies across such movements, to participate in strengthening communication links and collaboration when appropriate while taking care to avoid compromising the diverse purposes, ways of working, and identities that are the rich diversity and historical strength of progressive social movements. People’s Health Movement (PHM) as a field of practice and knowledge generation

PHM has always been reflective about its way of organizing as part of the social changes it aims to achieve. Such critical reflection respects its accountability towards the very claims it makes and its vision of “a world in which a healthy life for all is a reality; a world that respects, appreciates, and celebrates all life and diversity; a world that enables the flowering of people’s talents and abilities to enrich each other; a world in which people’s voices guide the decisions that shape our lives” (PHM 2000). These aspirational claims demand ongoing assessment of ways for improving the effectiveness of PHM actions and – particularly – increasing its power to influence the mechanisms that reproduce oppression. Being a member of a people’s movement means sharing the responsibility and ownership of these strategies, including their impact on the movement itself. It also implies a need to plan strategically to build stronger links with existing organizations and networks, taking part in coordinated global, regional, national, and local actions, and promoting a shared culture which supports and spreads the values and aspirations of the movement. Responding to this challenge, between 2014 and 2018 PHM undertook an action-research project involving around 130 health activists in six countries (Brazil, Colombia, DR Congo, India, Italy, and South Africa) and at the global level (Bodini et al. 2019). The practices mapped throughout the research, and the underlying principles that make them work (see Table CONCL.1), became the axes of PHM’s theory of change and its subsequent strategic plan (PHM 2020). The underlying principles also informed a popular publication developed to support health activists in strengthening collective action (Viva Salud and PHM 2017). The publication explores a set of core practices identified as key building blocks for a global people’s health movement: building relationships and sharing values, managing power to decide on organization and strategy, building visible actions, encouraging participation, networking, and learning from experience. PHM’s practices are complemented by the effort to strengthen the Health for All Campaign in six thematic areas: equitable health systems, trade and

CONCLUSION  |   431 TABLE CONCL.1:  Social movement practices of PHM, underlying principles, and strategic vision 2020– 2025 PHM’s practices

Underlying principles

Vision 2020–25

Increasing power through movement building

• Attend to all levels of the movement (individuals, relationships, communities, organizations and networks). • Understand the pathways to activism. • Community building, including mutualism, is part of movement building. • Collaborating with the state: a matter of judgement. • Social movements have deep roots: know your history. • Leadership is necessary but so is accountability. • Build constructive links between the Health for All movement and broader political movements. • Convergence (including solidarity, networking, and collaboration) is a key objective of movement building in the era of globalization.

More governments recognize the Right to Health as a constitutional right, and that PHM contributes to a global movement towards an alternative economic paradigm: more egalitarian, without exploitation, towards Health for All.

Creating social change through campaigns and advocacy

• Campaign strategies bring together theories of change, forms of action, and contingency. • Networking for campaigning is empowering but requires investment and compromise. • Need to balance policy advocacy with structural critique.

PHM’s campaigns and advocacy efforts are recognized globally and PHM is considered as one of the largest movements, with worldwide participation.

Expanding the base of strong advocates through capacity building

• Beyond individuals, think relationships, think organization, think culture. • Think of capacity building in relation to pathways to activism (understanding, hope, resilience). • Build on informal learning opportunities as well as organizing formally structured training programs. • Link curriculum planning to practice opportunities. • Bringing “body knowledge” into discourse (through popular education and “systematization of experience”) makes such knowledge available for sharing and building upon. • Avoid expert domination: value trust, reciprocity, and dignity.

PHM country circles, regions, and global coordination are able to intervene more effectively on health rights and health equity issues, and that younger persons across the world share PHM values, analysis, and capacities to enact such interventions.

Spreading PHM’s vision through analysis and knowledge dissemination

• New information flows can be empowering (from scientific, technical, and legal knowledges, to Indigenous knowledges which point towards new ways of understanding ourselves in the world). • Producing the knowledges that the activists need is a core social movement strategy, including: academic research, research synthesis, learning from activist practice, bringing lived experience into discourse, and re-appropriating history, culture, identity. • Knowledge sharing is a core social movement strategy, exemplified by Global Health Watch, but attention is needed to media, methods, and language, and awareness that knowledge sharing is embedded in relations of solidarity and relations of power.

The political economy perspectives and health equity are widely understood and regularly used to make decisions and measure progress within governance bodies and more generally. PHM’s input is sought by decision-makers, and PHM activists are regularly engaged with decision-making processes in all sectors that influence health.

432   |  Global Health Watch 6 Global and national policy change through global governance for health

• Critical policy engagement by social movements at the national level deals with both national issues and issues which have international ramifications. • There is an important role for critical policy engagement by social movements directly at the global level (linked to complementary advocacy at the national level).

PHM along with other progressive civil society organizations are able to influence the World Health Organization (WHO) and other global health institutions so that they function more democratically. Policy makers and planners in low- and middle-income countries (LMICs) are influenced by PHM to use a critical outlook on global policy dynamics and build their own position and alliances on key issues that affect them.

Source: Adapted from Bodini et al. (2019).

health, nutrition and food sovereignty, gender justice and health, environment and ecosystem health, war and migration and health. The more direct and cross-country engagement of PHM in these areas, through the development of six thematic circles, started prior to the fourth People’s Health Assembly, held in Savar, Bangladesh, at the end of 2018, and is already giving promising results which are found in different chapters of this book. Insights from Global Health Watch 6 and implications for PHM

Moving from past PHM experiences to look at the new analysis and stories of struggle included in this Global Health Watch volume allows us to draw some lines of reflection on the current developments of the health movement worldwide, the leveraging points where activists might usefully engage, and the strategies we might collectively pursue.

1. Health activism in a pandemic’s shadow A first consideration is taking account of the COVID-19 pandemic, and the restrictions it imposed on so many aspects of our lives including the possibility to organize, show our dissent, and practice our alternative ways of building society. Moreover, for a movement whose activists are, in a significant way, workers of the health sector, the pandemic also meant a period of incredible overwork, often coupled with increased care work at home due to school closures, where particularly (women) frontline health workers saw their (mental and physical) time for engagement dramatically shrink. Despite these challenges, activists’ thirst for transformative change did not diminish. Indeed, the pandemic’s magnification of the structural roots of health inequities made the reasons for our activism even more clear and compelling, both in the need to act in support of those who suffer the most from social injustices, and in the strive to bring about the radical changes needed for a more ecojust future.

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That in-person meetings, let alone rallies and demonstrations, for months were extremely difficult if not impossible to organize in many parts of the world did not stop health activists. Online platforms, already widely used for international coordination, became an increasingly populated (and popular) space for disseminating up-to-date analysis on the pandemic situation, governments’ reactions in countries (including increased repression of social movements, as in the case of the Philippines, Palestine, Colombia, to name a few), and new arenas for struggle (for instance, in the field of access to COVID-19 medical products). The availability and accessibility of critical information increased dramatically, although both language (predominantly English) and technology remain barriers for many activists, particularly in the Global South. Activism during a pandemic was not only confined to virtual spaces. Health activists, including from PHM circles in countries such as the USA, Argentina, and India, joined protests organized by the Black Lives Matter (BLM), the feminist, and the farmers movements. Backed by the work of PHM thematic circle on gender and health, the global health movement grew in its analysis of the intersections between systems of oppression (see Chapter A2), which in turn further incents the need for convergence across movements calling for a systematic change in how we organize society and distribute power. Mutualism also grew during the pandemic and became more visible. Many civil society organizations and hundreds of PHM activists from Italy to India quickly mobilized

Image CONCL.1  White sheet action on April 7, 2021. Source: Photo by Eva Gallova, PHM Scotland.

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to deliver basic needs and improve healthcare accessibility for marginalized populations most vulnerable to COVID-19’s spread and lockdown measures. The pandemic gave rise to creative ways of demonstrating, combining street actions, visuals, performances, and music. On World Health Day 2020, also a Global Day of Action against the commercialization and privatization of health, a combined physical and virtual mobilization had enormous success across Europe. Under the slogan “spread solidarity, not the virus,” people wrote messages supporting public healthcare on posters and white sheets that they hung from their windows, then took pictures for sharing on social media (see Image CONCL. 1) (“PHM Europe: Spread Solidarity, Not the Virus” 2020). The lockdown amplified both the local and the global dimensions of the action: as everyone was staying at home, the posters were seen more by neighbors and across buildings; since people were spending more time on social media (and health issues had suddenly become everybody’s worry) the mobilization soared in terms of virtual visualizations. Other examples of creative and effective social movement responses to COVID-19 have been collected by the Beautiful Trouble project (Bloch and Abileah 2020), while a crowdsourced research study has documented over 140 methods of non-violent action during the pandemic.1 This capacity to pull together lessons in real time from direct experience, and turn small, dispersed initiatives into a pool of common resources, was also used in academic-activist environments. One example is the initiative of two USA-based

Image CONCL.2  “Public healthcare for all.” Source: Sketch by Arun for Global Health Watch 6.

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public health groups (Public Health Awakened and The Spirit of 1848) that crowdsourced a database to inform a public health response to COVID-19 that centers on equity, racial justice, collective care, and community and power building.2

2. New threats, and new areas of engagement Along with unprecedented measures to control the spread of the infection, the pandemic brought unprecedented and widespread control of the population by governments. The “Only fighters win” campaign report by Viva Salud, a Belgian NGO affiliated to PHM, starkly warns that: To contain the coronavirus pandemic, many governments are taking drastic measures. … But in some countries these measures put human rights under strain. Some governments are curtailing democratic freedom for an undetermined time and deploy drastic measures to impose quarantine rules. A number of governments is also using the corona crisis against social movements and human rights defenders. They exclude social organizations from decision making, criminalize protests, impede vital humanitarian work and activists fall victim to police violence. (Viva Salud 2020)

The report finds that violence against human rights defenders and representatives of social movements persists, with activists and socio-cultural workers subjected to intimidation, bullying, false accusations, unlawful arrests, kidnappings, and even murder. All this at a time when we need social movements more than ever, including for the role they play in verifying that the impacts of COVID-19 are dealt with fairly and with respect to human rights, and in working for a healthier, more ecological and socially just post-pandemic society. One of the ways in which governmental control is exerted is in the increasing use of new technologies, a field that saw an exponential growth in the pandemic period. Chapter B2, a new entry in the Watch series dedicated to the digitalization revolution, identifies this as a relatively new arena in the struggle for health, one that will require activists to learn how to unpack the complex issues of control and confidentiality inherent in how such technologies are deployed and devise strategies to reposition their use for emancipation and empowerment. Collaborating with groups and organizations that are active in the field is crucial, including organizations such as the Electronic Frontier Foundation, that documents efforts by activists to resist repressive surveillance, activist networks that develop ethical tech alternatives (for instance the Algorithmic Justice League, Allied Media Projects, Data for Black Lives, the Feminist Data Justice project, and Bot Populi), and others that educate and empower communities to exercise their digital rights (examples include the Our Data Bodies project in the USA and the Ippolita research group in Italy) (Electronic Frontier Foundation n.d.). Besides learning how to defend themselves from digitally powered surveillance systems, health activists are also called to denounce how discriminatory design,

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Image CONCL.3  “Only Fighters Win” campaign poster. Source: Viva Salud. Licensed under CC BY-NC 4.0.

weak regulations, high costs, and questionable effectiveness challenge the ideal of digital public goods capable of advancing health equity, exposing the broader political determinants of digital health. As Chapter B2 concludes, “there is an urgent need for global health activists to include digital justice and regulation as a key part of their agendas … pushing back on the commercial, governmental, and ideological powers that have given digital technologies so much control over lives and livelihoods, while also embracing alternate systems of knowledgegeneration, connectivity, and innovation that will achieve health for all.”

