The Promise of PrEP for HIV Prevention

A large international study among gay men and transgender women,the so-called iPrEx trial, suggested that pre-exposure prophylaxys (PrEP) by a tenofovir/emtricitabine combination can reduce the risk of HIV infection by at least 92% when the pills are taken consistently. Other trials subsequently confirmed PrEP effectiveness. 

PrEP is not intended as a stand-alone intervention, but rather as part of a multi-faceted strategy involving the use of condoms as well as regular follow-ups including for HIV and other sexually transmitted diseases testing

By Marieke Bak

Research Intern at AFEW International

The Promise of PrEP for HIV Prevention


Despite significant progress in the past decades, the global HIV/AIDS epidemic remains a major public health issue. In 2015, an estimated 36.7 million people worldwide were living with HIV, representing a global prevalence of 0.8%. Declines in new HIV infections have slowed in recent years, and in some regions the incidence of HIV continues to grow. One of the most rapidly accelerating epidemics is currently taking place in Eastern Europe and Central Asia, where new HIV infections rose by 57% between 2010 and 2015. Thus, the fight against HIV continues, and has become intensified since the United Nations committed to ending the epidemic by the year 2030.

Recognising that universal access to testing and treatment alone will not stop the epidemic, UNAIDS has been calling for a “much stronger primary prevention response” and recommends that 25% of national HIV budgets is spent on prevention. Moreover, countries are urged to use a combination approach to HIV prevention, consisting of behavioural, biomedical and structural interventions.

However, current biomedical and behavioural interventions are of limited effectiveness in many settings. Behavioural strategies such as celibacy and mutual monogamy are not reliable or realistic for many people worldwide. In addition, negotiating condom use can be difficult or impossible in some settings, or the effect of condoms on sexual pleasure may lead to non-use. Moreover, it was found that self-reported consistent condom use only reduces the risk of HIV acquisition by 63% to 72% among men who have sex with men (MSM), one of the key populations at risk for HIV infection, and by 80% among heterosexual men and women. Treatment as prevention (TasP) also has limitations, since it is dependent upon partners’ medication adherence to ensure suppressed viral load. Moreover, viral suppression rates are not high enough to prevent new infections solely through TasP.

Considering these limitations, there has been a need for additional prevention strategies that are effective and do not place the risk of HIV infection in other people’s hands. Provision of pre-exposure prophylaxis (PrEP) may be such a strategy. PrEP is a daily pill consisting of a combination of tenofovir/emtricitabine, two anti-retroviral drugs. It is branded by Gilead Sciences as Truvada which was approved for prevention in 2012 by the Food and Drug Administration (FDA) in the United States. In contrast to PEP, or post-exposure prophylaxis, PrEP is taken before exposure to HIV to prevent any possible transmission. It works by blocking an enzyme called HIV reverse transcriptase, thereby preventing HIV from establishing itself in the body.

A large international study among gay men and transgender women, the so-called iPrEx trial, suggested that PrEP can reduce the risk of HIV infection by at least 92% when the pills are taken consistently. Other trials subsequently confirmed PrEP effectiveness.  However, because it is not 100% effective and because it does not protect from other sexually transmitted diseases (STDs), PrEP is not intended as a stand-alone intervention, but rather as part of a multi-faceted strategy involving the use of condoms as well as regular follow-ups. These visits should take place every three months and consist of HIV testing, testing for other STDs, assessment of side effects, and counselling on medication adherence and risk reduction.

In addition to the promising effectiveness data, one of the main advantages of PrEP is that it puts HIV prevention directly under the control of the at-risk individual. Because PrEP separates the act of prevention from the sexual encounter, it can be used without sexual partners knowing. This makes PrEP a “gender-sensitive” strategy: it does not require consent from a male partner, which is a major advantage in settings where women are disempowered to discuss condom use.

With PrEP, the individuals become empowered to take control of their own health, and it has been suggested that PreP might “transform HIV infection just like hormonal contraception transformed family planning”. Also, it enables those who are in serodiscordant relationships to have sex without condom, and is a welcome new option for couples who wish to conceive. Lastly, a well-functioning PrEP programme with regular follow-ups might have the added benefit of strengthening healthcare systems and HIV services.

There are some side effects associated with Truvada for PrEP, although these are generally minor symptoms such as nausea and headaches that resolve within a few weeks. In rare cases, people may experience small changes in kidney function or a decrease in bone mineral density. An updated version of Truvada known as Descovy, that is thought to have fewer side effects, is currently being investigated in the so-called “Discover study”.

Because PrEP does not prevent transmission of other sexually transmitted diseases, there have been fears that PrEP might be used as a “party drug” and lead to increasing rates of other STDs. In fact, in the iPrEx study as well as in a meta-analysis by the World Health Organisation (WHO), it was shown that PrEP does not lead to an increase in the number of STDs and has no effect on condom use. On the contrary, a recent study found that PrEP use can actually reduce the incidence of STDs among men who have sex with men, because it involves routine screening and treatment of other STDs.

The World Health Organization now recommends that PrEP should be offered as a choice to key populations affected by HIV as well as to anyone else at substantial risk of HIV infection. However, Truvada is currently approved for use as PrEP only in a handful of countries, while a number of countries are conducting pilots, and access is expanding slowly across the world. Global availability remains limited at 2% of the target set by UNAIDS to get three million people on PrEP by 2020.

At the moment, Truvada for PrEP has been approved in the United States, Canada, Australia, Peru, South Africa, Kenya, Zimbabwe, Israel, and the European Union. Approval is pending in Brazil and Thailand. In the European Union, PrEP has been approved by the European Medicines Agency (EMA) although the implementation of PrEP programmes is the responsibility of each member state separately. To date, only France and Norway have made PrEP available as part of their healthcare system. Scotland recently announced that it will do the same.

The hesitation to fund PrEP often stems not only from seemingly unfounded worries for risk compensation, but also from the high cost of PrEP. Even in low- and middle income countries where generic versions of Truvada are generally available, drug prices still present a barrier to the accessibility of PrEP and may lead to developing countries having to make trade-offs between prevention and treatment. Indeed, PrEP is more expensive than other HIV prevention methods, but it can be a cost-effective tool in some settings, especially when delivered to key population. According to the WHO, offering PrEP can be cost-effective when the HIV incidence is greater than 3 per 100 persons. A study published in the Lancet reported that by preventing the costs of lifetime HIV treatment, PrEP may eventually lead to healthcare savings, especially when the drug patents expire and the cost drops.

Since it is widely recognised that treatment alone is not sufficient to eradicate HIV, and given the high effectiveness of PrEP, countries should make an effort to provide access to PrEP among those at risk of HIV infection. While keeping in mind that PrEP is part of a combination prevention approach, scaling up of PrEP programmes will be a significant step towards ending the global HIV/AIDS epidemic.

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La République démocratique du Congo continue à être confrontée à une crise humanitaire de très grande ampleur, et cela depuis plus de deux décennies, bien que la grande majorité du territoire nationale demeure stable, mais les provinces du Sud-Kivu, du Nord-Kivu, du Tanganyika et du Kasaï central sont les théâtres des tueries, massacres et violations répétitives des droits de l’homme à l’heure actuelle

By Alphonse Kitoga

Secretary General, Grands-Lacs en Action pour la Paix et le Développement Durable -The Great-Lakes in Action for Peace and the sustainable Development

GLAPD_ Africa, asbl





Avec environ 65 millions d’habitant, la R.D.Congo a une superficie de 2 345 410 KM2 (4 fois la France et 80 fois la Belgique) et avec 26 provinces et, Kinshasa sa capitale compte environ 10 millions d’habitants (plus que les populations du Congo-Brazzaville, du Gabon et de la République Centrafricaine réunies).

En effet, dans plusieurs provinces de la RDC les milices ne font que se multiplier (on arme et on manipule les jeunes/les adolescents(es) qui ne peuvent plus étudier car leurs parents se sont appauvrit et n’ont pas de travail. Avec l’arrivée de près de 15.000 réfugiés Burundais dans la plaine de la Ruzizi au Sud-Kivu en raison des tensions ethniques qui se vit dans leur pays le Burundi qui sème panique et désolation dans le chef de la population de cette région martyrisée. Signalons également que les provinces du Nord et du Sud-Kivu compte plus de 1.000000 des déplacés et plus de 200 000 réfugiés Rwandais qui surplombe toutes les deux provinces!


La République démocratique du Congo continue à être confrontée à une crise humanitaire de très grande ampleur, et cela depuis plus de deux décennies, bien que la grande majorité du territoire nationale demeure stable, mais les provinces du Sud-Kivu, du Nord-Kivu, du Tanganyika et du Kasaï central sont les théâtres des tueries, massacres et violations répétitives des droits de l’homme à l’heure actuelle.

Cependant que, cette crise est principalement la conséquence de conflits armés, des conflits intercommunautaire, coutumiers et de violences armées qui perdurent dans l’Est, le nord-Est et dans le centre du pays. Ces conflits sont causés en particulier par des luttes pour le contrôle des ressources naturelles et l’accès à la terre, par des tensions ethniques et par l’activisme de groupes armés congolais et étrangers (FDRL, LRA, groupes Maï-Maï, AFD/NALU, le M23, les Pygmées/Batwa contre les Bantous-Baluba dans le Tanganyika et les miliciens du Chef coutumier Kamwina N’sapu dans le Kasaï central/Kananga avec les forces de l’ordre/l’armée régulière), dans un contexte caractérisé par une pauvreté exacerbée et une trop faible présence des institutions de l’Etat. Les exactions graves commises par les parties belligérantes sur les populations civiles, tels que viols, meurtres, recrutements forcés des enfants/adolescents dans les forces et groupes armés et pillages, demeurent la cause principale des déplacements de population et de la crise humanitaire liée à ces déplacements. Des centaines de milliers de civils ont fui ces exactions en 2011 à ces jours!

L’année 2016-2017 a également été marquée par des violences intercommunautaires entre les Pygmées/Batwa contre les Bantous-Baluba qui ont éclaté en la province de Tanganyika en octobre 2016, provoquant la fuite de près de 470.000 personnes déplacées et dont le site de Kalunga à Kalemie compte à lui seul 17.500 déplacés et nombreux dans eux sont des femmes, des enfants et des adolescents. A cela s’ajoutent près de 650 000 déplacés internes prenant fuite du conflit intercommunautaire et coutumier orchestré par les miliciens du Chef coutumier Kamwina N’sapu dans le Kasaï central/Kananga avec les forces de l’ordre/l’armée régulière.

Les besoins humanitaires demeurent également très importants dans les autres provinces où l’on a relevé des taux élevés de malnutrition aigüe et sévère, d’insécurité alimentaire, et de mortalité maternelle, infantile et néo-natale. Les causes en sont avant tout le faible niveau de développement, l’enclavement et la précarité des infrastructures, les épidémies et les catastrophes naturelles pour ne citer que ceux-là.

