Marstein E, Babich SM. Global health in transition: The coming of neoliberalism (Original research). SEEJPH 2018, posted: 04 January 2018. DOI 10.4119/UNIBI/SEEJPH-2018-179 1 ORIGINAL RESEARCH Global health in transition: The coming of neoliberalism Egil Marstein 1 , Suzanne M. Babich 1 1 Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, USA. Corresponding author: Egil Marstein, PhD Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University; Address: Health Sciences Building (RG), 1050 Wishard Blvd. Floor 5, Indianapolis IN 46202-2872, USA; Telephone: 317-274-3850; Email: egmars@iu.edu Marstein E, Babich SM. Global health in transition: The coming of neoliberalism (Original research). SEEJPH 2018, posted: 04 January 2018. DOI 10.4119/UNIBI/SEEJPH-2018-179 2 Abstract Global health as a transnational, intergovernmental, value-based initiative led by the World Health Organization (WHO), working toward improving health and achieving equity in health for all people worldwide, has for years yielded to a growing reliance on corporate-led solutions. Private organizations, non-governmental organizations (NGO), religious and other philanthropic and charitable organizations, increasingly serve a dominant role in setting the global health agenda. Short-term success in combating epidemics and in the provision of funding for project-based initiatives appeals to supporters of marketization of health services. For 30 years, a neoliberal paradigm has dominated the international po litical economy and hence the governance of global health. A utilitarian logic or the ethics of consequentialism have attained prominence under such banners as effective altruism or venture philanthropy. This contrasts with the merits and relevance of deontological ethics in which rules and moral duty are central. This paper seeks to explain how neo-liberalism became a governing precept and paradigm for global health governance. A priority is to unmask terms and precepts serving as ethos or moral character for corporate actions that benefit vested stakeholders. Keywords: global health governance, global health leadership, neoliberalism. Conflicts of interest: None. Marstein E, Babich SM. Global health in transition: The coming of neoliberalism (Original research). SEEJPH 2018, posted: 04 January 2018. DOI 10.4119/UNIBI/SEEJPH-2018-179 3 A new look at global health Global health has generally been perceived as a universal call to assist developing nations mediate health disparities and inequities in access to health services. Today, its transnational, institution-based foundation appears to be weakening. This is taking place at a time when we see an historic wave of migration, with refugees challenging the political will of sanctuary countries. The mass influx of refugees into European Union (EU) member countries dramatizes and confirms this. Some of the wealthiest regions of the world seem both unprepared and even hostile to the millions of multiethnic migrants seeking shelter (1). The humanitarian crisis appears endless, as politicians debate durable solutions to limit immigration, placing millions of people in limbo. Sounding the alarm are Barbara Adams and Jens Martens stating that: “While global economic, social and ecological crises have intensified in recent years, the ability of states and multilateral organizations to tackle these crises appears to have diminished” (2). Opinions on public health policy, global health initiatives and the potential for intergovernmental programs to “improve health and achieve equity in health for all people worldwide” vary within and between nations (3). Achieving consensus on an approach will require reconciling divergent views and policies. However, the first step requires a discussion that is conceptual and philosophical in nature. A value-based challenge The global disarray in managing the migration crisis demonstrates the lack of a universal understanding of the underlying global health policy precept. To remedy this, it is important to explain the relevance of conceptual terms that in turn help to explain political actions governing national health, safety and security. For example, the migration crisis is said to constitute a fiscal uncertainty, motivating policy makers to safeguard national welfare state schemes, of which public health is a critical part. Consequently, immigration policies of many countries have become more restrictive (2). Another term refers to “the issue of the humanitarian border” (4). This concept invites a common agreement on the ethical issues surrounding global health initiatives. A humanitarian intervention, for example, may be initiated that would safeguard people from the consequences of a state failing to provide adequate protection and relief for its citizens (5). Failure of the state to act in this case could incite a challenge to the political order of the countries involved. An intriguing new issue is the arrival of wealthy philanthropists and their foundations subscribing to venture philanthropy. Venture-based philanthropy or effective altruism is a term coined by the Australian professor Peter Singer (6). Singer is credited with producing a canonical text outlining applied ethics employing principles of utilitarianism to resolve moral disagreements. Singer’s concept encourages individuals to act in a way that brings about the greatest positive impact, based upon their empirical monetary values, distinguishing effective altruism from traditional altruism or charity. With