3. Emerging fields for convergence – gender, food, environment, trade One of the key principles that emerged through the PHM action-research is “convergence,” which in our usage refers to a coming together of people, organizations, and movements who share similar concerns about health and are critical of the role of neoliberal globalization plays in sustaining health inequities. Convergence includes the process of building consensus, understanding, trust, and collaboration between different streams of anti-hegemonic activism, across geographic borders, issues, and identities. One of the most dramatic examples was the “Battle of Seattle” in 1999 (Smith 2002), a mobilization centered on World Trade Organization (WTO) negotiations which brought together many different constituencies in a rowdy opposition to neoliberal economic globalization. One important challenge for convergence is that, while the current global order may be influencing people’s health chances in different countries and settings,

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its influences are mediated through local structures and forces and manifest in many ways. Throughout the PHM network, convergence is clearly happening on issues related to gender justice and health, where the dedicated PHM circle has continued to build cross-country solidarity and initiatives since the fourth People’s Health Assembly in 2018 (PHM n.d.[a]). The circle’s vision is to create accountable and equitable health policies and health systems in the context of intersectional justice, and to enhance access to quality public healthcare. The short-term goals focus on integrating a gender and intersectional justice lens into PHM’s broader work, and capacity building among activists. Chapter A2 in this Watch is an example, together with a series of webinars organized by the group around past and present learnings on pandemics and public health. A second challenge for convergence is that PHM’s political economy analysis of neoliberal globalization as a barrier to better health, and of the social determination of health, are not shared by many other movements in the global health field. However, learnings from the PHM action-research suggest a loose pathway towards convergence involving networking across different social movement organizations, expressions of solidarity across the different streams of activism, development, and deepening of personal relationships across streams, dialogues of analysis and strategy, recognizing areas of agreement, working on issues of difference, and deepening understanding and trust through collaboration in action. While this is not a linear process, it can be traced, for instance, in the development of a closer relationship between PHM and the global movement for food sovereignty, from the engagement of key individuals in PHM in the field of food and nutrition, to the mutual reinforcement of ongoing struggles through solidarity, to building stronger personal relationships, to developing joint strategies. The creation of the PHM thematic circle on nutrition and food sovereignty (PHM n.d.[b].), and Chapter C5 in this Watch coordinated by FIAN International, a network for the right to food and nutrition, are good examples of this growing convergence, as is their joint mobilization against the corporate capture of UN Food Systems Summit (see Chapter D3). The PHM thematic circle on environment and ecosystem health, contributor of Chapter C4, illustrates another example of convergence spanning several countries where extractivist powers act in similar ways to dispossess people and exploit the environment. Circles in the Global North such as PHM-Canada, act through a set of movement practices (generation and dissemination of popular and academic knowledge, responding to community requests for campaign support and appeals for urgent actions, and participating in direct action) to protest the harms of Canadian-based global extractive firms and to support communities in conflict with them at home and abroad. Communities and PHM activists in the South are not only part of the struggles in the affected sites but contribute to the vision that informs them through their conception of life and (collective) health rooted in the ancestral relationships between human beings and territories (Sumak Kawsayi or Buen Vivir, see Case study

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1 in Chapter C4). The view, expressed in Chapter C5, that these include both “material territories” – ecosystems, water, soil, land, seeds, or biodiversity – and “immaterial territories” – knowledge, care, ties, or cultures (Rosset and Martinez Torres 2016) is particularly useful to understand (and enter) them as contested spaces of struggle. The individual and collective participation of many PHM activists to global environmental movements such as Fridays for Future and Extinction Rebellion is yet another (early) step in the direction of convergence, backed by the perception that climate change, as declared in an editorial published in September 2021 in more than 200 medical and health journals worldwide, is the “greatest threat to global public health” (Choi-Schagrin 2021). Acknowledging this, in recent years health NGOs, such as Medact in the UK, built dedicated programs focusing on educating the health community about the science of climate change and the threats posed to human health, supporting the global fossil fuel divestment movement, promoting a transition towards more sustainable forms of food production and consumption, and enabling a more informed debate about what a healthy energy policy would look like. Medact also organizes trainings for health workers aimed at empowering them to speak to media about these threats, leveraging their credibility to sensitize the public and influence decision-makers. The field of trade is not a new space for social movement convergence, as it is where much of it began. From the “Battle of Seattle” on, health activists have joined with other civil society organizations pushing back against trade and investment agreements whose rules could imperil health. Activism on trade issues also shifted from earlier street protests of general opposition (though these still exist) to media campaigns and formalized advocacy in efforts to have new treaty rules be more health protective (see Chapter D2, Box D2.3). Currently, the PHM circle on trade and health is particularly concentrated on issues related to intellectual property and availability and accessibility of medical products, the importance of which cannot be underestimated during a pandemic.3 However, as several chapters in this Watch have documented, the impact of trade regulations on health happens at multiple levels and deserves our coordinated attention. We have powerful country experiences that could be scaled up, for example the ACT Health Promotion Network in Brazil that systematically monitors industry activity in tobacco, food, and beverage, and alcohol production, promotion, and consumption. Such monitoring is used to inform their advocacy and activism efforts (see Chapter C3, Box C3.3), such as exposing a new partnership between Coca-Cola and the Brazilian Ministry of Health, as well as revealing the extent of government subsidies to the soda industry. This work resulted in national press coverage and is mobilizing support to end these subsidies. Underlying these struggles is the power imbalance between transnational corporations and states as illustrated in Chapter D5. Focusing on building power from below, Box D5.1 in Chapter D5 presents several cases that, starting in

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the 1960s, combined resistance strategies (in advocacy, public mobilization, and juridical case work) with proposals for alternative development models, succeeding in pushing the issue of corporate impunity to the top of the international policy agenda. This set the basis for creating a Global Campaign to Reclaim Peoples Sovereignty, Dismantle Corporate Power and Stop Impunity in 2012, led by affected communities, trade unions, social movements, and human rights networks.4 Two years later, the Campaign obtained a historical victory when the UN Human Rights Council adopted a resolution on the elaboration of an International legally binding instrument on transnational corporations (TNCs) and other business enterprises with respect to human rights. As negotiations continue, the Campaign has increased its reach and engagement in order to organize broad consultations, provide critical feedback and make sure that the Binding Treaty is a key issue in the agenda of movements in a growing number of countries. Other areas where the global health movement could grow in terms of convergence are labor and war and health, addressed in this Watch in Chapters C2 and C6 respectively, documenting leveraging points where activists could engage for change. Both are fields of commitment for individual PHM members, and for some of the country circles or regional chapters. For example, PHM in Europe partners with health sector trade unions for the day of action against the commercialization and privatization of health, and engaged some of their representatives in an International People’s Health University (IPHU) organized in May–June 2021 together with the Barcelona-based network Health Rights Action. The PHM Middle East and North Africa region, for obvious geopolitical reasons, is very involved in exposing the devastating impact of war and conflict on people’s health.

Box CONCL.1: PHM global programs and the pandemic As with other organizations, PHM had to adapt to the pandemic situation moving most of its activities online. For a global movement, the virtual space has always been crucial to allow the ongoing exchange and coordination that keep it alive, but some in-presence activities regularly happened and provided vital energy to the movement. Among these have been the presence of “WHO Watchers” in Geneva during the meetings of the WHO Executive Board and its World Health Assembly, and numerous IPHUs (short training for health activists) that have taken place in all of the world’s regions. Since early 2020, both activities had to be shifted online. In the case of the WHO Watch, there was no other option since WHO meetings also became virtual. Given the increased possibilities of widespread reach,

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and the greater media and public attention to global health topics, PHM activists put even more effort into communicating about ongoing discussions by member states and critical positions by civil society. Participating in the civil society network Geneva Global Health Hub, they contributed to a series of online policy dialogues prior to the World Health Assembly to disseminate critical analysis of the WHO’s policy and program agendas in an effort to address the shrinking space of civil society voices within WHO. Watchers also created visual posters to illustrate the content of the statements delivered, increased social media presence, and recently contributed to a bulletin by the international media organization People’s Dispatch dedicated to global health issues.5 IPHUs have also been held online since the beginning of the pandemic. These include a course on access to affordable medicines, with a focus on Middle East and North Africa, held in late 2020, and one organized by PHM and EQUINET in East and Southern Africa in the second half of 2021, focusing on health equity. PHM Europe held its regional IPHU online in May to June 2021, thanks to a collaboration with a Barcelona-based network, “Health, Rights, Action.” The network includes an organization dedicated to communication for social change (Quepo) that empowered health activists with much-needed tools to improve PHM practices in strategic planning, power mapping, and communication. Despite undeniable challenges, including access to technology and data, the IPHU “from Barcelona” also managed to involve activists from outside Europe and to create a learning space that – hopefully – will continue to be accessible after the course.6 If the experience of in-person meetings is not replaceable, and the energy that the movement draws from events such as People’s Health Assemblies is crucial for its survival, it is also imperative for a global health movement to master the online possibilities for dissemination of its views and values, and for reaching out to new activists. Once again, partnering with media organizations and communication networks is crucial, both in terms of effectiveness and of convergence of struggles.7

Conclusion

As we look back at the past two years, the collective challenges of the global movement for Health for All, and the personal challenges of many of its activists, have greatly increased. Due to the pandemic and the failures of the collective response to it, some of us have lost their family, others their jobs, some their lives. Moreover, from the Philippines to Colombia, from Turkey to Nicaragua, health activists face increasing repression and violence. The Palestinian health NGO Health Work Committees (HWC), affiliated to PHM, has come under repeated attacks by the Israeli Occupation Forces,

CONCLUSION  |   441

culminating with the arrest in July 2021 of its president Shatha Odeh, member of PHM’s Global Steering Council. One month before, the HWC’s central office in Ramallah was severely disrupted and a military order forced it to close for six months (Amnesty International 2021). These violent acts are faced by local and global resistance: two weeks after the raid, Palestinian people removed the seals and reoccupied HWC office, and Palestinian and international activists are now joining forces in a legal battle and global campaign calling for justice and freedom for Shatha Odeh, including a letter requesting that WHO intervene for her immediate release (Devi 2021). Both the outrageous acts of repression (HWC is one of the main providers of health services in the occupied Palestinian territories and has been at the forefront of the COVID-19 response), and the determination of the people’s reaction symbolize well what we face and how we need to respond as a health movement in this era. The history of people’s movements, and the health movement is no exception, is full of acts of resistance that, though limited when considered as such, become relevant when combined in a joint narrative. The role of social movements is not only that of building coordinated action that may have the power to bring about change, but also that of providing a space for different struggles and lived experiences to know, learn from and mutually strengthen one another. We hope that this Watch contributes to these goals. In dedicating it to two comrades who passed away in recent years, Amit Sengupta and David Sanders, we stand on their shoulders and carry on their vision – and their stubbornness – towards Health for All, Now! Notes 1  View the collection of cases at ttps://docs. google.com/spreadsheets/d/179hz-OKrfcAr3O0xi_ Bfz9yQcK917fbLz-USxPZ3o_4/edit#gid=0. 2  View this database at https://docs. google.com/spreadsheets/d/1mUOmJK_ bSP3hlcUYPWsKMsSo_fHQDdnOe5ayECLuxvA/ edit#gid=412443731. 3  See PHM’s Trade and Health home page at https://phmovement.org/health-for-allcampaign/trade-and-health/. 4  Visit the website of the Global Campaign to Reclaim Peoples Sovereignty, Dismantle

Corporate Power and Stop Impunity at https:// www.stopcorporateimpunity.org/. 5  This bulletin can be accessed at https:// peoples-health-dispatch.ghost.io/bulletin-1-fromthe-frontlines-of-the-world-health-assembly/. 6  To access infographics and videos of the Barcelona IPHU, visit https:// agora.salutdretsaccio.org/assemblies/ IPHUCommunity/f/1903/. 7  For more information on PHM’s global programs, visit www.phmovement.org.

