Antonio Gramsci wrote around 1930 that the crisis precisely consists in the fact that “The old is dying and the new cannot be born; in this interregnum, a great variety of morbid symptoms appear.” This quote was used by Jane Kelsey, a law professor from the University of Auckland, during the opening plenary session of the 4^th People’s Health Assembly (PHA4) in Dhaka, Bangladesh, 16-19 Nov 2018.  According to her, modern morbid symptoms include huge inequality, poverty, instability, alienation, displacement and ecological collapse. There is a great need for a genuinely progressive alternative. This assessment and overall feeling stays with me after a visit to Iran and Bangladesh over the last two weeks.  It has been a wonderful, touching but also somewhat confrontational period for me. This blogpost provides too little space to provide a detailed account of the numerous exchanges and events I engaged in, and so it mainly aims to provide a reflection about the spirit encountered. I hope it will inspire you as well.

In Iran, we had been invited by colleagues from the Teheran University of Medical Sciences, School of Public Health with whom we collaborate on developing Global Health Educational programs. After visiting the bustling, captivating but polluted capital city, Teheran, we all went to Shiraz, another big city in Iran, to participate in the International Congress on Health for Peace.  This congress, coordinated by the University of Shiraz and co-organized by WHO, UNICEF and UNESCO made the strong plea that working towards health (by the medical community and others) is vital for peace and stability. Presentations referred to SDG16, working towards peace, justice and strong(er) institutions. Interestingly, WHO’s program on Health as a Bridge to Peace was being promoted as a way to contribute to peace in the Middle Eastern region which is, sadly, prone to so much violent and non-violent conflict, and this already for decades. Members from the International Physicians for the prevention of Nuclear War  provided some inspiration on how sustained international action can reduce the likelihood of nuclear (and other) wars. Other inputs during the conference included a great concern about the impact of the new American sanctions on public health in Iran as well as the ongoing humanitarian disaster in Yemen and the dire situation in Syria. After 15 years of an international political push towards global securitization, it was refreshing to hear this strong call for International Peace, in line with the Paris Peace Forum which took place at the same time, exactly 100 years after the end of World War I.

Over to PHA4 then. In Bangladesh, where we work with the BRAC university school of Public Health on reforming health education, the 4^th People’s Health Assembly took place. The People’s Health Assembly is the global gathering of the People’s Health Movement (PHM) , and takes place every 5 years or so. This unique, international social movement for health has been (politically and otherwise) mobilizing people and organizations towards the goal of ‘Health for All’ since (and actually already before)  the first People’s Health Assembly in 2000. This first gathering also took place in Bangladesh, at Gonoshasthaya Kendra (GK) Savar. I have been active in this great health movement since 2003, and am a representative of the Medicus Mundi International (MMI) Network in the PHM Steering Council. The organization team of PHA4 did a great job as they had to relocate – at the last minute! – the venue of the assembly from GK to BRAC premises due to domestic political issues. International participants were (temporarily) denied entry to the country and the entire assembly almost had to be canceled! Against this rather worrying backdrop, it brought much unity, relief and energy that the 4-day gathering could eventually take place and 1400 participants from 73 countries could engage in great discussions and solidarity actions to advance Health for All! To get a good impression of all action in Dhaka, check the tweeter feed #PHA4 and related stories and coverage on People’s Dispatch.

A major question is now: will these great Peace and Social Justice Health movements be able to (politically) contribute to a safer and fairer world? This is where the reflection and somewhat sobering analysis comes in. In my latest blog I wrote how mainstream global health actors are trying to ‘save’ multilateral liberal global health governance, one way or another.  In a (more ambiguous) way, peace and social movements are doing something similar, with one major difference.

The aim of all mainstream actors in global health and development is to ‘save’ the 20^th century multilateral United Nations order as it has developed after WWII, based on a democratic, capitalist, open trade and rule-of-law model of governance with nation states being sovereign (in theory, at least) in choosing their own path towards development. This is known as the so-called Bretton-Woods compromise. Progressive social movements share this focus on nation states – they aim for an International Economic Order where autonomy (non-alignment), solidarity, and respect for sovereignty and human rights between nation states is key.

My main point is, this entire construct is becoming defunct in the globalized 21^st century! I am increasingly becoming convinced that the nation state construct is a hindrance towards global ecological and social justice. The political economist Dani Rodrik describes this as the “Political trilemma of the World Economy”. In this theory, he argues that deep economic integration, the nation state, and democratic politics are mutually incompatible: we can combine any two of the three, but never have all three simultaneously and in full. This is where the ambiguity comes in; both in Iran and Bangladesh, the externalities of deep economic globalization are very visible, with respectively a water crisis  and floods due to climate change. Bangladesh has with > 4000 kilometers the longest border fence in the world as India has to protect its “national security”. In general, due to a worldwide rise in nationalism, border fences and walls have globally exploded over the last 15 years.  In contrast, democratic policies and practices are under tremendous pressure in many countries. This democratic regression is by now a global phenomenon.

I consider ecological degradation and socio-economic inequalities as the most urgent global, complex challenges of our times. All our attention must go towards avoiding more catastrophic scenarios and we should thus move towards a post-capitalist and just order, also in an attempt to avoid global conflict, which I believe by now has become a major possibility. The close interrelations between capitalism, the nation state and transnational companies have been for centuries major drivers of these global pathologies. While we, in the social movements and in our analysis, have constantly been bashing capitalism and private wealth, I think it’s time we also seriously challenge the unique legitimacy of nation states, and their international organizations.  Soaring nationalism is merely an expression of global anxiety to maintain an old but dilapidated order, to divide between ‘us’ and ‘them’.  In a 21^st century update of that famous saying of Ronald Reagan (in Berlin), we do need to tear these national walls down, and allow ourselves to imagine a new politics to provide for a circular economy that respects planetary boundaries and ensures human capabilities for all.

I realize, the above is dangerous political thinking. In fact, it is anarchy. But perhaps such civil disobedience is a good start to find a channel to have the Old die respectfully and let the New be born!

A quote by Hafez, the great Sufi poet from Shiraz, might provide some inspiration:

“Leave the familiar for a while. Let your senses and bodies stretch out. Like a welcomed season onto the meadows and shores and hills. Change rooms in your mind for a day.”  (from: All the Hemispheres)

People’s Health Movement Steering Council 2018