Bien que la situation se soit stabilisée depuis un certain temps, très peu de mouvements de retour ont été observés à ce jour. Les acteurs humanitaires ont répondu aux besoins les plus urgents et ont porté assistance à des millions de personnes. Mais cela reste très peu insuffisant et visible pour ceux qui en n’ont besoin le plus. L’action humanitaire a été confrontée à des défis importants, en particulier concernant l’accès aux populations vulnérables dans des zones très enclavées. Dans les régions en proie à la violence, les conditions de sécurité précaires affectant les partenaires humanitaires ont réduit les opérations d’assistance. Le bas niveau de financement a constitué un frein supplémentaire.

Pour pallier à cela, les axes suivants doivent être pris en ligne de compte:
1. Renforcer la protection de la population civile vulnérable (surtout les femmes, enfants et les adolescents) dans les zones d’intervention humanitaires ;
2. Réduire la morbidité et la mortalité maternelle, infantile et néonatale au sein des populations cible;
3. Améliorer les conditions de vie des personnes déplacées, retournées, rapatriées, réfugiées, et de leurs communautés d’accueils affectées, et
4. Restaurer les moyens de subsistance des communautés affectées, sur la base de critères de vulnérabilité.

Du fait de la persistance de violations graves des droits de l’homme et du droit international humanitaire, en particulier dans les zones affectées par des conflits armés, intercommunautaires et la violence armée, la protection des civils doit être au coeur de la communauté humanitaire dans toutes ses interventions.


Bien que la majorité du territoire national demeure peu stable, la RDC continue à être marquée par une crise humanitaire de très grande ampleur. Celle-ci est la conséquence des conflits armés et violences armées qui perdurent.

Les populations vivent dans un état de l’insécurité permanente, chaque jour des braquages des véhicules, les pillages, assassinats, tueries,…
La situation sécuritaire sur toute l’étendue du pays continue aussi à ce détérioré du jour au lendemain. Presque toutes les parties du pays sont confrontées à des problèmes récurrents d’insécurité et de l’activité des groupes armés, milices du Chef coutumier Kamwina N’sapu au Kasaï centrale, les conflits intercommunautaires entre les Bantous et les Pygmées, dans le Tanganyika, l’ancien Kivu avec sa multitude des groupes armés avec le retour du phénomène M23 et conflits intercommunautaires au Maniema. La crise humanitaire dans l’ensemble du pays a également pour cause la pauvreté, le manque de développement d’infrastructures, les épidémies et les catastrophes naturelles comme dit précédemment.

Secteur de la santé: Besoins identifiés:

Toutes les provinces de la RDC continuent d’être exposées, à des degrés divers, aux endémies ou épidémies, aux mouvements de population et aux catastrophes naturelles. Plusieurs épisodes d’épidémies ont été rapportés dans plusieurs zones de santé. Il s’agit essentiellement du paludisme (plus de 20 millions de cas, la RDC étant l’un des pays les plus touchés par le paludisme en Afrique), du choléra (12 161 cas), de la méningite (218 cas), de la fièvre jaune (5 cas confirmés) et 15 cas suspects de fièvres hémorragiques virales non confirmés.

La mortalité maternelle, néo-natale et infantile continue d’être une préoccupation dans presque toutes les provinces, soit un taux de 549 décès maternels pour 100 000 naissances vivantes et un taux de mortalité infantile des moins de 5 ans dépassant 2/10 000/ jour dans 22% des zones de santé.

Plan de réponse du Secteur:
Objectif général: contribuer à la réduction de la morbidité et de la mortalité liées aux conséquences Sanitaires dans les situations de crise.

Objectifs spécifiques:
1) Renforcer les actions en faveur de la réduction de 10%; de la mortalité maternelle, néo-natale et de la mortalité infantile des moins de 5 ans;

2) Activer les mécanismes de riposte en moins de 15 jours dans au moins 80% des épidémies constatées / confirmées;

3) Renforcer les capacités techniques et institutionnelles dans la prise en charge des cas / personnes en situation d’urgence sur tout chez les femmes, les enfants, les adolescents et les vieillards.

Secteur de la protection: Besoins identifiés:

Plusieurs facteurs mènent à l’heure actuelle à une aggravation de la vulnérabilité des populations. A une vulnérabilité structurelle très forte s’ajoutent une crise conjoncturelle due à la présence des groupes armés et autres acteurs non étatiques, les vaines tentatives de l’armée congolaise (FARDC) et de la MONUSCO de les déloger et les violations du droit international humanitaire (DIH) et des droits de l’homme (DDH) perpétrées par les agents de l’Etat eux-mêmes. Ces violations entraînent une aggravation de l’instabilité, une insécurité localisée permanente, des déplacements forcés et des séparations familiales dans les zones touchées.

La prévention des violences sexuelles et la prise en charge multisectorielle de toutes les victimes restent un besoin important dans le pays tout comme le sont la protection et la prise en charge des femmes et enfants/adolescents victimes de violations de leurs droits.

Plan de réponse du Secteur:
Objectif général: Accroître la protection de la population civile affectée par l’insécurité, les conflits, le déplacement et les violations sévères des droits de l’homme.

Objectifs spécifiques:
1) Renforcer et harmoniser le système de collecte et d’analyse de données sur la situation des populations civiles et leurs besoins de protection dans le but de surveiller les risques et d’améliorer l’identification des priorités des activités de protection.
2) Améliorer l’accès à l’assistance, la justice, la compensation, la réhabilitation et la restitution des victimes.

Secteur de l’éducation: Besoins identifiés:

Les chiffres les plus récents montrent qu’en moyenne 46% des filles achèvent l’école primaire contre 66,5% des garçons, et seulement 28,8% des filles s’inscrivent au secondaire contre 51,2% des garçons; 1 homme adulte sur 5 et près d’1 femme sur 2 sont analphabètes au Congo. Les chiffres pour l’Est du Congo ainsi que pour la province du Kasaï sont en dessous de la moyenne. La complexité actuelle de la situation nécessite une adaptation de l’assistance humanitaire et la mise en place de mécanismes de ciblage des besoins plus pertinents, basés sur l’analyse des vulnérabilités des familles bénéficiaires.

Plan de réponse du Secteur:
Objectif général: contribuer à l’accès à des activités éducatives de qualité dans un environnement protecteur et adapté en faveur des filles et des garçons, adolescentes et adolescents de 3 à 18 ans, en situation de handicap ou non, victimes de catastrophes naturelles ou causées par l’homme, de conflits ou vivant dans des conditions de forte vulnérabilité.

Objectif spécifique 1: l’accès de 240 000 filles et garçons (>50% filles) à une éducation de base et de qualité (formelle et non-formelle) est assuré;

Objectif spécifique 2: au moins 19 00 espaces d’apprentissage sont adaptés, aménagés et protecteurs;

Objectif spécifique 3: l’inégalité d’accès à l’apprentissage est réduite grâce à la mise oeuvre pour la prise en compte du genre et des enfants en situation de handicap;

Les activités suivantes sont possibles pour réaliser ces objectifs:

1. Appui à l’identification des enfants, des jeunes et des adolescents (f/g) de 3-18 ans en vue de leur inscription dans les écoles existantes ou dans les espaces d’apprentissage à créer;
2. Plaidoyer et sensibilisation des responsables de l’Enseignement primaire, secondaire et professionnel (EPSP) pour le recrutement des enseignants en quantité et de qualité suffisantes et leur déploiement rapide dans les régions d’intervention; tout en encourageant une égale représentation des femmes et des hommes et la non-discrimination à l’égard des enfants en situation de handicap;
3. Réhabilitation et aménagement d’espaces d’apprentissage temporaires avec l’accès aux blocs de latrines pour tous et distinct entre filles et garçons, la mise en place de points d’eau, en utilisant des matériaux locaux ou temporaires afin de réduire le coût de l’aménagement.
4. Appui aux activités d’allégement de la charge financière des parents (activités génératrices de revenus, AGR);
5. Organisation de cantines scolaires avec vivres;
6. Fourniture de kits d’apprentissage aux enfants;

Secteur de la sécurité alimentaire: Besoins identifiés:

La baisse de la production agricole, le mauvais état des routes de desserte agricole et la dégradation de l’état nutritionnel de groupes ciblés, l’abandon des moyens de subsistance, l’insécurité, le manque d’accès à l’eau de qualité et une alimentation saine et équilibrée. Les voies de communication sont délabrées empêchant les échanges et l’accès au marché des populations au pouvoir d’achat faible!

Plan de réponse du Secteur:

Objectif général: restaurer les moyens de subsistance des communautés en crise alimentaire.
Objectifs spécifiques:
1) Répondre aux besoins alimentaires d’urgence des populations cibles;
2) Rétablir l’autonomie de production alimentaire pour les familles d’accueil, les ménages nouvellement accessibles et ceux affaiblis par les crises;
3) Soutenir la production alimentaire d’urgence pour des ménages d’enfants malnutris, des personnes déplacées, retournées, rapatriées et autres groupes vulnérables;

Pour cela, les principales activités seront les suivantes:

-Assistance alimentaire d’urgence aux populations en crise pour atténuer les effets immédiats;
-Assistance urgente aux groupes vulnérables (distribution de vivres, non vires et de kits agricoles);
-Réhabilitation urgente des infrastructures de base (pistes et marchés ruraux, vivres contre travail);
-Protection contre la perte complète des avoirs relatifs aux moyens de subsistance et/ou soutien en faveur de l’accès à ces avoirs (vivres contre travail, rations de protection des semences, foires aux semences).

Secteur de l’Eau, hygiène et assainissement: Besoins identifiés:

La vulnérabilité dans les provinces précitées est les théâtres de mouvements perpétuels de population. Avec une telle instabilité, le choléra et les maladies d’origine hydrique peuvent se développer de manière exponentielle pour plusieurs raisons:
• Les déplacements favorisent la dispersion des germes pathogènes;
• Les personnes déplacées créent une pression additionnelle sur les ressources en eau et les infrastructures sanitaires des autochtones, ce qui génère une pénurie et une dégradation précoce des équipements existants;
• Les hôpitaux et Centres de Santé dans les zones d’accueil sont débordés du fait de l’arrivée de nouvelles personnes et sont de ce fait moins capables de répondre aux flambées d’épidémies endémiques;
• Les personnes déplacées sont souvent plus vulnérables aux maladies.

Plan de réponse du Secteur:
Objectif général: réduire les risques de transmission des maladies infectieuses d’origine hydrique sur les populations déplacées et retournées ou victimes d’épidémies et de catastrophes naturelles par des actions de prévention et de réponse d’urgence, ceci pour la sécurité et la dignité des filles, des femmes, des garçons et des hommes.

