This article highlights key touchstones for reflections on WHO’s role in the international health arena and raises a number of possibilities, relating to language, propaganda even, and power, which could contribute to reclaiming WHO’s capacity to unequivocally work for peoples’ health
Defending and Reclaiming WHO’s Capacity to Fulfil its Mandate
Suggestions from a Perspective of Language and Power
By Judith Richter[i]
Another ‘reform’ of WHO?
2021 will be a decisive year for the World Health Organization, the highest health authority of this world, whose decisions we must be able to trust as the discussions about its role in the public management of the Covid-19 pandemic has shown.
When President Trump started threatening WHO with the withdrawal of the United States funding, the government of Germany said that, even if the Democratic Party were to win and reinstate US-membership of WHO, there would still be a need to discuss reforming WHO. The problem is that WHO has been reformed under neoliberal ideology for over 20 years and unfortunately, WHO Member-states, as well as senior WHO officials, have not always played a constructive role in the reform of this UN agency. [ii]
In this short text, I raise a number of possibilities, relating to language, propaganda even, and power, which could contribute to reclaiming WHO’s capacity to unequivocally work for peoples’ health.
But before that, let us look at key touchstones for reflections on WHO’s role in the international health arena:
Remember WHO’s constitutional mandate and core-functions
WHO’s objective to work for the “attainment by all peoples of the highest possible level of health” (Article 1) where health is understood as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity….” (preamble)
WHO’s constitutional function to “act as the directing and co-ordinating authority on international health work.” (Article 2a)
WHO’s role as regulatory and standard setting body in international health matters. (Articles 2k and 2u)
WHO’s duty to “assist in developing an informed public opinion among all peoples on matters of health.” (Article 2r)
And “generally, to take all the necessary action to attain the objectives of the Organization.” (v)
The people involved in establishing this UN specialized agency after the second World War also stressed:
“Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people”; and
“Governments have the responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.” (Preamble) [iii]
But governments have often hindered efforts undertaken in the interests of their people due to the rise of neoliberal ideology. Harmful changes resulting from the neoliberal restructuring of WHO and the international health arena include:
1) a gradual narrowing and re-definition of the role of WHO in the international public health arena – more or less reducing WHO’s role to that of a broker of public-private partnerships and part of a global ‘multi-stakeholder governance’ system.
2) the weaving of opaque webs of influence between mega-philanthropies, transnational corporations, WHO (and other UN agencies), government institutions, academics, and a number of public-interest-Non-State actors (PINGOs and civil society organizations and networks) which influence our health policies more than we think.
3) the framing of a neoliberal multi-stakeholder/partnership narrative, including the redefinition of key-political and legal terms, in a way that prevents open and informed discussions and decisions and undermines WHO’s mandate to safeguard international public interests.
4) the rise of a culture of secrecy and censorship which has gradually seeped into all spheres.
Language and power
But we are not powerless in the face of these changes. Insights from language (including propaganda) as power can help us to question these harmful redefinitions and narratives (the storylines which may shape politics and our lives). This is an entirely cost free endeavour which will allow all relevant public actors to truly work towards Health for All.
More clarity in language is an indispensable ingredient in discussions on how to undo harmful neoliberal restructuring of WHO and other UN agencies and problematic public-private webs of influence. I suggest undoing harmful language changes through three strategies:
- Identifying and rejecting ‘dangerous non-sense’ in neoliberal narratives and terminology
- “Calling a Spade, a Spade” and replacing problematic terms by less-value laden terms
- Recovering, and further clarifying, key legal concepts – correct WHO’s misconception and popular misunderstandings of conflict of interest.
I elaborate on these three strategies below:
- Identify and reject dangerous ‘non-sense’ in neoliberal narratives and terminology
Nobody needs to be an academic expert to identify when they see ‘non-sense’. But many may be intimidated by the volumes of official and academic writing which asserts:
In complex situations ‘all stakeholders’ need to work together in ‘partnership’
This, and similar, sentences are presented as an ‘imperative’.
However are simply non-sense, but dangerous non-sense! It is time to reject it!
This alleged ‘imperative’ is part of neoliberal reframing of narratives and key concepts.
