Towards a Framework Convention on Global Health

By guest blogger Anna Malavisi

While we need to applaud the proposal of a Framework Convention on Global Health (FCGH) as a way to address health inequalities and inequities, we cannot be complacent in believing that such a framework will achieve its goal. Other frameworks have preceded this one (Global Strategy for  Health for All by the Year 2000, Millennium Development Goals, etc.), and yet the reality is that in the 21^st century, there are still millions of children, women, and men who do not have access to clean running water, a safe and secure supply of food, electricity, education, and other conditions necessary for the fulfillment of human rights. As the FCGH manifesto says, “The world fails nearly 20 million people every year.” This could be considered a moral failing on the part of individuals and institutions. Here, I  offer some reflections about the global situation as a way to ponder some of the considerations that we must consider if we are serious about transforming lives with an FCGH.

We must start with a critical analysis and understanding of why there is so much suffering in a world of affluence.   While it may be acceptable for rich and poor people to live in this world, the fact that there are people who are extremely rich or extremely poor is not acceptable. Some difficult questions must be asked – the answers to which we may prefer not to face; the only way forward is not to shun responsibility but to assume it.

After working as a development practitioner for many years in Latin America, beginning in the health sector, I became disillusioned about the “development industry.” For me, what was absent in development work was thinking through some of our actions from an ethical perspective.  Critical analysis and reflection just wasn’t taking place on the ground. It was frustrating to be part of a system of non-governmental organizations (NGOs) where one gets so caught up with writing grants and reports, executing projects, etc., that no time is spent pondering whether the work is having any real impact. We had all become cogs in a machine responding to grant requirements, reviewer questions, or the question of where the next round of support would come from. This disquietude pushed me to pursue a Ph.D. in philosophy.

Post-development and anti-development theorists reject the whole notion of development, which in theory may be the most appropriate response. In practice, it is implausible. Development (of which global health is a component) is so entrenched in the global economic system that institutions and countries will continue to invest large amounts of money through bilateral agencies or NGOs.  It is naïve to think that quashing development theory will lead to any desirable outcome. What is needed is not only a strong critique but also the  introduction  of alternative theories that will lead to alternative strategies; hopefully, this will lead to better outcomes. I believe it is important is to encourage a critical voice; this allows for analysis and reflection on development action but also proposes strategies consistent with ethical principles.

Many of us may turn away from philosophy because of its abstraction, but I think it can help us work through some complex and critical obstacles to reducing global health inequalities and inequities. Graham Priest, a prominent analytical philosopher sees the role of philosophy as such: “We all need to be challenged out of our mistakes, stupidities, complacencies—especially when it is our own intellectual blinkers that prevent us from seeing them as such. This is the preeminent role of philosophy.”[1] I would argue that epistemology and ethics could be especially helpful in challenging our mistakes, stupidities, and complacencies.

Epistemology is the theory of knowledge; it derives from the Greek word, episteme, which means knowledge. I believe that such a theory of knowledge could be useful in thinking about an FCGH. The knowledge used to make critical decisions about global policies and programs derives from so-called experts, predominantly economists within institutions such as the World Bank and the International Monetary Fund. Now, if you think about how our own knowledge is produced you can deduce that a number of factors influence how one “knows” something, such as the fact that antibiotics are essential for the cure of bacterial infections. This is based on scientific evidence and has been proven true. But what about answers to questions such as: “how do we know what the reasons are that contribute to a moral failing on part of institutions and governments to achieving global health for all?” This is a rather more convoluted and complex question. Scientific evidence may be helpful here, but it is not sufficient.

Knowledge claims are usually embedded in implicit bias, assumptions, and our own individual beliefs, which are often tainted by social and cultural influences. An indigenous woman with a sick, malnourished child may believe that the animo (soul) of that child left her body, causing her to become malnourished, rather than believing the cause may be a prolonged absence of sufficient nutrients. Thus, she will seek treatment to “recover” the soul, treatment that would not necessarily include a health clinic. Her knowledge may not be accurate, but to address this, we need to understand her situated knowledge. Therefore, a framework convention that does not start by understanding the perspectives of the people for whom it is intended becomes limited. A pluralist sense of knowledge is required, which would manifest itself as many forms of knowledge. We must listen to the voices of the poor as much as we listen to the voices of “experts.”

We can talk about “epistemic injustice,” which is reflected in the pervasive misinterpretation and misunderstanding of the situations of oppressed people. It is no coincidence that, when comparing overall health indicators, the African-American and Latino populations in the United States are worse off than their white counterparts. Theoretical applications of knowledge allow us to analyze dimensions of power and domination. Rather than depending solely on facts, we need to expand the scope of knowledge to include other forms such as experiential knowledge or know-how.

The second area of philosophy that I think would be useful is ethics. To think ethically means to consider the good and harm one can do. In relation to global health, current human development indicators such as infant mortality rates can be lauded as successful health gains. However, too many children still die before they reach their first year and too many women continue to die in childbirth or related deaths. So while we can talk about successful health initiatives, we can also talk about the failures. Furthermore, we need to talk more about the failures, particularly the moral failures, of individuals and institutions.

Dr. John Snow discovered the cure for cholera in 1854. His claim was that cholera would be eliminated in the presence of an adequate supply of clean water and good sanitation procedures. It seems implausible and highly disconcerting that in 2013, organizations like Partners In Health are still pleading to the United Nations for support in providing adequate medication to a cholera epidemic in Haiti. (This is just one example of situations that arise within the context of global health that expose the need for someone to assume moral responsibility).

Anyone who has worked on the ground is well-aware of ongoing development failures: duplication of projects, implementation of inappropriate projects (I recall visiting a newly built but empty center for malnourished children in a non-accessible rural community in the valleys of Cochabamba), power dimensions entrenched in relationships between actors, ignoring or inadequately responding to the intersections of race, gender, class, or sexual orientation, and responding to the global trends or buzzwords rather than social contexts of individual countries. And although my claim is that ethics is important, equally important is the type of ethical approach used.  An abstract form of ethics which is purely theoretical and analytical will not do. We need critical and practical ethics. Denis Goulet, a development ethicist described it as a praxis generating critical reflection which will lead to action.[2]

With ethics comes responsibility: assuming the responsibility for one’s actions but also for the consequences of these actions. An FCGH must articulate this. Calling out the harms  that those who wield power directly and indirectly visit upon much of the world’s population,  and holding them accountable for their actions would be a good place to start.

I would argue that before we can talk about the pursuit of justice, we need to understand and address flagrant injustices and inequities. This includes, for example, the imbalance of power between richer and poorer countries reflected in the prioritization of national interests over global interests (such as food aid policies) and a global economic order intended to benefit richer countries over poorer. One of the underlying problems I see lurking here is the lesser value some lives are given over others. This is what Judith Butler refers to as the grievability of lives.[3] This is a serious ethical issue that can only be addressed through critical analysis and reflection among all actors, including national governments and multilateral agencies, international and national NGOs, the private sector, and community-based organizations. It means facing difficult and uncomfortable situations such as the case of the UN’s lack of response to cholera in Haiti.  The language suggested for the FCGH is necessary, but still insufficient to achieve what it sets out to do. There need to be other instances (whether they should be included in the FCGH or treated as a collaborative effort will require more discussion) that delve in a more profound and critical way into the structural causes of health injustices, inequalities, and inequities where the obligations and responsibilities of governments, institutions, and other entities are not only pronounced but also contested.

I may have just opened Pandora’s Box, but I am tired of reading about ideal situations, perfect institutions we should strive for, without first thinking about where we are and how we got here.