Health should be in all policies

Dr Tikki Pang, Co-Chair of the S.T. Lee Project's Global Health Governance (GHG hereafter) Study Group and Director of Research Policy & Cooperation at the World Health Organisation (WHO) summarises the discussions of the various global health issues that have taken place at the recently completed 62nd Session of the World Health Assembly.


1. Endorsement of WHO leadership in the context of influenza crisis:

Member States (as well as the external media) have been complimentary and largely supportive of the way WHO has handled the crisis so far. There have been a few critics, but by and large, the "erring on the side of caution" approach has been accepted by most.

In the context of the ST Lee Project's GHG, this crisis has served to reiterate the central role WHO must play in the context of global heatlh issues. The Organization's image is probably at the highest it has been for many years. Make no mistake-it could've so easily gone wrong-and kudos to the Director General Dr Margaret Chan for her decisiveness in the past month or two. The new US administration (new Health Secretary Sebelius came to Geneva) has been particularly supportive of WHO's efforts in coordinating the global response.

Another highlight was that UN Secretary General Ban Ki Moon delivered the keynote address at the Assembly-his presence is yet another signal of the good coordination across the UN during this crisis.

Finally, WHO was also urged by its Member States not to move to phase 6 alert level although, based on current criteria, this should've happened-the countries urged the Organization to re-visit the criteria and take into account other factors such as disease severity, virus pathogenicity, clinical features, etc.

2. (However) tensions still running high on the virus sharing issue:

The IGM (Inter-governmental Meeting on Sharing of Influenza Viruses) met a few days before the assembly and, unfortunately, came to no agreement after 2 years of negotiations on trying to forge an equitable framework for sharing of viruses and benefits derived from any vaccines developed. Some developing countries mentioned, for example, that developed countries have signed agreements with vaccine manufacturers for 50% of the soon-to-be-developed vaccine against influenza A (H1N1) leaving the developing world highly exposed with the remaining 50%.

The agreement of the Assembly was to ask WHO/the Director-General to "support further negotiations", especially around a standard material transfer agreement for sharing of viruses. This topic was then linked to another one on the agenda in relation to "public health, innovation and intellectual property" which also has important implications for GHG as well as GHRG (R=research), i.e. how can GHG/GHRG tackle this issue of equitable access to health products and avoid the perception of "economics always trumps health" (expressed by a delegatiion at the Assembly).

3. Continued interest in primary health care and the social determinants of health:

In the context of the "dual burden" of the global financial crisis and potential influenza pandemic, the Member States were even more concerned about the state of their national health systems. In particular, it was felt that the basis for strengthening health systems should include considerations of equity, solidarity, social justice, universal access to services, multi-sectoral action, decentralization and community participation.

Financing was obviously a big issue and some countries highlighted the fact that low-income countries in particular rely a lot on overseas development aid for their health systems-which may be reduced due to the financial crisis. This underscores the view held by some that the ultimate objective of good GHG is the strengthening of health systems in low and middle income countries. This, in turn, has direct implications for global health security more generally.

4. Inter-sectorality important in future:

The message that "health should be in all policies" was repeatedly heard during the Assembly and the Norwegian delegation, for example, quotes their minister of health who had stated that "to close the health gap between rich and poor in a generation, every minister must be a health minister". I think this is part of a larger global trend- a meeting was held recently in Asia (the Prince Mahidol Award Conference) on "Mainstreaming Health into Public Policies". Although the idea and importance of an inter-sectoral approach is clearly relevant, whether it can be extended on a practical level, e.g. to inter-agency cooperation, is an open question. For example, there was debate at the Assembly on whose role is it to take on IPR (Intellectuual Property Rights) issues related to health products (WHO? WIPO? WTO?).

5. Tuberculosis (TB):

Amidst all the excitement about influenza, Member States also agreed that antibiotic resistance, as exemplified by the ongoing problem of multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB, deserves urgent attention and action. There are 500,000 cases of MDR TB and 50,000 cases of XDR TB annually (mostly in the developing world), and only 3% of patients are getting treatment according to standards recommended by WHO.

In terms of broader implications, it should be remembered that deaths during influenza pandemics in the past have been caused mainly by secondary bacterial infections (e.g. pneumonia)-so resistance to antibiotics may indeed be "the mother of all infectious disease challenges" (as expressed by one delegate).

