Here, we offer an overview of past and contemporary phenomena that bear witness to the tensions and geopolitical strategies that can emerge in relation to health issues.
It should be noted that these concepts and analyses are applicable to global health issues even before the emergence of the concept some twenty years ago: some sources demonstrate the existence of geopolitical tensions around infectious diseases, such as the HIV-AIDS pandemic (and the ideological conflicts surrounding the emergence of the disease). On the other hand, several references (press or academic articles) look back at the Ebola epidemic in sub-Saharan Africa and the tensions it generated, sometimes replaying old conflicts or opening the way to newforms of intervention and actors.
Finally, the Covid-19 pandemic has given rise to new diplomatic practices, new geopoliticalobjects such as healthcare products (masks, vaccines or traditional medicine) and new players, who have deployed strategies to compete with Western countries, thus overturning the world healthcare order and its traditional polarizations.
Hello everyone, We’re pleased to send you our latest review of press and literature on global health.
This time, it will be devoted to the history of global health.
A history of global health is, of course, a history of the epidemics that have struck the world: plague, cholera, Spanish flu, of course, but also trypanosomiasis, malaria,polio, Ebola, and so on. The emergence and spread of infectious diseases with epidemic potential have punctuated human history right up to the present day. AIDS obviously occupies a special place in this history, as it is sometimes said to have, in a way, “ invented ‘ global health, in the sense of a worldwide awareness of our interdependence.
Making the history of global health also means becoming aware of its links with tropical medicine(Andrew Gibson) or withcolonial history (Guillaume Lachenal). We have selected for you a few articles on key elements of this historical substratum, such as the creation of the Liverpool School of Tropical Medicine, or the career of Louis Pasteur.
Although the concept of “global health ‘ has gainedmomentum in recent years, it is actually more than forty years old, and was first used by theAmerican Institute of Medicine in 1997. The concept remains a subject of debate in its own right, particularly when it comes to distinguishing it from what is known as international public health: strong transnational and intersectoral dimensions, emergence of new players on the international scene, link with neo-liberal practices, etc.
A history of global health also means going back to the historical origins of theWHO in 1948, from the first international health conferences to the present day, and making room for critical approaches to this history, with Randall Packard and many others, notably on the security dimension of global health.
Last but not least, making the history of global health means realizing the importance of memory and thehistorical approach to health: historians have much to teach us.
In connection with the Ukrainian crisis, we have decided to devote our monthly press review to the theme of “War and global health”: How do war and conflict impact on people’s state of health? Which health determinants are most sensitive to conflict situations? How do war-related health crises spread beyond the borders of war-torn countries?
The health impact of the war in Ukraine is obviously at the heart of this press review: deterioration in living conditions, consequences in terms of public health, traumas, risk of interruption of treatment for certain diseases such as tuberculosis, HIV or Covid-19, aggravation of problems linked to sexual health , etc.
While the health of the Ukrainian population itself is a matter of great concern, the crisis is likely to have major health repercussions far beyond Ukraine’s borders, on the various bordering countries, such as Hungary, for example, on the region as a whole, but also potentially on a global scale, if we consider the effects of economic sanctions on the health of populations, the risks offood insecurity, the threat of the use of biological weapons or even the possibility ofnuclear accidents. For some, the war in Ukraine and Russian gas sanctions could even have an impact on achieving global targets in the fight against global warming.
This press review devoted to the links between health and war is also an opportunity to look back at other health crises linked to crisis contexts, such as the Democratic Republic of Congo, Lebanon,Iraq, Syria and Yemen.
Finally, several articles focus on more specific conflict-related themes: the health of refugees and displaced persons, the resurgence of post-conflict epidemics, the effects of armed conflict on the health of specific populations such as women and children, human rights, and the effects of war on mental health (here and here). Many other topics could be addressed, including the effects of war on international negotiations, or the instrumentalization of health issues for diplomatic or geopolitical purposes in conflict contexts. We can imagine that the war in Ukraine will have major repercussions on global health governance, and that it will polarize discussions in the international community for a long time to come, at a time when we so desperately need a common vision and a coordinated approach to health on a global scale.
