Amid the Covid-19 pandemic, which brings into sharp relief the failures of the US health system, Donald Trump has decided to cut funding to the World Health Organisation (WHO)
Thursday 16 April 2020
Trump accused the WHO of being in China’s pocket and of having accepted falsified figures from Beijing, though the biggest donor to the WHO is the US, and not China, as one sometimes hears. The scale of the human tragedy we are living through deserves better than a cold war over health that will deprive the WHO of essential means to act. Richard Horton, editor of the British medical journal The Lancet, has called Trump’s decision ‘a crime against humanity’. That said, in-depth reform of the WHO’s funding and the way programs are developed is essential. Back in 2013, Dominique Kerouedan pointed out the influence of states, laboratories and private foundations on the WHO, and how this affects treatment.
What comes after the millennium goals aren’t reached?
No development without better health
Even though the UN’s millennium development targets won’t be reached by 2015, new goals are being set, especially in health. They may not be the right ones
by Dominique Kerouedan
Back in 2000 the 193 member states of the United Nations and 23 international organisations set eight Millennium Development Goals (MDGs) — minimum levels of progress to be achieved by 2015 in reducing poverty, hunger and inequality, and improving access to healthcare, safe drinking water and education (see Health targets).
Gro Harlem Brundtland, then director of the World Health Organisation, identified funding as a key priority and chose Jeffrey Sachs, special adviser to UN Secretary-General Kofi Annan, to head the Commission on Macroeconomics and Health, responsible for promoting investment with a view to achieving the health goals at an early date (1).
Global funding for developing countries from public-private partnerships, especially vaccine and drug manufacturers, quadrupled between 2000 and 2007; between 2001 and 2010 it tripled, reaching $28.2bn in 2010. Most of the money came from US-based public and private funds. (The Bill and Melinda Gates Foundation contributed nearly $900m in 2012.) Global development aid rose by 61% during this time, reaching $148.4bn in 2010.
Africa is estimated to have received 56% of all funding in 2010 (2), but 2015 is fast approaching and for sub-Saharan Africa the MDGs are still far out of reach. A shortage of funds is not enough to explain this slow progress: other, less visible, factors have played an important role. Studies (3) show that the allocation of global aid is based not only on epidemiological, population or burden of disease criteria, but also on commercial interests and historic and geopolitical relationships. Those involved in drawing up new goals for after 2015 would do well to take these factors into account.
19th-century century concerns
The first international conferences on health, in the 19th century, were motivated less by a desire to prevent the spread of plague, cholera and yellow fever than by the need to minimise quarantine measures, which were impeding trade. Tensions between medicine, health, commercial interests and political power remain inherent to global public health: the problem of ensuring that the poor have access to medicines within the framework of the Agreement on Trade-related Aspects of Intellectual Property Rights (TRIPS) is a good example.
The Global Fund to fight AIDS, Tuberculosis and Malaria, and its partners, assume that the strategies for combatting these three diseases are pertinent to every country and that only the money is missing. To understand this finance-led view of health issues and the limits of its effectiveness, it is necessary to return to the context in which the fund was established. In 1996 President Bill Clinton called for a strategy focused on infectious diseases, less from altruism than for reasons of national security; the US government was concerned about disease propagation, its economic consequences, delays in the development of new drugs, resistance to antibiotics, population mobility, the growth of megapolises and the weakness of health systems in poor countries.
In 1997 the Institute of Medicine, the leading scientific authority in the US, published a report that first used the expression “global health”, and said it was of vital interest to the US: “The world’s nations — the United States included — now have too much in common to consider health as merely a national issue. Instead, a new concept of global health is required to deal with health problems that transcend national boundaries, that may be influenced by circumstances or experiences in other countries, and that are best addressed by cooperative actions and solutions” (4). At the same time AIDS was spreading rapidly in southern Africa, and a South African defence ministry report on the high rate of HIV infection among the armed forces of many African countries caused alarm: very soon national defence capabilities would not be enough to deal with internal or external conflict. According to the International Crisis Group, many countries would “soon be unable to participate in peacekeeping operations” (5).
Between 1999 and 2008 the National Intelligence Council, the US intelligence community’s centre for long-term strategic analysis, published six reports on global health. These defined disease as a “non-traditional” threat to the security of the US, which has military bases around the world. This threat even reached the UN. For the first time in its history, the Security Council’s agenda in January 2000 included a topic not linked to a direct risk of conflict: the impact of AIDS on peace and security in Africa. The US delegation chaired the discussions, which produced a number of resolutions. Article 90 of the Declaration of Commitment on HIV/AIDS adopted by the UN General Assembly in 2001 called for the urgent establishment of a global HIV/AIDS and health fund to finance a response to the epidemic based on an integrated approach to prevention, care, support and treatment, and to help governments combat HIV/AIDS, especially in sub-Saharan Africa and the Caribbean.