regards to international relations and intergovernmental institutions, terms and concepts and their etymology play key roles in setting the agenda for global health. Contributors to The Lancet have claimed global health to be poorly defined but frequently referenced (3). Authors tried to provide insights into the interpretations of terms and their conceptual relevance, suggesting key competencies for improved scholarship and practice. Follow-up articles have sought to distinguish between national, international and global health. Academia has fallen short of initiating a discourse necessary to understand the origins and current status of the conceptual debate and its implications for global health practice. https://en.wikipedia.org/wiki/Altruism https://en.wikipedia.org/wiki/Charity_(practice) Marstein E, Babich SM. Global health in transition: The coming of neoliberalism (Original research). SEEJPH 2018, posted: 04 January 2018. DOI 10.4119/UNIBI/SEEJPH-2018-179 4 Underscoring this, Beaglehole and Bonita point out that “without an accepted definition of global health, it will be difficult to agree on what global health is trying to achieve and how progress will be made and monitored” (7). In pursuing the semantic connections, the recent migration crisis, and the topics of climate change, the economic, food and energy crises all illuminate the need for different relief approaches supported by a common vision for global health. The avenue to conceptual clarity is broadened when McInnes and Lee revitalize the concept of social constructivism (8). McInnes and Lee draw on Alfred Schultz’s sociology of knowledge and Durkheim’s concept of institutions when interpreting the relationship between human thoughts in a social context and the effects these ideas have on society. Their argument is that varied positions on global health emerge as a product of different values and interests. Following the fusion of Schultz and Durkheim´s theories, priorities of nations emerge as social facts reflecting “the power of ideas rather than an independent understanding based on objective observations of the world”. The concept of social constructivism is linked to Jürgen Habermas’s theory of communicative action, bringing in the Eurocentric bias rooted in Occidental rationalism (9). Recognizing the ills and problems of the world is thus rooted in a weaker notion of rationality. Any problem of universality is thus a cognitive cultural phenomenon. In historical and normative terms, Mark Nichter sees global health as the purview of our thinking about global health responsibility and our future roles in it (10). International health was largely limited to programs funded by bilateral aid, a few foundations, and the World Health Organization (WHO). Now, health problems, issues, and concerns that transcend national boundaries are being influenced by circumstances or experiences in other countries, best addressed by cooperative actions and solutions (11). Nichter offers an answer to the conceptual challenge in his quest for semantic universalism. Global health should represent “collaborative transnational research and action for promoting health for all” (10). Using a similar catchall tenet, Beaglehole and Bonita propose that global health should build on national public health efforts, whether population-wide or individually based actions, across all sectors, not just the health sector (7). Though they may not fully diffuse the potential for cognitive bias, these broad concepts may be better than the rest for fostering cooperative efforts to resolve the global health challenges of the day. The “globalization” of global health Given the diversity of opinions and the scope of resources involved, the issue of governance is paramount in effectively addressing issues of global health. Given the range of current public and private stakeholders, in addition to those historically established, the locus of authority takes on special significance. The prominence of new global health actors and their divergent interests creates significant conflicts with the priorities of public institutions. Acknowledging the influence of new and resourceful stakeholders, Kay and Williams have created a definition of global health governance to represent “any means or mechanism used by various public and private actors, acting at sub-national, national and international levels, that seek to control, regulate or ameliorate this global system of disease” (12). Hence, with the appearance of multinational corporations, NGOs, philanthropic and other non- governmental organizations merging with intergovernmental institutions, the global health agenda has become linked to international relations. This broadening of the global health reach relates to the expansion of globalism where economic liberalism facilitates and impacts its governance. Marstein E, Babich SM. Global health in transition: The coming of neoliberalism (Original research). SEEJPH 2018, posted: 04 January 2018. DOI 10.4119/UNIBI/SEEJPH-2018-179 5 Kaye and Williams challenge the view that global health is just a discrete area of activity driven by biomedicine and public health objectives. Their work attests to the centrality of global economic institutions having created a particular neoliberal modality of global health governance inviting public and private international interests. McInnes and Leesee global health as having graduated to a broadened position in response to real world developments (13). Global health has