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" which was published 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, the second most eminent French health scientist in the 19th century (second only to Louis Pasteur). 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.

I have just reviewed a paper for the Faculty 1000 (global health section). The paper I reviewed (published in the Lancet) 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". The lead author is Dr Susan Moon, from the Harvard Global Health
Institute. I will here sometimes call this paper "the Lancet article (or paper)".

This paper is highly critical of WHO's slow response to the appalling and frightening tragedy of Ebola in West Africa but there is 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). Of more concern, there is not only 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. The closest mention to a criticism of market-based economies is in Recommendation 7: ("funders should establish a worldwide research and development financing facility for outbreak-relevant drugs, vaccines, diagnostics, and non-pharmaceutical supplies (such as personal protective equipment) when commercial incentives are not appropriate").

There seems little if any recognition that market forces, untramelled, combined with laissez-faire, environmental policies and population growth could 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 favor 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.

Woke up this morning listening to this report by an Australian journalist from China, a country whose policies have long disturbed me and which still do. Many Chinese people strive for greater freedom, but their hope seems to be fading under an increasingly repressive regime. This insightful report "Political reality: why are so many journalists in China giving up?" is the tip to the iceberg.  You can download the text here and also listen to it via the link.

Here are some highlights:
MATTHEW CARNEY: Since Xi Jinping became leader, the government has launched an all-out assault on freedom of expression, jailing journalists, bloggers and outspoken civil rights lawyers.

On the Reporters Without Borders press freedom ranking, China now occupies 176th position out of 180 countries.

DAVID BANDURSKI: We're seeing a lot more pessimism because it's impossible to do just about anything. It used to be that journalists had a kind of wiggle room. Journalists were finding a way to do stories.

In fact, in some cases they were finding a way to do exposés, investigative pieces of a quality that we would see outside China, internationally. World-class journalism was happening in China.

MATTHEW CARNEY: Many journalists can't see the point anymore. David Bandurski says there's an exodus of talented journalists leaving the profession.

DAVID BANDURSKI: The political environment is so tight right now that it's impossible to do anything professionally. So if you see yourself as a journalist, a professional journalist who wants to get the story, who wants to make your publication succeed, then your hands are basically tied.

And they can only deal with that frustration for so long.

MATTHEW CARNEY: This journalist worked at a prominent state media outlet for four years. He wants to remain unidentified as he fears reprisals.

He says reporters have little choice but to be a mouthpiece for the government.

CHINESE JOURNALIST 1 (translation): The general control of speech is tightening. It's a negative influence on reporting. I don't see any sign of it loosening up. All Chinese journalists are experiencing this problem.

MATTHEW CARNEY: When he covered recent workers' protests in China's coal belt, he had troubles getting his work published. But digging deeper into working conditions and company accounts was not acceptable.

(Sound of journalist speaking in Mandarin)

CHINESE JOURNALIST 1 (translation): I went to the north-east of China to cover a workers' strike. On the third day, I was required to draw back from it by an order from the Department of Publicity. And I was not allowed to do any follow-up reports.

MATTHEW CARNEY: He says there is a darker side to Chinese journalism that few talk about.

Many of his colleagues have been offered bribes, intimidated or threatened with violence by government or business. He says one of his colleagues was forced to leave China because of the threats.

(Sound of journalist speaking in Mandarin)

CHINESE JOURNALIST 1 (translation): Threatens from entrepreneurs could be: "We will send people to beat you up. We know the address of your home and we know where you work."

And threatens from government officials could be: "You are not acting in accordance with the publicity regulations," or, "We will take care of you later if you keep acting like this."

MATTHEW CARNEY: He became a journalist to change China and make it a better place. But he's realized that not possible, so now he has just taken a job in public relations.

(Sound of second journalist speaking in Mandarin)

MATTHEW CARNEY: Another Chinese journalist who wants to remain unidentified is still working in senior roles in Chinese state media.

He says an intricate, multi-layered system of censorship has developed over the decades of one-party rule - and it starts with oneself.

(Sound of second journalist speaking in Mandarin)

CHINESE JOURNALIST 2 (translation): The domestic media has formed a custom, which is to evaluate the risk of story proposals before starting them. We call it "self-castration". We would think whether we can publish it and the possible risks if we publish it.

MATTHEW CARNEY: The journalists we spoke to are not optimistic about the future and despair of Xi Jinping's ever-growing shadow over the profession and his quest for absolute control.

(Sound of second journalist speaking in Mandarin)

CHINESE JOURNALIST 2 (translation): There is a trend for journalists to leave this industry and many are disappointed. Journalism is supported by dreams and emotions, but the dreams have been broken.

Many capable people have left this industry and the ability to investigate has been shut down.

MATTHEW CARNEY: This is Matthew Carney reporting for Correspondents Report from Beijing.