The ‘New Anarchy’ and Global Health Governance before another ‘Ebola’

[caption id="attachment_33019" align="alignright" width="400"] Taking care of an Ebola patient:“The global coalitions, partnerships and networks that undermined China’s temptations to sovereignty tactics in the management of SARS meant the globalisation of global health governance forever beyond the Westphalia framework. The Westphalian order refers to the order of world politics based on independent, sovereign states whose domestic affairs no external actors can interfere in."[/caption] By Adagbo Onoja. Professor Peter Piot, the Belgian Virologist with the pedigree of discovering Ebola virus in 1976 and the head of the London School of Hygiene and Tropical Medicine, would say that the outbreak of an epidemic in Africa is a humanitarian catastrophe, something like the health equivalent of a war. The African specificity he points to in an interview on Aljazeera is the continent’s poor infrastructural foundation that made it impossible to arrest the Ebola epidemic in late 2014 at pre-epidemic stage as would have been the case in, say Europe. Piot’s view makes the thought of any epidemic breaking out on the continent dreadful for everyone, thereby making global health governance a specific challenge for journalism in terms of constantly mediatising every debate in that arena from the point of view of whatever such contributes to averting the mass misery that an ‘Ebola’ brings in Africa. In a virtually borderless world, a world defined by considerable movement of people across multiple frontiers though, the country/continent where an epidemic breaks out is not supposed to matter anymore but the global response to every epidemic. Hence, the displeasure of a frontline actor like Medicines San Frontieres (MSF) with the pace of global response over the last Ebola epidemic. The World Health Organisation, (WHO), had to admit failure of rising to the challenge. Dr. Margaret Chan, its Director-General said WHO, along the world was “too slow” to see what was unfolding. That privileges the question as to why it was that slow even as the United Nations Security Council declared it a threat to international peace and security. And if another epidemic were to break out today, would the global response be any less tardy? The distinctive argument on the ground to that question is the focus of attention here. It is David Fidler’s ‘The New Anarchy’ argument, the voice of a Professor of international law and leading global authority on infectious diseases. It is not an oven fresh argument but still highly referential. Fidler’s argument is to be found in a 2007 journal article titled “Architecture Amidst Anarchy: Global Governance Quest for Governance”. But the argument must be connected to an even larger text: SARS, Governance and the Globalisation of Disease, a 2004 book. In these two texts are intricate insights on how infectious diseases pushed global health governance to become the hottest arena of globalisation or world politics, second only probably to actual war. Straddling over trade, security, environment, development and human rights, it is no surprise that global health governance could be described as having acquired a “sentinel status for governance reform in contemporary international relations”. And with complicated consequences for everyone: from the most global city to the most rural settlement, with little or no distinction between the rich and the poor, the religious and the irreligious, the male and the female, the black and the white, the young and the old and, of course, the North and the South. [caption id="attachment_33023" align="alignright" width="740"] Peter Piot the discoverer of Ebola[/caption] Fidler’s argument established its own ranking by the overarching claim it makes that the Severe Acute Respiratory Syndrome, (SARS) epidemic which broke out in China in 2003 before spreading rapidly across the world marked an end of history. That is history in the sense that the global coalitions, partnerships and networks that undermined China’s temptations to sovereignty tactics in the management of SARS meant the globalisation of global health governance forever beyond the Westphalia framework. The Westphalian order refers to the order of world politics based on independent, sovereign states whose domestic affairs no external actors can interfere in. In the case of SARS, non-state actors such as the Global Outbreak Alert and Response Network (GOARN) outflanked China’s sovereignty claims by aligning laboratory scientists, clinicians and epidemiologists across the world towards ascertaining the clinical profile of the SARS virus and then disseminating the results through telephone and emails. Spread through international travel further worsened China’s grip and the tactics of keeping it within the remit of sovereignty. But while this argument about the pathogenic foundation of the 21st century and the era of the globalisation of disease beyond the Westphalian order remains fundamentally unchallenged, global health governance remains a case study in where success and failure came to have nearly the same meaning, a giant paradox. It is so in that in spite of a magical rise from nowhere to primacy in world politics in the post Cold War via the diverse activities by diverse actors in that arena, there is no quality health care delivery locally, nationally and internationally. So, everybody is asking, why? A major attempt at answering that question has been the argument that the problem is because global health governance lacks architecture or a hierarchical structure in a way. Felix Salmon provides in the New Yorker of November 26th, 2014 a graphic portrait of what lack of architecture in global governance means, “The awkward thing about independent organizations is that they’re independent. In Liberia, they include the World Health Organization, the World Bank, numerous U.N. bodies, the Centers for Disease Control and Prevention, the U.S. Agency for International Development, the U.S. Army, Doctors Without Borders, and representatives from many other countries. You can herd them all into a room, but they’re never going to want to do exactly what you want them to do. As a result, they will fight over things. If they