Health in the age of asset manager capitalism

A relatively small number of for-profit asset managers-financial intermediaries that invest capital on behalf of other investors-have emerged in recent decades to become some of the most influential commercial actors in the global political economy. Despite their important role in society, asset managers have received little attention from a public health perspective. In this article, we aimed to propose a conceptual framework of potential pathways and mechanisms through which asset managers may influence health and equity. The framework included asset class-specific pathways related to investments in publicly listed corporate equity, private equity, 'real assets' (e.g. housing, hospitals, farmland) and commodities. The framework also included more generalized pathways, focusing on ways in which the large and highly concentrated asset management sector can drive economic inequities, influence policy and political decision-making and shape the global 'development' agenda. We argue that measures challenging so-called 'asset manager capitalism', such as promoting and protecting the public ownership of companies and assets in essential sectors, are imperative to address the commercial determinants of ill health and inequity.

The social lives of point-of-care tests in low- and middle-income countries: a meta-ethnography

Point-of-care tests (POCTs) have become technological solutions for many global health challenges. This meta-ethnography examines what has been learned about the 'social lives' of POCTs from in-depth qualitative research, highlighting key social considerations for policymakers, funders, developers and users in the design, development and deployment of POCTs. We screened qualitative research examining POCTs in low- and middle-income countries and selected 13 papers for synthesis. The findings illuminate five value-based logics-technological autonomy, care, scalability, rapidity and certainty-shaping global health innovation ecosystems and their entanglement with health systems. Our meta-ethnography suggests that POCTs never achieve the technological autonomy often anticipated during design and development processes. Instead, they are both embedded in and constitutive of the dynamic relationships that make up health systems in practice. POCTs are often imagined as caring commodities; however, in use, notions of care inscribed in these devices are constantly negotiated and transformed in relation to multiple understandings of care. POCTs promise to standardize care across scale, yet our analysis indicates nonstandard processes, diagnoses and treatment pathways as essential to 'fluid technologies' rather than dangerous aberrations. The rapidity of POCTs is constructed and negotiated within multiple distinct temporal registers, and POCTs operate as temporal objects that can either speed up or slow down experiences of diagnosis and innovation. Finally, while often valued as epistemic tools that can dispel diagnostic uncertainty, these papers demonstrate that POCTs contribute to new forms of uncertainty. Together, these papers point to knowledge practices as multiple, and POCTs as contributing to, rather than reducing, this multiplicity. The values embedded in POCTs are fluid and contested, with important implications for the kind of care these tools can deliver. These findings can contribute to more reflexive approaches to global health innovation, which take into account limitations of established global health logics, and recognize the socio-technical complexity of health systems.

Is qualitative social research in global health fulfilling its potential?: a systematic evidence mapping of research on point-of-care testing in low- and middle-income contexts

BACKGROUND

Qualitative social research has made valuable contributions to understanding technology-based interventions in global health. However, we have little evidence of who is carrying out this research, where, how, for what purpose, or the overall scope of this body of work. To address these questions, we undertook a systematic evidence mapping of one area of technology-focused research in global health, related to the development, deployment and use of point-of-care tests (POCTs) for low-and middle-income countries (LMICs).

METHODS

We conducted an exhaustive search to identify papers reporting on primary qualitative studies that explore the development, deployment, and use of POCTs in LMICs and screened results to identify studies meeting the inclusion criteria. Data were extracted from included studies and descriptive analyses were conducted.

RESULTS

One hundred thirty-eight studies met our inclusion criteria, with numbers increasing year by year. Funding of studies was primarily credited to high income country (HIC)-based institutions (95%) and 64% of first authors were affiliated with HIC-based institutions. Study sites, in contrast, were concentrated in a small number of LMICs. Relatively few studies examined social phenomena related to POCTs that take place in HICs. Seventy-one percent of papers reported on studies conducted within the context of a trial or intervention. Eighty percent reported on studies considering POCTs for HIV and/or malaria. Studies overwhelmingly reported on POCT use (91%) within primary-level health facilities (60%) or in hospitals (30%) and explored the perspectives of the health workforce (70%).

CONCLUSIONS

A reflexive approach to the role, status, and contribution of qualitative and social science research is crucial to identifying the contributions it can make to the production of global health knowledge and understanding the roles technology can play in achieving global health goals. The body of qualitative social research on POCTs for LMICs is highly concentrated in scope, overwhelmingly focuses on testing in the context of a narrow number of donor-supported initiatives and is driven by HIC resources and expertise. To optimise the full potential of qualitative social research requires the promotion of open and just research ecosystems that broaden the scope of inquiry beyond established public health paradigms and build social science capacity in LMICs.