Of course, it would be ideal if all societal actors worked harmoniously together when there is an important societal problem. But we all know that this does not correspond to reality, especially when one of these ‘partners’ or ‘stakeholders’ is a powerful for-profit actor who is invited into various fora, on the neoliberal principle of ‘trust’ associated with these arrangements. French popular wisdom warns “you do not invite the wolf into the sheep pen.” And literature in political science, as well as literature on conflicts of interest in public service, or conflicts of interest in medicine, is full of examples why corporations should not be part of certain decision-making processes. [iv]
Yet the above empty slogan has given rise to plutocratic ‘governance’ (decision-making) systems with totalitarian features. In other words, systems where money, not people (interests), rule (often through manipulation) and where critics are sidelined and silenced.
The draft concept paper underlying WHO’s current Global Work Plan (GWP) is based on such a partnership view. If one undertakes a simple analysis of its discourse by asking “What is said? How is it said? And “What is left out?”, a key suggestion in this document was for WHO to become a humble broker of multi-stakeholder partnerships and part of what was presented as a harmonious, evolving, system of multi-stakeholder governance in health. WHO’s regulatory function of corporate practices – which is distinct from standard setting function – seems to have been lost.[v]
Networks challenging the above imperative and insisting on questioning partnership-approaches, and such as the International Action Network on Infant Feeding (IBFAN), are being discredited and defunded on the grounds that they are not joining the “narrative of the 21st century”.[vi]
Critics have often failed to deconstruct – to fully take apart – such non-sensical terms and narratives. It is not enough, for example, to state that there is a need to consider power differences between business- and civil society- ‘stakeholders’ because this does not challenge the idea that social actors, simply because they have an interest ‘at stake’, are legitimate stakeholders in public affairs; it implicitly reinforces the stakeholder discourse. Calling all kind of societal actors ‘stakeholders’ or ‘partners’ contributes to blurring of fundamental differences between actors in terms of power, interests, and legitimate societal roles and has favoured the rise of public-private hybrids which have acted as Trojan horses for business interests.[vii]
Remember: People are human rights holders whose rights UN agencies are meant to protect, promote, and respect.[viii] Transnational corporations (TNCs) are artificial legal entities whose key driver is profit-making for shareholders. Their power – including that of political lobbying against transnational public-interest regulation – should be kept in check by our governments and the intergovernmental system.
Dangerous ‘non-sense’ is also the more recent redefinition of key concepts such as ‘civil society’ to include transnational corporations (TNCs) and their associations, and of ‘academia’ to include (e.g. corporate-funded) think tanks.
Public-interest actors can of course, where appropriate, interact with business actors. For example, under the late Dr. Halfdan Mahler, WHO cooperated with pharmaceutical companies in its Tropical Disease Research Programme (TDR). At the same time, Dr Mahler did his best to work for transnational regulation of harmful business practices and of the products of pharmaceutical, food, tobacco, and alcohol companies, and towards systems that provide access to Health for All, including access to affordable essential medicines.[ix]
Times have changed. Today there is a need to:
- re-establish a clear separation of spheres, and an ‘arms-lengths’ distance between public-interest actors and big business actors as well as hyper rich funders and their mega-foundations
- protect sensitive public interest inside information from firms and associated actors instead of inviting them into fora where they do not belong and giving them roles that are inappropriate
- allow for public scrutiny
- and protect whistleblowers – persons who report wrongdoing in the international public interest – and listen carefully to them, instead of sidelining, silencing, or persecuting them.[x]
- “Call a spade a spade” – Be specific and replace problematic terms by less-value laden terms
The following terms should never be used without reflection. They should be replaced by terms which do not promote undue influences by giant firms and wealthy funders. These terms include:
- Partners, partnership, in particular public-private partnership (PPP);[xi]
- Stakeholder, multi-stakeholder-anything: such as MS-partnership (MSPs), MS-dialogue, MS-platform, MS-governance;
In fact, PPPs and MS-anythings usually denote public-private hybrids and hybridization (PPHs) – the blurring of boundaries between private/business sphere and the public sphere. They introduce, and legitimize, undue influence of big corporations and mega-funders. Since the introduction of the term governance in the international arena, and the link with a redefined “stakeholder” term, the term multi-stakeholder governance simply means inviting corporations and big funders into decision-making.
This is why health activists working for Health for All, which includes appropriate health care systems accessible to all, and regulation of harmful practices of transnational corporations, have called neoliberal PPPs and MS-arrangements Trojan horses.