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healthcare/?fbclid=IwAR3ehNSOtLjTU UXwnYxfk3QZh5uZd93DEghtMz2SUwz 6CvyCbMDF_USFpAA. Bloch, Nadine, and Rae Abileah. 2020. “Beautiful Trouble’s Guide to Activism during the Coronavirus Pandemic.” The Commons Social Change Library. March 20. https://

442   |  Global Health Watch 6 commonslibrary.org/beautiful-troublesguide-to-activism-during-the-coronaviruspandemic/. Bodini, Chiara, Fran Baum, Ronald Labonté, David Legge, David Sanders, and Amit Sengupta. 2019. “Methodological Challenges in Researching Activism in Action: Civil Society Engagement Towards Health for All.” Critical Public Health 30 (4). doi: 10.1080/09581596.2019.1650892. “Bulletin #1: From the Frontlines of the World Health Assembly.” 2021. Peoples Health Dispatch. May 31. https://peoples-healthdispatch.ghost.io/bulletin-1-from-thefrontlines-of-the-world-health-assembly/. Choi-Schagrin, Winston. 2021. “Medical Journals Call Climate Change the ‘Greatest Threat to Global Public Health.’” New York Times, September 7, sec. Climate. https://www. nytimes.com/2021/09/07/climate/climatechange-health-threat.html. Devi, Sharmila. 2021. “Palestinian Health NGO Leader Detained.” The Lancet 398 (10299): 477. doi: 10.1016/S0140-6736(21)01793-1. Electronic Frontier Foundation. n.d. “Surveillance Technologies.” Electronic Frontier Foundation. Accessed June 9, 2021. https://www.eff.org/issues/masssurveillance-technologies. “PHM Europe: Spread Solidarity, Not the Virus – People’s Health Movement.” 2020. Peoples’ Health Movement. March 17. https:// phmovement.org/spread-solidarity-not-thevirus/. PHM [People’s Health Movement]. 2000. “People’s Charter for Health.” https:// phmovement.org/the-peoples-charter-forhealth/. PHM [People’s Health Movement]. 2020. “The People’s Health Movement Strategic Plan 2020–2025: Re-Energizing Health for All for a New Global Context.” https://phmovement. org/phm-strategic-plan-2020-2025/.

PHM [People’s Health Movement]. n.d.[a]. “Gender Justice and Health.” People’s Health Movement (blog). Accessed July 2, 2021a. https://phmovement.org/health-for-allcampaign/gender-justice-and-health/. PHM [People’s Health Movement]. n.d.[b]. “Nutrition and Food Sovereignty.” People’s Health Movement (blog). Accessed July 2, 2021b. https://phmovement.org/ health-for-all-campaign/nutrition-and-foodsovereignty/. Rosset, Peter, and María Elena Martinez Torres. 2016. “Agroecología, Territorio, Recampesinización y Movimientos Sociales.” Estudios Sociales: Revista de Alimentación Contemporánea y Desarrollo Regional 25 (47): 273–299. https://dialnet.unirioja.es/ servlet/articulo?codigo=5831955. Sanders, David. 1985. The Struggle for Health. Medicine and the Politics of Underdevelopment. London: Macmillan. Smith, Jackie. 2002. “Globalizing Resistance: The Battle of Seattle and the Future of Social Movements.” In Globalization and Resistance: Transnational Dimensions of Social Movements, edited by Jackie Smith and Hank Johnston, 207–228. Lanham, MD: Roman & Littlefield. “Ursula K Le Guin’s Speech at National Book Awards: ‘Books Aren’t Just Commodities.’” 2014. The Guardian. November 20. https:// www.theguardian.com/books/2014/nov/20/ ursula-k-le-guin-national-book-awardsspeech. Viva Salud. 2020. “All Heroes for Health: Only Fighters Win.” Campaign paper. Brussels: Viva Salud. https://www.vivasalud.be/en/ all-heroes-for-health/. Viva Salud and PHM [People’s Health Movement]. 2020. “Building a Movement for Health | People’s Health Movement.” Issuu. April 20. https://issuu.com/m3m-g3w/docs/ movement_building_en.

CONTRIBUTORS

Aakriti Pasricha, Sama Resource Group for Women and Health, India.

Centre for Health Governance, Australia National University.

Abdalaziz Al-Salehi, Researcher at Social and Economic Policies Monitor (Al Marsad), Public and Social Economic Policies Researcher, Palestine.

Baijayanta Mukhopadhyay, People’s Health Movement Extractive Industries Circle, Ottawa, Canada.

Adsa Fatima, Sama Resource Group for Women and Health, India. Alane Andrelino Ribeiro, Doctoral student at the University of Brasília; Brazilian Centre for Health Studies (CEBES), Brazil. Alba Llop-Gironés is a nurse with a Ph.D. in Public Health based in Copenhagen, Denmark. She has worked as a clinical nurse, as a researcher in the interface of policy and health system research, and as a consultant for governments and WHO. Alice Fabbri is a Research Fellow at the University of Bath, UK. Amulya Nidhi, People’s Health Movement India (Jan Swasthya Abhiyan). Ana Vračar is the regional coordinator of PHM Europe. She is based in Zagreb, Croatia, where she works with the Organization for Workers’ Initiative and Democratization (OWID). Anita Gurumurthy is a founding member and Executive Director, IT for Change, India. Anne Marie Thow, Associate Professor of Public Policy and Health at the Menzies Centre for Health Policy, School of Public Health and Charles Perkins Centre, University of Sydney, Australia. Anne-Emanuelle Birn, Professor of Critical Development Studies and Global Health at the University of Toronto, Canada. Arianna Rotulo, Barts and The London School of Medicine and Dentistry, UK. Arne Ruckert, Senior Researcher, Globalization and Health Equity Research Unit, University of Ottawa, Canada. Ashley Schram, Braithwaite Fellow in the School of Regulation and Global Governance (RegNet) and Deputy Director of the Menzies

Barbara Adams, Senior Policy Analyst, Global Policy Forum, USA. Belinda Townsend, Deputy Director of the Menzies Centre for Health Governance and Fellow in the School of Regulation and Global Governance at the Australian National University. Ben Eder, Climate & Health Campaign and Programme Lead, Medact, UK. Brid Brennan is a political economist and activist, and coordinates the Corporate Power work at the Transnational Institute (TNI). Bridget Lloyd, health activist, People’s Health Movement global and South Africa Steering Committee. Bryan Parras, Sierra Club, People’s Health Movement Extractive Industries Circle, Houston, Texas, USA. Carmen Baez, People’s Health Movement, Argentina. Catia Cecilia Confortini is Associate Professor of Peace & Justice Studies at Wellesley College, USA. Charlotte Dreger, Policy and Advocacy Officer Sustainable Food Systems, FIAN International. Chiara Bodini is a founding member of the Centre for International and Intercultural Health (CSI) of the University of Bologna, Italy, collaborates with the Belgian NGO Viva Salud, and is part of the People’s Health Movement Global Steering Council and co-editor of Global Health Watch 6. D. Brendan Johnson, Duke University Divinity School and the University of Minnesota Medical School, USA. Damiàn Verzeñassi (PHM Argentina, Instituto de Salud Socioambiental de Rosario). Daniel Ciurla, Research Assistant, Globalization and Health Equity Research Unit, University of Ottawa, Canada.

444   |  CONTRIBUTORS Débora Tajer, Professor, Gender Studies and Public Health, School of Psychology, University of Buenos Aires, Argentina; former general coordinator of ALAMES; feminist activist. Deborah Gleeson, Associate Professor in the School of Psychology and Public Health at La Trobe University, Melbourne, Australia. Deepika Joshi, People’s Health Movement Global Secretariat, India. (Dian) Maria Blandina, School of Medicine, Aristotle University of Thessaloniki, Greece. Elias Kondilis, School of Medicine, Aristotle University of Thessaloniki, Greece. Elizabeth Orr, Borderlands Co-operative and People’s Health Movement, Australia. Emilie McSwiggan works on public health evidence synthesis, and campaigns for nuclear disarmament and holds a Master of Public Health degree from the University of Edinburgh, UK. Erika Arteaga-Cruz, Ph.D. (c), Universidad Andina Simón Bolívar, Faculty, School of Medicine, Universidad San Francisco de Quito, PHM Extractive Industries Circle, Quito, Ecuador. Faseeha Riaz Ghazi is an undergraduate student at the University of Manchester and a research volunteer with the Peace and Security research cluster at Medact, UK. Florence Rodgers, National Coordinator, Universities Allied for Essential Medicines UK. Gisela Llop-Gironés is a nurse and a midwife based in Bristol, United Kingdom. Gonzalo Berrón, Ph.D. in Political Science, is a member of the Corporate Power team at the Transnational Institute (TNI) with expertise on social movements, alternative regionalisms, and the asymmetries of power between corporations and states. Hani Serag is an Assistant Professor at the Department of Internal Medicine at the School of Medicine and Associate Member of the Graduate Faculty at Graduate School of Biomedical Sciences, University of Texas Medical Branch (UTMB), Galveston, Texas, USA. Hanna Blåhed, Várdduo-Center for Sámi Research, Umeå University, Sweden. Hil Aked is a writer and investigative researcher with a Ph.D. from the University of Bath, and they are Research and Policy Manager at UKbased public health charity Medact.

Isabel Álvarez Vispo, Vice President, Advocacy Officer, URGENCI, Spain. Isabel Ortiz is Director of the Global Social Justice Program at the Initiative for Policy Dialogue, Columbia University, USA, and former director of the International Labour Organization (ILO) and UNICEF. Isabela Soares Santos, Researcher, Doctor in Public Health; Brazilian Centre for Health Studies (CEBES), Brazil. Janet Price, activist and academic, based in Liverpool, UK, who works at the intersection of disability, sexuality, and gender. Jean-Louis Aillon works at the Frantz Fanon Center as medical doctor and Adlerian psychotherapist and is the spokesperson of the Italian Network for Sustainability and Health, Italy. Joan Benach is the group leader of the Research Group on Health Inequalities, Environment, and Employment Conditions (GREDS-EMCONET) at the Universitat Pompeu Fabra, Barcelona, Spain. John Calvert, Associate Professor, Faculty of Health Science, Simon Fraser University, Canada. Kapoori M. Gopakumar, Legal Advisor, Third World Network, New Delhi, India. Karen Judd, Associate Editor, New Labor Forum, School of Labor and Urban Studies, City University of New York, USA. Katerini Storeng, Associate Professor, Centre for Development and the Environment, at the University of Oslo, Norway. Laura Macdonald, Professor, Department of Political Science and Institute of Political Economy, Carleton University, Ottawa, Canada. Leigh Haynes, People’s Health Movement, USA. Liana Lopez, People’s Health Movement Extractive Industries Circle, Houston, Texas, USA. Livia Angeli-Silva graduated in nursing, has a Ph.D. in public health and is a lecturer and researcher of the School of Nursing at the Federal University of Bahia, Brazil. Lucero Jaimez Ochoa graduated in nursing, is a lecturer at the College of Technical Professional Education of the State of Mexico and nurse at the Ruben Leñero General Hospital, Mexico City. Luciani Martins Ricardi, Technical Analyst of Social Policies, Doctor in Public Health, Brazilian Centre for Health Studies (CEBES), Brazil.