Challenges in international health financing and implications for the new pandemic fund

BACKGROUND

The failures of the international COVID-19 response highlighted key gaps in pandemic preparedness and response (PPR). The G20 and WHO have called for additional funding of $10.5 billion per year to adequately strengthen the global PPR architecture. In response to these calls, in 2022 the World Bank announced the launch of a new Financial Intermediary Fund (The Pandemic Fund) to catalyse this additional funding. However, there is considerable unclarity regarding the governance makeup and financial modalities of the Pandemic Fund, and divergence of opinion about whether the Fund has been successfully designed to respond to key challenges in global health financing.

METHODS/RESULTS

The article outlines eight challenges associated with global health financing instruments and development aid for health within the global health literature. These include misaligned aid allocation; accountability; multistakeholder representation and participation; country ownership; donor coherency and fragmentation; transparency; power dynamics, and; anti-corruption. Using available information about the Pandemic Fund, the article positions the Pandemic Fund against these challenges to determine in what ways the financing instrument recognizes, addresses, partially addresses, or ignores them. The assessment argues that although the Pandemic Fund has adopted a few measures to recognise and address some of the challenges, overall, the Pandemic Fund has unclear policies in response to most of the challenges while leaving many unaddressed.

CONCLUSION

It remains unclear how the Pandemic Fund is explicitly addressing challenges widely recognized in the global health financing literature. Moreover, there is evidence that the Pandemic Fund might be exacerbating these global financing challenges, thus raising questions about its potential efficacy, suitability, and chances of success. In response, this article offers four sets of policy recommendations for how the Pandemic Fund and the PPR financing architecture might respond more effectively to the identified challenges.

An Epidemic of Drug Resistance: Tuberculosis in the Twenty-First Century

With an estimated two billion people being carriers of latent tuberculosis infection (LTBI), the gains achieved by increasing access to diagnostics and treatment, although substantial, have had a modest impact on the global burden of tuberculosis (TB). At the same time, increased access to treatment has had the unintended consequence that drug-resistant TB (DR-TB) has increased dramatically. Earlier TB control strategies strongly emphasizing medical treatment have failed to address these issues effectively. The current strategy to eliminate TB by 2050 is accompanied by a call for a paradigm shift, emphasizing patient rights and equity more. Based on ethnographic fieldwork in Odisha, India, and global-level TB conferences, this paper contrasts the dynamics of global health policy and strategy-making with the lived realities of patients with DR-TB. A more thorough rethinking of the biosocial dynamics that impact the pathogenic disease is required to develop a comprehensive paradigm shift for TB control in the twenty-first century.

Health for all? Pasts, presents and futures of aspirations for universal healthcare

In this special issue, we bring together anthropological and historical work that considers successive aspirations towards 'health for all': their pasts, their futures, and their diverse meanings and iterations. Across the world, hopes for providing 'health for all' were central to nation building in the long 20th century, and for international relations, particularly after the second world war and the establishment of the WHO. Health became seen as a fundamental good by citizens of North and South and has remained a central force shaping global and national politics until today. But what does 'health for all' actually mean, and how did it come to matter? In this introduction we approach 'health for all as a situated, multi-faceted phenomenon, that - while having a shared aspiration towards universality of access and equality of care - comes into focus in partial, diverse and contentious policies, programmes, projects and practices. Beyond homogenising narratives that frame 'health for all' in terms of either success or failure, the special issue highlights the diverse iterations that 'health for all' has taken on the ground for different subjects and groups of people, exploring exclusions and limitations as well as dreams and aspirations.

Regulation of genetically engineered (GE) mosquitoes as a public health tool: a public health ethics analysis

BACKGROUND

In recent years, genetically engineered (GE) mosquitoes have been proposed as a public health measure against the high incidence of mosquito-borne diseases among the poor in regions of the global South. While uncertainties as well as risks for humans and ecosystems are entailed by the open-release of GE mosquitoes, a powerful global health governance non-state organization is funding the development of and advocating the use of those bio-technologies as public health tools. In August 2016, the US Food and Drug Agency (FDA) approved the uncaged field trial of a GE Aedes aegypti mosquito in Key Haven, Florida. The FDA's decision was based on its assessment of the risks of the proposed experimental public health research project. The FDA is considered a global regulatory standard setter. So, its approval of the uncaged field trial could be used by proponents of GE mosquitoes to urge countries in the global South to permit the use of those bio-technologies.

METHOD

From a public health ethics perspective, this paper evaluates the FDA's 2016 risk assessment of the proposed uncaged field trial of the GE mosquito to determine whether it qualified as a realistic risk evaluation.

RESULTS

The FDA's risk assessment of the proposed uncaged field trial did not proximate the conditions under which the GE mosquitoes would be used in regions of the global South where there is a high prevalence of mosquito-borne diseases.