Scholars such as Susan George, who has long worked against the seizing of power by corporations, advocates abandoning the terms stakeholder and governance in public discourse. She stresses: “Non-native English speakers… don’t necessarily realize that in English a stake is always concerned with money, property or a bet of some kind. In the days of the American frontier, a pioneer moving West could lay, or ‘stake’ a claim to land, marking it physically with posts – or stakes at the corners…” [xii]
Two further reflections may help to undo the power of the multi-stakeholder governance notion:
I would like to remind people that the term stakeholder has been redefined in a Novartis-sponsored publication from then UN Secretary General Kofi Annan’s definition of stakeholders as: “those individuals and groups that have an interest, or take an interest, in the behaviour of a company… and who therefore establish what the social responsibility of a company entails” to a definition of stakeholders as “those who have an interest in a particular decision, either as individuals or as representatives of a group. This includes people who influence a decision, or can influence it, as well as those affected by it.”[xiii]
It is also useful to remember that the term governance comes from the Greek gybernan, which originally means to be at the rudder, to steer a boat. What must be vigorously defended is for our ‘health boat’ to be steered in the public interest, with the aim of achieving Health for All. (according to a map and by actors, which allow to reach Health for All.)
- Recover and further clarify key legal concepts – conflict of interest (a conflict within an actor)
The neoliberal restructuring can also be reversed by recovering legal meanings of redefined key-concepts.
For example, the power of the broad stakeholder definition can be undone by pointing out that the law continues to define a stakeholder as “any person/group which can affect/be affected by the actions of a business. It includes employees, customers, suppliers, creditors and even the wider community and competitors.”[xiv]
But most important is to recover the meaning of conflicts of interest. During the last ‘reform’ of WHO under Dr. Margaret Chan, Member States had asked WHO’s Secretariat to clarify the concept of conflict of interest and help distinguish appropriate from inappropriate interactions with corporations and other Non-state actors.
Instead, WHO actively redefined the conflict of interest (COI) concept in a way that makes genuine conflict of interest regulation impossible. In its work, the Secretariat build on, rather than publicly rejected, a misleading COI definition that had been developed in a Gates-funded project for use in the Scaling-Up Nutrition (SUN) initiative, a public-private hybrid of which WHO and UNICEF are part.[xv]
The erroneous conception of conflict of interest, which is used in FENSA, WHO’s Framework of Engagement with Non-state Actors, unduly influences WHO’s relations with TNCs and wealthy funders. Among other things, it does not posit conflicts of interests as conflicts WITHIN an actor, but conflicts BETWEEN actors.[xvi] World expert on conflicts of interest in medicine, Professor Marc Rodwin, warned the agency since its Technical consultation “Addressing and managing conflicts of interest in the planning and delivery of nutrition programmes at country level” in 2015, that wrong conceptions may actually lead to an increase of conflicts of interest, among others by diverting attention from identification and genuine regulation of conflicts of interest to risk assessments. He proposes as most suitable COI definition for WHO engagement with Non-state Actors a conception which takes financial conflicts of interest and loyalty conflicts into account.[xvii] In such a conception it becomes clear that public-private arrangements in which public-interest actors are asked to look for win-win situations for both parties are placing them into a loyalty conflict. Is this why SUN’s Gates-funded project had to redefine conflicts of interest?
Non law-based COI concepts, such as the notion of ‘intellectual conflicts of interest’, risk sidelining critical civil society actors or scientists from public debates. This situation is compounded by a problematic confidentiality clause for WHO experts.
In the medical sphere, it is long known that individual researchers, health professionals, or civil servants, cannot resolve certain conflicts of interest, if their institution is caught in what is called an institutional conflict of interest. If WHO had referred to existing institutional conflict of interest definitions, its leaders could have pointed out to its Member States that they have placed our specialized health agency into a severe institutional conflict of interest – a conflict between its mandate (its ‘primary interest’) and the need to collect funds – by their long-standing refusal to fully fund WHO via assessed contributions (which are the equivalent of taxes).
Some political and legal scientist have gone beyond the institutional conflict of interest frame by developing an institutional corruption/integrity theory. It clearly identifies the risk that public-interest organizations’ mandates can be undermined – and their agendas shifted – depending on where their money comes from.