Kofi Annan’s mobilisation of the G8 resulted in the establishment of the Global Fund, but this is far from being the “AIDS and health” fund called for by the UN: its mandate covers only AIDS, tuberculosis and malaria.
Restoring US leadership
US national security policy is driven by fears of communism, terrorism and disease, and the US does not hesitate to use the UN Security Council to defend its position on global health issues. After the wars in Afghanistan and Iraq, Barack Obama is steering his country towards struggles other than external conflicts. The aim is to restore US leadership abroad, and deal with the control of epidemics, as mentioned in the National Security Strategy in 2010. In July 2012 the US government announced the establishment of an Office of Global Health Diplomacy within the State Department: “We have made a collective recommendation to ... shift our focus from leadership within the US Government to global leadership by the US Government.” According to international relations historian Georges-Henri Soutou, “The US has understood that real power today means being able to operate in both spheres — international and transnational” (6).
Analysis of health policy in recent decades reveals that global health is seen variously as an economic investment, a tool for security and an element of foreign policy. (Charity and public health complete the picture according to David Stuckler and Martin McKee (7).) Security demands quick action, a short-term approach and the control of contagious diseases, rather than the holistic and systematic long-term approach required to strengthen institutional capabilities. This threatens the survival of initiatives in which money has been invested for almost 15 years.
So no matter how much the Global Fund and the US government allocate under the president’s emergency programme for AIDS relief (8), the actual results are disappointing because so little account has been taken of the need for prevention, or of demographic, urban, social, economic and conflict factors, or of national characteristics of disease propagation.
Thirty years into the HIV/AIDS pandemic, little funding is being allocated to local, epidemiological, anthropological and economic research to help decision-making. For every two people treated, five new cases of HIV infection are reported. Despite the many conflicts in Africa, the role of rape in the spread of the virus among women has not been examined. The world is shocked by the embezzlement of Global Fund monies, but ignores the failure of governments to analyse the effectiveness of the strategies adopted in their own countries. The financial choices (influenced by lobbyists) favour cure, to the benefit of the pharmaceutical industry, rather than prevention of the spread of HIV.
Who is accountable?
The growing number of entities in development aid has led to conflicts between decision-makers and partners, and a blurring of responsibilities: who should be accountable for the use of funds allocated through global partnerships or through new mechanisms. Financial issues are the responsibility of the Global Fund’s board, rather than its executive secretariat. Technical and strategic issues are supposed to be handled by individual countries and their partners (UNAIDS, Unicef and the WHO). Where UN agencies have given technical support to member states, have they guided them towards a strategy that heeds national characteristics? If not, then it’s time they did.
Africa (and the EU, including France) face unparalleled challenges. Africa’s population is set to double by 2050, from one billion to two billion, 20% of the global population. The economist François Bourguignon claims poverty, strictly defined, will be an exclusively African problem by 2040 or 2050 (9).
Africa is undergoing major demographic and epidemiological change, with rapid urbanisation and the as yet unquantified spread of chronic diseases — cancer, diabetes, cardiovascular and respiratory disease, mental illness, diseases linked to environmental pollution. These, diagnosed late or not at all and spreading like pandemics, together with more road accidents, add to the burden on healthcare workers, already in very short supply. Economic and social inequalities are creating health inequalities. Health insurance and social protection systems are being put in place too slowly, and unevenly. Universal health coverage would help the poor if it were part of a policy based on national priorities, especially prevention.
Given their historic links and centuries of political, economic and commercial interaction with sub-Saharan Africa, European countries have important contributions to make on the political front, as well as in terms of expertise and funding, and these should not be obscured by US priorities. The situation in central and western francophone Africa calls for large-scale, long-term action.
In equating the MDGs with sustainable development goals for after 2015, we risk focusing only on shared global issues, and neglecting fragile states and the most vulnerable people. The priorities are education for girls, maternal health, unknown tropical diseases and the development of institutional capability to formulate and implement complex policies.
The Indian economist Amartya Sen said: “Those who ask if better health is useful for development are missing the point: health and development are inseparable. You don’t need ... to try to prove that good health stimulates economic growth.” Long-term health for everyone on the planet should be the goal, not just the funding mechanisms that would allow universal health coverage, currently being presented as a sustainable development goal.