Objectif spécifique 1: assurer l’accès en eau potable en quantité et en qualité suffisante aux populations affectées dans des conditions de sécurité et de dignité, en consultation avec les communautés locales, en particulier les femmes et des adolescents, pour la désignation de l’emplacement des points de distribution d’eau.

Objectif spécifique 2: assurer l’accès à un environnement sain et protecteur aux populations affectées dans des conditions de sécurité et de dignité par la mise à disposition d’infrastructures d’hygiène et d’assainissement.

Activité 1: construction des latrines collectives différenciées et sécurisées (pour les femmes et les filles), et des latrines familiales. Les latrines collectives visent les communautés ou les lieux publics tels que les écoles, les hôpitaux et les marchés;
Activité 2: construction de douches collectives différenciées et sécurisées.

Par ailleurs, les principaux enjeux en protection des civils dans les provinces affectées par les conflits armés, en particulier dans le Nord, Sud-Kivu , le Tanganyika et en province du Kasaï central, sont liés à l’inaccessibilité et l’enclavement de certaines zones, ce qui favorise les violations graves des droits de l’homme ou du droit international humanitaire par les FARDC et d’autres groupes armés/milices présentes dans ces contrées.

Cette situation, est à l’origine de déplacements massifs des populations, se traduit par des violations de nombreux abus des droits de l’homme. Ceux-ci incluent l’utilisation des enfants (recrutement d’enfant/adolescents dans les groupes et forces armés, exploitation pour le transport de matériel, violences sexuelles); violences sexuelles faites à la femme; administration et justice illégale et/ou parallèle; pillage et taxation illégale, barrières illégales; limites à la liberté de circulation des populations civiles; prises d’otage de civils; attaques à l’encontre de villages; incendies de maisons; occupation de maisons, d’écoles des centre de santé et de villages par les groupes armés; utilisation des biens et des infrastructures civiles; recrutement et travaux forcés des civils et déplacements/retours forcés.

Pari cochet, au vu et au su de tout ce qui se passe en RDC, GLAPD_Africa, asbl, condamne avec une dernière énergie, les exactions, tueries, massacres, viols, pillages et violation répétitive des droits de l’homme, ce qui met en péril la santé de la mère, de l’enfant, du nouveau-né et de l’adolescent, demandons qu’une enquête juste et indépendante soit diligentée pour éclairer cette situation qui prévaut dans les provinces du Nord, Sud-Kivu, Kasaï central et dans le Tanganyika pour que les auteurs de ces exactions ignobles puissent répondre et purgent de leurs actes.

Les fosses communes sont devenues monnaies courantes dont 23 dans le Kasaï, des fosses communes à Maluku/Kinshasa, au Tanganyika, au Sud-Kivu (Kasika, Mwenga, Makobola/Baraka et dans le Nord-Kivu (Beni, Butembo, Lubero, Walikale, Kitchanga, Rutshuru,…). Ces actes ne doivent pas demeurer impunis, car Trop c’est Trop;

Nous déplorons et fustigeons également la mort tragique et inopinée des deux experts des Nations-Unies ainsi que leurs interprètes et motards Congolais qui ont été tués dans le Kasaï central en l’exercice de leurs fonctions, demandons que leurs bourreaux soient punis sévèrement et conformément aux lois de la République et internationales;

La situation socio-économique, politique et sécuritaire de la population en RDC est au bas de l’échelle mondiale, la liberté d’expression et de manifestation publique de la population est piétinée, l’on ne peut lire au quotidien une paupérisation de la population prise en otage et ne sachant pas à quel saint se vouer.


Nous recommandons à l’Etat congolais d’assurer la sécurité de la population et de leurs biens et d’améliorer la situation socio-économique de la population et de traduire en justice les auteurs de violation des droits de l’homme, De restaurer l’autorité de l’Etat sur toute l’étendue du territoire national;

D’améliorer l’espace de la liberté d’expression et de manifestation pacifique publique ainsi que la liberté de presse;

Aux acteurs politiques Congolais de privilégier, le dialogue, la coopération et l’intérêt général de la population en lieu et place de leurs intérêts égoïstes et mesquins;

Aux organisations de la société civile et forces vives de ne pas céder aux intimidations politiciennes et partisanes, de bien jouer leur rôle de neutralité, d’impartialité, de l’indépendance, le principe de Do Not Harm et d’accompagnateur au lieu de se mêler dans les commérages des politiciens;

Au conseil de sécurité des Nations, d’assurer un suivi de proximité sur le nouveau mandat de la MONUSCO, l’application de la résolution 2348 et l’accord de la saint Sylvestre du 31 décembre 2016 et lutte contre les groupes armés et milices et de jouer pleinement leur mandat de la protection des civiles;

A la communauté nationale et internationale de mobiliser les fonds nécessaires pour accompagner la RDC dans le processeur démocratique d’organisation des élections libres et transparentes au financement des différents projets et programmes d’intérêt public et communautaire et s’impliquer dans le processus de la sécurisation de la population civile aux éventuelles violations des droits de l’homme;

Aux organisations humanitaires, caritatives, systèmes des nations-unies, publiques, privées, aux donateurs, aux hommes et femmes de bonne volonté de venir en aide, les populations déplacées de guerre afin de restaurer la santé de la mère, de l’enfant, du nouveau-né et de l’adolescent actuelle a son plus bas niveau et le ramener aux standards internationaux.

Au PMNCH/Partnership for Maternal, Newborn and Child Health  et au mouvement Every Women Every Child/EWEC de nous aider à faire le plaidoyer auprès des donateurs, bailleurs de fonds et décideurs afin de libérerez le fonds nécessaires pour répondre à la situation humanitaire et à la santé de la mère, de l’enfant, du nouveau-né et de l’adolescent en RDC, car le développement de l’Afrique est assujetti par la stabilité permanente de la RDC ainsi pour permettre d’atteindre les ODD à l’horizon de 2030.

Une action humanitaire bien soutenue et avec compassion permet sans ambages à sauver des vies des milieux des Congolais qui sont dans le besoin le plus (surtout chez la femme, l’enfant, le nouveau-né et les adolescents) ainsi promouvoir la santé reproductive.

En définitive, GLAPD_Africa, asbl, reste bras ouverts pour recevoir vos appuis et soutiens éventuels pour aider la RDC de sortir dans l’impasse humanitaire et d’avance droit chemin vers les ODD à l’horizon 2030.

Fait à Kalemie, le 07 avril 2017

Alphonse KITOGA
Secrétaire Général.


Published under licence from Alphonse Kitoga  © Copyright SOS situation Humanitaire-DRC | Great-Lakes in Action for Peace and the
Sustainable Development / GLAPD_Africa, asbl. Tél: +243 81 78 85 806& + 243 85 53 04
686. E-mail: &


The Uganda’s “Narcotic Drugs and Psychotropic Substances (Control) Act”

The essence of the Uganda's Narcotic Drugs and Psychotropic Substances (Control) Act (NDPSA) is to treat people who use and inject drugs (PWUIDs) as criminals who need to be locked up instead of viewing them as human being in need of assistance. The criminalisation of drug use has had the effect of limiting the range of medical  intervention available and accessible to PWUIDs in both private and public facilities. There is no comprehensive facility for the provision of public health services to PWUIDs. There is also no treatment available within Uganda for people who are on drugs and need critical and urgent medical attention like opioid substitution therapy. And there is a direct link between the criminalisation of drug use and HIV/AIDS as well as mental health challenges

By Muhwezi Edward

Harm Reduction Counselor, Uganda Harm Reduction Network

The Uganda’s “Narcotic Drugs and Psychotropic Substances (Control) Act” and how it impacts on Public Health and Human Rights


The criminalisation of the use of drugs is barely a Ugandan affair. It is part of an internationalised system that regards drug use as dangerous and which is willing to suppress it using all means and more so the law. Although States began with a much more relaxed approach towards drugs, they later started looking at drug use through the lenses of race and immigration, and after the first world war, undertook international commitments to fight drug use. This has resulted into today’s ‘war on drugs’ with all its negative effects especially on the individuals who use drugs.

Uganda started criminalising drug use following this international trend and with the enactment of the Narcotic Drugs and Psychotropic Substances (Control) Act (NDPSA) has made strides towards being part of this global movement to suppress the use of drugs. The NDPSA came into force in 2016.

The NDPSA, has a decided penal focus and does not prioritise the welfare of persons who use drugs. One of the primary aims of the Act is to give effect to punitive international conventions. Along with the criminalisation of trafficking in narcotics drugs and psychotropic substances, the Act also criminalises the possession of these drugs and prescribes heavy penalties such as a fine of Ugx 10,000,000 (approx. USD 3,000) or three times the market value of the drug, whichever is greater, or imprisonment of a minimum of ten years or both such a fine and imprisonment. The Act also criminalises acts associated with narcotic drugs such as possession of any pipe or utensil for the illicit use of such drugs; ‘recruiting’ or ‘promoting’ the smoking, inhaling, sniffing or other use of such substances and owning, occupying or being ‘concerned in the management’ of any premises used for the cultivation, sale or manufacture of such substances.

The Act makes a measure of provision for the welfare of People Who Use and Inject Drugs (PWUIDs) by empowering the Minister of Health to establish ‘rehabilitation centers’ aimed at providing ‘care, treatment and rehabilitation of persons addicted to narcotic drugs or psychotropic substances’. The Minister is also empowered to appoint an ‘Advisory Committee for the Rehabilitation of Narcotic Addicts’ in order to advise the Minister on matters relating to the administration of the centers and the ‘care, treatment and rehabilitation of drug addicts’. The Act furthermore provides that a person may be committed to spend a part of their period of imprisonment in such a rehabilitation centre upon  conviction of an offence under the Act.

Despite these seemingly progressive provisions, the mechanism for ‘rehabilitation’ contemplated under the Act can only be accessed after one has been convicted and sentenced. Since the time spent in the ‘center’ is considered as part of one’s custodial sentence, it is feared that the provision may have the direct and adverse effect of triggering custodial sentences where fines would otherwise have been imposed. The fact that the envisioned Advisory Committee’ membership does not provide for participation or inclusion of PWUIDs is also viewed as problematic.

Overall, the NDPSAi  conflates support for PWUIDs with the criminal law and even the limited health services provided under such a framework are rendered meaningless and effectively inaccessible. It also leaves the judicial officer with broad and unqualified power to determine which PWUIDs access treatment and who does not, which severely undermines not only the agency and autonomy of such persons but also their rights to health and, ultimately, to life. The essence of the Act is to treat PWUIDs as criminals who need to be locked up instead of viewing them as human being in need of assistance.

The criminalisation of drug use has had the effect of limiting the range of medical  intervention available and accessible to PWUIDs in both private and public facilities. There   is no comprehensive facility for the provision of public health services to PWUIDs. There is also no treatment available within Uganda for people who are on drugs and need critical and urgent medical attention like Opioid Substitution Therapy (OST). The emphasis on criminal approaches to drug use has discouraged many PWUIDs from seeking even those medical services which might be available in the public and private health systems. This is because of the way they are treated by medical professionals and the threat of being taken to court to answer charges related to their drug use upon their recovery.

