Monday, February 10, 2014

Lancet/Oslo Commission on Global Governance for Health: Preliminary Response

Consider, if you will, the The Lancet–University of Oslo Commission on Global
Governance for Health report entitled "The political origins of health inequity: prospects for change." Really, consider it. It's extremely interesting. Roughly speaking, the Commission wishes that the world's attention were focused on health as a "precondition, outcome and indicator" of sustainable society. It's not satisfied to wish for improvements in "global health governance"--the functioning of the network of folks already focused on health. Instead, it aims for the establishment of "global governance for health," under which "health equity should be an objective for all sectors"--governments, NGOs, firms, individuals, alliances, and so on. In other words, it argues for the establishment of a global regime for which health is an important goal, and which therefore attends closely to all of the social determinants of health. A central assumption of the report is that the health of populations is not primarily to be achieved through the healthcare sector.

The report stresses the powerful role of inequality in establishing and reinforcing global health inequities. It criticizes global regimes for trusting too much in unregulated global markets; criticizes global over-reliance on biomedical approaches to health, rather than social-determinants approaches; and promotes the human-rights approach to health promotion. It offers various examples of failures of global governance to advance health: the austerity regime imposed on Greece by the EU; the international intellectual property regime's affects on drug availability in the developing world; the impact of investment treaties on health equity; the impact of agricultural and food policy on health; the impact of transnational corporate pollution; the impact of armed violence; of immigration; and more.

On the whole, the report's recommendations strike me as an unrealistic wish-list for ideal global governance, entirely divorced from consideration of the political and legal constraints under which real countries and international associations operate. (The cure for this sort of irrealism is to be found in John Coggon's wonderful book, What Makes Health Public?, which makes admirable and fair use of political and legal reality to test theory in this area.) Unrealistic though it may be, however, the report also makes a number of important observations and recommendations which, I hope, might eventually inform the debate in the real world.

I will not, at this moment, run through the arguments of the report. I will instead--hopeless academic that I am--make note of one feature of the document that disappoints me profoundly. That is: the citations. Here is a report on the need to attend to social determinants of health worldwide, and on the ways in which structural wealth differences and global political inequality perpetuate health disparity. How can it make no mention of Thomas Pogge? of Norman Daniels? of Amarty Sen and Martha Nussbaum? of Madison Powers and Ruth Faden? The report laments the lack of global policy standards relating to health, and promotes the human rights arguments for global health, but makes no mention of the academic and global-policy work of, to take one example, Larry Gostin.

The authors of the report, had they looked, would have found a large number of highly-respected and very sympathetic authors doing politically and legally well-informed work which both anticipates and supports the goals articulated in their report. This is work by people who identify themselves, variously, as bioethicists, philosophers and lawyers. These people (and their work) are already well-known in academic circles having to do with health law and policy, both national and international. I fear the authors of the Lancet report just didn't look for these supporters, not because of any disagreement on their part with the various authors I've mentioned, but simply because they didn't know these authors existed; and because they didn't think to search for support from academics in non-medical fields. And this leads me to despair that academics is hopelessly divided.  An alternative thesis is that the report's authors feared that citing the authors I've mentioned would alienate their primarily medical audience; I hope that's not the explanation, but I also believe it's not.

Ah well, more later.


  1. As a member of the Commission I am pleased that Stephen Latham seems to agree with its central argument, and that the report “makes a number of important observations and recommendations which, I hope, might eventually inform the debate in the real world”. But I would like to react to his two criticisms. One is that the report's recommendations are “an unrealistic wish-list for ideal global governance, entirely divorced from consideration of the political and legal constraints under which real countries and international associations operate”. We are very well aware of precisely these constraints, and spend much of the report describing them. The question is: what is to be done? Should one have utopian visions or be satisfied with just another small step in the right direction? Ironically, the report has been criticised by Charles Clift at Chatham House for the opposite reason from Latham’s– for not being radical enough. (See the response to Charles Clift by my co-Commissioner Gorik Ooms at
    Latham’s other criticism is that the authors of the report did not know of the existence of Amartya Sen, Thomas Pogge and others. Quite the contrary: some of us are, like Latham, ‘hopeless academics’ who are well aware of them and discussed their work at our meetings. We should perhaps have made explicit reference to their writings in the report, but they certainly influenced our ideas. (And contrary to Latham’s assumption, the majority of the Commission’s members were not medics, nor were we fearful of alienating a ‘primarily medical audience’.)

    Desmond McNeill, SUM, University of Oslo

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