Health targets
UN Millennium Development Goals relating to health, to be achieved by 2015:
Goal 4: to reduce mortality among children under 5 by two thirds
Goal 5: to improve maternal health and reduce maternal mortality by three quarters
Goal 6: to combat HIV/AIDS, malaria and other diseases
Goal 8, target E: in cooperation with pharmaceutical companies, to provide access to affordable essential drugs in developing countries
Africa’s 2010 figures
76% of deaths in Africa are from infectious diseases, maternal and neonatal illnesses and nutritional disorders.
Africa accounts for 70% of deaths from HIV/AIDS worldwide.
Africa accounts for 75% of new HIV cases worldwide — of which the majority are among young people, girls and women (60% of all cases).
75% of HIV-positive young people aged 15-24 in Africa are girls. HIV/AIDS is more common in cities, where promiscuity-linked diseases (such as tuberculosis) spread with urbanisation.
Condom use is still infrequent (less than 20% in high-prevalence countries).
75% of HIV-positive men in four high-prevalence African countries admit recently having unprotected sex.
According to a study conducted in Abidjan with the support of Unicef, HIV/AIDS is more prevalent among the best-informed, best-educated and richest young people.
75% of Africans aged 15-44 do not know their HIV status. Among those aged 15-24, only 10% of boys and 15% of girls have taken an HIV test.
Only 25% of eligible patients in central and western Africa take antiretroviral treatments. (20% of HIV-positive pregnant women take them for their own sake, 33% of them to prevent the transmission of the virus to their child.)
Africa accounts for 50% of deaths among pregnant women and deaths due to complications arising from abortion procedures worldwide. Africa has the highest rate of teenage pregnancy (girls aged 15-18) worldwide. 97% of abortions in Africa are carried out under poor conditions.
Africa accounts for 91% of deaths from malaria worldwide (including 87% of deaths among children under 5, according to the World Health Organisation).
Africa is short of healthcare workers: Africa accounts for 25% of the global shortfall, and has only 3% of all healthcare workers worldwide.
Sources: MDG Africa and Global reports; Measuredhs.com; “Financing Global Health 2012: the end of the Golden Age?”, Institute for Health Metrics and Evaluation, University of Washington, Seattle, February 2012
Dominique Kerouedan
Savoirs Contre Pauvreté chair at the Collège de France and author of Géopolitique de la Santé Mondiale (The Geopolitics of World Health), Fayard, Paris, 2013. She also edited Santé Internationale: les Enjeux de Santé au Sud, (International Health: the Health Issues Facing the South), Presses de Sciences Po, Paris, 2011
Translated by Charles Goulden
What comes after the millennium goals aren’t reached?
No development without better health
Even though the UN’s millennium development targets won’t be reached by 2015, new goals are being set, especially in health. They may not be the right ones
by Dominique Kerouedan
Back in 2000 the 193 member states of the United Nations and 23 international organisations set eight Millennium Development Goals (MDGs) — minimum levels of progress to be achieved by 2015 in reducing poverty, hunger and inequality, and improving access to healthcare, safe drinking water and education (see Health targets).
Gro Harlem Brundtland, then director of the World Health Organisation, identified funding as a key priority and chose Jeffrey Sachs, special adviser to UN Secretary-General Kofi Annan, to head the Commission on Macroeconomics and Health, responsible for promoting investment with a view to achieving the health goals at an early date (1).
Global funding for developing countries from public-private partnerships, especially vaccine and drug manufacturers, quadrupled between 2000 and 2007; between 2001 and 2010 it tripled, reaching $28.2bn in 2010. Most of the money came from US-based public and private funds. (The Bill and Melinda Gates Foundation contributed nearly $900m in 2012.) Global development aid rose by 61% during this time, reaching $148.4bn in 2010.
Africa is estimated to have received 56% of all funding in 2010 (2), but 2015 is fast approaching and for sub-Saharan Africa the MDGs are still far out of reach. A shortage of funds is not enough to explain this slow progress: other, less visible, factors have played an important role. Studies (3) show that the allocation of global aid is based not only on epidemiological, population or burden of disease criteria, but also on commercial interests and historic and geopolitical relationships. Those involved in drawing up new goals for after 2015 would do well to take these factors into account.
19th-century century concerns
The first international conferences on health, in the 19th century, were motivated less by a desire to prevent the spread of plague, cholera and yellow fever than by the need to minimise quarantine measures, which were impeding trade. Tensions between medicine, health, commercial interests and political power remain inherent to global public health: the problem of ensuring that the poor have access to medicines within the framework of the Agreement on Trade-related Aspects of Intellectual Property Rights (TRIPS) is a good example.