CONTRIBUTORS  |   445 Luiz Vieira, Coordinator, Bretton Woods Project, a UK-based NGO that challenges the World Bank and IMF and promotes alternative approaches. Maan Tablang (PHM Phillipines). Magdalena Ackermann, Policy and Advocacy Officer, Food Systems, Nutrition and Agroecology, Society for International Development. Marco Sassoon, is a Psychologist and Psychotherapist, and a member of Sportello TiAscolto, Italy. Mariela Muñoz (Argentina). Marta Buszewicz is a General Practitioner and Honorary Associate Professor at University College London, UK, with a particular interest in the interface between mental and physical health. Martin Drewry is the Director of the UK-based NGO Health Poverty Action. He is part of the Mental Health Innovation Network and of the People’s Health Movement. Matteo Bessone is a Psychologist and Psychotherapist, and co-founder of Sportello TiAscolto, Italy. Mauricio Torres-Tovar, Professor Universidad Nacional de Colombia, and member Red de Salud y Trabajo de ALAMES and Grupo de Trabajo Estudios Sociales para la salud, CLACSO; People’s Health Movement. Michael Cardito is a medical doctor and current co-president of the Movimento Decrescita Felice (Happy Degrowth Movement), Italy. Michael Orgel is a campaigner for the abolition of nuclear weapons with a MD from Case Western Reserve University, and a long-time member of Medact Scotland and the Medact Nuclear Weapons Group, UK. Michael Tonkins is an emergency medicine doctor in the National Health Service and holds a Master’s degree in Social Anthropology from the University of Edinburgh and a Master’s degree in Clinical Research from the University of Sheffield, UK. Miguel San Sebastián, Department of Epidemiology and Global Health and VárdduoCenter for Sámi Research, Umeå University, Sweden. Mireia Julià is a postdoctoral researcher at Research Group on Health Inequalities, Environment, and Employment Conditions (GREDS), and Adjunct Professor at Department

of Political and Social Sciences of the Universitat Pompeu Fabra, Barcelona, Spain. Mónica Vargas Collazos, Ph.D., is a member of the Corporate Power team at the Transnational Institute (TNI) with a background in social anthropology and sociology. Morena Lentini is a Psychologist and Psychotherapist, and a member of Sportello TiAscolto, Italy. Mulenga Mukanu is a public health researcher from Zambia currently pursuing her Ph.D. from the University of the Western Cape, South Africa. Natalie Rhodes, European Coordinator, Universities Allied for Essential Medicines Europe. Neelanjana Das, Sama Resource Group for Women and Health, India. Nicoletta Dentico is a journalist and writer, Director of the Global Health Justice Program, Society for International Development (SID, www.sidint.net). Nora Kenworthy, Associate Professor, School of Nursing and Health Studies, University of Washington, USA. Pramila Thapa is the academy advisor of the Yeti Health Science Academy, Kathmandu, Nepal. Ramesh Bhatta is Principal and Chairperson of Research Department at Yeti Health Science Academy, Purbanchal University Nepal, Kathmandu, Nepal. Raphael Lencucha, Associate Professor in the School of Physical and Occupational Therapy and Associate Member of the Institute for Health and Social Policy at McGill University in Montreal, Canada. Red Calisas (Red de Cátedras Libres de Soberanía Alimentaria y Colectivos Afines), network created in 2013 in Argentina. Remco van de Pas, Senior Research Fellow Institute of Tropical Medicine, Antwerp, Belgium, and Honorary Lecturer, Maastricht University, the Netherlands. Rhiannon Osborne, Campaign Advisor, Universities Allied for Essential Medicines UK. Rita Dayoub is a Syrian dentist, Academy Associate at Chatham House, London, UK, and founder of Health Workers at the Frontline. Rob Abrams, Climate & Health Organizer, Medact, UK.

446   |  CONTRIBUTORS Roman Gnaegi is a development cooperation/ humanitarian professional and doctoral student at University of Leicester, UK. Ronald Labonté, Professor and Distinguished Research Chair, School of Epidemiology and Public Health, University of Ottawa, Canada; co-editor Global Health Watch 6. Sabrina Wimmer, Research Coordinator, Universities Allied for Essential Medicines UK. Santosh Mahindrakar is a nurse pursuing doctoral studies on the policy issues of human resources for health, and is a research coordinator of Innovative Alliance for Public Health, New Delhi, India. Sara Bontempo Scavo is a nurse working in Bologna, Italy. She participated in the Italian Campaign “2018: Primary Health Care Now or Never” and is a member of the Italian Association of Family and Community Nurses. Sarai Keestra, Research coordinator, Universities Allied for Essential Medicines UK. Sarojini Nadimpally, Coordinator, Gender, Justice and Health Thematic Group, People’s Health Movement, India. Sheila Regehr, Co-Chair, Basic Income Canada Network, Toronto, Canada. Silvio Cristiano is Postdoctoral researcher at the Department of Environmental Sciences, Informatics and Statistics, Università Ca’ Foscari Venezia, Italy. Sol Trumbo Vila is a member of the Corporate Power team at the Transnational Institute (TNI) with expertise on social media communications and platforms. Sonia Nar is a midwife, nurse, and cultural mediator born in India, living between Spain and Ireland, and is part of the WHO panel to address the challenges of migration among nursing staff. Sridhar Venkatapuram, Senior Lecturer in Global Health and Philosophy, King’s Global Health Institute, London UK. Stephen Brown, Professor in School of Political Studies, University of Ottawa, Canada.

Sulakshana Nandi is National Joint Convener of People’s Health Movement India (Jan Swasthya Abhiyan) and Co-chair of PHM Global Steering Council. Susana Barria, People’s Health Movement and Public Services International, India. Susana Marcos Alonso is a nurse and anthropologist with a Ph.D. in Society and Culture. She is a Registered Nurse working in primary health care services in Barcelona, Spain. Tadesse Kassaye is based in Ethiopia and works as Africa Programmes Director of the UK-based NGO Health Poverty Action. Taher Qassim Taher, Scholar Emeritus, School of Psychology and Public Health, La Trobe University, Australia. Taher Qassim was born in Yemen and studied in Yemen, Sweden, and England, and is currently a full-time Public Health Practitioner with Liverpool City Council. Tanay Mahindru, Research Associate at IT for Change, India. Thomas Hart is based in Guatemala and works as country director of the UK-based NGO Health Poverty Action. Thomas Stubbs is a Senior Lecturer in International Relations at Royal Holloway, University of London, and a Research Associate in Political Economy at the Centre for Business Research, University of Cambridge, UK. Todd Jailer, Hesperian Health Guides, People’s Health Movement Extractive Industries Circle, California, USA. Vikram Patel, Professor of Global Health in the Blavatnik Institute’s Department of Global Health and Social Medicine at Harvard Medical School, USA, and co-founder of Sangath, an Indian NGO that addresses the psychological and social needs of people through comprehensive community interventions. Vuk Stambolović, retired Professor at the Institute of Social Medicine, Medical Faculty, Belgrade, Serbia.

INDEX

2030 Agenda for Sustainable Development 370, 375–378 Aarogya Setu App 131 abortion 53–55 AB-PMJAY see Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana absolute income in US dollars 1980–2016 23 access 147–171, 378–381 Access to COVID-19 Tools Accelerator (ACT-A) 11–12, 152–153, 323, 325–326, 328–329, 422 access and UN funding 378–381 Accredited Social Health Activists (ASHAs) 56–57, 186 ACT Health Promotion (Brazil) 245–246 activism degrowth 78–79 digital health 114–116 labor markets 222, 225 public health and geopolitics 361–362 re-greening 37 advertising 238–239, 346–347 advocacy efforts in Canadian mining 260–261 Affordable Care Act (ACA) 134 Afghanistan 48 Africa A&T healthcare 94 austerity 202–203 employment and COVID-19 214 inequality 20–21 ISHU public–private partnership 95–96 migration 28 Ogoni People vs Shell in Nigeria 411 politics of access 148–149 trade and investment regimes 244–245 trade treaties and government 359 UNECA report 393 unhealthy commodities 238, 239, 241–244 Universal Basic Income 229 universal/primary healthcare divide 91–92, 94, 95–96 WEF treaty content 418–419 World Bank/digital health startups 107 World Economic Forum 380–381 see also South Africa

AGRA see Alliance for a Green Revolution in Africa agriculture 222, 225–226, 240–241, 247–249 see also food agroecology 286–289 agro-industrial models 277–282 AI see Artificial Intelligence Aid and Trade (A&T) 94, 206 Alabama, US 222, 413 ­ALAMES see Latin American Social Medicine movement alcohol 237–238, 239, 240, 241, 242, 244–246, 346–347 Algorithmic Justice League 122 Alliance for a Green Revolution in Africa (AGRA) 380–381 Allied Media Projects 122 Alma-Ata declaration of PHC 83, 85–86 Alphabet 113, 119 see also Google Alston, P. 113–114 alternative livelihoods to unhealthy lifestyles 247–248 Amazon 3, 113, 117, 119, 222, 413 “America First” policy 357–358 Android/iOS platforms 131 anti-austerity protests 200–201 anti-democratic sentiment 109–110 anti-mining initiatives 260 anti-vaxxers 310, 312 Apple 113, 117, 120 Argentina abortion 53–55 Buenos Aires Declaration 351–352 fight for water 258–259 international investment agreements 354–355 sovereignty and food systems 292–294 Artificial Intelligence (AI) 6, 105, 108, 113, 116–119 Deepmind 116–118 ASEAN countries 358 ASHAs see Accredited Social Health Activists Asia austerity 58, 202–203 digitization of the economy 221

448   |  INDEX garment and textile industry 216 gender-based violence 49 heatwaves 21, 23 industry promotion of unhealthy commodities 239 inequality 20–21 migrantion 28 unhealthy commodities 242 WEF treaty content 418–419 al-Assad, B. 305–306 Associazione per la Decrescita (Association for Degrowth) 75 Astana declaration of 2018 83, 85–86 AstraZeneca 156, 158 asylum policies 308 “Attack on labour rights” 217 austerity 20, 58, 193–210 2010–2025 193–197 2020 and onwards 202–205 alternatives for health and social protection 204–206 health impacts 197–199, 200 inequitable pandemic outcomes 199, 201–202 protest 200–201 universal/primary healthcare divide 90 Australia Health Star Ratings 244 ­privatization of healthcare 138 Australia–US Free Trade Agreement (AUSFTA) 164–165 authoritarianism 20, 39, 308–309 Automating Inequality (Eubank) 113 automation 221 autonomization/privatization 130 avian flu 322 Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) 93–94 Bangladesh primary healthcare privatization 135 Rana Plaza Fashion Factory Collapse 412 Bangladesh and Rohingya refugees 53, 57 bans on unhealthy foods 245 BAT see British American Tobacco Bauman, Z. 26–27 BBC see British Broadcasting Corporation “behavioral surplus” data 113 Belgium, privatization of healthcare 138 Bello, W. 67 “Belt and Road” initiatives 36, 358 Benjamin, R. 122 Better Life Index 70–71

beverages see alcohol; soda Beyond GDP report on happiness 71 Bezos, J. 3 see also Amazon Bharatiya Janata Party (BJP) 307–308 Biden, J. 36 Big Brother 238 big data analytics 113–116 “Big Data is watching you” 106 “Big Data for Social Good” scheme 117–118, 119 Big Oil 24 Big Pharma 6–7, 185, 328–329, 422–423 see also medicine; vaccines Big Tech 105–107, 109–119, 120, 131–132 surveillance 110–116 see also digital health bilateral foreign aid 414–416 bilateral investment treaties (BITs) 353 bilateral trade agreements 154–155, 340–343 Bill & Melinda Gates Foundation (BMGF) 107, 152, 241–242, 324–326, 380–381, 422–427 BIO see Biotechnology Innovation Organization biodiversity 248–249, 263–265, 279 BioNTech 158 see also Pfizer Biotechnology Innovation Organization (BIO) 162 BITs see bilateral investment treaties BJP see Bharatiya Janata Party booster shots 7, 156–157 borrowing existing debt 205 Bot Populi 122 bottom-up approaches to peace 302–303 BP Deepwater Horizon-Gulf Mexico 411 Brazil alternative livelihoods to unhealthy lifestyles 247–248 gender-based violence 49 industry promotion of unhealthy commodities 238 Mariana and Brumadinho Communities 412–413 primary healthcare privatization 135 promoting healthy environments 245–246 WEF and the “Great Reset” 424 women’s rights 50–52 British American Tobacco (BAT) 240, 242, 243–244 British Broadcasting Corporation (BBC) 215 Brumadinho Communities vs Vale Brazil 412–413 Buen Vivir concepts 10, 72, 255–256 Buenos Aires Declaration 351–352

