A sorcerer out of control? Inequality, Trump, Brexit and reasons to avoid despair

This is the draft editorial for the 50th issue of BODHI Times, the periodic newsletter of the NGOs BODHI and BODHI Australia. I hope the newsletter will be published in early 2017.

In 1848, Karl Marx published the first issue of a slim (23 pages) pamphlet, called The Communist Manifesto. Within it is the famous phrase “Modern bourgeois society, with its relations of production, of exchange and of property, a society that has conjured up such gigantic means of production and of exchange, is like the sorcerer who is no longer able to control the powers of the nether world whom he has called up by his spells.”

This sentence, written so long ago, mesmerises me. It suggests that the forces of capitalism, beyond a threshold, are like a demon, and that capitalism itself (and the society that depends on it) can become victim of the spells which the excesses of capitalism have released. I am not a Marxist, nor a communist, but I do believe in a much fairer global society than we now have. It was partly my attraction for greater fairness that made me study medicine, focussing especially on the health problems of low-income settings – including in 1985 when I spent 10 months away from Australia, as a senior medical student, mainly learning about health problems in Africa and South Asia.

It did not take long for me to decide that purely biomedical approaches (eg better drugs or more doctors) could have little impact on the health issues of what was then called “The Third World”. This understanding propelled me to a career in public health, but in 1997 an experience I had at the Ronald Ross Centenary conference convinced me that fundamental changes in economic and political power are needed even more than vaccines and interventions such as handwashing and more toilets. This experience was the realization while many in public health work for good health, far fewer work for the economic and social reforms which underpin health, which is also necessary (as are moral and spiritual change is also needed).

Friedrich Engels, the great colleague and sponsor of Karl Marx, had similar views. His book The Conditions of the Working Class in England, which documents the harrowing living conditions of the poor in the growing industrialised city of Manchester, during a time of scarcely regulated capitalism in the 1840s, is still recommended to students of public health.

Also in the 1840s, the great German physician, Rudolf Virchow was instrumental in the formation of social medicine. In 1848 he helped establish a weekly publication called die Medizinische Reform (Medical Reform). This publication is reported to have had headlines such as “medicine is a social science” and “the physician is the natural attorney/lawyer of the poor”.

The Gilded Ages

It is unlikely to be a coincidence that the end of the 1840s (also called the “hungry 40s”) was a time of social upheaval in Europe – laissez faire capitalism had raised economic growth, but also deepened inequality, and with it, the risk of revolt against elites. Much later, Hirschman, in 1982, argued that excessively unrestrained market forces (such as in the 1840s, the gilded age of the late 19th century, the 1920s and since about 1980) can undermine the moral values that are its own essential underpinnings, generating the satire “greed is good" in the 1989 film Wall St. Hirschman's arguments support the idea that there are great cycles in the world economy; not just booms and busts, but periods of self-restraint by elites, followed by a gradual forgetting of the consequences of too much inequality. This leads to the relaxation of rules and norms intended to reduce the risk of economic collapse, for example when US President Bill Clinton repealed the Glass-Steagall Act, a cornerstone of Depression-era regulation.

The conjuring  

What happens when inequality runs out of control? It could mean revolution and regicide, but there were times when hyper-capitalism accepted greater regulation and self-restraint, such as during the Depression and following World War II. But those lessons have recently been forgotten, with consequences including Brexit, the election of Donald Trump and the rise of nationalism in many countries. The recently (and still?) dominant ideology – neoliberalism – was doomed to worsen inequality, but it remains to be seen if these new regimes will do any better. These reactions could, as Marx foreshadowed, presage an out of control sorcerer, such as a period of neo-totalitarianism, but this is uncertain. Social media and search engines have apparently been manipulated by narrow interests, and it can be argued such dark methods paved the way for Trump’s election. 

However, this is not the 1930s in Europe and Japan. With vigilance, social institutions and civil society could lead to a more prosperous and fairer future, despite President Trump’s rule, despite the clear existence of a US "shadow state" as documented by David Talbot and many others. Trump's phone call with Tsai Ing-wen, not only gave hope in Taiwan, but must also have heartened Tibetans. 

The early signs of President Trump’s rule are disturbing, such as the proposed appointment of the Goldman Sachs and hedge-fund veteran Steven Mnuchin, for US Treasury Secretary. As Joseph Stiglitz notes,  the expertise he will bring to the job will be in tax avoidance, not constructing a well-designed tax system. Also of concern is the the appointment of Rex Tillerson, the chief executive officer of ExxonMobil, as Secretary of State. But even on climate change the position is not hopeless. The drive toward renewable energy, including its declining prices, is now so strong that greenhouse gas emissions from fossil fuel combustion and industry will continue to decline. Note, however, that even if this occurs, greenhouse gas concentrations will continue to rise, and the rate of increase could even steepen due to reinforcing feedbacks, such as from melting tundra.

Irrespective of the effectiveness of politicians and the big, often neoliberal-minded development foundations (such as the Gates Foundation, the Clinton Foundation*, and even the Wellcome Trust, which continues to invest in fossil fuels) groups such as BODHI and Aryaloka Computer Education   (cover story for newsletter) are needed to reduce inequality and give hope at the ground level. 

* According to the prolific author Professor Michael Hudson, the Saudi Arabian government has been a major funder of the Clinton Foundation, a view supported by a fact checking website.

