Examination of Witnesses (Questions 980
- 999)
MONDAY 12 MAY 2008
Professor David Fidler and Dr Kelley Lee
Q980 Lord Jay of Ewelme:
How do you get that traction? Like you, I did not see very strong
arguments against everything that was put forward, but I still
come back to the question of how do we get the traction to encourage
the kind of better co-operation that we are looking for, if we
are going to deliver the goals that I think we all want. How do
we do that?
Professor Fidler: I think you have to match
up these innovative governance proposals with the self-interests
of States. Kelley mentioned that the problem is a double-edged
sword. You appeal to certain new types of ways of thinking about
global health: security, economic power. Even in the context of
development, this is new. If you think about what are the basic
functions of a country's foreign policies, they are to protect
security, economic prosperity, development in strategically important
areas, and human dignity agendas. If you look at those four functions
of foreign policy, global health and public health can play a
very powerful role, so you need to work across those functions
to embed the importance of public health as much as possible.
If you start to do that, you are then picking up public health
in more of these nodes of network governance than you were before,
so it is being talked about in the Security Council as well as
in the UN human rights organisations; it is being talked about
in the WTO as well as at the Gates Foundation. Iteratively, this
is a source code. It develops over time and becomes the standard
against which the next innovation has to achieve. You are building
through this network a source code that can be used for any given
initiative. It is still to a certain extent decentralised: it
does not have this sort of command and control feature. I do not
think we can get there, but I do think it is possible to make
progress with regard to embedding public health across these different
policy areas in different types of governance initiatives that
are taken inside the health context as well as outside the health
context.
Q981 Lord Jay of Ewelme:
Could I ask you, Dr Lee, whether you would like to comment on
this. I got the impression that you had a slightly more directive
approach than Professor Fidler.
Dr Lee: Perhaps I need to think about this network
idea and source codes, to understand it a bit better. I suppose
it is no secret that I have always been a supporter of the WHO,
for all its faults. Maybe that is because it is probably the most
democratic organisation for health that we have, although it is
not perfect by any means. Maybe it is a step forward—if
not the step that we need, enough of a step—maybe going
back to what the WHO could do and what we could do to support
the WHO. The thing that really comes out when I have looked at
the organisation is that it has not been enabled to do what it
is supposed to do. From the very beginning, it has always had
one hand tied behind its back, if not two. As certain countries
have been unhappy with its performance, they have withdrawn resources
and they have withdrawn programme areas, and that, in turn, weakens
the organisation more, so you get into this kind of cycle. I am
not trying to be an apologist for the organisation—there
are some huge problems with it. But, if we got rid of the WHO,
we would have to create another one anyway. So somehow we have
to fix this thing we have. There was a suggestion in the Lancet
a few weeks about creating a Committee C which is a practical
suggestion of how the World Health Assembly could bring in these
various non-State actors, these various other institutions that
influence global health probably more so than the WHO. In such
a committee, global health actors would reach some sort of an
agreement, a consensus. This would be a mechanism to create some
sort of agreement. It is more of an immediate step, I suppose,
a small practical step. I do not think it is going to solve everything,
but I thought that was quite an interesting idea, to have somewhere
where people could meet. I also thought the UK particularly had
an interesting role, because of being part of the EU and having
to negotiate giving up some degree of sovereignty as a result
of EU membership to this supranational authority. There must be
some lessons there for other countries, not just from the UK but
other EU Members, about how we got there. I know it has been a
painful process, but it is notable that, as a Member State, the
UK as been willing to give up some sovereignty in order to serve
some collective good. EU policy on public health admittedly has
been a bit slow to develop and in the kinds of policy areas that
the EU has focused on, but it is starting to come onto the negotiating
table. Maybe this is where somebody could look at how this could
be extended beyond the EU and think about some practical steps
forward. I have some general observations about the Framework
Convention. I do not feel I am an expert on the legal side, but,
having worked on Tobacco Control. It is an area of interest to
me. I have observed how the whole negotiation process works and
have attended some of the negotiations. It is a very interesting
political process in itself, but it was a particular issue. If
we could not get an agreement on Tobacco, I do not think we could
get an agreement on anything. It was an obvious public health
issue. When you get into other areas, when you get into a Global
Health Framework Convention, what would go into that? How would
you identify what you need to do, what are the policy measures?