This month’s press review focuses on human resources in healthcare.
We have chosen this theme for the press review because we consider it to be central. In fact, we’ve decided to make it a priority theme for the think tank in 2022. While we look forward to sharing our findings and reflections with you at a workshop to be held next autumn, in partnership with the AFD, we hope that this press review will contribute to further reflection on these important issues.
As always, our press reviews include links to reference documents, such as the Global Strategy to 2030, as well as links to reports or working papers in the “grey literature” that we have found enlightening, and scientific articles.
For once, we have chosen to focus primarily on OECD countries, with a few more specific articles on France (such as this prospective analysis of trades and qualifications), and of course a few articles onFrench-speaking Africa. The Covid crisis has clearly demonstrated the importance of these issues.
First of all, we’ve put together a series of institutional and scientific documents to help you better understand the global issues at stake. These documents point to numerous imbalances, particularly geographical, within countries of course, but also at international level, creating a real imbalance between supply and demand in healthcare on a planetary scale. Sub-Saharan Africa accounts for a quarter of the global burden of disease, yet only 3% of the world’s healthcare professionals. Beyond migration issues (which can be considered on a global, European or even French departmental scale), several points of attention emerge from these documents, notably the need for healthcare professions to evolve to meet new needs, such as the ageing of certain populations, or gender issues.
Of course, policies can be put in place to address these inequalities, whether in terms of recruitment conditions, training, retention or the distribution of healthcare personnel. Here are some examples of policies implemented to meet these needs, in both low- and high-incomecountries.
This month’s press review is devoted to digital health issues.
We’ve chosen to devote some time to these issues – which, let’s face it, we’re not specialists in – because of their growing importance: the crisis has both revealed and amplified them. While the use of digital technologies has become an integral part of our lives in the space of just a few months, the healthcare sector has been particularly affected by these new practices. Working with experts in the field, including Florence Gaudry Perkins, we not only looked at the conceptual, technical, scientific and ethical issues at stake, but also, as you will see in this note, at the challenges of global governance of digital health.
Adopting a broad definition, which sees digital health as the use of digital technologies for health purposes, we have selected a series of concrete examples of the use of digital tools:
In the field of healthcare data exploitation (big data and data mining) and artificial intelligence for healthcare.
Finally, we invite you to reflect on the ethical issues raised by the use of digital technology in healthcare: How can we ensure that healthcare data is not used for social and health control purposes? What international strategies should be put in place to regulate and evaluate the use of digital technology in health? Is “5P medicine” (preventive, personalized, predictive, participative and evidence-based) just talk? How can we respond to the democratic (and legitimate) demand for control over digital technologies? How can we ultimately control our digital space and ensure that digital health does indeed contribute to empowering patients over their own health? In short, how can we achieve what Claude Kirchner and Jérôme Perrin call a “ fraternal digital world”?
This month’s press review will focus on the central issue ofunequal access to Covid vaccines worldwide.
While the vaccine is considered to be the main pillar of the response to the pandemic, only 8.93% of the African population has received at least one dose (compared with a global average of 49.6% as of November 2, 2021). This gap is unacceptable, both morally and epidemiologically.
The articles we’ve selected for you obviously deal with the financial stakes of access to vaccines (note, for example, Suerie Moon’s thoughts on the creation of dedicated international funds), but also with the political stakes (how to combat “vaccine nationalism”, ensure that vaccines will not be an object of geopolitical influence or blackmail, and that the promises of vaccine donations made by decision-makers in rich countries will be followed by deliveries as large as announced).
On this issue, as on others, the Covid crisis is a powerful indicator of inequalities. The fragility of healthcare systems is also an obstacle to access to vaccines. Such basic material issues as access to syringes and the management of expiration dates can be major obstacles to vaccination. Alice Desclaux and Khoudia Sow have also shown in Senegal that unpredictable access to vaccines can fuel vaccine hesitancy in certain contexts.
These are complex issues, and it is vital to avoid simplistic, caricatured arguments that pit access to vaccines for countries with limited resources against the need for a booster dose (a third dose scientifically justified on the basis of age or co-morbidities in the target population) in countries where the population is already largely vaccinated (see our article in Le Monde).