There is a direct link between the criminalisation of drug use and HIV/AIDS as well as mental health challenges. This is so because the criminalisation of drug-use makes it less likely for PWUIDs to be offered information and services in relation to needle-sharing, which increases transmission of HIV among injecting drug users in particular. Furthermore, the social stigma created in large part by the criminal approach to drug use has further entrenched the isolation and related suffering and depression of PWUIDs.

Owing to criminalization of drug use, the police and other law enforcement agencies use a whole range of legal provisions, even beyond those provisions which have a direct link to drug prohibition, to harass, intimidate, blackmail and extort money from PWUIDs. Laws most frequently used in this respect are offences under the Penal Code including ‘being a common nuisance’; ‘being idle and disorderly’; ‘being a rogue and vagabond’; and carrying on offensive trades.

Criminalisation of drug use is found to cause social stigma and related socio-economic consequences for PWUIDs who have been convicted and imprisoned or who have even just been arrested and detained. They face disruptions in their family lives and education as well as the loss of employment and decreased chances of obtaining employment. An indirect consequence of the criminalisation of drug use is that, when incarcerated, PWUIDs are  often exposed to a wider range of drug use.

In considering the overall effect of criminalisation of drug use, it is suggested that any regulation of drug use should not involve a direct or indirect violation of the rights to life and health of persons who use drug. It is suggested that the principle of ‘harm reduction’ should be embraced in order to reduce the negative consequences associated with drug use. Uganda is in need of the adoption of a nation-wide harm reduction policy which would create an enabling legal environment for PWUIDs to access health services relevant for them to enjoy the highest attainable standard of physical and mental health; and would also involve increased state funding to support the legal and public health needs of the PWUIDs.



i Narcotic Drugs and Psychotropic Substances (Control) Act, 2015


“The Narcotics Drugs and Psychotropic Substances (Control) Act 2015 and the Legal Regulation of Drug Use in Uganda” report by HRAPF & UHRN.


Health Breaking News: Link 238

Health Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

Health Breaking News: Link 238


Longest, Biggest World Health Assembly Ever Set To Open With Election, Budget Topping Agenda 

WHO, Stakeholders Take ‘First Step’ On Fair Pricing For Medicines 

WHO Touts Its Past Work On Improving Access To Medicines 

Overview of WHO financial situation: Programme Budget 2016-17 

WHO improves transparency of financial data 

PHM: WHO tracker 

Conference: Health commercialisation in Europe: 6th of June 2017 European Parliament 

MSF Warns Of Threats To Public Health In Asian Trade Agreement IP Proposals 

What is Health Policy and Systems Research and how can it strengthen Health Systems? 

Healthy ecosystems as a building block of resilient health systems: Challenging health systems researchers to take action 

From partnerships to self-interest: how can we reverse the trend in EU Development Cooperation? 

China’s Xi Jinping says he will ‘protect’ Paris climate deal, as it hangs in the balance 

Trump could do more damage by staying in the Paris climate deal 

Next month’s ocean conference eyes cutting $35 billion in fisheries subsidies – UN trade officials 

Investment In Primary Care Is Needed To Achieve The Triple Aim 

Boosting agriculture could mitigate African famine threat in a warming world 

Using Agriculture and Agribusiness to Bring About Industrialisation in Africa 

New WFP Report Finds Food Insecurity Accelerates Global Migration 

Preventing the Next Pandemic: Opportunities and Challenges 

Zika virus: Brazil says emergency is over 

U.S. Army/Sanofi Zika Vaccine Collaboration Timeline and Update 

Coming This Summer: More Ticks and Powassan Virus  

First large-scale survey of Chagas disease in the United States confirms that the “Silent Killer” is a major public health challenge for the country 

THE EDGE OF ELIMINATION Racing drug resistance to end malaria in the Mekong 

Landmark agreement signed to prevent malaria in pregnancy and reduce life-threatening complications in sub-Saharan Africa 

Global Fund Accelerates Efforts To End Epidemics 

New open source project engages universities in neglected diseases drug discovery 

Health experts call for new tools to tackle vector-borne diseases 

Shortage Of Affordable Insulin: Should WHO Extend Prequalification To Biosimilars? 

Empowering women: the ‘Tree Tomato Project’ in Rwanda 

‘Stop TTIP’ petition is legitimate, top EU court rules

Review: Textbook of Global Health Fourth Edition, Oxford University Press 2017

…Achieving health equity is not just a matter of coming up with technical solutions and providing the means to finance them. We have to consider the political landscape and rectify the dysfunctions in global governance that undermine health… 

professor Ole Petter Ottersen, rector of Oslo University 

By  Daniele Dionisio

PEAH – Policies for Equitable Access to Health



Textbook of Global Health

 Co-authored* by Anne-Emanuelle Birn, Yogan Pillay, Timothy H. Holtz

Fourth Edition, Oxford University Press 2017**


This book provides a forward-looking, highly exhaustive, up-to-date and balanced analysis over the unsolved issues and gaps still impairing the equitable access to global health on a world scale.

The fourteen chapters (674 pages) are like-minded and uniformly structured as regards introductory key questions that provide a basis for reflection, and closing learning points that summarize key take-home messages. Each chapter includes tables, boxes and figures serving as instrumental tools to enhance clarity while adding building block information for the sake of readers – be they students, stakeholders, politicians or advocates.

‘Example’ paragraphs and case studies all over the text appropriately focus on the critical points at stake and the root realities to deal with.

The first section of the textbook (chapters 1-7) provides the basic tools for understanding global health. The next section (chapters 8-12) analyzes global health and its ongoing challenges from a set of key lenses – the priority areas and building blocks for understanding and improving global health efforts. The final section (chapters 13 and 14) turns to the making of healthy policies across the world – and the roles and responsibilities of those working in the field locally, internationally and transnationally.

So compounded, the book dates back to the historical origins and allows the readers to understand (while offering itself robust explanation of) the reasons underlying  a host of conflicting issues most accounting for the current health inequities on a world scale.

In a nutshell, the authors maintain that the rampant neoliberal globalization underpinning  unfettered trade liberalization (meaning collusion between national-transnational corporations and their political counterparts) is directly responsible for the social inequities and health worsening worldwide.

As the authors stress ‘..the exigencies of market competition and enormous corporate power mean that governments privilege economic priorities and corporate interests over social and environmental needs, even in settings where democratic institutions and decision-making processes are marked by integrity and representativeness…’

The book makes it clear that the root causes of health inequities are to be found in weaknesses in political domains at the national and supranational level. These include democratic deficit, weak accountability, institutional stickiness, missing institutions and restricted policy space for health. This context entails that unbiased solutions for global health only hinge on political will to improve equity, coherence, coordination, collaboration, transparency and accountability both at domestic and international level.

In such connection, the book refers to the recently adopted 2030 UN Agenda for Sustainable Development consisting of 17 Sustainable Development Goals (SDGs) and 169 targets. In this scheme, the health goal ranks high as an overarching aim amidst the other 16 SDGs. It includes nine targets: three related to the Millennium Development Goals (MDGs), three to non-communicable diseases and injuries, and three cross-cutting or focusing on systems encompassing universal health coverage, universal access to sexual and reproductive health care services, and also to reduced hazards from air, water and soil pollution. Furthermore, the health goal strictly entwines with a number of the other 16 goals. As for this, the book highlights that health is a contributor to (and a beneficiary from) poverty reduction, hunger relief and improved nutrition, safer cities, lower inequality, sustainable consumption, affordable and clean energy, toxic chemicals management, clean water and sanitation, and to the efforts to combat climate change and safeguard aquatic and terrestrial ecosystems as well.

Unfortunately, as the authors remark, the current governments’ directions and trade agreements, largely by the most affluent countries, run contrary to these principles while turning agendas into policies which protect monopolistic interests at the expense of equitable access to care and lifesaving treatments in the resource-limited settings.

In this regard the book messages that, since the incentives of  present  patent system are driven by profits (where short-term maximization of returns to shareholders is prioritized), the lower-income countries lacking profitable markets are all the more discriminated.

Below are just few examples of much debated questions from a great many timely featured in the book because of their actual potential to negatively affect health and worsen inequalities in access to care and treatments:

– The credit policies of International Monetary Fund, World Bank and European Commission still incur criticism of indirectly stifling public spending, including for health, in the borrowing countries.

– Mushrooming TRIPS-plus measures still enforce intellectual property (IP) protection beyond what is required by the WTO TRIPS agreement. These measures encompass making it easier to patent new forms of old medicines that offer no added therapeutic benefit for patients (the so-called ‘ever-greening’); restricting ‘pre-grant opposition’, which allows a patent to be challenged before it is being granted; allowing customs officials to impound shipments of drugs on mere suspicion of IP infringement, including ‘in transit’ products that are legal in origin and destination countries; expanding data exclusivity beyond WTO’s request for data protection against unfair commercial use only; extending patent lengths beyond 20-year TRIPS requirements; and preventing drug regulatory authorities from approving new drugs if they might infringe existing patents.

– Investor state dispute settlement (ISDS) provisions are in the crosshairs now that most currently-being negotiated or finalized trade agreements are charged with introducing ISDS clauses whereby many forms of government regulations, including TRIPS-compliant price cuts of medicines, could be sued by the patent owners for making pointless or erode their expectations.

– Pharma companies and their allies still are lobbying governments to scupper any rules that would require them to disclose the real R&D costs and profits of their medicines and the rationale for charging what they do. As such, it is almost unpredictable whether laws enforcing transparency on costs would help curb extortionate drug prices in today’s world.

– Neo-liberal policies still impair the capacity of resource-limited countries to feed themselves. Adding to  investment reduction in food production and support for peasant and small farmers,  state-managed food reserves have been dismantled as ‘too expensive’ and governments have failed to protect farmers and consumers against sudden price fluctuations, while being ‘forced’ to liberalize€ their agricultural markets through reducing import duties.

– Land grabbing and evictions as part of neo-colonialism policies, including for biofuel agribusiness, are on the rise in Africa and elsewhere under national governments complacency and a widespread corruption.

– Health threats from waste continue to thrive on socio-economic inequalities: while high-income countries produce mass consumption and rapid discarding of products (i.e. waste), poor countries incur the concentration and uncontrolled dumping of waste which enhances its dangers to health. Meaningfully, this transfer of waste from rich to poor unfolds when most affluent countries export part of their hazardous waste to Africa and Asia.

– Meanwhile, governments, companies, and institutions at the international level are exceedingly behindhand with fossil fuel divestment in order to promote a healthy climate and a safe planet.