I guess that, when we tried to look at the global strategy for
diet, nutrition, and physical activity, there was a lesson that
perhaps Tobacco was just different and it just had legs that other
health issues did not. I am happy to consider all sorts of ideas
but it does not immediately strike me as a way forward.
Lord Jay of Ewelme: Thank you.
Q982 Lord Avebury:
If I can summarise what you were saying earlier, Professor Fidler,
it was that we cannot control the behaviour of "States or
Gates". In the circumstances, we have what you described
in the final paragraph of your memorandum as "open-source
anarchy". I suppose you have used that in a pejorative sense.
In some of the things that you have been saying in your previous
answers, I am in some doubt about that, because, drawing the analogy
from the world of software, open source has been tremendously
successful, not only in the development of Linux but in something
that people play with every day, Wikipedia. It might be a useful
analogy because, even though Wikipedia started off as being totally
unpoliced, I believe that there are mechanisms now whereby things
that are objectionable in one way or another can be removed. In
the public health debate we do not have any sort of Darwinian
mechanism for removing things that are not productive or useful,
so we get this proliferation of actors which is virtually without
limit, so far as I can see. I wonder if you think that one could
analyse the tasks that need to be done and divide them up into
sectors (such as surveillance, monitoring the spread of existing
diseases, treating people already affected, and building health
systems) and create particular mechanisms that work within each
of those fields? So far there has been a concentration on particular
diseases, and you have already criticised that and you have said
it is at the expense of developing public health systems, particularly
in the countries that are lacking in proper standards of governance.
Should there be some international mechanism for doing those things?
Professor Fidler: I think there needs to be
an international mechanism for working on all those areas. To
a certain extent, there has been a division of labour, if you
will, with regard to those tasks for a long time. The question
is: how is the division of that labour changing? Is the new context,
which I call open-source anarchy, making things worse? Or is it
making things better? Or is it too early to tell? I use that concept
not to be pejorative or to be negative. I am trying to capture
in a more conceptual and theoretical way how the nature of international
relations is changing. I can send you an article where the entire
theory is laid out, if you want, in more detail.
Q983 Lord Avebury:
I would be interested.
Professor Fidler: I develop this idea not just
for public health. This is also happening in every other area
as well. This is a big problem with terrorism and counter-terrorism.
What I mean by open-source anarchy is the following. Just to make
sure you understand how I am using the terms, anarchy does not
mean chaos. It just means that there is lack of—
Q984 Baroness Falkner of Margravine:
Absence of order?
Professor Fidler: Well, no, it does not mean
that. In the way it is used in international relations, it just
means that the actors in the system do not recognise a common
superior body.
Q985 Baroness Falkner of Margravine:
Hedley Bull's absence of order?
Professor Fidler: There is order in anarchy.
It is the anarchical society. That is what Hedley Bull meant by
that. How is anarchy changed? How is that creating order and anarchical
system change? It used to be State-centric. States treated it
as their property: they decided what happened, they filtered all
the ideas, they were the only actors that really had material
power to emphasise what ideas we chosen. That is changing now.
Non-State actors can now access anarchy and influence anarchy
in a way that we have never seen before. Again, that is true of
terrorist groups and that is true of Bill Gates. This is a phenomenon
that is permeating international relations generally.
Q986 Lord Avebury:
I am sure he would not enjoy the comparison!
Professor Fidler: No, he would not, but this
is part of what is going on. So, when I talk about open-source
anarchy, that is what I mean. Again, this is where the "source
code" comes from. How is that going to operate differently
from the anarchical society that operated in ways proprietary
to States. There is potential for great progress here. We have
started to see this in global health: new International Health
Regulations; the International Finance Facility for Immunisation;
Advance Market Purchase Commitments; the Global Fund. These are
all happening, where non-State actors are working with intergovernmental
organisations and States in accessing that anarchy and trying
to change the way in which things operate. You can see that happening.