INDEX  |   449 “Build Back Better” 36 see also “Great Reset” ­“build-own-transfer” (B-O-T) models 95–96 Burger King 242 business intermediaries and UN funding 378–381 CAA see Citizenship Amendment Act calorie labeling at point of sale 245 Canada digitization of the economy 221 inflation 34 mining and People’s Health Market 259–261 NAFTA 243 politics of access 155, 164–165 private companies and bilateral foreign aid 415–416 privatization of healthcare 138 trade treaties and government 357 Universal Basic Income 228, 229 see also US/Mexico/Canada Agreement Canada’s Index of Wellbeing (CIW) 70 capitalism 25–26, 38–40 circular economies/degrowth 67–71 growth/degrowth 65–81 localization/deglobalization 66–67 philanthrocapitalism 324–327, 333 stakeholders and the WEF 420 surveillance 113 see also growth caps/wage bill cuts 195 carbon dioxide (CO2) emissions 21, 23–26, 37, 277–279 carbon industries/re-greening policies 35–38 care home privatization 138 Caribbean austerity 202–203 digitization of the economy 221 Catalonia, Spain 201–202 CDoH see commercial determinants of health Center for Social and Economic Rights (CESR) 197 Centers for Disease Control and Prevention (CDC) 59, 130–131, 391, 414 Central Asia, austerity 202–203 central banks the “Fed” 34–35 foreign exchange reserves 205 CEPI see Coalition for Epidemic Preparedness Innovations CESR see Center for Social and Economic Rights CETA see Comprehensive Economic and Trade Agreement

CEWG see Consultative Expert Working Group CFE see Contingency Fund for Emergencies Chan, M. 387 Chevron-Texaco Ecuador 411 Chile agroecology 288 transnational corporations 416 Chilean health food labels 239 China “America First” policy 357–358 “Belt and Road” initiatives 36, 358 digital health 110, 120 genocide 307 ­inequality 20–21 political economy of COVID-19 332 staff/funding shortfalls 320 trade treaties and government 359 UN funding 371 WEF and the “Great Reset” 424 CHWs see community health workers circular economies 67–71 Citizenship Amendment Act (CAA) 307–308 City of New York 245 civil rights protest 200 Civil Society Engagement Mechanism (CSEM) 85 Civil Society and Indigenous Peoples Mechanism (CSM) 10–11, 289–291 civil society organizations (CSO) 359, 361–362, 375, 377, 378, 415 CIW see Canada’s Index of Wellbeing climate change 21, 23–26, 35–38, 236, 257–258, 277–279 Clinton, C. 386 Coalition for Epidemic Preparedness Innovations (CEPI) 325–326, 422–423 Coca-Cola 238, 241–242, 245–246 Codex Alimentarius Commission 240 Codex standard 343–344 Cold War 26, 359–360 Colombia, occupational illness 222–223 commercial determinants of health (CDoH) 235–252 definitions 235–236 determinants of health 245–248 industry and unhealthy commodities 238–242 interventions along supply chain 248–249 Committee on Food Security (CFS) 289–291 community health workers (CHWs) gendered inequities 55–60 privatization of healthcare 135, 140 Comprehensive Economic and Trade Agreement (CETA) 155, 342, 357, 361–362

450   |  INDEX Comprehensive and Progressive Transpacific Partnership Agreement (CPTPP) 12, 342, 344, 353, 357, 358, 361–362 Conference of the Parties (COP) 37 conflict and health 299–316 violence/gendered inequities 49–52, 57–59 ConocoPhillips v. Venezuela 354 Consultative Expert Working Group (CEWG) 158–159 Consumer Protection Association 203–204 Consumer Technology Association 107 consumption, localization/deglobalization 66–67 consumption tax increases 195 consumption as way of life 25–26 Contingency Fund for Emergencies (CFE) 320, 323 contracting-out/privatization 130 Convention on the Rights of Persons with Disabilities (CRPD) 178, 184–185 “core capacities” 327 corporate intermediaries and UN funding 378–381 corporate sights on global governance and the WEF 419–421 corporate social responsibility (CSR) 13, 14, 240–242, 416, 417 corporate taxes 30–31, 33 corporate testing and contact tracing systems 131–132 Costa Rica politics of access 156 universal/primary healthcare divide 91–92 COVID-19 Technology Access Pool (C-TAP) 156, 158, 325, 328–329, 331 COVID-19 Vaccines Global Access (COVAX) 13–14, 119, 152–153, 328–329, 399–400, 422–423 ­CPTPP see Comprehensive and Progressive Transpacific Partnership Agreement Crimean expansionism 359–360 Croatia, austerity 58 CRPD see Convention on the Rights of Persons with Disabilities CSM see Civil Society and Indigenous Peoples Mechanism CSO see civil society organizations CSR see corporate social responsibility customer-centric approaches 219 Cyprus, gender-based violence 49 DALYs see Disability Adjusted Life Years data, privatization 131–132

data analytics 113–116 Data for Black Lives 122 data mining 118 “Davos Class” 419–421, 423–424 deaths in elderly populations/privatization of healthcare 138 debt 26, 205 see also recession Debt Service Suspension Initiative (DSSI) 392 décroissance see degrowth deglobalization 66–67 degrowth 65–81 explaining 71–73 Italian case study 74–75 lab to politics 73–77 post-capitalism 77–79 delivery-related services 218–219, 221–222 Department of Peacekeeping Operations (DPKO) 371–372 deprivatization in healthcare 98–99 deregulating e-signature provisions 347 deregulation 20 diabetes 133–134 see also sugar diagnostics (ACT Accelerator) 152–153 digital health 73–74, 105–127 activism 114–116 big data analytics/governmentality 113–116 definition 106–107 global governance 121–122 risks/health challenges 108–112 sovereignty 120 state-corporate cooperation in pandemic response 116–119 surveillance 110–112 techno-optimism 108 unhealthy commodities 242 digitization of the economy 221 direct health impacts of austerity 197–198 Disability Adjusted Life Years (DALYs) 175–176 District Health Information Software (DHIS2) 107 Djarum (tobacco company) 240–241 Doha Development Round 339–341 domestic regulation disciplines (DRD) 345–346 Doughnut Economics (Raworth) 23–24, 74 DPKO see Department of Peacekeeping Operations drinks see alcohol; soda drugs 7–8 see also medicine DSSI see Debt Service Suspension Initiative Dutch Aid & Trade in Health 94

INDEX  |   451 East India Company 413–414 EC (European Commission) 204, 325–326 ECLT see Eliminating Child Labour in Tobacco Growing Foundation ecology of zoonotic disease 321–323 e-commerce 413 economic capital 70–71 “economic partnership agreements” (EPA) 359 Economic and Social Council (ECOSOC) of the UN 417 ­Ecuador, Chevron-Texaco Ecuador 411 “effective rate”/corporate tax 31 elderly populations and privatization of healthcare 138 electric vehicles (EV) 38 electroconvulsive therapy (ECT) 185, 187 Eliminating Child Labour in Tobacco Growing Foundation (ECLT) 240 elite classes 419–421, 423–424 employment 89–90, 213–214, 216–219 EMPOWER 185, 186 empowerment and trade treaties 349–352 Energy Charter Treaty 354 England austerity 201–202 privatization of healthcare 138 see also United Kingdom environmental cost of healthy food 66 EPZs see Export Production Zones Equitable Technology Access Framework (ETAF) 159–160 e-signature provisions 347 Etsy 218 Eubank, V. 113 Europe austerity 202–203 WEF treaty content 418–419 see also individual European countries … European Commission (EC) 204, 325–326 European Union (EU) gender-based violence 49 localization/deglobalization 67 politics of access 155, 158, 162, 164 “quantitative easing” 34–35 re-greening policies 37–38 taxes and civilization 33–34 trade treaties and government 357, 359 wealth tax 32 WEF and the “Great Reset” 424 EV see electric vehicles “existential” trinity 19–29 Export Production Zones (EPZs) 212, 416

extractavism 253, 261–263 see also mining companies extremism 52, 109–110, 307–308 Facebook 109–110, 113, 117 fair and equitable treatment (FET) 353–354 FAO see Food and Agricultural Organization “farm to fork” programs 37 farmers’ markets 248–249 farming see agriculture far-right extremism 307–308 far-right government of Brazil 50–52 fatigue 17–18 fatty acids 245 FCTC see Framework Convention on Tobacco Control FDA see Food and Drug Administration FDI see foreign direct investment Feminist Alert movement 52 Feminist Data Justice project 122 FENSA see Framework for Engagement with Non-State Actors FET see fair and equitable treatment FIAN International 422 Financial Times 113, 117 financial transaction taxes (FTT) 33–34 financialization 20 FINANSI/ROKO Construction SPV Limited 95–96 Finland, Universal Basic Income 229 fiscal decentralization/privatization 130 fiscal foreign exchange reserves 205 fixed-term contracts 217–218 follow-on biologics/regulatory regimes 163–164 food 66, 346–347, 422 ­hunger and malnutrition 285–286 interventions 248–249 obesity 236 unhealthy commodities 237–245 Food and Agricultural Organization (FAO) 287, 381–382 Food and Drug Administration (FDA) 108 food systems 275–296 agroecology 286–289 breaking of 282–286 current food system 277–282 history of production model 282–283 other forms of governance 287–291 pollution 277–279 public policy 283–285 transformation of 286–291 football 215–216, 238 FOPNL see “front-of-pack nutrition labeling”

452   |  INDEX foreign direct investment (FDI) 243, 355–356 foreign exchange reserves 205 for-profit private sectors 91–94 fossil fuels 24, 38 see also carbon dioxide emissions; mining companies Foundation for a Smoke-Free World 240–241 Framework Convention Secretariat, Brazil 247 Framework Convention on Tobacco Control (FCTC) 243, 247, 346 Framework for Engagement with Non-State Actors (FENSA) 163, 377 France privatization of healthcare 138 Universal Basic Income 228 Free Trade Agreements (FTAs) 164–165, 340–343, 344–345, 347–349, 353 Free the Vaccine Campaign Carnival March, London 2020 161 “front-of-pack nutrition labeling” (FOPNL) 239, 240, 244 FTAs see Free Trade Agreements FTT see financial transaction taxes “Funding on arms trade and health” 311 G20, Debt Service Suspension Initiative 392 G20 countries 35–36, 397 Gabor, D. 395–396, 402 GAEN see Google-Apple Exposure Notification Gallup World Poll on Happiness 69 garment and textile industry 214–221 gas emissions see carbon dioxide emissions gatekeeping/digital surveillance 112 GATS see General Agreement on Trade in Services GATT see General Agreement on Tariffs and Trade Gaza Strip 150–151, 309–310 GBV see gender-based violence GDP see Gross Domestic Product gender climate change 257–258 employment 220–221 inequities 47–64 pay gap 55–56 politics of access 148 and trade 349–352 see also women gender-based violence (GBV) 49–52, 53–55 ­General Agreement on Tariffs and Trade (GATT) 154, 346 General Agreement on Trade in Services (GATS) 344, 346 “Geneva Consensus Declaration” 51

genocide 307–308 Genuine Progress Indicator (GPI) 70 geopolitics of trade and investment 357–360 George, S. 419–421 Germany global warming 26 privatization of healthcare 138 UN funding 371 Ghana, universal/primary healthcare divide 91–92 gig workers 218, 219 Gilead Science 157 Global Alliance for Vaccines and Immunization (GAVI) 119, 325–326, 422 global architecture 2–5 Global Burden of Disease models 175–176, 188–189 Global Campaign to Reclaim Peoples Sovreignty, Dismantle Corporate Power, and Stop Impunity 416, 418–419 Global Citizens NGO 242 global financing and healthcare 94–95 “global footprint” methodologies 73, 78 Global Fund 241–242, 325–326 global governance, WEF and the “Great Reset” 419–421 global governance of digital health 121–122 Global Health Risk Framework for the Future 311–312 Global Interparliamentary Network (GIN) 418 Global Justice Now 94–95 Global Mental Health Peer Network (GMHPN) 177–178 global peace agenda 299–301 global profit and labor income share 213 “Global Reboot” see “Great Reset” Global Redesign Initiative (GRI) 421–423 Global South gendered inequities 47–64 labor markets 211–212 women and trade treaties 351–352 Global Strategy on Digital Health (WHO) 121 “Global Tech Challenge” (World Bank) 107 global warming 21, 23–26 globalization, taming capitalism 66–67 globalization and inequality 19 GNH see Gross National Happiness Google 107, 113, 116–118, 119, 120 Google-Apple Exposure Notification (GAEN) 117 governmentality and digital health 113–116 government-run care homes 138 governments and trade treaties 339–367 GPI see Genuine Progress Indicator