The Global Fund to fight AIDS, Tuberculosis and Malaria, and its partners, assume that the strategies for combatting these three diseases are pertinent to every country and that only the money is missing. To understand this finance-led view of health issues and the limits of its effectiveness, it is necessary to return to the context in which the fund was established. In 1996 President Bill Clinton called for a strategy focused on infectious diseases, less from altruism than for reasons of national security; the US government was concerned about disease propagation, its economic consequences, delays in the development of new drugs, resistance to antibiotics, population mobility, the growth of megapolises and the weakness of health systems in poor countries.
In 1997 the Institute of Medicine, the leading scientific authority in the US, published a report that first used the expression “global health”, and said it was of vital interest to the US: “The world’s nations — the United States included — now have too much in common to consider health as merely a national issue. Instead, a new concept of global health is required to deal with health problems that transcend national boundaries, that may be influenced by circumstances or experiences in other countries, and that are best addressed by cooperative actions and solutions” (4). At the same time AIDS was spreading rapidly in southern Africa, and a South African defence ministry report on the high rate of HIV infection among the armed forces of many African countries caused alarm: very soon national defence capabilities would not be enough to deal with internal or external conflict. According to the International Crisis Group, many countries would “soon be unable to participate in peacekeeping operations” (5).
Between 1999 and 2008 the National Intelligence Council, the US intelligence community’s centre for long-term strategic analysis, published six reports on global health. These defined disease as a “non-traditional” threat to the security of the US, which has military bases around the world. This threat even reached the UN. For the first time in its history, the Security Council’s agenda in January 2000 included a topic not linked to a direct risk of conflict: the impact of AIDS on peace and security in Africa. The US delegation chaired the discussions, which produced a number of resolutions. Article 90 of the Declaration of Commitment on HIV/AIDS adopted by the UN General Assembly in 2001 called for the urgent establishment of a global HIV/AIDS and health fund to finance a response to the epidemic based on an integrated approach to prevention, care, support and treatment, and to help governments combat HIV/AIDS, especially in sub-Saharan Africa and the Caribbean.
Kofi Annan’s mobilisation of the G8 resulted in the establishment of the Global Fund, but this is far from being the “AIDS and health” fund called for by the UN: its mandate covers only AIDS, tuberculosis and malaria.
Restoring US leadership
US national security policy is driven by fears of communism, terrorism and disease, and the US does not hesitate to use the UN Security Council to defend its position on global health issues. After the wars in Afghanistan and Iraq, Barack Obama is steering his country towards struggles other than external conflicts. The aim is to restore US leadership abroad, and deal with the control of epidemics, as mentioned in the National Security Strategy in 2010. In July 2012 the US government announced the establishment of an Office of Global Health Diplomacy within the State Department: “We have made a collective recommendation to ... shift our focus from leadership within the US Government to global leadership by the US Government.” According to international relations historian Georges-Henri Soutou, “The US has understood that real power today means being able to operate in both spheres — international and transnational” (6).
Analysis of health policy in recent decades reveals that global health is seen variously as an economic investment, a tool for security and an element of foreign policy. (Charity and public health complete the picture according to David Stuckler and Martin McKee (7).) Security demands quick action, a short-term approach and the control of contagious diseases, rather than the holistic and systematic long-term approach required to strengthen institutional capabilities. This threatens the survival of initiatives in which money has been invested for almost 15 years.
So no matter how much the Global Fund and the US government allocate under the president’s emergency programme for AIDS relief (8), the actual results are disappointing because so little account has been taken of the need for prevention, or of demographic, urban, social, economic and conflict factors, or of national characteristics of disease propagation.
Thirty years into the HIV/AIDS pandemic, little funding is being allocated to local, epidemiological, anthropological and economic research to help decision-making. For every two people treated, five new cases of HIV infection are reported. Despite the many conflicts in Africa, the role of rape in the spread of the virus among women has not been examined. The world is shocked by the embezzlement of Global Fund monies, but ignores the failure of governments to analyse the effectiveness of the strategies adopted in their own countries. The financial choices (influenced by lobbyists) favour cure, to the benefit of the pharmaceutical industry, rather than prevention of the spread of HIV.
Who is accountable?