You can see progressive steps being made. We are concerned about
whether or not this is going to have a sustainable long-term impact,
but there is no question but that really interesting, important
stuff is happening in this new context. Another feature of open-source
anarchy is that those conditions which exist today that have allowed
all this to happen could disappear very quickly, and you could
see the re-emergence of a State-dominated proprietary system that
is back to the old balance of power problems—what Hedley
Bull was thinking about in terms of those issues. If that happens,
you will see Health disappear—and I use that word intentionally—from
the global agenda. The political prominence we have in Health
today is the result of the very specific political conditions
that have developed in the post-Cold War period. Unless Health
gets embedded in all these functional areas of foreign policy
and gets deeply embedded, if we have big systemic changes, where
we have great power rivalries coming back to the surface again,
this will disappear. We will not be talking about health as a
foreign policy issue in the way we do today.
Q987 Lord Avebury:
The great thing about the AMC is it does not encroach on the political
sovereignty of states. Mechanisms of that kind could be developed
with everybody's approval. It does not require some consent mechanism
from the international community.
Professor Fidler: That is also interesting about
the International Finance Facility for Immunisation organisation:
you are accessing private debt markets to fund childhood immunisations.
Wow! This really is thinking outside the box. In the PRODUCT(RED)
campaign, you buy a product that is coloured red and part of the
profits go to the Global Fund to help AIDS, Malaria and Tuberculosis.
These are all interesting initiatives which are having a positive
impact. The big question is: are they sustainable in the long
term? There is a public health concern about that and then there
are larger political concerns, but the conditions have facilitated
that at this particular moment in time.
Q988 Baroness Falkner of Margravine:
From your rather Hobbesian, Leviathanesque State, let us go to
developing countries, where perhaps life is pretty nasty, brutish
and short. Many of the witnesses we have had here have identified
some factors that are common to many developing countries that
face public health issues, of far larger significance than in
the developed world. They focus on governance, poverty, and some
of the usual suspects in identifying where problems lie. If you
were to leave Hobbes and move to Immanuel Kant, which is where
I come from, where would you place external actors (whether they
are intergovernmental organisations, other States, the donor community)
and their ability to be able to help with some of these challenges?
You were quite negative about regime change. I am a great believer
in regime change. I think we have evidence of regime change all
over the place. Incidentally, perhaps I could take you back to
something you said earlier which I was dying to come in on, when
you were talking about the power of Gates intervening in Indonesia.
Chickens come home to roost. Back in the 1970s, it was the multinationals
which had those powers; even more recently Monsanto. If Gates
is a counter to Monsanto, some of us are not complaining about
that.
Professor Fidler: Let us go with Immanuel Kant,
if you will. In Kant's recipe for perpetual peace, the first principle
is that every constitution of every State shall be a republican
democracy. The second thing you need to do is to develop economic
interdependence between States. These are major macro political
changes that have to be pursued with regard to improving governance.
There is not a whiff of Health here at all, in terms of Health
being a factor in creating the conditions necessary for good governance
in the societies. Let us connect this immediately to the EU. Why
can we not EU the rest of the world? How did the EU develop? Public
health was not on the agenda for integration, right, until—
Q989 Baroness Falkner of Margravine:
But Coal and Steel were!
Professor Fidler: Coal and steel were, but it
was not Health. From a foreign policy point of view, if I want
to fix the governance problems that exist in developing countries,
I have these governance problems, and if I am versed in what the
EU did and I understand or I believe in what Immanuel Kant did,
I am not talking about health issues. Health issues are not on
my agenda. I am talking about the bigger changes. I am talking
about regime change with a big `R': (1) we have got to change
the nature of the government; (2) we have to hook that government
into the global market-place, so that it becomes economically
interdependent, so it is less likely to go to war.