The circumstances highlighted above let the authors state that the burden of consequences on health is borne everywhere by those excluded from power and decision-making, even as the more powerful enjoy greatest profits.

In such context, the authors infer that local governments around the world should tackle neoliberal globalization in an efficient manner to ensure that citizens enjoy equal health benefits on an equitable basis, while advancing public health over political and commercial interests.

This looks even more stringent in today’s arena where a WHO strapped for public financing sees its role thwarted by a number of international bodies and private donors resulting in overlapping/duplication of initiatives and undue pressure towards earmarked programs.

Overall, the book calls for an array of inter-sectorial policies the governments should embrace to achieve equitable global health goals (including through a ‘degrowth’ approach and the safeguard of climate and food access), while ending the misalignment among the right to health, trade rules, and the patent system.

Actually, some recipes for administrations worldwide emerge from the book contents and ideology. These entail, besides other measures:

  • Seeking synergies among global level institutions to address global health challenges, support stronger leadership by the WHO to improve global health, and enhance dialogue and joint action with key players in order to coordinate actions, advance in the achievement of commitments, and avoid overlapping and fragmentation.
  • Ensuring that leading institutions and organizations enhance working with health ministries to strengthen national systems, invest in infrastructures, improve transparency and accountability, and boost needs-driven rather than market-driven rules.
  • Pushing for a coordinated response to fight corruption, while refraining from being caught with corporate holdings in a circle of mutually reinforcing political and commercial interests over public health concerns.
  • Rejecting pressures towards adopting heightened IP rights while banning TRIPS-plus clauses and ISDS provisions.
  • Pushing for open knowledge and new approaches to pharmaceutical innovation that do not rely on the patent system and de-link the costs of R&D from the end price of medicines.
  • Backing generic competition as the most effective way to lower medicine prices in a sustainable way.
  • Pushing  for full-exemption of out-of-pocket expenses for the poor; poor-friendly pathways towards universal health coverage; heavy taxation on tobacco and other harmful substances; and reduction or elimination of agricultural export subsidies  and energy subsidies on air-polluting fuels.
  • Opposing land grabbing, deforestation and state-managed food reserve dismantling policies.
  • Reversing ‘brain drain’, health worker shortage by promoting strategies to retain expert faculty staff.



*Author information

Anne-Emanuelle Birn is Professor of Critical Development Studies (UTSC) and Social and Behavioural Health Sciences (Dalla Lana School of Public Health) at the University of Toronto, where she served as Canada Research Chair in International Health from 2003 to 2013. She is widely published in North America, Latin America, Europe, and Africa; her books include: Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico (2006); and Comrades in Health: US Health Internationalists, Abroad and at Home (2013). Professor Birn’s honors include Fulbright and Rotary fellowships, election to the Delta Omega Public Health Honor Society, and numerous endowed lectureships across the Americas and Asia. In 2014 she was recognized among the top 100 Women Leaders in Global Health. 

Yogan Pillay is Deputy Director General for HIV, Tuberculosis, and Maternal, Newborn, and Child Health Programmes in the National Department of Health, South Africa. He has 20 years’ experience in the planning and implementation of health system reforms and has published widely on the topics of HIV, tuberculosis, and health systems.

Timothy H. Holtz is an Adjunct Associate Professor of Global Health at the Rollins School of Public Health at Emory University. His field experience has focused on infectious disease epidemiology and disease control, and he has worked with the U.S. Centers for Disease Control and Prevention and as a consultant to the World Health Organization. From 2002-2010 Dr. Holtz worked in southern Africa, Eastern Europe, and South America on multidrug-resistant tuberculosis control and tuberculosis/HIV program capacity building. He is an internationally recognized expert on the emerging threat of anti-tuberculosis drug resistance and was part of the team of scientists that discovered extensively drug-resistant tuberculosis (XDR TB). He has also directed an HIV prevention clinical trial research program in Thailand, and an HIV and TB technical assistance program in India. He is a founding member of Doctors for Global Health, a health and social justice nongovernmental organization with projects in the U.S., Latin America, and sub-Saharan Africa.


** Table of contents

Preface: Why Global Health?


1. The Historical Origins of Modern International Health

Antecedents of Modern International Health: Black Death, Colonial Conquest, and the Atlantic Slave Trade
Health, the Tropics, and the Imperial System
Industrialization, Urbanization, and the Emergence of Modern Public Health
The Making of International Health
International Health Institution-Building: The LNHO and the Inter-War Years

2. Between International and Global Health: Contextualizing the Present

The Post-World War II International (Health) Order
The Rise of the WHO and “Third World” Development
Straddling International and Global Health

3. Political Economy of Health and Development

Political Economy of Health (and Development)
Political Economy of Development (and Health)
Recent Development and Global Health Approaches
Conclusion: What Does a Political Economy Approach Bring to the Global Health Arena?

4. Global Health Actors and Activities

Snapshot of Global Health Actors, Agencies, and Programs
Political Economy of Global Health Actors and Activities

5. Data on Health: What Do We Know, What Do We Need to Know, and Why Does it Matter

Why Health Data Matter
Types of Health Data

6. Epidemiologic Profiles of Global Health and Disease

Leading Causes of Morbidity and Mortality Across Societies and the Life Cycle
Epidemiology and the Political Economy of Disease

7. Health Equity and the Societal Determinants of Health

Social Determinants/Determinants of Health: What Makes the Underlying Determinants of Health Societal as Opposed to Individual
Operationalizing Political Economy of Health through SDOH
Understanding Health Inequities
From Political, Economic, Social, and Historical Context to Population Health and Health Inequities: Pathways and Possibilities
Societal Governance and Social Policies
From Living Conditions to Embodied Influences
Addressing Health Inequities and the Social Determinants of Health

8. Health under Crises and the Limits to Humanitarianism

“Ecological Disasters” and Their Implications
Famine and Food Aid
War, Militarism, and Public Health
Refugees and IDPs: Numbers, Types, Places
Complex Humanitarian Emergencies
Political Economy of Disasters and CHEs: Where Does Humanitarianism Fit In?

9. Globalization, Trade, Work, and Health

Globalization and Its (Dis)contents
Health Effects of Neo-liberal Globalization
Work and Occupational Health and Safety Across the World
Signs of Hope for the Future: Resistance to Neoliberal Globalization

10. Health and the Environment

Framing Environmental Health Problems: the Motors and Drivers
Health Problems and Environmental Problems and Vice Versa
Climate Change
What Is to Be Done? Multiple Layers of Change

11. Understanding and Organizing Health Care Systems

Principles of Health Systems
Health Systems Archetypes
Primary Health Care, Its Renewal, and the Turn to Universal Coverage
Health System Reform
Building Blocks of a Health System

12. Health Economics and the Politics of Health Financing

Health Economics: A Snapshot
Health Care Financing Redux
Cost Analyses in the Health Sector
Market Approaches to Health in LMICs
The Role of International Agencies in Health Care Financing
Contrasting Approaches to Investing for Health

13. Building Healthy Societies: From Ideas to Action

What Constitutes Success in Global Health
Vertical Health Programs and Global Health Interventions: Successes and Limitations
Health Societies: Case Studies
Healthy Public Policy: Health Promotion, Healthy Cities, and Emerging Frameworks
Conclusion: The Making of Healthy Societies

14. Social Justice Approaches to Global Health

Recapping the Global Health Arena: Dominant Approaches, Ongoing Challenges, and
Points of Inspiration
A Social Justice Approach to Practicing Health: Individuals, Organizations, and the
Logic of the World Order
Conclusion: What Is To Be Done?

U.S. Philanthrocapitalism and the Global Health Agenda

Collective activism to overturn philanthrocapitalism’s hold on global health is an urgent necessity. This effort should draw from, and build upon, the resistance to the UN’s promotion of “multi-stakeholder partnerships” and neoliberal global restructuring since the 1990s. Those actors who have contributed either unwittingly, or through silent assent, or even with active collaboration, to the global health plutocracy also share responsibility in re-democratizing it
Advance preview of Chapter 10 from Health Care under the Knife: Moving Beyond Capitalism for Our Health, Howard Waitzkin and the Working Group for Health Beyond Capitalism, eds. Monthly Review Press (forthcoming 2018). Published under licence from the authors

U.S.  Philanthrocapitalism and the Global Health Agenda: The Rockefeller and Gates Foundations, Past and Present

By Anne-Emanuelle Birn

 Professor of Critical Development Studies, University of Toronto, Canada.

and Judith Richter 

Affiliated Senior Researcher, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland


A fiercely competitive and enormously successful U.S. businessman turns his attention mid-career to worldwide public health. Historic curiosity? Or the most powerful contemporary actor in this field? As it turns out, both. At the beginning of the twentieth century, the Rockefeller Foundation (RF) began to use John D. Rockefeller’s colossal oil profits to stake a preeminent role in international health (as well as medicine, education, social sciences, agriculture, and natural sciences). About a century later, the Bill and Melinda Gates Foundation (BMGF), named for the software magnate and his wife, had become the most influential agenda-setter in the global health and nutrition arena (and in agriculture, development, and education).

Each of these powerhouse foundations emerged at a decisive juncture in the history of international health. Each foundation was started by the richest, most driven capitalist of his day. Each businessman faced public condemnation for his unscrupulous, monopolistic business practices.1 Both have been subject to adulation and skepticism regarding their philanthropic motives.2 Sharing narrow, medicalized understandings of disease and its control, the RF sought to establish health cooperation as a legitimate sphere for intergovernmental action and shaped the principles, practices, and key institutions of the international health field,3 while the BMGF appeared as global health governance was facing a crisis.

Both foundations and their founders were/are deeply political beings, recognizing the importance of public health to capitalism and of philanthropy to their reputations, while claiming the purportedly neutral technical and scientific basis of their efforts.

However, there is one critical difference between them: the RF supported public health as a public responsibility, while BMGF actions have challenged the leadership and purview of public, intergovernmental agencies, fragmenting health coordination and allotting a massive global role for corporate and philanthropic “partners.”4

Given the confluence of largesse and agenda setting at distinct historical moments, several questions emerge: How and why have U.S. mega-philanthropies played such an important role in producing and shaping knowledge, organizations, and strategies to address health issues worldwide? What are the implications for global health and its governance?

Such questions are particularly salient given that “philanthrocapitalism” is hailed as the means to “save the world” even as it depends on profits amassed from financial speculation, tax shelters, monopolistic pricing, exploitation of workers and subsistence agriculturalists, and destruction of natural resources—profits that are channeled, albeit indirectly, into yet more profiteering. The term philanthrocapitalism, coined by The Economist’s U.S. business editor, refers both to infusing philanthropy with the principles and practices of for-profit enterprise and to demonstrating capitalism’s benevolent potential through innovations that allegedly “benefit everyone, sooner or later, through new products, higher quality and lower prices.”5

Most government entities are subject to public scrutiny, but private philanthropies are accountable only to their own self-selected boards. Just a few executives make major decisions that affect millions of people. In North America (and various other jurisdictions), corporate and individual contributions to non-profit entities are tax deductible, removing an estimated $40 billion from U.S. public coffers each year.6 At least one-third (depending on the tax rate) of private philanthropies’ endowments thereby is subsidized by the tax-paying public, which has no say in how such organizations’ priorities are set or monies spent.