INDEX  |   453 “Great Reset” 14, 18, 409–427 Greece, privatization of healthcare 137–138 “Green New Deal” 36–37, 72, 76, 78 Green New Deal (GND) 267–268 greening policies 35–38 GRI see Global Redesign Initiative Gross Domestic Product (GDP) 8 austerity 193–210 circular economies/degrowth 69 digital surveillance 110 explaining degrowth 71–72 happiness 69–71 IFIs and the pandemic 401 labor markets 211, 212–213 localization/deglobalization 67 politics of access 153 UN funding 375 UN human rights reports 384–385 ­universal/primary healthcare divide 90 war-time spending 311–312 see also growth Gross National Happiness (GNH) 69–71 gross national income (GNI) 148 growth taming capitalism 39 UN human rights reports 384–385 see also Gross Domestic Product growth in untaxed global income 2002–2019 31–32 growth/degrowth 65–81 Guidelines on Evaluation of Similar Biotherapeutic Products (SBP) 164 Guiding Principles on Business and Human Rights (UNGPs) 383–384 Gulf States 28–29 guns advertising 346–347 Guterres, A. 19 H1N1/H5N1 pandemics 322 hate 109–110 see also racism; violence “#HaveItYourWay” 242 HCP see Human Capital Project health, labor markets 211–213 Health Emergency Program (WHE) 320 health food labels 239 health impacts of austerity 197–199, 200 Health Star Ratings 244 health systems 5–8 health systems strengthening (HSS) 89, 152–153 healthcare privatization 129–146 reforms 195 see also universal health coverage

health-negative impacts of inequality 19–21 healthy food 66 heatwaves 21, 23 hegemony, corporate 416 Heineken 242 Heinrich Böll Foundation 398–399 “Helping British Columbians access healthy food” 248 hepatitis C 148 Hickel, J. 72 high-income countries (HICs) austerity 194 beyond healthcare 9 circular economies/degrowth 68 explaining degrowth 71–72 garment and textile industry 216 global/political architecture 3 health systems 7 income under neoliberalism 22 industry promotion of unhealthy commodities 238 lab to politics degrowth 74, 76, 77 labor markets 212–213 labor/wealth 29–30 migration 27–28 philanthrocapitalism 325–326 ­political economy of COVID-19 332 politics of access 149, 151–152 privatization of healthcare 131, 132, 135, 138 redistributive decline 30–31, 34, 35 tobacco 237 trade treaties and government 339, 340–341, 358 Hindu nationalist government of India 28–29 HIV/AIDS 119, 148–149, 154, 159, 177–178 Holmes, O. W. 32 “Home” (2020) 28 homelessness 73 Hong Kong, umbrella protests 112 hospitals and austerity 203–204 see also healthcare HSS (health systems strengthening) 89, 152–153 human capital 70–71 Human Capital Project (HCP) 394, 395 Hungary, privatization of healthcare 138 hunger and malnutrition 285–286 ICD-II see International Classification of Diseases ICH see International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use

454   |  INDEX ICN see International Council of Nurses ICSID see International Centre for Settlement of Investor Disputes ICUs see intensive care units IDPs see internally displaced persons IF see investment facilitation IFC see International Finance Corporation IFIs see international financial institutions IFPMA see International Federation of Pharmaceutical Manufacturers Associations IHRs see International Health Regulations ILE see Legal Interruption of Pregnancy illicit financial flows and austerity 205 ILO see International Labor Organization IMF see International Monetary Fund immigration policies see migration income growth 1980–2016 22 income inequality 19–21 income tax rates for OECD countries 30–31 income in US dollars 1980–2016 23 Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme (IOAC) 327 Independent Panel on Pandemic Preparedness and Response (IPPPR) 330 India AB-PMJAY/healthcare 93–94 Accredited Social Health Activists 56–57 gendered inequities 48, 49–50, 56–57, 59 Islamophobia/genocide 307–308 migration 28–29 National Digital Health Mission 93, 115 NDHM 93, 115 privatization of healthcare 131, 132–133, 137, 139–140 Union Carbide-India 411 United Nurses Association 59 Universal Basic Income 229 WEF and the “Great Reset” 424 workers and environmental struggles 265–266 indigenous people in Sweden and law 256–257 indirect health impacts of austerity 198 indirect taxes 33 individual income taxes 32 ­Indonesia corporate social responsibility 240–241 universal/primary healthcare divide 92 industry involvement in international regulatory regimes 161–163 industry promotion of unhealthy commodities 238–242 inequality 19–21

inflation 34–35 “infodemics” 109–110 information technology (IT) 91 see also digital health insulin 133–134 intellectual property rights (IPRs) 6–7, 153–161, 424 intensive care units (ICUs) 136 interest rates 34–35 Intergovernmental Panel on Climate Change (IPCC) 24, 38, 72 internal market reforms/privatization 130 internally displaced persons (IDPs) 383 see also refugees International Centre for Settlement of Investor Disputes (ICSID) 399 International Classification of Diseases (ICD-II) 183–184 International Conference on Degrowth, Ecological Sustainability, and Social Equity 75 International Council for Harmonisation (ICH) of Technical Requirements for Pharmaceuticals for Human Use 161, 162, 163 International Council of Nurses (ICN) 57–58 International Covenant on Civil and Political Rights 393 International Federation of Pharmaceutical Manufacturers Associations (IFPMA) 162, 328–329, 422–423 International Federation of Red Cross and Red Crescent Societies (IFRC) 242 International Finance Corporation 13–14 International Finance Corporation (IFC) 140–141, 394, 395–396, 397, 400 international financial institutions 391–407 international financial institutions (IFIs) 197, 204–206, 373–374, 375, 391–407 International Health Partnership + Network 85 International Health Regulations (IHRs) 318, 319, 329–330, 332 international investment agreements (IIAs) 353–357, 385 International Labor Organization (ILO) 30, 58 austerity 196 employment and COVID-19 213–214 migration and agriculture 225–226 new trade regimes 347–348 social protection floor 229–230 universal/primary healthcare divide 89–90 WHO response to COVID-19 331 women and trade treaties 349–352 international migrants, by regions of origin and destination, 2020 27

INDEX  |   455 International Monetary Fund (IMF) 8, 13–14 austerity 193–195, 196, 197–198, 202–203, 204–205 corporate hegemony 416 IFIs and the pandemic 401 international financial institutions 391–392 international investment agreements 354 privatization of healthcare 129, 140–141 ­reformulation 394–395 structural adjustment programs 393–394 taxes and civilization 32 universal/primary healthcare divide 88, 90 WEF and the “Great Reset” 410, 419–420 WHO response to COVID-19 318, 331 International Organization of Employers (IOE) 417 international public health alerts (IPHA) 329 International Specialized Hospital of Uganda (ISHU) 95–96 International Telecommunication Union (ITU)-WHO Focus Group on Artificial Intelligence for Health 108 investment facilitation (IF) 346 investment geopolitics 357–360 investor-state disputes settlements (ISDS) 353–355, 356, 357, 361–362, 384–385, 399, 419 WEF and the “Great Reset” 410 iOS platforms 131 IPCC see Intergovernmental Panel on Climate Change IPPPR see Independent Panel on Pandemic Preparedness and Response IPRs see intellectual property rights Iran/Syrian conflict 305–306 Ireland, privatization of healthcare 136–137 ISDS see investor-state disputes settlements ISDS, universal/primary healthcare divide 96 Islamophobia 307–308 Israel 150–151, 305–306, 309–310 IT see information technology Italy austerity 58 degrowth movement 74–75 gendered inequities 59 mental healthcare 181–183 No TAP movement, Leece, Italy 412 privatization of healthcare 137, 138 Jaminan Kesehatan Nasional (JKN) 92 Japan politics of access 162 “quantitative easing” 34 UN funding 371

JEET see Joint External Evaluation Tool JIU see Joint Inspection Unit of the UN Joint External Evaluation Tool (JEET) 327, 329 Joint Inspection Unit (JIU) of the UN 377–378, 379 Jonas, O. 396, 397 KENUP Foundation 156 Kenworthy, N. 109 Kenya A&T healthcare 94 employment and COVID-19 214 unhealthy commodities 243–244 Universal Basic Income 229 universal/primary healthcare divide 92, 94, 95–96 Kerry, J. 36–37 Kickbusch, I. 114 “knowledge dialogues” 287 Korea–US Free Trade Agreement (KORUS) 164–165 KORUS see Korea–US Free Trade Agreement Kutupalong refugee camps 307 labeling food 239, 240, 244, 245 labor flexibilization reforms 195 labor markets 211–233 ­digitization of the economy 221 employment and COVID-19 213–214 garment and textile industry 214–221 migration and agriculture 222, 225–226 neoliberalism/health 211–213 organized labor and COVID-19 221–226 regulations 230 social protection floor 229–230 universal basic income 226–229 labor rights 216–219 labor and wealth 29–30 Lagarde, C. 401 Lancet 116 Lancet Commission 184 Lancet journal 386 Latin America austerity 202–203 digitization of the economy 221 unhealthy commodities 242 WEF treaty content 418–419 see also individual Latin American countries …; South America Latin American Social Medicine movement (ALAMES) 55 Legal Interruption of Pregnancy (ILE) 54 Lesotho Consumer Protection Association 203–204

456   |  INDEX levies 244–245 see also taxes LICs see low-income countries Limits to Growth (Club of Rome) 65–66 liquidation/privatization 130 Liquor Amendment Bill of South Africa 244–245 livestock farming 279 lobbying 206, 239–240 localization/taming capitalism 66–67 lockdown 3, 21, 28–29, 57, 309, 310, 312 Lonmin Platinum Mine PLC 412 low- and middle-income countries (LMICs) alcohol 237 beyond healthcare 8–9 climate change 25 digital health 106, 107, 117, 119, 120, 121 gendered inequities 48–49 health systems 5, 6–7 IFIs and the pandemic 399–400 industry promotion of unhealthy commodities 239 inequality 21 international financial institutions 391–392 interventions along food/agriculture supply chain 248–249 lab to politics degrowth 74, 76 mental healthcare 176, 177 migration 26–27 political economy of COVID-19 332 ­politics of access 149–150, 154, 156, 164 privatization of healthcare 129, 132, 136, 140 public–private partnerships 398 redistributive decline 30–31, 35 re-greening policies 38 taxes and civilization 33–34 tobacco 237 trade and investment regimes 243, 244–245 trade treaties and government 339–341, 355–356, 358, 359, 360–362 unhealthy food 238 Universal Basic Income 227 universal/primary healthcare divide 84, 86, 88–89, 90–92, 98 watching 13–14 WHO response to COVID-19 318, 329 low-income countries (LICs) circular economies/degrowth 68 employment and COVID-19 214 explaining degrowth 71–72 politics of access 151–152 privatization of healthcare 129 McDonald’s 238, 242 McKee, M. 199, 201

macroeconomic frameworks 206 Madres de Plaza de Mayo 53–54 MAI see Multilateral Agreement on Investment malnutrition 285–286 manual vacuum aspiration (MVA) 54–55 Mariana and Brumadinho Communities vs Vale Brazil 412–413 Marikana Massacre: Lonmin Platinum Mine PLC 412 marketing 238–239, 346–347 masks 155–156, 319–320 “Maximizing Finance for Development” (MFD) approaches 394, 398, 400 MDF see Movimento per la Decrescita Felice MDGs see Millennium Development Goals MEAs see multilateral environmental agreements “Medicaid Expansion” 134 medicine 346–347 and politics of access 147–171 QSE 161, 162 telemedicine 136 memorandum of understanding (MOU) 380 mental healthcare 7–8, 173–191 “5C” approach 187 barriers to justice/equity 176–179 categories/people 183–189 definitions 174–175 during COVID-19 179–183 frontline workforce 186 pre-pandemic crisis 175–176 ­MERS see Middle East respiratory syndrome Mexico gendered inequities 58, 59 H1N1 pandemic 322 “#HaveItYourWay”/Burger King 242 NAFTA 243 politics of access 155, 164–165 promoting healthy environments 245 see also US/Mexico/Canada Agreement Microsoft 107, 117, 119 see also Bill & Melinda Gates Foundation Middle East austerity 202–203 heatwaves 21, 23 migration 28 Middle East respiratory syndrome (MERS) 322 migration 26–29, 308 and agriculture 222, 225–226 “Militarization of quarantine/lockdown” 309 military coups 416 Millennium Development Goals (MDGs) 375 WEF and the “Great Reset” 417, 419, 421, 422 mining 256–257, 258–261, 412