Q990 Baroness Falkner of Margravine:
Then the Compact comes back on the table, because the Compact
is one way forward?
Professor Fidler: The Global Compact?
Q991 Baroness Falkner of Margravine:
Yes.
Professor Fidler: No. That has nothing to do
with spreading democracy and spreading free trade.
Baroness Falkner of Margravine: No, but
it is a co-operative mechanism.
Chairman: We are heading off into a different
area here. Essentially, you are after whether we should be focusing
more on, if you like, the ability of governments to cope. We will
not get into regime change now. It is a very interesting discussion
and I would be very keen on such discussion, but not here and
not now.
Q992 Baroness Falkner of Margravine:
My Lord Chairman, that is right.
Professor Fidler: From a Kantian point of view,
intergovernmental organisations are not the key.
Q993 Chairman:
That is what I picked up from your paper. You are saying it is
not the intergovernmental organisations.
Professor Fidler: If we are talking about the
Kantian approach, we would not be talking about the role of intergovernmental
organisations. If you get those underlying domestic conditions
set properly (democracy, free trade), intergovernmental organisations
are secondary. We can move from Kant to the real world, where
intergovernmental organisations have to play a facilitating role;
for example, on Free Trade, the WTO; or the European Union, to
go from Coal and Steel to a Common Market. You need institutional
mechanisms in order to do that. But what is interesting, if you
are talking about the big reform issues—and the EU is the
classic example of this—public health has not been on that
integrating agenda until very recently. If other countries are
going to take a lesson away from that, it would be: to fix these
problems, you are not worrying about public health.
Lord Jay of Ewelme: I think myself there
is a slightly tighter connection between the two. The real motivation
behind the European Union was the avoidance of war. The equivalence
here is the avoidance of disease. I think there is a slightly
more interesting link than perhaps you have suggested. Anyway,
that is another point.
Q994 Baroness Whitaker:
There are those who argue that, far from fading from foreign policy,
health is becoming more part of it. Not, unfortunately, in the
way that I think Dr Lee advocates—that there is a point
in investing in the health infrastructure of developing countries
so that the disease will not be communicated to the developed
world—but health as a security issue is part of national
policy: all this stuff about screening migrants and so on. Health
as a security issue—which is quite bad for the improvement
of health—is surely a live matter in foreign policy?
Professor Fidler: It is at the moment. There
is no question that health as a foreign policy issue is now more
important today than it has ever been in history across all of
these functions. That is true today. My point is that there are
particular political conditions that have allowed that to happen.
For example, many of us in the United States are quite worried
about what happens if Iraq goes under. We pull out; things go
bad; you are not going to see health talked about as a security
issue. We are going to have much bigger problems on our hands
with regard to these issues. Or if the rivalry with China intensifies.
The competition with China in Africa, I know, is of huge concern
to the United States as well as to African countries. I am here
to tell you that public health is not on that agenda as a security
issue. Things could change that alter the political conditions
which have allowed health to become more important. That is why
it is so critical right now, at this moment, to try to get that
right and embed it as deeply as possible, so that it will remain
higher on the agenda as these changes occur—which we know
they are going to. That is just the nature of international politics.
That is why, again, this network, this iterative approach, might
be more effective from that point of view than trying to think
about a command and control structure from one or any number of
intergovernmental organisations. That is my concern. I do not
think we are disagreeing in that context, but I think we have
to be careful not to assume that the conditions that exist today,
which have allowed health to be more important politically, are
going to continue.
Q995 Baroness Eccles of Moulton:
Professor Fidler, before I get into asking you your views about
Health Impact Assessments, there is something I am quite curious
about. Earlier on you have mentioned once or twice that we are
in a state of transition with regard to global communicable diseases,
and I just wondered if you could say what has caused this and
why we are at this particular point.
Professor Fidler: The major reasons why we are
in the transition that we are in at the moment are: first, there
has been global realisation but, more importantly, realisation
on the part of the rich developed countries, the great powers,
that emerging and re-emerging infectious diseases are a threat
to us and our interests directly and indirectly. That is part
of the reason why it has arisen on all these various agendas.