Legal expert and ethicist Jonathan Marks writes in his book The Perils of Partnership that public agencies need not only conflict of interest policies but also “comprehensive counterstrategies to insulate themselves from corporate influence”. And he asserts, “public health needs another paradigm”.[xviii]
Both, institutional conflict of interest, and institutional corruption/integrity, frameworks center on the need to ensure the integrity, independence, and trustworthiness (respectively credibility) of public institutions. This is a complex task. It entails ensuring that they have the capacity and political will to fulfill their public mandates.
WHO’s Framework of Engagement with Non-state actors (FENSA) lists the above three terms under its ‘principles’ of engagement. This triad is further key-touchstone when trying to recover WHO’s capacity to work for peoples’ right to health.
Many of the neoliberal ‘principles’ of engagement need to be questioned. It should be noted that the term ‘trust’ does not figure under FENSA’s principles of engagement. Member States have eliminated during the discussions on earlier drafts. It should therefore also be eliminated from principles of all other ‘engagement’ policies in public health which involve cooperation with private-sector actors.
However, it is important to recognize the limits of WHO’s Secretariat. They are set by funding and Member State willingness to act in the international public interest rather than in their narrow national interests or that of their transnational companies. The United States and EU Member States, for example, have often resisted effective regulation of harmful TNC practices and reshaping of pharmaceutical and health systems policies in the public interest. As we can see right now, China can prevent WHO, and journalists, from undertaking genuine investigations into the origins of the Covid-19 virus[xix]
Full public funding and the recovery of WHO’s mandate
To resolve WHO’s key institutional conflict of interest, to enable it to recover its integrity, independence and trustworthiness, any Member State or civil society actor criticizing WHO’s handling of the world’s health problems, must therefore also call to undo the long-standing ban on raising assessed Member state contributions to WHO, as critics supportive of WHO have said for two decades.
Today, the question is: Will WHO’s Director-General and its high-level officials engage in, and support, efforts to defend the mandate and core-functions of WHO and start extricating our UN specialized agency for health from opaque and inappropriate relations with venture philanthropies and transnational corporations? Otherwise, our tax money contributes to further strengthening public-private, plutocratic, global governance systems in health.
[i] Independent scholar. Author of the books Holding Corporations Accountable and Public-private partnerships and international health policy making: How can public interests be safeguarded? and numerous publications ranging from analysis of corporate lobby against international regulation to work on conflicts of interest regulation and other ways to maintain the integrity of public-health policy making. Declaration of interests: throughout my long career as sociologist, I have never relied on corporate or venture philanthropy funding. This paper was self-funded. Acknowledgments: I thank Alison Katz for language editing and editorial advices.
[ii] Birn, Anne-Emanuelle and Nervi, Laura. “(Re-)Making a People’s WHO,” American Journal of Public Health, 110: 9 (September 2020): e1-e2. https://doi.org/10.2105/AJPH.2020.305806 (see author’s website for French, Spanish and German versions)
Richter, J. (2012) “WHO reform and public interest safeguards: An historical perspective. Editorial.” Social Medicine 6 (3): 141-150, April 2012 (& Spanish translation) www.medicinasocial.info/index.php/socialmedicine/article/viewArticle/637
[iii] https://www.who.int/about/who-we-are/constitution; https://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua=1 , accessed 12.01.2021
[iv] Since Corona-policies have started impacting peoples’ lives it starts becoming common knowledge that companies which are producing emergency vaccines are not just charitable institutions but have clear financial interests at stake; unfortunately there is too little research and media coverage examining how concretely the Bill and Melinda Gates foundation and its’ webs of influence have been shaping – and continue shaping – WHO’s and national advices on how to address this latest transmissible health challenge. Is it due to their influence that the current narrative presents widespread vaccination as the light at the end of the tunnel? To what degree was the neglect of low-tech approaches, such as the provision of FFP2/N95 respirators and plexi-shields in shops and offices due to plans elaborated in Gates-corporate-webs of influence?
Most media coverage focusses on debunking wild theories on the role of Bill Gates which circulate in social media, some newspapers present him as a hero in the ‘war on the virus’. Thorough analyses of Gates’s role in shifting and influencing international and national health agenda risk to be sidelined even further sidelined as yet another ‘conspiracy theory.’