6. Ongoing concern about support for WHO:

Dr Margaret Chan, Director General of WHO appealed to the Member States for enhanced financial support for WHO. Dr Chan reiterated that only 20% of WHO's budget comes from Member States contributions (this figure is around 80% for other UN organizations) and that the other 80% are from external donors, often highly specified for specific project areas. This, of course, compromises WHO's independence and credibility as it runs the risk of having its agenda defined by donors-in all reality, WHO is now a "soft money" organization just like academic institutions relying on external grants . This clearly has important implications in light of the expectation of WHO leadership in global health in the future. [Tikki]

Global health's quest for governance

The Lancet, a leading medical journal published out of New York and London, recently ran an editorial which highlights an ongoing concern with governance within The Gates Foundation – one of the most active and generous philanthropic foundations in the world (US$ 3 billion annually).

The editorial starts out by, deservedly praising the invaluable contributions made by the Gates Foundation, particularly for its deep commitment to global health. The Lancet credits the Foundation for adding “renewed dynamism, credibility and attractiveness to global health” as well as “inaugurating an important new era of scientific commitment to global health predicaments”.

Much of the criticisms on the Foundation consist on two areas: the Foundation’s choice of investments; and its alleged lack of transparency in governing process.

On the choice of investment, the article points out following issues:

• “The Foundation gave most of its grants to organizations in high-income countries”

• “The grants made by the Foundation do not reflect the burden of disease endured by those in deepest poverty”

• “Important health programmes are being distorted by large grants from the Gates Foundation. In some countries, the valuable resources of the Foundation are being wasted and diverted from more urgent needs”

On the lack of transparency, the article argues that for such an influential investor in global health like the Gates Foundation should not just be governed by the Foundation’s guiding principle #1 - “This is a family foundation driven by the interests and passions of the Gates family.”

The article then proposes five recommendations for the Gates Foundation: Improve governance, increase transparency and accountability, allocate grants to better reflect disease burdens, invest in health systems and research capacity in low income countries and listen and be prepared to engage with others.

The following is a statement released by the Gates Foundation in response:

“We welcome this article and its finding. We try to be very thoughtful about how to target our resources and we constantly seek out feedback from outside experts and stakeholders. In the end, we use our best judgment to determine where our finding can achieve the greatest reductions in health inequity around the world. We are committed to communicating information about our strategy, grants, and results, and are using our website to make it easier to find this information.”

Read The Gates Foundation's Guiding Principles
Read The Gates Foundation's Approach to Giving

Centralised vs. Decentralised

Tikki Pang, a member of the S.T. Lee Project's Global Health Governance study group and Director, Research Policy & Cooperation at the World Health Organisation (WHO), emailed in few days ago a thought-provoking piece written by David Brooks of The New York Times. The Brooks' article addresses global health governance in the current context of the potential swine flue epidemic and the relative merits of a "top-down" centralised response versus a much more "bottom-up", decentralised approach in the context of responding to transnational threats like pandemic.


Swine flu isn’t only a health emergency. It’s a test for how we’re going to organize the 21st century.

In these post-cold war days, we don’t face a single concentrated threat. We face a series of decentralized, transnational threats: jihadi terrorism, a global financial crisis, global warming, energy scarcity, nuclear proliferation and, as we’re reminded today, possible health pandemics like swine flu.

These decentralized threats grow out of the widening spread and quickening pace of globalization and are magnified by it. Instant global communication and rapid international travel can sometimes lead to universal, systemic shocks. A bank meltdown or a virus will not stay isolated. They have the potential to hit nearly everywhere at once. They can wreck the key nodes of complex international systems.

So how do we deal with these situations? Do we build centralized global institutions that are strong enough to respond to transnational threats? Or do we rely on diverse and decentralized communities and nation-states?

A couple of years ago, G. John Ikenberry of Princeton wrote a superb paper making the case for the centralized response. He argued that America should help build a series of multinational institutions to address global problems. The great powers should construct an “infrastructure of international cooperation ... creating shared capacities to respond to a wide variety of contingencies.”

If you apply that logic to the swine flu, you could say that the world should beef up the World Health Organization to give it the power to analyze the spread of the disease, decide when and where quarantines are necessary and organize a single global response.