INDEX  |   457 Ministries of Agriculture and Industry 240 Ministries of Health 51, 150–151, 245–246 modern monetary theory (MMT) 34–35 Moderna 156 Modi’s Hindu nationalist government 28–29 monetary theory 34 monoclonal antibodies 164 Morocco, universal/primary healthcare divide 92 MOU see memorandum of understanding Movimento per la Decrescita Felice (MDF) 75 Multilateral Agreement on Investment (MAI) 361 multilateral environmental agreements (MEAs) 348–349 multilateral trade agreements 340–343 multilateralism and the “Great Reset” 409–427 Multistakeholder Integrity (MSI) Work Group 421, 422, 424 Muslim populations 28–29, 307–308 “mutant” neoliberalism 20 MVA see manual vacuum aspiration N95 masks 155–156 see also masks NAFTA see North American Free Trade Agreement National Audit Office (NAO) of the UK 398 National Digital Health Mission (NDHM) 93, 115 National Health Authority (NHA), India 93 National Health Insurance Fund, Kenya 92 National Health Service (NHS) 114–115, 117–118, 131, 137–138 National Register of Citizens (NRC) 307–308 natural capital 70–71 NCDs see non-communicable diseases neoliberalism 18, 20–22, 39 global warming 26 labor markets 211–213 “Neoliberalism” (2000) 97 net zero carbon policies 35–38 New Economics Foundation’s Happy Planet Index 70 New International Economic Order (NIEO) 86–87 New York City 245 New Zealand, Health Star Ratings 244 Next Generation Recovery Fund 37 NGOs austerity 198 ­digital health 107 labor markets 211–212 localization/deglobalization 67 unhealthy commodities 242

NHA see National Health Authority NIEO see New International Economic Order Nigeria industry promotion of unhealthy commodities 238 Ogoni People vs Shell in Nigeria 411 NKS see Nya Karolinska Solna hospital NMC see Nursing and Midwifery Council No TAP movement, Leece, Italy 412 non-communicable diseases (NCDs) 9, 52 commercial determinants of health 235 politics of access 148 non-governmental organizations (NGOs) 382–383 Global Citizens 242 Global South 47–64, 211–212, 351–352 Norad (Norwegian development agency) 107 North America labor markets 222 see also Canada; United States North American Free Trade Agreement (NAFTA) 243, 353 #Notoneless movement 53–54 NRC see National Register of Citizens nuclear weapons 301 nurses and health during pandemic 57–59 Nursing and Midwifery Council (NMC) 59 “Nursing Now” campaign 59 nutrition labeling 239, 240, 244 Nya Karolinska Solna (NKS) hospital 204 obesity 236 Observatory of Favelas initiative 52 occupational illness 222–223 OEIGWG see Open Ended Intergovernmental Working Group official development assistance (ODA) 94, 194, 205, 373, 374, 375 offshore tax havens 30–31 Ogoni People vs Shell in Nigeria 411 Okonjo-Iweala, N. 340–341 on-call contracts 216–217 online exchange platforms 73–74 Ontario, Canada 138 OOP see out-of-pocket spending Open Ended Intergovernmental Working Group (OEIGWG) 418–419 “Operational Framework for Primary Health Care” (WHO) 98 Organization for Economic Cooperation and Development (OECD) austerity 194, 196 corporate taxes 30–31, 33 employment and COVID-19 213–214

458   |  INDEX garment and textile industry 220–221 happiness indices 70–71 international financial institutions 391–392 labor markets 212–213 localization/deglobalization 67 migration 27–28 new trade regimes 349 politics of access 149–150 ­redistributive decline 30–31 taxes and civilization 32 UN funding 375, 384 universal/primary healthcare divide 89–90 WHO response to COVID-19 331 organized labor and COVID-19 221–226 “origins story” of COVID-19 321 Our Data Bodies project 122 out-of-pocket (OOP) spending 87, 92, 93, 131, 132, 139 outsourcing/privatization 130 OXFAM 203–204, 400 Oxford University 324–325 Pacific, austerity 202–203 packaging materials 236 Pajal Communities, Chile 288 Pakistan 48 Palantir 114–115, 117, 131–132 Palestine 309–310 pharmaceuticals industry 150–151 Palme, O. 372 Pan American Health Organization (PAHO) 50 “pandemic bonds” 396–397 Pandemic Emergency Financing Facility (PEF) 396 Pandemic Framework Convention 321 Paraguay, sovereignty and food systems 292–294 Paris Accord 24, 33–34 part-time contracts 216–217 PATH (Bill & Melinda Gates Foundation) 107 pay gap 55–56 peacebuilding/global partnerships 299–301 pension privatization reforms 196 pensions 195 People’s Health Movement (PHM) 10, 15, 253–254, 259–261 PepsiCo 238, 241–242 personal data protections 114–116 personal protective equipment (PPE) gendered inequities 57, 58 labor markets 214, 222 privatization of healthcare 130–131, 135, 136, 138, 139, 140 WHO response to COVID-19 317, 318

PFHI see publicly funded health insurance Pfizer 7, 156–157, 158 pharmaceuticals 328–329 ICH 161, 162, 163 mental healthcare 185 politics of access 147–171 see also Big Pharma “pharmerging markets” 148 PHC see primary health care PHEIC see public health emergency of international concern PHIC see Philippine Health Insurance Corporation philanthrocapitalism 324–327, 333 Philip Morris International (PMI) 240, 241, 242, 244 Philippine Health Insurance Corporation (PHIC) 92 Philippines universal/primary healthcare divide 92 workers and environmental struggles 263–265 PHM see People’s Health Movement “Pillar 2” privatization programs 131 plurilateral negotiations/health implications 345–347 PMI see Philip Morris International policing and digital surveillance 111–112 political architecture 2–5 politics of access 147–171 affordability 148–151 colonial control/Palestine conflict 150–151 ­global inequities 151–153 inequities 147–148 intellectual property rights 153–161 regulatory regimes 161–165 politique 29 pollution 277–279 carbon dioxide emissions 21, 23–26, 37, 277–279 post-pandemic policy 17, 29–38, 77–79 post-traumatic stress disorder (PTSD) 188 poverty 19–21 Power of the Consumer (Mexico) 245 PPE see personal protective equipment PPPs see public–private partnerships pregnancy 53–55 pre-pandemic pathologies 17, 19–29 primacy of universal health coverage 85–86 primary health care (PHC) 5, 83–103, 135–136 “primordial” neoliberalism 20 private companies and bilateral foreign aid 414 private healthcare spending 94–95

INDEX  |   459 private provisioning/public funding in healthcare 97–99 privatization of healthcare 129–146 austerity 196 financing 132–134 food systems 283–285 hospital provision 136–140 primary healthcare 135–136 public health services and functions 130–132 Project Last Mile 241–242 promoting healthy environments 245–246 protests, austerity 200–201 PTSD see post-traumatic stress disorder public health emergency of international concern (PHEIC) 11–12, 88, 318, 319, 329 public spending, reallocation of 205 publicly funded health insurance (PFHI) 91–92 public–private partnerships (PPPs) 11–12, 397–399 austerity 196, 203–204 corporate social responsibility 241–242 International Specialized Hospital of Uganda 95–96 philanthrocapitalism 325–326 private provisioning/public funding 97–98 privatization of healthcare 130, 136, 137–138, 139, 141 universal/primary healthcare divide 90, 91, 93–94, 95–96, 97–98 public-run care homes 138 Qatar World Cup 215–216 quality, safety, and efficacy (QSE) of medicines 161, 162 “quantitative easing” (QE) 34–35 “quasi” market reforms/privatization 130 Queen Mamohato Memorial Hospital, Lesotho 203–204 “Quien sostiene la vida” (“Those who sustain life”) 220 R&D see research and development racialized digital surveillance 111–112 racism 52, 307–308 Rana Plaza Fashion Factory Collapse, Bangladesh 412 RAND Corporation 153 Raworth, K. 23–24, 74 reallocation of public spending 205 recession 21, 26 see also austerity Red Cross 242, 301 redistributive decline 30–35 reducing subsidies 195 Rees, W. 73, 78

r­ eforming the geopolitical agenda 360–362 reforming healthcare systems 195 reforming of International Health Regulations 329–330 reforms of labor flexibilization 195 reforms of pension privatization 196 Refresh project by Pepsi 242 refugees 53, 57, 307, 383 see also migration Regional Comprehensive Economic Partnership (RCEP) 343, 358, 361–362 regional power-brokering 340–343 regional trade agreements 154–155 re-greening policies 35–38 regulation failures and digital surveillance 110–111 regulations, labor markets 230 regulatory environments and unhealthy commodities 243 regulatory regimes and medicine 161–165 remdesivir 157 remunicipalization/deprivatization 98–99 repression/digital surveillance 111 reproductive health services 52–55 research and development (R&D) 153–154, 158–159, 165, 328–329 research efforts in Canadian mining 260–261 resource inequality 19–21 Responsibility Bill of the United Kingdom 245 restructuring existing debt 205 rights to access see politics of access Rio Summit 416, 418 risk digital health 108–112 employment and COVID-19 213–214 labor markets 214, 222 Roadmap for Digital Cooperation (UN) 121 Rohingya people 53, 57, 307 ’roll out’/’roll-back’ 20 Roma people 28 rotavirus 148 Russia Crimean expansionism 359–360 Syrian conflict 305–306 “safety nets” 195 salt reduction pledges 245 Salvador Allende government of Chile 416 San Francisco 219 Sanders, D. 83, 86–87 Sanitary and Phytosanitary Measures (SPS) 343–344, 352 SAPs see structural adjustment programs SARS see Severe Acute Respiratory Syndrome

460   |  INDEX Saudi Arabia United Nurses Association 59 Save the Children 242 SBP see Similar Biotherapeutic Products Guidelines Scaling Up on Nutrition (SUN) movement 422 Scientific Advisory Group for Emergencies (SAGE) 116–117 SDGs see Sustainable Development Goals SDRs see special drawing rights self-employment 216–217, 218–219 Severe Acute Respiratory Syndrome (SARS) 11–12, 318, 321 sexual and reproductive health services 52–55 “shadow pandemic” and gender-based violence 49–52 Shell in Nigeria 411 “shelter in place” 219 Similar Biotherapeutic Products (SBP) Guidelines 164 Skogly, S. 393 social capital 70–71 social determinants and austerity effects 198–199 social protection and austerity 204–206 social protection floor (SPF) 229–230 social security expansions 205 social security reforms 195 Socorristas en Red movement 55 soda 238, 243, 245–246 Solidarity Response Fund 242 source code/software checks 347 South Africa digitization of the economy 221 employment and COVID-19 214 privatization of healthcare 137 ­promoting healthy environments 245 trade and investment regimes 244–245 WEF and the “Great Reset” 424 South African Western Cape Province and primary healthcare privatization 135 South America Buen Vivir concepts 10, 72, 255–256 Chevron-Texaco Ecuador 411 industry promotion of unhealthy commodities 239 South Korea 135 sovereignty and digital health 120 spaghetti bowl of free trade agreements 341, 342 Spain austerity 58, 201–202 labor markets 219 privatization of healthcare 137, 138 “Spanish flu” 322 special drawing rights (SDRs) 13–14, 202–203

sport 215–216, 238 Sportello TiAscolto 181–183 SPS see Sanitary and Phytosanitary Measures Sri Lanka primary healthcare privatization 135 weaponizing the coronavirus 308–309 Sridhar, D. 386 staff/funding shortfalls 320 “stagflation” 26 stakeholder capitalism 420 standard-setting processes/regulatory regimes and medicine 161–163 state-corporate cooperation and digital health 116–119 statutory tax rates and redistributive decline 30–31 Stockholm International Peace Research Institute 311 Strategic Purchasing Africa Resource Centre (SPARC) 91 structural adjustment 20 structural adjustment programs (SAPs) 393–394 Stuckler, D. 199, 201 sub-saharan Africa 20–21, 202–203 subsidy reduction 195 sugar 239 see also soda Sumak Kawsay/Buen Vivir 10, 72, 255–256 SUN see Scaling Up on Nutrition movement Sunrise Movement see Green New Deal supply chains 248–249 surveillance 110–116 capitalism 113 sustainability and food systems 285–286 Sustainable Development Goals (SDGs) 8 austerity 195 conflict and health 299–300, 303 digital health 105, 121 FTTs 33–34 inequality 20–21 Islamophobia/genocide 307–308 politics of access 147–148 UHC/PHC 83 UN funding 375–377, 385–386 universal/primary healthcare divide 84–85, 89 ­WEF and the “Great Reset” 414, 417, 421, 422 Sweden 203–204 mining companies 256–257 Syria 11 conflict and coronavirus 305–306 Taiwan, global COVID-19 experience 317–318 Tax Justice Network 31–32 taxes 3, 7