don’t fight over things, that’s when you start to worry”. In other words, global health governance faces a crisis of a crowded, leaderless room. Subsequently, the advocacy for architecture has dominated global health governance, ignited by a Dean of the Harvard School of Public Health. The advocates want a movement out of this chaos or unstructured plurality to organized unity, something like during the Cold War when the World Health Organisation, (WHO) was basically in charge. But, as far as Fidler is concerned in the 2007 journal article, the architecture metaphor and what it communicates has been rendered obsolete. For him, there has been a sea change in global health governance that a hierarchical structure will not resolve the paradox whereby the global primacy of global health is not translating to quality health care delivery relatively across the world. By implication, that is his own answer to the question we posed above as to why global response to Ebola was tardy. [caption id="attachment_33024" align="alignright" width="400"] Margaret Chan head World Health Organisation:“The fear is that these new actors might have been thinking along the same line that Stalin did when he questioned the military worth of the Pope: how much is WHO worth when it comes to the resources? WHO relies on member states of the UN system. That gives it much less than 30% of the global health governance budget in some years. The balance of over 70% is provided by the giant new actors. So, WHO is out-monied, out-performed and out-shone unlike before when it could impose “restrictions, codes and “ethical criteria” on the marketing of infant formula, pesticides and tobacco” in the Westphalian order.”[/caption] He begins by conceiving the crowded room as the new anarchy corresponding to the post-Westphalian order. The first element of this new anarchy is the rise of new actors in the activism of those like Bill Gates Foundation, pharmaceutical conglomerates, powerful international non-governmental organisations like Medicines Sans Frontieres, (MSF), individuals like Bono, the Iris entertainer and public-private partnerships like the Global Fund to Fight AIDS/TB. There are yet others like the Global Alliance for Vaccines and Immunization, (GAVI), UNAIDS, the World Bank and former US President’s Emergency Plan for AIDS Relief, (PEPFAR). The second element is where we are not just dealing with the rise of new actors but new actors whose own resistance to control might even be tougher than the resistance of nation states to anything that smells of interference in their domestic affairs. Fiddlers asserts, for example, that “governing Bill Gates may prove as challenging in its own way as governing the United States in terms of global health”, (p.2). In the Westphalian order, the leadership of the World Health Organisation (WHO) was basically unchallenged. With the post-Westphalian order, the question became “where is the house WHO has built?” WHO had not built any ‘house’ which is an acceptable accommodation for these new set of giant actors. The result is what Fidler calls an unstructured plurality resulting from an open-source code in terms of values framing the activism of each of the new actors on ground. The fear is that these new actors might have been thinking along the same line that Stalin did when he questioned the military worth of the Pope: how much is WHO worth when it comes to the resources? WHO relies on member states of the UN system. That gives it much less than 30% of the global health governance budget in some years. The balance of over 70% is provided by the giant new actors. So, WHO is out-monied, out-performed and out-shone unlike before when it could impose “restrictions, codes and “ethical criteria” on the marketing of infant formula, pesticides and tobacco” in the Westphalian order. One implication of this is what Fidler calls under and over – exploitation in global health governance. It is under-exploitation when Non-Communicable Diseases, (NCDs), for example, are neglected in favour of communicable diseases even with NCDs (cardiovascular diseases, cancer, diabetes and chronic respiratory diseases) accounting for the rise to 54% of deaths/disabilities globally in, say, 2010, according to a 2014 University College London background paper. In a 2011 article in Foreign Affairs published by the influential New York based Council on Foreign Relations, Sonia Sha, a science journalist, traced NCDs, among others, to Tobacco, food, mining and oil companies asserting themselves in selling their products by writing that “These private firms are playing a double game: disrupting local communities with one hand and writing big checks (cheque) to ostensibly help them with the other”. Over-exploitation, on the other hand, is the stress in Africa, for example, in governments coping with the avalanche of initiatives, interventions and projects on HIV/AIDS from different set of actors. It is to under and over-exploitation we turn in seeking understanding of conflictual responses in global health governance such as when Indonesia withdrew from avian influenza sample sharing in 2007 on the ground that more powerful actors were using information from those samples to produce drugs which countries like Indonesia cannot afford. Indonesia sent a message to global power. South Africa equally did the same on patent, even got former President Clinton on its side and won. Interestingly, Indonesia and South Africa are all from the Southern hemisphere. [caption id="attachment_33025" align="alignright" width="400"] Bill Gates:“The first element of this new anarchy is the rise of new actors in the activism of those like Bill Gates Foundation, pharmaceutical conglomerates, powerful international non-governmental organisations like Medicines Sans Frontieres, (MSF), individuals like Bono, the Iris entertainer and public-private partnerships like the Global Fund to Fight AIDS/TB.”