If we had a body like that, we wouldn’t be seeing the sort of frictions that are emerging from today’s decentralized approach. Europe has offended the U.S. by warning its citizens not to travel across the Atlantic. Ukraine is restricting pork imports. Europe could hoard flu vaccines, leaving the U.S., which has only one manufacturing plant, high and dry. Fear of a pandemic could lead to a restrictionist race, as nations compete to curtail movement and build walls.

Those dangers are all real. Yet, so far, that’s not the lesson of this crisis. The response to swine flu suggests that a decentralized approach is best. This crisis is only days old, yet we’ve already seen a bottom-up, highly aggressive response.

In the first place, the decentralized approach is much faster. Mexico responded unilaterally and aggressively to close schools and cancel events. The U.S. has responded with astonishing speed, considering there are still few illnesses and just one hospitalization.

The Times published a photo on Monday of the New York City health commissioner, Dr. Thomas R. Frieden, leading a crisis response meeting. The photo is the very image of a focused, local response. People are wearing polo shirts and casual wear — intensely concentrating on the concrete incidents in their own backyard.

If the response were coordinated by a global agency, those local officials would not be so empowered. Power would be wielded by officials from nations that are far away and emotionally aloof from ground zero. The institution would have to poll its members, negotiate internal differences and proceed, as all multinationals do, at the pace of the most recalcitrant stragglers.

Second, the decentralized approach is more credible. It is a fact of human nature that in times of crisis, people like to feel protected by one of their own. They will only trust people who share their historical experience, who understand their cultural assumptions about disease and the threat of outsiders and who have the legitimacy to make brutal choices. If some authority is going to restrict freedom, it should be somebody elected by the people, not a stranger.

Finally, the decentralized approach has coped reasonably well with uncertainty. It is clear from the response, so far, that there is an informal network of scientists who have met over the years and come to certain shared understandings about things like quarantining and rates of infection. It is also clear that there is a ton they don’t understand.

A single global response would produce a uniform approach. A decentralized response fosters experimentation.

The bottom line is that the swine flu crisis is two emergent problems piled on top of one another. At bottom, there is the dynamic network of the outbreak. It is fueled by complex feedback loops consisting of the virus itself, human mobility to spread it and environmental factors to make it potent. On top, there is the psychology of fear caused by the disease. It emerges from rumors, news reports, Tweets and expert warnings.

The correct response to these dynamic, decentralized, emergent problems is to create dynamic, decentralized, emergent authorities: chains of local officials, state agencies, national governments and international bodies that are as flexible as the problem itself.

Swine flu isn’t only a health emergency. It’s a test for how we’re going to organize the 21st century. Subsidiarity works best.


This article "Globalism Goes Viral" by David Brooks was published in The New York Times on 28 April 2009.

The wrong way to fight AIDS

CAG has recently launched a multidisciplinary global governance project which will look at how state, the private sector and civil society can better organize strategies to address the deficiencies in global governance. One focus is on global health governance which over the past several years has risen rapidly on the global agenda. Thanks to the Gates Foundation and new resources from various donors, substantial funds have become available, particularly for HIV/ AIDS. However, have the funds been used effectively?

Laurie Garrett, a Senior Fellow for Global Health at the Council on Foreign Relations and one of the most respected intellects on global health, points out in an article published in the International Herald Tribune that the fight against AIDS today has been all about “treatment”, rather than finding a long-term cure. She laments: “the slogan of the first 15 years of the pandemic was 'until there is a cure!'. Today it seems the global health leadership of the world is satisfied with, ‘until there is lifelong drug therapy for everybody, and no prevention strategy!'." Laurie warns that “a dangerous sentiment is sweeping over the AIDS establishment, calling for elimination of all funding for HIV vaccine research and prevention programs, shifting those dollars. euros and yen to expanding HIV treatment”. Read Laurie Garrett's article "The wrong way to fight AIDS"

To make things worse, the standard HIV drug treatment given to new patients in poorer countries in Africa is developing alarming levels of resistance ("When the drugs don't work", FT, 1 August, 2008). This warrants a serious concern given the escalating economic burden of HIV treatments and the lack of options in using alternatives. Compounding this problem is that there is only little data available on resistance. The article points out that many donors and HIV drug treatment companies have spent a lot of efforts and funds in accelerating drug-based treatment but not much in monitoring the resistance. Most of them lack the capacity to carry out appropriate resistance studies, the article finds. Clearly, there is an urgent need to build in appropriate governance mechanisms for long-term capacity building in monitoring resistance. Read "When the drugs don't work". [Sung]