moved from a focus on technical competencies toward a more politicized view of relationships between growing numbers of stakeholders. Clearly, the potential consequences of this fragmentation of actors and issues create a demand for coordination between nation-states and the increased number of non-state participants. To develop new forms of networking and governance, the reconciliation of interests and progress toward a common cause require a deeper understanding of stakeholders’ motives and the required means. Reaching this common vision is particularly difficult given the influx of dominating private donors acting independently and governed by the precepts of venture philanthropy. In the ensuing discourse, we must scrutinize how public policies at local and intergovernmental levels have come to reflect revived liberal – or so-called neo-liberal – ideas. The orthodoxy of liberalism As a political philosophy, liberalism in its classical sense is associated with principles of individual freedom, such as freedom of speech, freedom of religion, civil rights, secular government and gender equality. As an ideology, it represents a set of ethical ideals, principles or even a social movement explaining how a society should work. As such, liberalism, in a contemporary fashion, functions as a political blueprint for social order. The modern intellectual history of liberalism dates back to the Age of Enlightenment. Several principles critical to today’s understanding of neo-liberalism were debated as they pertained to economic policies of the day. Proponents such as Hugo Grotius (1583-1645) and John Locke (1632-1704) introduced the concept of social contract in which life, liberty and property were subject to governance. Opposing this was Thomas Hobbes (1588-1679) arguing that individuals’ actions should be balanced only by their own consciences. Locke and Grotius warned that a State of Nature, if unchecked, would eventually require individuals to act in abidance with a Law of Nature, ensuring a minimum of security, rights and liberty. The French philosopher, Jean-Jaques Rousseau (1712-1778), balanced the State of Nature through his social contract theory, introducing the notion of popular sovereignty, rejecting Hobbes’s notion of individual sovereignty. Here Pierre-Joseph Proudhon (1809-1865) warned of a surrender of sovereignty: people should coexist in a State of Nature, refraining from coercing or governing each other. Everyone should have complete sovereignty over themselves. Proudhon and other 19 th century philosophers such as David Ricardo, Thomas Malthus, Adam Smith and James Mill inspired precepts of economic liberalism or classical economics. Common ideological ground was established with classical liberalism, conceptually transposing into today’s political neo-liberal tenets of privatization, deregulation, free trade, and reductions in government spending. Per Rosseau’s Social Contract Theory, Continental Europe saw more than one hundred years of social welfare state program expansions. Social insurance schemes of Chancellor Otto von Bismarck and Germany were introduced in the 1880s and 1890s, partly a result of escalating labor unrest but also an effort to build a strong and durable nation in an age of geo-political conflicts. https://en.wikipedia.org/wiki/Ideal_(ethics) https://en.wikipedia.org/wiki/Social_movement https://en.wikipedia.org/wiki/Privatisation https://en.wikipedia.org/wiki/Deregulation https://en.wikipedia.org/wiki/Free_trade https://en.wikipedia.org/wiki/Government_spending Marstein E, Babich SM. Global health in transition: The coming of neoliberalism (Original research). SEEJPH 2018, posted: 04 January 2018. DOI 10.4119/UNIBI/SEEJPH-2018-179 6 The National Insurance Bill of 1911 in the UK, the Social Insurance Law in 1928 in France, and the 1983 French free medical assistance program are three examples of such outcomes. Pierre Rosanvallon referred to this as the State being the “institutionalizer of the social”. In other words, the State began to be seen as an agency of social solidarity working to correct inequalities and increasingly intervening in aspects of everyday life, such as education, housing and transportation (14). These ideas mirrored those of the Enlightenment, particularly as argued by John Lock, Jean J. Rosseau, François-Marie Arouet (Voltaire) and Charles Montesquieu. After WWII, the UK developed a social welfare system, the hallmark being the introduction in 1948 of the National Health Service (NHS), a public health system that became the model for evolving social democracies throughout Europe. Inspired by economists such as John M. Keynes and later the Post-Keynesian economics of John Kenneth Galbraith, their socio- economic tenets promoted an active and comprehensive State governing to secure fair trade practices and workers’ social welfare. Classical Keynesian economics (as opposed to the later and much debated Post/Neo-Keynesian economics) served as the standard economic model in developed nations during the latter part of the Great Depression, World War II, and the post- war economic expansion (1945–1973). The most prominent of social reforms of its time, however, was the NHS. At the time, it was considered “the most civilized step by any country”, with universal health coverage, comprehensive and free at the point of delivery (15). The emergence of neoliberalism How neoliberal philosophies came into being as a dominating policy precept and governance model in global health