The challenge is obviously to respond to today’s health emergency, while preparing ourselves for tomorrow’s vaccine challenges, and you will also find in this selection some of the avenues identified by several high-level panels (the one set up by theWHO, and the one which has just presented its conclusions to the G20).
Access to vaccines for all is not only a question of solidarity or moral justice, it is also the best way for us to fight against the appearance of new variants and protect ourselves collectively against the virus.
Echoing the Generation Equality Forum held in Mexico City in March and in Paris from June 30 to July 2, 2021, we offer a summer press review (July-August) dedicated to the consequences of the Covid-19 pandemic from a gender perspective.
As early as spring 2020, it appears that women are paying a higher price than men to the epidemic. Several factors are immediately identified: greater exposure of women to the virus due to their over-representation in the health and service sectors and, compared to men, a greater proportion of women affected by job losses related to the pandemic.
While these studies are growing for high-income countries, they are still relatively scarce for resource-poor countries. Existing studies show that in Latin America and the Caribbean, women have been more vulnerable than men to the labor market changes brought about by the pandemic. Indeed, they occupied – and continue to occupy – a greater proportion of jobs in the informal sector and/or so-called “frontline” jobs, i.e. requiring face-to-face interactions, with less possibility of remote work, such as trade, personal care or tourism. In addition, they have been subjected to an increased domestic workload, with the care of children and dependents falling overwhelmingly to them.
In this month of World Africa Day (May 25), we offer a round-up of African news related to the Covid-19 pandemic.
Data on Covid-19 is lacking on the continent. We know too little about about how the epidemic is actually affecting Africa. The main reason for this is the very limited means of testing, which are almost non-existent away from the main cities. Difficulties are even more pronounced in terms of sequencing and therefore monitoring of variants, since only a handful of African countries have the required equipment. However, we now know a little more about Covid-19-related mortality south of the Sahara. A recently published study shows that the mortality rate among patients with severe forms of the disease is much higher on the continent (48.2% versus 30% on average on other continents), reflecting the scarcity of intensive care units and related equipment and health products (including oxygen) needed for the management of severe forms.
These trends should be read in the light of the circulation of several variants south of the Sahara. The “Indian” variant was first detected in Uganda, before being detected in Kenya, South Africa, Botswana, Angola, DRC, Nigeria, Zambia and Zimbabwe. The so-called South African variant, identified in 2020, has since been found in twenty other African countries. In December 2020, another variant was identified in Nigeria, but it is not yet possible to determine its contagiousness. The so-called British variant is also circulating on the continent, where it has been found in twenty countries.
But it is certainly the question of vaccines that is currently dominating the conversations. The United Nations Security Council on May 19 recalled the facts: Africa has received only 2% of all vaccines administered worldwide to date. As a reminder, it is primarily through Covax – one of the three pillars of the Accelerated Access to Vaccines for AIDS-19 (ACT) – that vaccines are made available on the continent. The mechanism favors the AstraZeneca vaccine, which is manufactured in India by the Serum Institute of India. But since February, the continent has faced two new challenges. First, the AstraZeneca vaccine is much less effective against the “South African” variant, as shown by researchers at the KwaZulu-Natal Research Innovation and Sequencing Platform. As soon as these elements were known, the South African government decided to put aside the one million doses of AstraZeneca vaccine already ordered. At the end of March, India announced that it was temporarily suspending its vaccine exports in the midst of an unprecedented wave of Covid-19 outbreaks. The Serum Institute of India, the world’s largest vaccine producer, stopped shipments to Covax. Initially announced for June, the resumption of exports has now been postponed until the end of the year.
While the covid-19 pandemic continues to occupy the days and minds of global health actors, we focus this month on pandemic preparedness and its global governance. We evoke the major historical stages in the structuring of preparedness policies, before turning the gaze to the main issues currently discussed.
