Firms and global health

On June 4, 2010, Deborah Cohen, editor of British Medical Journaland Philip Carter, of Bureau of Investigative Journalismpublished a critical article on the management of the influenza A crisis by theWHO. The two authors attacked the “lack of transparency” of the institution in terms of conflicts of interest with industrialists and concluded that the credibility of theWHO risked being undermined. This article, published in numerous general media (BBC, The World etc.), and published on the same day as a report, also critical, from the Parliamentary Assembly of the Council of Europe, marked a peak in the media controversy which, since the start of the (alleged) pandemic, has was committed to the influence of pharmaceutical manufacturers on international strategy.

Following such controversies, there is a great temptation to read the relationships that develop between public and private actors, in the conduct of public affairs, solely through the prism of conflicts of interest – and moreover in an exclusively financial sense – or of capture. But certain recent texts invite social science researchers to explore the complexity of these relationships in more detail (Ferguson, 2010; Carpenter and Moss, 2013; Hauray, Henry and Dalgalarrondo, 2015). In this perspective, Auriane Guilbaud’s book, which offers a vast overview of the modes of involvement of private firms in international public health, comes at the right time. Despite its reasonable size (206 pages), the book is, to our knowledge, unprecedented in the breadth of the spectrum it covers on these aspects. Although the question of property rights of medicines and that of North/South relations have already been well studied, the author puts this public problem into perspective with other problems where the place of firms (mainly pharmaceuticals) and their relations with the other actors in international health governance are crucial: child nutrition, research and development, vaccination, healthcare provision, etc. Taking as a case study, over the long term, the fight against HIV/AIDS, tuberculosis, malaria and neglected tropical diseases, it traces the strategies of different firms and international organizations (OI), but also foundations (like, obviously, the Bill Gates Foundation) andNGOas well as the diversity of configurations of relationships between these actors. From a situation, in the first half of the XX^e century, where firms appeared to be outside an international health system dominated by States, it describes the progressive institutionalization, since the 1970s, of cooperation between firms and public actors.

From ignorance to partnerships

Mutual ignorance and evasion have long characterized relations between multinational firms and international organizations, includingWHO first and foremost. On a highly symbolic basis, the latter’s Constitution does not mention firms as potential partners. It was not until the mid-1970s that relationships were established on a more regular basis and within a more formalized framework. The first three chapters describe how, from “peripheral actors” in the international health system at the beginning of the period, from the end of the 1990s, firms became “co-producers of international health action and partners of OI » (p.114).

In a first movement, it was under the sign of tensions and conflicts that these interactions were established: the firms mobilized, collectively and internally (via the creation of services ad hoc responsible for relations with OI), to limit the restrictive nature of the initiatives of theWHO which aimed to regulate their commercial practices (chapter 1). They were supported in this by the administration of Ronald Reagan. This painful experience reinforced, according to Auriane Guilbaud, the distrust of the actors of theWHO towards industrialists. But, at the same time, during this same period, more collaborative relationships were able to develop around the creation of a Special Research Program on Tropical Diseases (TDR), in order to accelerate the production, evaluation and distribution of molecules (chapter 2). Although the firms andWHO had complementary resources to bring to bear in the context of their exchanges, relations were not completely devoid of tensions. The fluctuating trajectory of a Merck donation program for an antiparasitic drug, developed as part of the TDRis fascinating in this respect. L’WHO and the NGO were initially reluctant, because the donation was seen – rightly – as a strategy to escape public questioning of the price of medicines; Added to this was the fear that such an initiative would discourage other firms from investing in product development. Despite these reluctances, Merck managed to set up this program, with the participation ofWHOand to derive considerable indirect benefits (taxation, image, access to new countries, etc.), so that other firms in turn embarked on such programs.