The growing number of entities in development aid has led to conflicts between decision-makers and partners, and a blurring of responsibilities: who should be accountable for the use of funds allocated through global partnerships or through new mechanisms. Financial issues are the responsibility of the Global Fund’s board, rather than its executive secretariat. Technical and strategic issues are supposed to be handled by individual countries and their partners (UNAIDS, Unicef and the WHO). Where UN agencies have given technical support to member states, have they guided them towards a strategy that heeds national characteristics? If not, then it’s time they did.
Africa (and the EU, including France) face unparalleled challenges. Africa’s population is set to double by 2050, from one billion to two billion, 20% of the global population. The economist François Bourguignon claims poverty, strictly defined, will be an exclusively African problem by 2040 or 2050 (9).
Africa is undergoing major demographic and epidemiological change, with rapid urbanisation and the as yet unquantified spread of chronic diseases — cancer, diabetes, cardiovascular and respiratory disease, mental illness, diseases linked to environmental pollution. These, diagnosed late or not at all and spreading like pandemics, together with more road accidents, add to the burden on healthcare workers, already in very short supply. Economic and social inequalities are creating health inequalities. Health insurance and social protection systems are being put in place too slowly, and unevenly. Universal health coverage would help the poor if it were part of a policy based on national priorities, especially prevention.
Given their historic links and centuries of political, economic and commercial interaction with sub-Saharan Africa, European countries have important contributions to make on the political front, as well as in terms of expertise and funding, and these should not be obscured by US priorities. The situation in central and western francophone Africa calls for large-scale, long-term action.
In equating the MDGs with sustainable development goals for after 2015, we risk focusing only on shared global issues, and neglecting fragile states and the most vulnerable people. The priorities are education for girls, maternal health, unknown tropical diseases and the development of institutional capability to formulate and implement complex policies.
The Indian economist Amartya Sen said: “Those who ask if better health is useful for development are missing the point: health and development are inseparable. You don’t need ... to try to prove that good health stimulates economic growth.” Long-term health for everyone on the planet should be the goal, not just the funding mechanisms that would allow universal health coverage, currently being presented as a sustainable development goal.
Health targets
UN Millennium Development Goals relating to health, to be achieved by 2015:
Goal 4: to reduce mortality among children under 5 by two thirds
Goal 5: to improve maternal health and reduce maternal mortality by three quarters
Goal 6: to combat HIV/AIDS, malaria and other diseases
Goal 8, target E: in cooperation with pharmaceutical companies, to provide access to affordable essential drugs in developing countries
Africa’s 2010 figures
76% of deaths in Africa are from infectious diseases, maternal and neonatal illnesses and nutritional disorders.
Africa accounts for 70% of deaths from HIV/AIDS worldwide.
Africa accounts for 75% of new HIV cases worldwide — of which the majority are among young people, girls and women (60% of all cases).
75% of HIV-positive young people aged 15-24 in Africa are girls. HIV/AIDS is more common in cities, where promiscuity-linked diseases (such as tuberculosis) spread with urbanisation.
Condom use is still infrequent (less than 20% in high-prevalence countries).
75% of HIV-positive men in four high-prevalence African countries admit recently having unprotected sex.
According to a study conducted in Abidjan with the support of Unicef, HIV/AIDS is more prevalent among the best-informed, best-educated and richest young people.
75% of Africans aged 15-44 do not know their HIV status. Among those aged 15-24, only 10% of boys and 15% of girls have taken an HIV test.
Only 25% of eligible patients in central and western Africa take antiretroviral treatments. (20% of HIV-positive pregnant women take them for their own sake, 33% of them to prevent the transmission of the virus to their child.)
Africa accounts for 50% of deaths among pregnant women and deaths due to complications arising from abortion procedures worldwide. Africa has the highest rate of teenage pregnancy (girls aged 15-18) worldwide. 97% of abortions in Africa are carried out under poor conditions.
Africa accounts for 91% of deaths from malaria worldwide (including 87% of deaths among children under 5, according to the World Health Organisation).
Africa is short of healthcare workers: Africa accounts for 25% of the global shortfall, and has only 3% of all healthcare workers worldwide.
Sources: MDG Africa and Global reports; Measuredhs.com; “Financing Global Health 2012: the end of the Golden Age?”, Institute for Health Metrics and Evaluation, University of Washington, Seattle, February 2012
Dominique Kerouedan
Savoirs Contre Pauvreté chair at the Collège de France and author of Géopolitique de la Santé Mondiale (The Geopolitics of World Health), Fayard, Paris, 2013. She also edited Santé Internationale: les Enjeux de Santé au Sud, (International Health: the Health Issues Facing the South), Presses de Sciences Po, Paris, 2011
Translated by Charles Goulden
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