Second, what we have in place now is not working. We have had
to move towards creating new types of mechanisms, new types of
strategies in order to deal with it. As part of this proliferation,
in all of these areas we see all these kinds of initiatives taking
place. Underlying all of that in terms of this crisis of emerging
and re-emerging infectious diseases are all of the things which
are accelerating the processes of globalisation. The speed and
the scale of change, economically and politically or epidemiologically,
if you will, is speeding up events. This is part of the world
in the 21st century, but globalisation still being tethered to
the 19th century apparatus. We have got to shift that. That is
part of the causation factors underneath why this transition is
happening.
Q996 Baroness Eccles of Moulton:
It is important to understand that in order to move forward progressively
rather than regressively?
Professor Fidler: Yes. There is, to a certain
extent, a widespread understanding that we are in transition.
There are various levels of happiness and unhappiness about the
transition and where it is going. That is part of this process
that we are going to need to go through. Even in connection with
the establishment of the World Health Organisation, that just
did not happen. We had international health organisations prior
to that, so that was also an iterative process leading to a mechanism
which had its day in the sun, if you will. It is still very important,
I agree with Kelley. We do not throw the WHO out of the window—far
from it—because there are aspects of this transition where
the WHO is going to become even more important than it has ever
been in the history of its existence. That is also important to
remember about this transition.
Q997 Baroness Eccles of Moulton:
Perhaps against that background you can give us your views on
Health Impact Assessments and whether they can be used in non-health
areas as well in order to promote their function.
Professor Fidler: I think it is a possibility.
I do not know whether the Committee has looked at the experience
that the World Bank's International Finance Corporation has had
with health, social, and environmental standards in connection
with financing foreign direct investment, but there is already
a built-in process in that mechanism, where health, environmental,
and other social impacts are assessed prior to decisions made
on financing. Also in connection with the application of the Equator
Principles, where a consortium of private banks that do development
assistance have signed up to similar principles to what the World
Bank uses. To some extent, there is already fairly extensive evidence
of positive as well as negative impacts of using these sorts of
impact assessment statements. Let me take you again to the health
context specifically. I have not written specifically about this,
but my sense in terms of looking at specific concrete disease
areas is that Health Impact Assessments might play a role. I have
some scepticism that, when you start broadening this out and you
are back into the social determinants of health again, then, in
order to have a Health Impact Assessment mean something, you really
have to have two things in place. The first, whatever entity is
doing the Health Impact Assessment, has to have the ability then
to say, "You need to do x, y or z, because we find a problem."
That entity also has to have enough resources to help that country
do it according to the conditions laid out with regard to capacity
building. That is exactly what the WHO does not have. It does
not have the resources. It does not have the authority to do that.
What organisation has that authority? The World Bank. This is
what they do with their principles. Even the WTO does not have
the mandate to engage in a Health Impact Assessment, or any type
of assessment for that matter. That is something that is left
to the State. When you start getting out these bigger capacity-building,
horizontal systemic concerns that we are worried about, that is
the point at which I start to wonder whether or not Health Impact
Assessments are going to be effective, absent those conditions
which make it effective in those contexts where we already see
it.
Q998 Chairman:
Perhaps I could ask you, Dr Lee, if you would like to come in
on what has just been said about Health Impact Assessments.