Ebola, WHO and the timidity of some infectious diseases experts to criticise those with power

This is slightly adapted from a blogpost published in BODHI, one of the NGOs I co-founded in 1989. That is called Ebola, WHO and the failures of a market based approach to global health.

The importance of the "milieu" (the social and environmental, or "eco-social") context

In 2012 I wrote a paper called "Infectious disease emergence and global change: thinking systemically in a shrinking world" in the inaugural issue of Infectious Diseases of Poverty (impact factor now 4.1). It has been moderately successful; cited 24 times to date, and for several years it was the most viewed article in the journal (and it might still be). That paper attempted to make several controversial points. One was that the risk of a globally catastrophic influenza outbreak has been grossly exaggerated. But the most important point was that the global health community needs to pay far more attention to the "milieu", the "terrain" in which infectious diseases thrive, a point about populations analogous to that made concerning the personal milieu, the individual immune system, by the Claude Bernard, who rivalled Pasteur as the most famous French health scientist in the 19th century. I suggested that there are forms of social immunity, not just determined by "herd" immunity (conferred by vaccination) but by health literacy, poverty, health systems and environmental conditions.

In 2015 I gave an invited talk at an infectious diseases conference in Spain, which I called Poverty, demography and infectious disease. This again stressed the milieu. The opening paragraph of my abstract read:

"Generations of slash and burn neoliberal, almost laissez faire development policies, with only rhetorical nods to global conservation and equity, continue to erode not only many environmental determinants of health, but also many factors that underpin social and health development. Here are three warnings to all who will listen that we live in One World with One Health."  My three warnings concerned (a) Ebola; (b) slowed poor development even in affluent Indian children, speculatively linked to the inadequacy of the sanitation system, in turn related to discrimination against the poor, and (c) how "Planetary Overload" could produce a future milieu in which public health systems fail and old diseases (e.g. TB, plague) return.

The political correctness of leading infectious diseases experts

Unfortunately, very few people in global public health seem to be in sympathy with my main point. This perception has been strengthened by my review (forthcoming for Faculty 1000 Global Health) of a recently published report concerning the Ebola epidemic in West Africa, which is still ongoing (as of March 2016). This long article is called Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola".

Its lead author is Dr Susan Moon, from the Harvard Global Health Institute. This paper is highly critical of WHO's slow response to the appalling and frightening tragedy of Ebola in West Africa, but there seems no criticism of other big players in global health, such as the Bill and Melinda Gates Foundation, the Clinton Foundation (indeed, Chelsea Clinton is a co-author) nor, indeed, of Médecins Sans Frontières‎ (who are also represented in the authors). Worse, there is no mention of neoliberalism (or any synonym for it, such as market-based approaches) but also no criticism of vertical health programs (i.e. interventions focusing on single diseases, at the expense of  broader health systems).

The crisis of funding for WHO

In 2002, the budget of WHO was reported to be less than that spent on advertising by two cola companies (Coca Cola and PepsiCo) (1). Since then the WHO budget may have fallen even more, as evidenced by quotes (in the Lancet paper) such as: "in the wake of the global financial crisis (2008) when WHO laid off more than a tenth of its headquarters staff, outbreak response capacity was deeply and disproportionately cut." "Decades of reducing assessed contributions in real terms has starved the organisation of resources."

The Lancet article includes extensive recommendations for how WHO might be strengthened, mainly by narrowing its focus and trying to wrest a different form of funding. But, again, there is no criticism of the international milieu which determines this funding.

The paper recommends that a global strategy be developed to invest in, monitor, and sustain core national health capacities. However, the onus seems then to be largely placed on WHO to do this ("WHO should convene governments and other major stakeholders within 6 months to begin developing a clear global strategy to ensure that governments invest domestically in building core capacities and to mobilise adequate external support to supplement efforts in poorer countries.")

We cannot just focus on firefighters: we need to reduce the risk of catastrophic fires

But the broader challenge of promoting development in low-income settings appears to have been overlooked in this paper. Firefighters are needed, but so is fire prevention. London banned thatched roofs following its Great Fire (1666).

WHO cannot do everything. There is far too little recognition that market forces, untramelled, combined with laissez-faire, environmental policies and population growth generate the milieux in which Ebola and other pandemics thrive (the point I made in my 2012 paper mentioned above.) This blindspot is also evident in a paper written by Bill Gates about Ebola.

This difference can also be seen as that between Bernie Sanders and Hilary Clinton. Clinton and other supporters of neoliberalism hold most power, and appear to sincerely believe in their own rhetoric; they know best. But many younger Democrat  supporters, who strongly favour Sanders, recognise the failure of conventional policies to give hope to the poor and the young. Donald Trump's support is driven by some similar factors; especially the realisation that so-called free markets are failing the inner-cities. Trump's isolationism is likely to further erode support for WHO, and the U.N. However I am uncertain Trump's policies will be that much worse for other determinants of global health than of Hilary and Bill Gates. However, at least, Melinda Gates has some awareness of the risk of unrestrained population growth.

References

1. Lang, T., Rayner, G.; E., K. The food industry, diet, physical activity and health: A review of reported commitments and practice of 25 of the world’s largest food companies. Report to the World Health Organization; City University Centre for Food Policy, London UK: 2006.