[/caption] Notwithstanding the new anarchy so well elaborated, Fidler says the message embedded in the rise of health in international politics is that it has gone beyond “the House that WHO built”, (p.6). For him, this is for good reasons because the problem is somewhere, what he calls the ‘hardware’ problem – the very bare level of infrastructural foundation in majority of the countries and how this creates a gulf between the domestic level and the flurry of activities going on at the global level in relation to quality health care delivery. Fidler calls this the “plurality of incapacity” at the national level. So, although the globalisation of diseases compels a global response, global response is constrained by a sea change in which the new anarchy and the ‘hardware’ crisis are key. The outcome is failure everywhere, be it in fighting tuberculosis, malaria, rising mortality and morbidity in NCDs. He makes three major analyses: the impossibility of building adequate public health infrastructure generally everywhere because “despite the globalisation of public health, the political and financial responsibility for public health infrastructure and capacity falls on governments”, (p.15) and, in fact, building better public health infrastructure is far more difficult in the post-Westphalian anarchy. [caption id="attachment_30363" align="alignright" width="277"] Adagbo Onoja :“Something about the ‘new anarchy’ should draw attention to what might be called its domestic versions in many countries: mobile medicine sellers proclaiming via powerful loudspeakers herbal and related concoctions that they pose as cure for all sorts of imaginable ailments. For all we know, their claims might be completely true but are they licensed, supervised, authorised and monitored? There is also a reportedly thriving new medical culture in which Non-Governmental Individuals are operating hospitals where medicine are not allowed but only prayers.”[/caption] The challenge of Fidler’s position is how accommodation could be negotiated out of the new anarchy. New wealthy actors have entered global heath security with lots of money but which they spend in their own way, not the way any big brother like WHO will superintend. So, in spite of this in-flow of much larger resources, both the infrastructural foundation relatively across the world as well as some areas of global public health are neglected. What is to be done? Fidler thinks very poorly of the option of a global treaty on health as a way out. He says the history of grand summits on global crises does not make that option attractive. It remains unclear why Fiddler wouldn’t call the dominant ‘normative source code’ by its real name. The closest he comes to calling it neoliberal globalisation is where he stated that: “Behind unstructured plurality are political attitudes that complicates and constrain building organised unity through governance architecture”, (p.8). Whatever the deficits of his intervention, he has given us his own picture of the problem in global health. What is our own Ministry of Health, global health intellectuals, political parties, NGOs, the medical sector, among others, thinking on the subject? And are we publishing our own views? Are those who talk of public-private partnership, networking and such stuff as if these are innocent concepts taking note? Something about the ‘new anarchy’ should draw attention to what might be called its domestic versions in many countries: mobile medicine sellers proclaiming via powerful loudspeakers herbal and related concoctions that they pose as cure for all sorts of imaginable ailments. For all we know, their claims might be completely true but are they licensed, supervised, authorised and monitored? There is also a reportedly thriving new medical culture in which Non-Governmental Individuals are operating hospitals where medicine are not allowed but only prayers. There might be no one single meaning of what is medical but until we change the law to reflect that, we should have seen, in Nigeria, the police, the SSS, the early warning establishment and, above all, the media in possibly a joint operation on this. That would have been national security at its best, striped of mystification to put human beings as its core. Public health as the cornerstone of national security can be seen in how the language of health is assuming the language of security in the literature, best exemplified in how Global Health Governance becomes Global Health Security, for example. The fact that some of the above examples of the ‘new anarchy’ at the domestic level persist might be taken as evidence that the contested concept of state failure is not only when central authority has collapsed and everyone is running helter-skelter. It is also when the state is Away without Official Leave (AWOL), to borrow that lexicon. Too many actors in Africa might have gone on AWOL in terms of governing in many such realms. So, when Peter Piot says an epidemic in Africa is an automatic humanitarian catastrophe, he has a point. This cannot continue like that. As Fidler further claims, the 21st century began with infectious diseases as the fulcrum of global security strategies. It began with HIV/AIDS which was considered to be capable of bringing about collapse of many armed forces and, by implication, their nations, including the US. The fear of weaponization of pathogens by those the US called the ‘axis of evil’, became the basis of grand strategy too. He even adds how responses to the SARS epidemic led to loss of power by some incumbents. So the new anarchy is a problem both at the domestic and the global level. The 2003 SARS, the 2009 (H1NI) influenza virus and the 2014 Ebola epidemic might actually have domestic health foundations even as they might have been globalised by movement of population, animals and food items. It’s been two months of activism in global health governance. The United Nations system adopted the Sustainable Development Goals, the successor to the Millennium Development Goals, (MDGs), a huge chunk of it touching on health one way or the other. Outside the UN system, researchers at Chatham House, London: Marco Schaferhoff, Elina Suzuki, Philip Angelides and Steven Hoffman released a 54 page Research paper “Rethinking the Global Health System” last September. In August, another set also at Chatham released “Analysing Proposals for Reform of the Global Health Architecture”. The African specificity of global health challenges compel journalistic attention to these developments and publications in terms of whatever new value they bring to the table.