This chapter compares and contrasts the goals, modus operandi, and agenda setting roles of the RF and BMGF. We proposed that both the early twentieth century RF and the contemporary BMGF have significantly shaped the institutions, ideologies, and practices of the international/global health field, sharing a belief in narrow, technology-centered, disease-control approaches. The RF, however, favored creation of a singular, public, coordinating agency for global health (eventually, the World Health Organization, WHO), while the BMGF’s privatizing approaches undermine WHO’s constitutional mandate to promote health as a fundamental human right. Indeed, the BMGF’s venture-philanthropy approach—applying methods from the venture capital field to charitable giving7—underpins and is emblematic of the business models that now penetrate the global public health field. These conditions have resulted in extensive private, for-profit influence over global health activities and have blurred boundaries between public and private spheres, representing a grave threat to democratic global health governance and scientific independence.8

Rockefeller International Health in an Age of Imperialism

In 1913, as “tropical” health problems plagued imperial interests, oil mogul-cum- philanthropist John D. Rockefeller established the RF with the professed goal of “promot[ing] the well-being of mankind throughout the world.” His efforts were part of a new American movement: “scientific philanthropy.” In his 1889 manifesto, The Gospel of Wealth,9 Scottish-born, rags-to-riches steel magnate Andrew Carnegie had called on  the wealthy to channel their fortunes to the societal good by supporting organized social investments rather than haphazard forms of charity.

Rockefeller followed this gospel by donating to the nascent field of public health, burnishing his social benefactor image in the process. His advisors advocated starting by tackling anemia-provoking hookworm disease: it was easily diagnosed and treated with medication and was viewed as central to the economic “backwardness” of the U.S. South, impeding industrialization and economic growth. That hookworm was not a leading cause of death, or that treatment occasionally provoked fatalities, seemed immaterial.

The handsomely-funded Rockefeller Sanitary Commission for the Eradication of Hookworm Disease (1910–1914) showered eleven southern states with teams of physicians, sanitary inspectors, and laboratory technicians who administered deworming medication; promoted shoe wearing and latrine use; and disseminated public health materials, working through churches and agricultural clubs. (These activities brought favorable attention to the Foundation until a [false] rumor spread that the campaign aimed to sell shoes, prompting the Rockefeller name to fade into the background).10 Even if did not “eradicate” the disease, the hookworm campaign ignited popular interest in public health, and the RF swiftly created an International Health Board to expand the work.

The RF’s public health activities also served to counter negative publicity about the Rockefeller oil monopoly. Bad press mounted in 1914 when some two dozen striking miners and their families were killed at the Ludlow, Colorado, mine, owned by a Rockefeller-controlled coal producer. Workers, investigative journalists, and the general public readily linked Rockefeller business and philanthropic interests, regarding “robber barons’” donations as attempts to counter working class unrest, political radicalism, and other threats to big business.11

The Rockefeller family was thus advised to engage in philanthropic spheres such as health, medicine, and education, perceived as neutral and unobjectionable. Over the next four decades, the RF dominated international health. Its staff, steered by active trustees and managers (initially overlapping with Rockefeller business advisors), oversaw a global enterprise of health cooperation through regional offices in Paris, New Delhi, Cali, and Mexico City. Hundreds of RF officers led its country-based public health work in scores of countries around the world.12 By the time the International Health Division (as the International Health Board was renamed in 1927) was disbanded in 1951, it had spent the equivalent of billions of dollars on major tropical disease campaigns against hookworm, yellow fever, and malaria, plus smaller programs combatting yaws, rabies, influenza, schistosomiasis, and malnutrition, in almost 100 countries and colonies. The Division also marshaled national commitment to its campaigns by obliging government co-financing, typically starting at 20 percent of costs and rising to the full amount within a few years. It also founded 25 schools of public health across the world and provided fellowships to 2,500 public health professionals to pursue graduate study, mostly in the United States.13

But the RF rarely addressed the most important causes of death, notably infantile diarrhea and tuberculosis, for which technical fixes were not then available and which demanded long-term, socially oriented investments, such as improved housing, clean water, and sanitation systems. The RF avoided disease campaigns that might be costly, complex, or time-consuming (other than yellow fever, which imperiled commerce). Most campaigns were narrowly construed so that quantifiable targets (insecticide spraying or medication distribution, for example) could be set, met, and counted as successes, then presented in business-style quarterly reports. In the process, RF public health efforts stimulated economic productivity, expanded consumer markets, and prepared vast regions for foreign investment and incorporation into the expanding system of global capitalism.

Alongside its disease campaigns, the RF sustained the international health field’s evolving institutional framework. The League of Nations Health Organisation (LNHO), founded after World War I, was modeled partially on the RF’s International Health Board and shared many of its values, experts, and know-how in disease control, institution building, education, and research, even though the LNHO strived to challenge narrow, medicalized understandings of health. Instead of being supplanted by the LNHO, the RF became its major patron and lifeline.14 Addressing the socio-political conditions underlying ill health was an important political rationale for public health in the 1930s’ climate of anti-fascist, labor, and socialist activism. The RF drew on, listened to, and even bankrolled certain progressive political perspectives, including those of avowed left-wing scientific researchers and public health experts,15 although such support was always subordinate to its technical model and to bolstering U.S. capitalist power.

Yet the RF identified its most significant international contribution as “aid to official public health organizations in the development of administrative measures suited to local customs, needs, traditions, and conditions.”16 Thus, its self-defined, broader gauge of success was its role in generating political and popular support for public health, creating national public health departments, and furthering the institutionalization of international health (Table 10-1).

tabella Byrn

Philanthropic status conferred independence from public oversight; the RF was accountable only to its board. Its influence over agenda setting and institution building was enabled by its presence at the international level, bolstered by behind-the-scenes involvement in virtually every kind of public health activity and by missionary zeal in setting priorities. Yet, responding dynamically to shifting political, scientific, economic, cultural, and professional terrains, the RF’s activities also involved extensive give and take, marked by moments of negotiation, cooptation, imposition, rejection, and productive cooperation. Uniquely for the era, it operated not only as a funding agency but simultaneously as a national, bilateral, multilateral, international, and transnational agency.18

The Cold War Interlude and the Rise of Neoliberalism

After WHO was established in 1948, the RF drew back from its leading role in international health, leaving a powerful but problematic legacy: it had generated political and popular support worldwide for public health and championed the institutionalization of international health, but it also entrenched outside agenda setting and a technobiological approach. WHO inherited the RF’s personnel, fellows, ideologies, practices, activities, and equipment, pursuing high profile, vertical eradication campaigns against malaria, smallpox, and other diseases.19

During the Cold War, WHO was joined on the international health stage by bilateral agencies, international financial institutions, and other United Nations (UN) agencies, plus a dizzying array of humanitarian and non-governmental organizations (NGOs). The U.S. and Soviet blocs both employed health infrastructure in their political and ideological rivalry, building hospitals, clinics, and pharmaceutical plants, sponsoring thousands of fellowships, and participating in RF-style disease campaigns.

In the 1970s, WHO’s vertical approach began to be challenged. Its member states, especially newly decolonized countries not aligned with either the Soviet Union or the United States, sought to address health socio-politically. Halfdan Mahler, WHO Director-General from 1973 until 1988, provided the visionary leadership in this reorientation. The primary health care movement, enshrined in the seminal 1978 WHO- UNICEF Conference and Declaration of Alma-Ata and WHO’s accompanying “Health for All” policy, called for health to be addressed as a fundamental human right through integrated social and public health measures that recognized the economic, political, social, and cultural contexts of health and focused on prevention rather than cure.20 Health for All was also part of a larger UN effort, the New International Economic Order (NIEO), which also called on UN agencies to help regulate transnational corporations via binding international codes.

Just as WHO was trying to escape the RF’s legacy of narrow health interventions, however, it became mired in political and financial crises. The economic situation in the late 1970s and early 1980s prevented many member countries from paying WHO dues. Meanwhile, U.S. resistance to what it portrayed as illegitimate “supra-national regulation,” amid the overall rise of neoliberal political ideology dampened support for publicly funded international health institutions. These conditions also contributed to a budget freeze in terms of dues paid by member states, which still remains in place. Moreover, U.S. President Ronald Reagan’s administration unilaterally cut its assessed contributions to the UN by 80 percent in 1985 and then withheld its WHO member dues in 1986 to protest WHO’s regulation of health-related commercial goods and practices,21 particularly pharmaceuticals and infant foods.22 By the early 1990s, less than half of WHO’s budget came from member country dues, while many donors, now including a variety of private entities, stipulated the programs and particular activities to which they assigned funds. Today almost 80 percent of WHO’s budget comes from donors who determine how their contributions are to be spent.

After the Cold War, international health efforts were justified on the grounds of promoting trade, disease surveillance, and health security.23 By this time, WHO was being sidelined by the World Bank, armed with a far larger health budget and a drive to privatize health systems as well as water and other essential public services, and by an emerging paradigm forging UN “partnerships” with corporate actors. Many bilateral agencies, plus certain UN agencies such as UNICEF, bypassed WHO altogether.24 With reduced intergovernmental spending, what was now dubbed “global health” philanthropy returned, its re-emergence coinciding and intertwined with the rise of neoliberalism.

 Enter the Gates Foundation

By 2000, overall global health spending had become stagnant. Negative views of overseas development assistance were encouraged by political and economic elites and corporatized mass media. Many low- and middle-income countries (LMICs) were floundering under the multiple burdens of HIV/AIDS, re-emerging infectious diseases, and burgeoning chronic diseases, all compounded by decades of World Bank and IMF- imposed cuts in social expenditures and the negative effects of trade and investment liberalization. Into this void a self-proclaimed savior for global health appeared, quickly molding its agenda within just a few years.

The BMGF was established in 2000 by Microsoft founder and long-serving CEO Bill Gates, the world’s wealthiest person, and his wife Melinda.25 As with Rockefeller, Gates’s philanthropic entry coincided with bad press. He launched the Children’s Vaccine Program, a BMGF precursor, in 1998,26 when Microsoft was attracting negative publicity for lobbying to cut the U.S. Justice Department’s budget precisely when the company was mired in a federal antitrust suit.27 In 1999, Gates gave a $750,000 founding donation to the Global Alliance for Vaccines and Immunization (now “GAVI, the Vaccine Alliance”), an initiative announced at the World Economic Forum in Davos. Later that year Microsoft faced a class-action lawsuit for abusing its software monopoly from millions of California consumers. BMGF-funded initiatives rapidly proliferated, even as Microsoft was facing further anti-competitive charges in the European Union. In 2002 the BMGF co-founded the Global Alliance for Improved Nutrition (GAIN) and became a major funder of the Global Fund to Fight AIDS, Tuberculosis and Malaria (now called the Global Fund).