Dr Lee: I have only done a little bit of work
on Health Impact Assessments. I think there is a tendency to think
it is a quantitative tool, I suppose. However, there is still
a lot of qualitative skills and judgment used in the methodology
around this. I think it really is not necessarily a bad approach
but it always comes back to a battle of political vision a normative
issue. I am not making myself very clear. I have been looking
at trade issues. When trade agreements are agreed, public health
people notoriously complain that they are not around the table
to discuss trade issues and then some of these policy decisions
are found to be quite adverse to health: The belief is that if
we had a Health Impact Assessment perhaps we could get a bigger
voice and prove that we should be around the table. However, I
think it is a bigger political problem than that. There are limitations
to how much we can use Health Impact Assessment. We may be able
to use it more at the national level than the global level. There
are examples where we have one initiative that is trying to promote
health in a country, and then another initiative comes along and
completely wipes out any benefit. It might be a trade issue. Or
it might be a situation where we are trying to train up health
workers in sub-Saharan Africa, and then another initiative seeks
to recruit those health workers and bring them to another part
of the world. There are these contradictions. If we had those
sorts of concrete things, maybe we could apply HIA, but beyond
that I am not sure. Maybe we could look at that more. Overall,
at the global level, I think there are limitations.
Q999 Baroness Eccles of Moulton:
We have been looking ahead very much for the wider, global policy
aspects of this. I wonder, if we could travel through country
governance, through regional to local, to the village, and look
at the horizontal-versus-the-vertical effect on applying health
work to the locality, where having the horizontal structures in
place are obviously hugely important in order to be able to provide
the vertical health care—although so often, as we understand
it, the vertical comes in and has a project and dishes out the
medicine and goes away again. What is your view on doing everything
possible to encourage the powers that be to get better established
the horizontal structures?
Professor Fidler: Part of that, again, as you
embed the public health principles of what is needed, even if
you are just talking about raw self-interest—or maybe this
is enlightened self-interest or whatever phrase you want to use
in connection with that—we need to understand that we are
concerned about protecting ourselves. That is not only in terms
of my understanding of the capabilities that we need, but I think
it is also important that developing countries have to understand
that as well. Again this goes to the governance issue: unless
they are willing to understand that—again, they do not care
about health in the US, right, but for their own purposes, their
own security, their own economic power, their own sense of development,
they need to pay attention to these issues. That would be an enormous
step forward, because, despite all the talk and rhetoric about
global health, it is often the case that governments do not care.
They will take the vertical programme, take the money, but they
then pull money out: "Bill will pay for it, and I will spend
the money on something else, or put it in my Swiss bank account."
There is not a sense yet, even in terms of that raw sense of national
self-interest in many of these countries around the world, that
this is an important issue. It sometimes frustrates people in
global health that selling the issue as a human right to health
or as a humanitarian concern has not worked. We have to have a
different approach that cuts across all of these interests that
a State would have with regard to these issues. Second, if you
start to have a little bit of resonance there, then perhaps you
can start with programmes.—and maybe they are a hybrid of
vertical and horizontal—which go with the basics of what
you need. Surveillance, for example, is a classic example of that.
You need to build core surveillance capabilities. We have the
International Health Regulations here which focuses exactly on
that. Here is an opportunity to implement this understanding now
that we have about surveillance's importance. Implementing that
then obviously gives more credence and credibility to the World
Health Organisation in terms of it trying to systematically—from
local to sub-regional, state, national, global-build these systems.
It is going to be bit by bit, because you cannot just all of a
sudden have a health system developed. The second aspect, also
stressed by the IHR, is core response capabilities with regards
to these issues. Again, that is a horizontal and vertical issue
that you need to work on. Implement that particular set of obligations
that you have, tie these interests together, make them more interdependent,
in the way that we have seen interdependence in other areas. This
is something where people in public health confuse two things.
They confuse inter-dependence and inter-connectedness. We are
inter-connected in virtually every health context; we are not
inter-dependent in all health contexts. It is inter-dependence
that gives you the stronger basis for collective action internationally.
Dr Lee: I would support the idea that vertical
and horizontal are mutually exclusive. There are ways of building
in, and taking advantage of the political support for specific
diseases that we will always have for various reasons and combining
this with capacity building and other elements of the horizontal
approach—disease-focused initiatives as a kind of Trojan
horse, for health systems development perhaps. I think donors
can do that very effectively. That may not cost more money, but
it is the way you may train local health workers and build institutions
for the longer-term. I think there are ways of integrating them
better given I do not think we are ever going to get away from
vertical approaches unfortunately. That is all I would say.
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