CONCLUSION

Given that health and disease have political-economic determinants, whether a risk assessment of a product is realistic or not particularly matters with respect to interventions meant for public health problems that disproportionately impact socio-economically marginalized populations. If ineffective public health interventions are adopted based on risk evaluations that do not closely mirror the conditions under which those products would actually be used, there could be public health and ethical costs for those populations.

Risky business: COVAX and the financialization of global vaccine equity

BACKGROUND

During the first year and a half of the COVID-19 pandemic, COVAX has been the world's most prominent effort to ensure equitable access to SARS-CoV-2 vaccines. Launched as part of the Access to COVID-19 Tools Accelerator (Act-A) in June 2020, COVAX suggested to serve as a vaccine buyers' and distribution club for countries around the world. It also aimed to support the pharmaceutical industry in speeding up and broadening vaccine development. While COVAX has recently come under critique for failing to bring about global vaccine equity, influential politicians and public health advocates insist that future iterations of it will improve pandemic preparedness. So far COVAX's role in the ongoing financialization of global health, i.e. in the rise of financial concepts, motives, practices and institutions has not been analyzed.

METHODS

This article describes and critically assesses COVAX's financial logics, i.e. the concepts, arguments and financing flows on which COVAX relies. It is based on a review of over 109 COVAX related reports, ten in-depth interviews with global health experts working either in or with COVAX, as well as participant observation in 18 webinars and online meetings concerned with global pandemic financing, between September 2020 and August 2021.

RESULTS

The article finds that COVAX expands the scale and scope of financial instruments in global health governance, and that this is done by conflating different understandings of risk. Specifically, COVAX conflates public health risk and corporate financial risk, leading it to privilege concerns of pharmaceutical companies over those of most participating countries - especially low and lower-middle income countries (LICs and LMICs). COVAX thus drives the financialization of global health and ends up constituting a risk itself - that of perpetuating the downsides of financialization (e.g. heightened inequality, secrecy, complexity in governance, an ineffective and slow use of aid), whilst insufficiently realising its potential benefits (pandemic risk reduction, increased public access to emergency funding, indirect price control over essential goods and services).

CONCLUSION

Future iterations of vaccine buyers' and distribution clubs as well as public vaccine development efforts should work towards reducing all aspects of public health risk rather than privileging its corporate financial aspects. This will include reassessing the interplay of aid and corporate subsidies in global health.

Pandemics in the age of the Anthropocene: Is 'planetary health' the answer?

Some observers have described the coronavirus pandemic as an 'Anthropocene disease,' thereby highlighting its connection with this new ecological era that is characterised by the considerable pressure human activities are exerting on ecosystems and the consequences on public health, society and the environment. This article focuses on the recent emergence of the 'Planetary Health' paradigm. Launched by the Rockefeller Foundation and the medical journal The Lancet, Planetary Health is one of the most ambitious attempts in recent years to systematize global health in the Anthropocene. While recognising the interest and necessity of reflecting on human health and the health of the planet, this article aims to show, however, that the Planetary Health paradigm is problematic and aporetic for two reasons. First, because it is based on a scientistic and depoliticised conception of the Anthropocene, which obscures capitalism's responsibility for the contemporary global and, especially, ecological crisis. Second, because this conception leads to a promotion of solutions that are essentially based on the financialization and technoscientific management of the living world - precisely the underlying cause of the degradation of ecosystems and living conditions that created the Anthropocene in the first place. A different kind of 'planetary health' remains possible and desirable.

The uses of disorder in negotiated information orders: information leveraging and changing norms in global public health governance

The SARS epidemic that broke out in late 2002 in China's Guangdong Province highlighted the difficulties of reliance on state-provided information when states have incentives to conceal discrediting information about public health threats. Using SARS and the International Health Regulations (IHR) as a starting point, this article examines negotiated information orders in global public health governance and the irregularities in the supply of data that underlie them. Negotiated information orders within and among the organizations in a field (here, e.g., the World Health Organization, member states, government agencies, and international non-governmental organizations) spell out relationships among different categories of knowledge and non-knowledge - what is known, acknowledged to be known, and available for use in decision making versus what might be known but cannot be acknowledged or officially used. Through information leveraging, technically sufficient information then becomes socially sufficient information. Thus it is especially information initially categorized as non-knowledge - including suppressed data, rumour, unverified evidence, and unofficial information - that creates pressure for the renegotiation of information orders. The argument and evidence of the article also address broader issues about how international law and global norms are realigned, how global norms change, and how social groups manage risk.

The financialisation of global health

Global health is increasingly reliant on financial markets. The ongoing financialisation of global health raises new questions of governance, which we expect to affect policy makers as much as doctors, nurses and patients in the years to come. In this editorial, we will first explain what is meant by financialisation, then illustrate its nature in the field of global health via three examples, and end by highlighting some of the governance issues that the financialisation of global health raises.