Today the BMGF, co-chaired by the couple together with Bill Gates Senior, is by far the largest philanthropic organization involved in global health and the largest charitable foundation in the world. The BMGF spends more money on global health than any government except the United States.28 Its 2015 endowment was $39.6 billion, including $17 billion donated by U.S. mega-investor Warren Buffett, the BMGF’s sole trustee.29

Through 2015, the BMGF had granted $36.7 billion in total; recent annual spending is around $6 billion. Approximately $1.2 billion goes into “global health” (including HIV, malaria, and tuberculosis) and $2.1 billion into “global development” (including polio, vaccine delivery, maternal and child health, family planning, and agricultural development). The BMGF’s budget for global health-related activities has surpassed that of WHO in some recent years. Since 2008, the BMGF has been the largest private donor to WHO (much of this funding is earmarked for polio eradication).

The BMGF’s stated global health aim is “harnessing advances in science and technology to reduce health inequities,”30 encompassing both treatment (via diagnostic tools and drug development) and preventive technologies (such as vaccines and microbicides). Initially, the Seattle-based Foundation focused on a few disease-control programs, mostly as a grant-making agency. Now its efforts reach over 100 countries. It maintains offices in Africa, China, India, and the United Kingdom, with more than 1,400 staff members.

Echoing RF practices, the BMGF requires co-financing from its governmental “partners,” designs technologically oriented programs to achieve positive results from narrowly defined goals, and emphasizes short-term achievements. The BMGF has developed an extraordinary capacity to marshal other donors to its efforts, including bilateral agencies, which collectively contribute ten times more resources to global health each year than the BMGF but with considerably less recognition.31 The BMGF has been widely lauded for infusing cash and life into the global health field and encouraging other participants.32 But even some of its supporters decry its lack of accountability and transparency (over what are, after all, taxpayer-subsidized dollars) and its undue power in setting the global health agenda.33

The BMGF Approach and Its Dangers

As a key funder of global health initiatives, the BMGF collaborates with a range of public, private, and intergovernmental agencies, as well as universities, corporations, advocacy groups, and NGOs. Like the RF, the BMGF sends the vast majority of its monies for global health to or through entities in high-income countries. Through 2016, three quarters of the total funds granted by its Global Health Program went to sixty organizations, 90 percent of which are located in the United States, United Kingdom, or Switzerland.34

A major focus of BMGF global health funding is vaccine distribution and development. In 2010 it committed $10 billion over ten years to vaccine research, development, and delivery. While vaccines are important and effective public health tools, historical evidence demonstrates that mortality declines in high income as well as some LMICs since the nineteenth century have been mostly due to improved living and working conditions (including access to clean water, sanitation, and primary health care) in the context of social and political struggles.35

The BMGF’s reductionist approach emerged clearly in Bill Gates’s keynote address in May 2005 to the fifty-eighth World Health Assembly, the annual gathering at which WHO member states set policy and decide on key matters. Gates invoked smallpox eradication through vaccination, whose cost was low due to its non-patented status, to chart a global health agenda: “Some… say that we can only improve health when we eliminate poverty. And eliminating poverty is an important goal. But the world didn’t have to eliminate poverty in order to eliminate smallpox – and we don’t have to eliminate poverty before we reduce malaria. We do need to produce and deliver a vaccine.”36 Gates’s deceptively simple technological solution to the complex problem of malaria implies that approaches based on social justice can simply be ignored.

Similarly, the BMGF’s Grand Challenges in Global Health initiative funds scientists in nearly 40 countries to carry out “bold,” “unorthodox” research projects as long as they largely disregard the underlying social, political, and economic causes of ill health, including unprecedented accumulation of wealth.37

To be sure, the BMGF has also supported other kinds of initiatives, albeit at a smaller scale. In 2006, it gave a $20 million startup grant to the International Association of National Public Health Institutes and a $5 million grant to the WHO-based Global Health Workforce Alliance, which sought to address the shortage of health personnel in LMICs. BMGF funding has often had a privatizing impetus. Recently, the BMGF has begun funding “universal health coverage” (not the same as access to publicly-funded universal health care),38 for example via a $2.2 million grant to the Results for Development Institute, which works to “remov[e] barriers impeding efficiency in global markets (for instance in health).”39

Despite the shortcomings of a technology-focused, disease-by-disease approach to public health problems, this model now prevails, shepherded by the BMGF’s role in formal global health decision-making bodies. Its role mounted in 2007 with the formation of the “H8”—WHO, UNICEF, the UN Population Fund (UNFPA), UNAIDS, the World Bank, the BMGF, GAVI, and the Global Fund. Most are involved with and/or heavily influenced by the BMGF. The H8, akin to the former G8 (composed of 8 powerful nations collaborating on economic policies and “security” issues: United States, Japan, Germany, France, United Kingdom, Canada, Italy, and Russia; now G7 without Russia) holds meetings behind closed doors to shape the global health agenda.40

Like the RF at its height, the BMGF’s sway over the global health agenda stems from the magnitude of its donations, its ability to mobilize resources quickly and allocate substantial sums to large initiatives, the high profile of its patron, and the leverage it garners from the extraordinary range of organizations with which it partners. Yet Bill Gates’s response to the 2014-15 Ebola outbreak in West Africa raises yet more questions about his vision. He called for a supranational, militarized global health authority, modeled on the North Atlantic Treaty Organization, to be mobilized in the event of future epidemics, usurping WHO’s coordinating mandate while undercutting national sovereignty and democratic rule.41

The BMGF and Conflicts of Interests

Conflicts of interest in financing and staffing pervade the BMGF. In recent years it has been critiqued for investing its endowment in polluting and unhealthy food and beverage industries and in private corporations that benefit from its support for particular global health and agriculture initiatives.42 Although the BMGF sold many of its pharmaceutical holdings in 2009,43 its financial interests in Big Pharma remain through Warren Buffett’s Berkshire Hathaway holdings (almost half of the BMGF’s endowment investments).

Overly close relationships between the BMGF and Big Pharma put into question the Foundation’s stated aim of reducing health inequities, given that profiteering by these corporations impedes access to affordable medicines.44 In addition, various senior BMGF executives used to work at pharmaceutical companies.45 For instance, Dr. Trevor Mundel, president of the BMGF’s Global Health Program, was previously a senior executive at Novartis; and his predecessor, Dr. Tachi Yamada, was an executive and board member of GlaxoSmithKline. Yet such “revolving door” problems are rarely discussed publicly.46

Advocates for affordable life-saving medicines have also raised questions about the BMGF’s stance on intellectual property (IP). Gates admits that his Foundation “derives revenues from patenting of pharmaceuticals.”47 Microsoft has long been an ardent supporter of IP rights – which facilitate its worldwide capture of markets48 – and has taken a leading role in assuring passage of the World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS).49 The BMGF and Microsoft are legally separate entities (as the RF and Rockefeller companies were), but linkages, such as BMGF’s hiring of a Microsoft patent attorney in 2011 for its Global Health Program,50 are troubling. The government of India became so concerned about the BMGF’s pharmaceutical ties and related conflicts of interest that, in early 2017, it cut off all financial ties between the national advisory body on immunization and the BMGF.51

Such conflicts of interest also manifest themselves at WHO, due to the increasing role of the BMGF as the main financier for WHO’s budget. The problem of WHO’s dependence on “voluntary” funding – its most fundamental institutional conflict of interest – remains unaddressed despite concerted efforts by civil society organizations.52 It would take just $2.2 billion – which is only half that of New York- Presbyterian Hospital’s budget,53 – to fully fund WHO through Member State dues.

Instead of lifting the freeze on WHO member state dues, WHO’s most recent reform produced the 2016 Framework of Engagement with Non-State Actors.54 This further legitimized BMGF and corporate influence on WHO by specifically allowing philanthropic and corporate actors to apply for “Official Relations” status, which was originally meant for NGOs that shared the specific goals articulated in WHO’s constitution.

The BMGF, Public-Private Partnerships, and Multi-Stakeholder Initiatives

Among the key levers through which the BMGF has garnered influence over agenda setting and decision making are “public-private partnerships” (PPPs). The generic term PPP covers a multitude of arrangements, activities, and relationships. In the early 1990s, PPPs were promoted as a way of funding and implementing global health initiatives in line with neoliberal prescriptions for privatizing public goods and services. By the late 1990s, UN agencies had classified a wide range of public-private interactions as “partnerships” or “multi-stakeholder initiatives” (MSIs). Both concepts lump all participants together, erasing key differences in the roles and objectives of those striving for human rights to health and nutrition, and those ultimately pursuing their bottom line.55 Many of the major global health PPPs now in existence, with budgets ranging from a few million to billions of dollars – such as GAVI, Stop TB, Roll Back Malaria, and GAIN – were launched by the BMGF or have received funding from it.

These public-private hybrids encourage a close relationship between a public institution and business rather than an arms-length one and promote a shared process of decision making among supposedly equal partners or “stakeholders.” Such arrangements have enabled business interests to obtain an unprecedented role in global health policy making with inadequate public scrutiny or accountability56 and are markedly different from the RF’s advocacy of public health as the responsibility of the public sector to which public health activities should be accountable.

The BMGF’s prominent role in the two most powerful PPPs – GAVI and the Global Fund, both H8 members – and its founding of GAIN underscore the primacy of the foundation in shaping and enhancing the clout and business venture orientation of PPPs. GAVI has been the model for almost all global health PPPs. When Bill Gates first funded it, he was following the venture philanthropy model created in the mid-1990s by billionaires who advocated bringing business thinking and jargon into the public arena. The arrangements are characterized by the active involvement of the donor entrepreneurs and foundation staff in the recipient organizations and by board representation from the for-profit sector,57 with corporate presence creating an intimidating environment for some government representatives.58

GAVI has been critiqued for emphasizing new vaccines instead of ensuring that existing effective vaccination against childhood diseases is universally carried out. It has been characterized as a “top-down” arrangement emphasizing technical solutions that pay scant attention to local needs and conditions59 and underwrite already hugely profitable pharmaceutical corporations in the name of “saving children’s lives.”60 Indeed, GAVI has subsidized companies, such as Merck, for already profitable products such as pneumococcal vaccine, while countries eligible for GAVI support are expected over time to take on an increasing proportion of costs, eventually losing both direct subsidies and access to lower negotiated vaccine prices.61

Similar issues surround the Global Fund, the largest global health PPP in dollar terms; it received a $100 million startup grant from the BMGF, which has since given it almost $1.6 billion. Sidelining UN agencies, the Global Fund had disbursed $33 billion to fund programs in 140 countries as of early 2017, in the process further debilitating WHO and any semblance of democratic global health governance. WHO and UNAIDS have no voting rights on the board, but the private sector, currently represented by Merck and the BMGF, does. The Global Fund, like many PPPs, is known to offer “business opportunities” – lucrative contracts and influence over decision making – as a prime feature of its work.