may best be rationalized by studying the public policy reform agenda in the U.S., China and Western Europe over the past 40 years. The American professor of anthropology, David Harvey, points to 1978–1980 as a revolutionary turning point in the world’s social and economic history. Ronald Regan was elected U.S. president, serving from1981 to 1989. Only one year earlier, Paul Volcker took command of the U.S. Federal Reserve (1979-1987) and within a few months dramatically changed U.S. monetary policy. Across the Atlantic, Margaret Thatcher, England’s Prime Minister fro m 1979 to1990, advanced economic and social practices that deemed human well being could best be advanced by liberating individual entrepreneurial skills within an institutional freedom characterized by strong private property rights, free markets and free trade (16). The precept was clear. Both Thatcher and Regan moved quickly to curb the power of unions, deregulate industry, agriculture and resource development while liberating the powers of finance. According to Harvey, if markets did not exist in areas such as land, water, education, health care, social security and environmental pollution, then they had to be created, if necessary by the state. State intervention was kept to a minimum. So, too, began the process of deconstruction of the public health models in Europe, models largely vested in universalistic principles. Again, according to Harvey the theoretical precept for neoliberalism emerged from a small and exclusive group of passionate advocates of the Austrian political philosopher Friedrich von Hayek and the American economist Milton Friedman. Neoliberal doctrines, as they emerged, were deeply opposed to state intervention. Awarding the Swedish National Bank´s Prize in Economics Sciences in Memory of Alfred Nobel (often erroneously referred to as the Nobel Prize in Economics) to both Hayek (1974) and Friedman (1976), though both controversial at the time, gave credence to the doctrines they professed. Almost all countries, from those newly created after the collapse of the Soviet Union, to old-style social https://en.wikipedia.org/wiki/Developed_nations https://en.wikipedia.org/wiki/Great_Depression https://en.wikipedia.org/wiki/World_War_II https://en.wikipedia.org/wiki/Post-World_War_II_economic_expansion https://en.wikipedia.org/wiki/Post-World_War_II_economic_expansion Marstein E, Babich SM. Global health in transition: The coming of neoliberalism (Original research). SEEJPH 2018, posted: 04 January 2018. DOI 10.4119/UNIBI/SEEJPH-2018-179 7 democracies such as the Nordic countries, have since aligned their public policies, particularly within the public health under the Health and Social Care Act, which served to dismantle the constitutional basis of the NHS, making way for a market-driven system of health care. On the international scene, institutions such as the International Monetary Fund (IMF), the World Bank and the World Trade Organization encouraged and facilitated neoliberal measures through lending policies, making neoliberalism the hegemonic model. To conclude, neoliberalism has become the orthodoxy of global health. The implications for policy and practice should have prominence in discussions that seek to find effective and sustainable solutions to the world’s most critical and complex public health challenges. References 1. Glasas RI. Americas Vital Interest in Global Health. Perspectives from the Fogarty International Center. Institute of Medicine; 24 March, 2008. 2. Adams B, Martens J. Fit for whose purpose? Private funding and corporate influence in the United Nations. Global Policy Forum/Global Policy Watch; 27 July, 2015. 3. Kopland JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK et al. Towards a common definition of global health. Lancet 2009;9679:1993-5. 4. Williams JM. From humanitarian exceptionalism to contingent care: Care and enforcement at the humanitarian border. Political Geography, 2015;47:11-20. 5. Brown BS. Humanitarian Intervention at a Crossroad. William & Mary Law Review 2000;41(5/6). 6. Singer. P. Practical Ethics (3 rd ed.) Melbourne: Cambridge University Press; 2011. 7. Beaglehole R, Bonita R. What is global health? Global Health Action 2010;3. 8. Mcinnes C, Lee K. Global Health and International Relations. John Wiley & Sons; 2012. 9. Delanty G. Habermas and Occidental Rationalism: The Politics of Identity, Social Learning, and the Cultural Limits of Moral Universalism. Sociological Theory 1997;15:30-59. 10. Nichter M. Global Health: Why Cultural Perceptions, Social Representations, and Biopolitics Matter. Human Ecology 2009;37:669-70. 11. The Institute of Medicine, Board on International Health. Americas Vital Interest in Global Health. Protecting Our People, Enhancing Our Economy, and Advancing Our International Interests; 1997. 12. Kay A. Williams OD (ed.). Global Health Governance: Crisis, Institutions and Political Economy. Palgrave McMillan, UK; 2009. 13. McInnes CJ, Lee, K. Global Health & International Relations, Cambridge; Polity Press; 2012. 14. Rosanvallon P. The Society of Equals, Cambridge, Mass, Harvard University Press; 2013. 15. People’s Health Movement. Global Health Watch # 4. Alternative Health Report. London: ZED Books; 2014 (p. 96). 16. Harvey D. A Brief History of Neoliberalism. New York: Oxford University Press; 2005. ______________________________________________________________________________________ © 2018 Marstein et al; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.