INDEX  |   461 austerity 194–195, 204–205 and civilization 32–33 IFIs and the pandemic 401 lab to politics degrowth 76–77 rates for OECD countries 30–31 unhealthy commodities 244–245 wealth taxes 32, 204–205 Technical Barriers to Trade Agreement (TBT) 344, 352 technologies 73–74 see also digital health Ted Turner’s UN Foundation 326–327 telemedicine 136 temporary contracts 216–217 termination/privatization 130 Tethyan Copper v. Pakistan 354 Texas 261–263 textile industry 214–221 Thailand alcohol tax rates 245 community health workers 57 primary healthcare privatization 135 trade and investment regimes 244 universal/primary healthcare divide 91–92 Third World Network 116, 121 Thunberg, G. 88 tobacco 237, 239–247, 346–347 top-down approaches to peace 302–303 TPNW see Treaty on the Prohibition of Nuclear Weapons TPP see Trans-Pacific Partnership Agreement trade degrowth 67 FTAs 164–165, 340–343, 344–345, 347–349, 353 geopolitics 357–360 investment regimes 243 and travel 319 wars 357–358 see also consumption; growth Trade in Services Agreement (TiSA) 343 Trade-Related Aspects of Intellectual Property Rights (TRIPS) trade treaties and government 339, 343 WHO response to COVID-19 328, 330 Trade-Related Intellectual Property Rights (TRIPS) 6–7, 13–14 IFIs and the pandemic 400 ­politics of access 154–155, 157–158 public health and geopolitics 361–362 trade treaties and government 356 WEF and the “Great Reset” 410 transnational corporations (TNCs) 409, 410–414, 416, 417, 419–420, 422–424

Trans-Pacific Partnership Agreement (TPP) 155, 164–165 trans-unsaturated fatty acids 245 Treasury Bonds 34–35 treaties 330–331 trade and government 339–367 see also individual treaties … treatments (ACT Accelerator) 152–153 Treaty on the Prohibition of Nuclear Weapons (TPNW) 301 les trentes glorieuses 25–26 TRIPS see Trade-Related Intellectual Property Rights Trump, D. 320, 340, 357–358, 359–360 Turkey, Syrian conflict 305–306 UAEM see Universities Allied for Essential Medicines Uber 218–219 Uber v Aslam 218–219 UBI see Universal Basic Income Uganda ISHU public–private partnership 95–96 unhealthy commodities 243–244 UHC see universal health coverage umbrella protests in Hong Kong 112 UN see United Nations UN Foundation non-profit 372–373 UN Global Compact (UNGC) 378–379 UN Guiding Principles (UNGPs) 416, 417, 418 UN High-Level Meeting (UN-HLM) 87–88 UN Human Rights Council Binding Treaty Resolution 416 UN Population Fund (UNFPA) 371–372 UN Relief and Works Agency (UNWRA) 371–372 UN Women 372 UNCITRAL see United Nations Conference on Trade and Investment Law UNCTAD see United Nations Conference on Trade and Development undepleted cumulative carbon dioxide emissions by country, 1950–2000 25 undernutrition 236 UNECA see United Nations Economic Commission for Africa unemployment 216–218 see also employment; growth unemployment/employment 89–90, 213–214, 216–219 UNESCO see United Nations Educational, Scientific and Cultural Organization UNFPA see UN Population Fund UNGC see UN Global Compact

462   |  INDEX UNGPs see Guiding Principles on Business and Human Rights unhealthy commodities 237–245 UN-HLM see UN High-Level Meeting UNHRC see United Nations Human Rights Council UNICEF see United Nations Children’s Fund Union Carbide-India 411 unionization 222, 223–224, 413 UNITAID 325–326 United Kingdom austerity 199, 201–202 conflict and health 301 corporate taxes 33 digital health 114–115, 117–118 garment and textile industry 218–219 global warming 26 industry promotion of unhealthy commodities 238–239 international financial institutions 391 NAO 398 politics of access 159–161 private companies and bilateral foreign aid 414 privatization of healthcare 131–132, 136–137 promoting healthy environments 245 public–private partnerships 398 re-greening policies 35–36 UN funding 371 universal/primary healthcare divide 94–95 United Nations Children’s Fund (UNICEF) 98, 119, 383 ­United Nations Conference on Trade and Development (UNCTAD) 21, 40, 213 United Nations Conference on Trade and Investment Law (UNCITRAL) 357 United Nations Economic Commission for Africa (UNECA) 393 United Nations Educational, Scientific and Cultural Organization (UNESCO) 371–373, 381–382 United Nations Global Humanitarian Response plan 323 United Nations Human Rights Council (UNHRC) 383–384, 416, 418–419, 424 United Nations (UN) 13 austerity 197, 204–205 conflict and coronavirus 305–306 conflict and health 301 digital health 113–114, 121 digitization of the economy 221 employment and COVID-19 213–214 food systems 289–291 global governance/funding failures 369–389

mental healthcare 178 migration and agriculture 225–226 peace and health “from below” 302 re-greening policies 37 taxes and civilization 33–34 universal/primary healthcare divide 84, 86–87 weaponizing the coronavirus 309–310 WEF and the “Great Reset” 410 WEF and the “Great Reset” 423–424 see also Sustainable Development Goals United Nations (UN) Committee on World Food Security 10–11 United Nurses Association, India 59 United States Amazon and unionization 413 “America First” policy 357–358 corporate taxes 33 digital health 108, 114–115, 120 global warming 26 Green New Deal 36–37, 72, 76, 78, 267–268 income in US dollars 1980–2016 23 industry promotion of unhealthy commodities 239 labor markets 222 mental healthcare 186 NAFTA 243 new trade regimes 347–348 nurses and the CDC 59 political economy of COVID-19 332 ­politics of access 155, 157, 162, 164–165 privatization of healthcare 131, 132, 133–134, 138 promoting healthy environments 245 “quantitative easing” 34–35 re-greening policies 35–38 staff/funding shortfalls 320 Syrian conflict 305–306 trade treaties and government 340–341 UN funding 371–372 Universal Basic Income 229 weaponizing the coronavirus 308 WEF and the “Great Reset” 418–419, 424 United States/Mexico/Canada Agreement (USMCA) 12–13, 343–344, 348–349, 352–353 politics of access 155, 164–165 public health and geopolitics 361–362 Universal Basic Income (UBI) 30, 226–229 universal health coverage (UHC) 5, 50, 83–103 and COVID-19 88–90 digression 86–87 for-profit private sectors 91–94 global financing 94–95

INDEX  |   463 implementation 90–91 neglect of workforce 89–90 primacy 85–86 private provisioning/public funding in healthcare 97–99 privatization 141 remunicipalization/deprivatization 98–99 SDGs 84–85 zenith 87–88 Universities Allied for Essential Medicines (UAEM) 159–161 University Chairs Network 292–294 unsaturated fats 245 untaxed global income 2002–2019 31–32 UNWRA see UN Relief and Works Agency US Agency for International Development (USAID) 196, 241 US central bank (the “Fed”) 34–35 US Gulf South and extractavism 261–263 USAID see US Agency for International Development USMCA see United States/Mexico/Canada Agreement USSR 359–360 utility taxes 76–77 Uyghur Muslim populations 307 “Vaccine apartheid” 310 vaccines 7, 17–18, 58, 156–158, 161, 164 ACT-A 152–153 anti-vaxxers 310, 312 conflict and health 310, 312 ­COVAX 13–14, 119, 152–153, 328–329, 399–400, 422–423 GAVI 119, 325–326, 422 politics of pandemics 324–326, 332 value-added tax (VAT) 194–195 “victim-blaming” 114 video surveillance in China 110–111 Vietnam, global COVID-19 experience 317–318 violence 49–52, 53–55, 57–59 von Friedeburg, S. 394–395 wage bill cuts or caps 195 Wales austerity 201–202 privatization of healthcare 138 see also United Kingdom Wall Street Consensus/financialization 395–396 war-time spending 311–312 water resources 258–259 WB see World Bank wealth inequality 19–21

wealth taxes 32, 204–205 wealth/labor 29–30 weaponizing the coronavirus 306–312 WEF see World Economic Forum welfare 113–114, 195 West Bank 150–151, 309–310 WFP see World Food Programme WHA see World Health Assembly WHE see Health Emergency Program WHO see World Health Organization “Who sustains life?” (2020) 39 wildfires 21, 23 WMG see Women’s Major Group Wolf, M. 38–39 women and employment 220–221 women and food systems 281–282 Women, Peace, and Security agenda 304–305 women and trade treaties 349–352 Women on Waves Movement 55 Women’s Major Group (WMG) 375 Women’s National Committees of the UN 381 women’s rights in Brazil 50–52 World Bank (WB) 13–14 austerity 196 corporate hegemony 416 digital health 107 Human Capital Project 394 IFIs and the pandemic 399–401 inequality 21 “pandemic bonds” 396 philanthrocapitalism 325–326 privatization of healthcare 129, 140–141 public–private partnerships 397–399 reformulation 394–395 structural adjustment programs 393–394 universal/primary healthcare divide 83, 84–85 Wall Street Consensus/financialization 395–396 WEF and the “Great Reset” 410, 419–420 World Commission on the Social Dimensions of Globalization 19 World Cup 215–216, 238 world debt crisis 26 World Economic Forum (WEF) 14, 378, 380–381, 409–427 World Food Programme (WFP) 382–383 World Health Assembly (WHA) 11, 321 digital health 121 politics of access 164 ­World Health Organization (WHO) 11–12, 13 beyond healthcare 9 climate change 25 commercial determinants of health 235

464   |  INDEX COVID-19 response 318–320 digital health 105, 108, 116, 121 “front-of-pack nutrition labeling” 240 funding 323–327 IFIs and the pandemic 399–400 “pandemic bonds” 396–397 pandemic key lessons 323–329 politics of access 153, 157, 158–159, 162, 163, 164 politics of pandemics 317–337 privatization of healthcare 129, 130–131, 141 sexual and reproductive health services 52 trade and investment regimes 243 UN funding 177, 371–372, 386–387 unhealthy commodities 242 universal/primary healthcare divide 84–85, 86, 89–90, 98 WEF and the “Great Reset” 410, 422 World Summit on the Information Society WSIS 420–421 World Trade Organization (WTO) 6–7, 13 corporate hegemony 416 “front-of-pack nutrition labeling” 240 IFIs and the pandemic 400

new trade regimes 347–353 plurilateral negotiations/health implications 345–347 politics of access 154, 157–158 public health and geopolitics 361–362 role of the WEF 419–420 trade and investment regimes 243, 244 trade and the pandemic 355–356, 357 trade treaties and government 339–341 UN funding 375 weaker government regulatory powers 343–347 women and trade treaties 349–352 WSIS see World Summit on the Information Society xenophobia 28, 307–308 Yemen 11, 48, 303–305 Yemeni Women’s Union (YWU) 304–305 Zimbabwe, employment and COVID-19 214 Zionism 150–151 Zuboff, S. 113

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