Similarly, since the BMGF and UNICEF founded GAIN, this PPP has popularized the term “micronutrient malnutrition” to justify its prime focus on food fortification and supplementation. GAIN argues that “in an ideal world we would all have access to a wide variety of nutrient rich foods which provide all the vitamins and minerals we need. Unfortunately, for many people, especially in poorer countries, this is often not feasible or affordable.”62 This reasoning ignores food supply and distribution problems. Severe malnutrition prevails in regions with extremely fertile soil and advantageous growing conditions, producing some of the world’s most nutritious crops, but these are largely for export markets, leaving local people on low incomes priced out of access to nutritious food.63

Overall, the PPP- and MSI-peppered global health architecture fragments and destabilizes the global health landscape, undermining WHO’s authority and capacity to function and coordinate.64 These arrangements allow private interests to frame the public health agenda, provide legitimacy to corporations’ involvement in the public domain, conflate corporate and public objectives, and raise multiple conflicts of interest, with most PPPs channeling public money into the private sector, not the other way around.65 Most recently, a new global health campus built to house the headquarters of major PPPs, just a stone’s throw from WHO, will further shift the node of global health governance physically and metaphorically away from UN agencies.66

Other Avenues of Influence

Relatively unexamined is the $3.5 billion in grants from the BMGF in recent years for “policy and advocacy” work. These grants fund extensive health and development media coverage, including of BMGF-supported programs, in outlets spanning the U.S. Public Broadcasting System to the United Kingdom’s Guardian newspaper.67 This coverage adds to the considerable self-publicity generated by Bill and Melinda Gates themselves, who have been featured in countless profiles over the years. Their 2017 annual letter, for example, used cherry-picked evidence to promote an overly positive and misleading spin on the BMGF’s achievements.68 By contrast, the RF historically underplayed its public profile, largely because it was faced with a more vigilant media and a public skeptical about the intermixing of business and philanthropic interests, and usually exerted influence at the highest political levels behind closed doors.

Venture philanthropy funding from the BMGF increasingly influences civil society movements,69 universities and researchers,70 and government programs. This influence leads to modification of mandates, scientific research foci, and methodological approaches and also squeezes out more critical analyses. Indeed, it is widely known that the BMGF – via the Seattle-based Institute for Health Metrics and Evaluation, which it bankrolls – “claims for itself a core WHO role: ‘diagnosing the world’s health problems and identifying the solutions.”71 Meanwhile, critics within UN agencies, civil society organizations, and academia are silenced or excluded, depicted as holding outdated views. For instance, a Gates-funded Evaluation Report of the Scaling Up Nutrition multi-stakeholder initiative portrayed those who raised conflict-of-interest concerns as harboring “phobias” and “hostile feelings” towards industry, which could “potentially sabotage the prospects of multi-stakeholder efforts to scale up nutrition.”72

Another telling illustration is a 2017 high-level Memorandum of Understanding between the BMGF and the German development agency BMZ. This MOU commits BMGF and the BMZ to join forces in advancing the UN’s 2030 Sustainable Development Goals (SDGs) through “revitalization” of global “partnership” approaches. Among other effects, this MOU opens up BMZ’s large network of contacts to the BMGF and invites staff exchanges between the organizations.73 If this MOU becomes a model for future government-foundation relations, it will further upend democratic and accountable decision making in the global health and development sphere.

Philanthrocapitalism Redux: Comparing the RF and the BMGF

Philanthropic largesse and the social-entrepreneurial mission of twenty-first century billionaires are today touted as unparalleled, as though capable of “sav[ing] the world.”74 This is underscored by the ever more welcoming and enabling environments for corporate investment and “charitable” sponsorship of the UN’s flagship SDGs, adopted in 2015 with the stated aim of ending poverty, reducing inequality, and advancing health, social well-being, and environmental sustainability.75 The claims for selfless, philanthropic generosity merit critical consideration,76 for which comparisons with the past are illuminating.

Philanthropy circa 1900 derived from the profits and exploitative practices of leading oil, steel, railroad, and manufacturing interests. Similarly, the colossal profits earned during the 1990s and 2000s by investors in the information-technology, insurance, real estate, and financial sectors, as well as industries linked to mining, oil, and the military, were built on the rising inequality to which they contributed, abetted by massive, if often lawful, tax evasion.77 In both eras, profits were amassed thanks to depressed wages and worsening labor conditions; trade and foreign investment practices obstructing and weakening protective regulations; illicit financial outflows; externalizing and transferring the social and environmental costs of doing business onto the public and future generations; and tacit support for military regimes to guarantee access to valuable raw materials and commodities.78

On the eve of launching his foundation, Bill Gates’s net worth exceeded that of 40% of the US population.79 The company he created, and in which he and the BMGF still hold shares, was recently accused of heavily lobbying against reforms that would curtail corporate tax evasion.80 Gates remains the wealthiest of eight megabillionaires who are as rich as the poorest half of humanity.81 Yet these men are celebrated for their philanthropy rather than scrutinized for their business practices.

The tenet that business models can resolve social problems – and are superior to redistributive, collectively deliberated policies and actions developed by elected governments – rests on the belief that the market is best suited to these tasks, despite ample evidence to the contrary. Still, the BMGF’s support of such models and incentives diverges from that of the RF. Although following a business model and undergirding an expanding capitalist system, the RF explicitly called for public health to be just that: in the public sphere.

Tax-deductibility of philanthropic donations is an affront to democracy. The belief that charitable giving can change the world is just another variant of the decidedly undemocratic doctrine that the rich know best. Whereas “governments used to collect billions from tycoons and then decide democratically what to do with it,”82 today they cede agenda setting about social priorities to the class that already wields undue economic and political power.

Applauding and encouraging the munificence of elites will not create equitable, sustainable societies. Ironically, people living on modest incomes are proportionately far more generous than the rich, often donating money and time at considerable personal sacrifice, without receiving comparable recognition or tax breaks for their contributions.83 A century ago, the millions of people involved in social and political struggles for decent, fairer societies were far more skeptical than many are today about big philanthropy and its effect on public policy making, including policies about public health.

In short, a plutocratic health governance system with authoritarian features is becoming entrenched. Fading independent critical media have facilitated the philanthrocapitalist onslaught, with the emergence of an engineered “consensus” claiming that the world’s problems can only be solved through “partnerships” of all “stakeholders.”

By contrast, through the 1940s, the RF supported a small number of leftwing advocates of social medicine even as it privileged a medicalized, reductionist approach; the BMGF, however, remains largely impervious to opposing viewpoints. As the premier international health organization of its day, the RF had an overarching purview and was instrumental in establishing the centrality of the field of public health to the realms of economic development, nation-building, diplomacy, scientific diffusion, and capitalism writ large, while institutionalizing lasting, if problematic, patterns of health cooperation. The BMGF, for its part, while reliant on the public sector to deliver many of its technology-focused programs,84 appears largely indifferent to the survival of the “public” in public health.

“A Rich Man’s World, Must it Be?”

These many examples demonstrate that capitalism trumps philanthropy – or “love of humankind,” from the word’s ancient Greek roots – making philanthrocapitalism an oxymoronic enterprise indeed. The pivotal, even nefarious, role it has played in global health depends on gargantuan resources enabled by profiteering of titanic proportions amidst relentless ideological assaults on redistributive approaches, within a pro-corporate geopolitical climate of dominant, if currently cracking, global capitalism.

In the twenty-first century, it may still be a rich man’s world, but we need not settle for a rich man’s agenda. Collective activism to overturn philanthrocapitalism’s hold on global health is an urgent necessity. This effort should draw from, and build upon, the resistance to the UN’s promotion of “multi-stakeholder partnerships” and neoliberal global restructuring since the 1990s.85 Those actors who have contributed either unwittingly, or through silent assent, or even with active collaboration, to the global health plutocracy also share responsibility in re-democratizing it. Governments and UN agencies need to take their public mandates seriously. Scientists, scholars, activists, civil servants, international organization staff, parliamentarians, journalists, trade unionists, and ethical thinkers of all stripes have a duty to question and counter philanthrocapitalists’ unjustified influence; work together for accountability and democratic decision-making: and reclaim a global health agenda based on social justice rather than capital accumulation.



This piece was adapted and updated from: Anne-Emanuelle Birn,”Philanthrocapitalism, Past and Present: The Rockefeller Foundation, the Gates Foundation, and the Setting(s) of the International/ Global Health Agenda,” Hypothesis 12, no. 1 (2014): e8. We are grateful to Sarah Sexton, Alison Katz, Esperanza Krementsova, Mariajosé Aguilera, Jens Martens, and Lída Lhotská for their support and suggestions.



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  8. This is magnified by other actors, in particular the World Economic Forum’s Global Redesign Initiative (WEF GRI), a corporate-led campaign that set out in 2009 to restructure the architecture of global decision-making so that UN agencies become just one of many “stakeholders” in “multi-stakeholder governance.” See Judith Richter, “Time to Turn the Tide: WHO’s Engagement with Non-State Actors and the Politics of Stakeholder-Governance and Conflicts of Interest,” BMJ 348 (2014): g3351,; Flavio Valente, “Nutrition and Food – How Government for and of the People Became Government for and by the TNCs,” Transnational Institute, January 19, 2016, https:// .
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  69. Shack/Slum Dwellers International, “Partners,”
  70. Callahan, The Givers.
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  74. Bishop and Green, Philanthrocapitalism.
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  81. Hardoon, “An Economy for the 99%.”
  82. Robert Reich cited in Peter Wilby, “It’s Better to Give than Receive,” New Statesman, March 19, 2008,
  83. Alex Daniels and Anu Narayanswamy, “The Income-Inequality Divide Hits Generosity,” Chronicle of Philanthropy, October 5, 2014,
  84. David McCoy and Linsey McGoey, “Global Health and the Gates Foundation – in Perspective,” in Owain D. Williams, Simon Rushton, eds., Health Partnerships and Private Foundations: New Frontiers in Health and Health Governance (Houndmills, Basingstoke, Hampshire, UK: Palgrave, 2011).
  85. Kenny Bruno and Joshua Karliner, “Tangled Up In Blue: Corporate Partnerships at the United Nations,” San Francisco, Transnational Resource & Action Centre, 2000,; Richter, “We the Peoples”; Judith Richter, “Building on Quicksand: The Global Compact, Democratic Governance and Nestlé,” Geneva, IBFAN/GIFA, CETIM, Berne Declaration, 2004, democratic-governance-and-nestle/.



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