But, secondly, theWHO managed to re-appropriate the program and, despite Merck’s reluctance, to make it a tool for strengthening primary health care. Chapter 3 addresses the (neo)liberalization of international health policy. Consistent with its strategy of privatization of health systems in developing countries, the World Bank, the largest public contributor to health programs since the 1980s, promoted public-private partnership in the health field. Weakened on the international scene, theWHO changed strategy and ostensibly followed suit, rather than opposing an alternative model. As part of the Uruguay Round trade negotiations, firms obtained a strengthening of intellectual property rights. However, the mobilization of NGOin the context of the epidemic of HIV/AIDS, made it possible to obtain certain relaxations and certain countries, such as Brazil, managed to negotiate downwards the price of certain drugs.

In the last two chapters of the book, the author focuses on the institutionalization of relations between businesses and public actors. Encouraged by theUN and its Global Compact (Overall compact), which “provides legitimacy to participating companies in return for support in achieving the objectives and disseminating the values ​​of the organization” (p.117), the rise of public-private partnerships (PPP) is also observed in the international health field. This results in particular in a form of government by labels, which allows certain companies to display (often in the form of a logo) the support ofOI provided that their actions respect certain specifications. Auriane Guilbaud lists no less than 17 to fight against HIV/AIDS and neglected diseases, 7 to improve access to medicines, 7 to develop new products and 3 to advocate for certain causes. Product development in this framework is distinguished from initiative TDR (see above) by greater structuring of the organization and by the allocation of financial resources to firms to mitigate the risks associated with research. Although they have made it possible to develop products for neglected diseases and sometimes obtain fairly low marketing prices, these partnerships protect ultimately the global regime of intellectual property rights. Public actors, and in particular OIdeploy strategies to “frame these relationships” (chapter 5). In particular, theWHO seeks to preserve and demonstrate its independence from companies: preference for internal management of partnerships rather than involvement in projects developed “outside” the organization, public information on partnerships, creation of a unit in responsible for controlling these partnerships, developing procedures, etc.

Varied relationships between firms and international organizations

The author’s methodological bias, which brings together and compares numerous cases of partnerships rather than studying a few specific cases in depth, has the disadvantage of presenting the organizations under a reified appearance and, above all, does not allow us to understand the differences and tensions within the organizations themselves regarding these partnerships, which undoubtedly weigh on their trajectories. Experts and their disciplines, the jurisdictional struggles between disciplines, so important in the governance of international health policies (see for example Demortain, 2016), are also relatively absent from the analyses. Converselythe way in which this (large) study was designed makes it possible to clearly show, in an innovative way, the differences in approaches between firms and the variety of configurations of relationships between organizations around these partnerships. Certainly, the protection of the intellectual property rights regime appears to be the touchstone of international health governance, which no one, not even theWHOdoes not really risk questioning. Certainly, in the relationships between NGO, OI and firms, exchanges appear on the whole to benefit the latter. But this book shows us that not only is this not always the case, but it is also not always the result of an intentional strategy on their part. Above all, and this is one of the most striking results, companies are not spontaneously interested in greater involvement in international health governance and in the development of partnerships with public organizations. In fact, they contribute very little financially.

The book also shows how theWHO remains generally suspicious and tries to keep its distance from firms. Therefore, we wonder if we can speak of “hybridization” of international health action, which would blur the distinction between public and private, as the author suggests in the conclusion. Indeed, it also clearly shows the border work, more or less successful, carried out by most public and private actors. It is also one of the great contributions of this book to provide a key to understanding the growing influence of the Bill Gates Foundation, due to the fact that it appears as a intermediate essential to the conclusion of PPP : not only, due to the lack of financial involvement of companies, its financing is often crucial to their smooth running, but above all the foundation deploys great efforts to put in touch firms and OI. We can even hypothesize that his enthusiasm for promoting and developing PPP is all the stronger because it draws its power from there: in an institutional environment which values PPP as a legitimate mode of action, but in which both, OI like firms, are not spontaneously ready to play the game, the foundation, which helps with the rapprochement, proves to be an essential entrepreneur.