Health risk preparedness has been the subject of growing interest since the early 2000s. In Foreign Policy, analyst Mark Perry recalls the various concerns from which it stems. First, it is framed in the context of the “war on terror” declared by the Bush administration in the wake of the 2001 World Trade Center attacks. The fear was that large-scale attacks would be carried out using a pathogen. But the concern for spontaneous outbreaks was also growing. More and more scientists warned then of the inevitable occurrence of pandemics similar to the one we are experiencing today: of animal origin, caused by a respiratory pathogen, and which would spread to the four corners of the planet through human circulation. In the United States, preparedness policies were particularly influenced by simulation exercises conducted between 2001 and 2019 to prepare US policy makers for such critical events. The first of these, called Dark Winter, had a profound effect on policymakers and shaped preparedness policies of the following decade.
The desire to respond to health risks on a global scale can be seen as early as 1851. Hélène De Potter, lecturer in public law, evokes the founding moment of this history: the international sanitary conference held in Paris at the initiative of Louis-Napoléon Bonaparte. She shows that the transition to a global scale raised issues that are still very relevant today: scientific uncertainties, the question of national sovereignty, the weight of economic and political issues in decision-making. In 2005, the global governance of health security took an important step forward with the adoption of a treaty called International Health Regulations. Its main tool is the declaration of a public health emergency of international concern (PHEIC), defined as “an extraordinary event that is determined to constitute a risk to public health in other States due to the risk of international spread of disease and that may require coordinated international action. Prior to Covid-19, five such extraordinary events have been reported: in 2009 (H1N1 virus), 2014 (polio and Ebola), 2016 (Zika), 2019 (Ebola).
As journalist Marc Allgöwer points out in an article in Le Temps, policies and preparedness plans oscillate according to the imperatives of the moment. In the wake of the 2008 financial crisis, the Obama administration dismantled some of the preparedness measures put in place by George Bush in 2005, before putting them back in place following the H1N1 epidemic in 2009. More recently, Ebola outbreaks of the mid-2010s have sparked renewed interest. The ability to maintain preparedness over the long term is thus a major issue. This is shown by Andrew Lakoff, a sociologist, in a reference book on the subject, published in 2017 and entitled Unprepared, Global Health in a Time of Emergency. In the French context, the non-renewal of mask stocks illustrates this point. Arnaud Mercier, professor of information-communication, offers a genealogy of the mask shortage, dating back to 2005 and shedding light on the situation observed in spring 2020.
Recent conversations point to the need for significantly increased funding for preparedness policies on a global scale. In her recent address to the United Nations, Kamala Harris calls for the creation of a global funding mechanism for pandemic response. There is indeed much to be done. A recent study by the Institute for Health Metrics and Evaluation points out that of the $41 billion (dollars) spent on global health in 2019, only $374 million were spent on pandemic preparedness. Far too little according to the International Working Group on Financing Preparedness, which estimates that in low- and middle-income countries, the need is $5 billion to $10 billion per year for the next two to three years, and that this level should be maintained for at least ten years.
Finally, many call for a broadening of the framework to include environmental issues. Henrique Lopes, professor and expert in public health at the Catholic University of Lisbon, and John Middleton, president of the Association of Schools of Public Health in the European Region (ASPHER), remind us that it would be futile not to put in place measures to prevent the occurrence of new pandemics by acting on the destruction of ecosystems. In the same line, a group of academics invites to make deep prevention, i.e. the prevention of the passage of pathogens from animals to humans, a major axis of the possible future treaty. These conversations are fueled by the upcoming United Nations conference on biodiversity to be held in Kunming next October, during which civil society organizations would like to see clear objectives set.
This month the review addresses the notion of health as a global public good. If the notion is widely used, what it exactly means is often not so clear.
We first look back at its theoretical foundations in political economy, and suggest few other articles in which elements of definition, conceptual issues raised by this notion in health policy and development, and challenges triggered by its operationalization in global health governance are addressed.
This concept appears particularly relevant in the midst of the Covid-19 crisis. We point to articles addressing Covid-19 vaccines issues through this lens. Their authors highlight discrepancies between the political and institutional discourses promoting vaccines as global public goods and the observed realities regarding their production and distribution.
Finally, some articles expand this notion to pharmaceutical products as a whole, or mobilize it for the issue of insulin.
We hope that this selection, which combines press articles and scientific articles, will provide you with useful insights into global health issues.