[v] Richter, J. (2017) Comments on Draft Concept Note towards WHO’s 13th General Programme of Work, 14 November, http://g2h2.org/wp-content/uploads/2017/09/Judith-Richter-1.pdf
Richter, J in cooperation with Alessia Bigi (2017) “Comment on WHO’s draft 13th General Programme of Work”, IBFAN-GIFA Briefing Paper, 28 November https://www.gifa.org/wp-content/uploads/2017/11/IBFAN_GIFA_2017_comment-on-dGPW13.pdf
[vi] Richter, J (2015) “Conflicts of interest and global health and nutrition governance – The illusion of robust principles,” BMJ RR, 12 Feb., www.bmj.com/content/349/bmj.g5457/rr
[vii] The term stakeholder is not easy to translate into other languages. A German translation as ‘Interessensträger’ (interest-bearer), for example, is problematic. It fails to address the problem of redefinition of the term stakeholder; and this translation does not contribute to undoing the discursive and propagandist power of the term stakeholder in anglo-saxon literature and official documents.
[viii] This was stressed by Nora McKeon in her neglected comment on the FAO HLPE Report on Multi-stakeholder partnerships to finance and improve food security and nutrition in the framework of the 2030 Agenda http://www.fao.org/publications/card/en/c/CA0156EN/
[ix] Richter, J. (2001) Holding corporations accountable: corporate conduct, international codes, and citizen action. London & New York: Zed Books
[xi] For a shift in the meaning of partnership, see e.g. Richter, J (2005) Global partnerships and Health for All: Towards an institutional strategy. A discussion paper prepared for WHO’s Department of Government, Civil Society and Private Sector Relations (GPR). Geneva, WHO, 20 pages, 2005 http://info.babymilkaction.org/files/Richter%20Global%20Partnerships%20and%20health%20for%20all.pdf
[xii] Susan George (2015) Shadow Sovereigns: How global corporations are seizing power, Polity Press, Cambridge, p. 7-8
[xiii] Hemmati, M. (2002). Multi-stakeholder processes for governance and sustainability: beyond deadlock and conflict. London, Earthscan. Forother references &context of this shift, see Richter, J. (2002). Dialogue or engineering of consent? Opportunities and risks of talking to industry. Geneva, International Baby Food Action Network/Geneva Infant Feeding Association (IBFAN-GIFA), p. 18 ff.
[xiv] It comes from the “Stakeholder theory” which “states that a company owes a responsibility to a wider group of stakeholders, other than just shareholders.” See Corplaw Admin. (2013, July 16). Shareholder and stakeholder theories of corporate governance. Retrieved from Corpolaw: https://blog.corplaw.ie/bid/317212/Shareholder-Stakeholder-Theories-Of-Corporate-Governance
[xv] Richter, J (2017) “Comments on Draft Approach for the prevention and management of conflicts of interest in the policy development and implementation of nutrition programmes at country level”, WHO online consultation, 29 October 2017, http://www.who.int/nutrition/consultation-doi/judith_richter.pdf
[xvi] Richter, J. “Time to debate WHO’s understanding of conflicts of interest.” British Medical, Journal (BMJ) rapid response, 22 October 2015, www.bmj.com/content/348/bmj.g3351/rr.
Many civil society organisations still do not seem to have understood that they replicate this conception in some way. They still talk about conflicting – and diverging – interests BETWEEN public and for-profit interest actors as conflicts of interest. For a reference concerning Gates and Member State funding and WHO’s institutional conflict of interest, see the section on CoI in :
Birn, A.-E. & J. Richter (2019) U.S. Philanthrocapitalism and the Global Health Agenda: The Rockefeller and Gates Foundations, Past and Present. Health Care under the Knife: Moving Beyond Capitalism for Our Health. eds. Howard Waitzkin and the Working Group for Health Beyond Capitalism, Monthly Review Press (advance chapter see) http://www.peah.it/2017/05/4019/
[xvii] Marc A. Rodwin (2020) .WHO’s Attempt to Navigate Commercial Influence and Conflicts of Interest in Nutrition Programs While Engaging With Non-State Actors: Reflections on WHO Guidance for Nation States; Comment on “Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool”, IJPM, September https://www.ijhpm.com/article_3914.html
[xviii] Marks, Jonathan H. (2019) The perils of partnership: industry influence, institutional integrity, and public health, Oxford University Press, New York
[xix] A recent article argues that it may have created during research on vaccines to immunize against harmful corona-viruses – and this “lab-escape theory” does not sound implausible https://nymag.com/intelligencer/article/coronavirus-lab-escape-theory.html