Multiple crises and global health: new and necessary frontiers of health politics.

The world economy is entering an era of multiple crises, involving finance, food security and global environmental change. This article assesses the implications for global public health, describes the contours of post-2007 crises in food security and finance, and then briefly indicates the probable health impacts. There follows a discussion of the crisis of climate change, one that will unfold over a longer time frame but with manifestations that may already be upon us. The article then discusses the political economy of responses to these crises, noting the formidable obstacles that exist to equitable resolution. The article concludes by noting the threat that such crises present to recent progress in global health, arguing that global health researchers and practitioners must become more familiar with the relevant social processes, and that proposed solutions that neglect the continuing importance of the nation-state are misdirected.

Introduction and context

In August 2008, the World Health Organization (WHO) Commission on Social Determinants of Health argued that ‘[s]ocial injustice is killing people on a grand scale’ as ‘the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics'. The Commission's insistence that reducing health inequities is ‘critically dependent upon changes in the functioning of the global economy’ (Commission on Social Determinants of Health 2008, p. 76, and chap. 3, 11 and 15) at first appeared vaguely utopian. Two months later, a financial crisis that spread across the world underscored the importance of this observation, and warnings about the dangers of global economic interconnections temporarily found a larger audience. For example, observers identified multiple crises arising from the interacting influences of financial volatility, food insecurity and price inflation, as well as climate change (Addison ), or finance, environment and security (Held ).

The events of 2008 and the food price increase that began in the preceding year, in conjunction with the WHO Commission's emphasis on ‘upstream’ influences on health, should have made multiple crises and the forces driving them a central concern of the global health research and policy communities, but there is little evidence that this has happened. This article describes the challenges for health equity presented by global interconnectedness in the areas of food security, finance and climate change, leaving out for reasons of space other dimensions of global environmental change with potentially important health consequences. Having shown the importance of multiple crises for the future of health equity, itself a worthwhile advance on current understandings, this study argues the limits of ‘seeking to find a technical path through a politically laden minefield', as Lee (2010, p. 12) suggests the WHO Commission may have done. Advancing health equity in an environment of multiple crises requires recognition of the global political economy of unequal distribution of the opportunity to live a healthy life – what the authors of a paper that informed the WHO Commission called ‘those central engines in society that generate and distribute power, wealth and risks’ (Diderichsen , p. 16).

Contours of crisis: food

Adequate nutrition is one of the most basic prerequisites for health and, at least in countries that have ratified the International Covenant on Economic, Social and Cultural Rights, a human right under international law (Narula 2006, De Schutter 2008). Between February 2007 and February 2008, the overall food price index calculated by the UN Food and Agriculture Organization (FAO) increased by almost 50%, the dairy price index by 65% and the cereals price index by 59% (United Nations Food and Agriculture Organization 2011) (Figure 1a). On the best available evidence the food price increases of 2007–2008 affected millions of low- and middle-income country (LMIC) households, at the very least undoing progress in reducing deprivation that had been achieved during several years of solid economic growth (Mason ).

Figure 1.

Global food price trends, 2007 through 2011.

Source: Data from United Nations Food and Agriculture Organization, Monthly Real Food Price Indices. Available from: http://typo3.fao.org/fileadmin/templates/worldfood/Reports_and_docs/Food_price_indices_data_deflated.xls.

These events must be understood against the background of what George (1976) described as a world agricultural division of labour, often reflecting colonial legacies and increasingly organised around the priorities of agribusiness firms and food processors as well as marketers positioned at the top of global commodity or value chains (McMichael 2005, Hendrickson , De Schutter 2009). Causes of the price increase included the rapid increase in crude oil prices over the same period (many agricultural inputs are petroleum-based) and competition for available land from biofuels production. Another probable contributor was increased financial speculation as agricommodity markets emerged as a new potential profit centre (Pace , Wahl 2009, United Nations Conference on Trade and Development 2009, pp. 53–79). It appears that the spike in food prices was not primarily driven by shortages of supply, although such shortages – resulting from population growth, climate change and the use of land to produce animal feeds rather than crops for direct human consumption – could certainly contribute to similar price volatility in the future (Godfray , Headey and Fan 2010). The stagnation of agricultural productivity in sub-Saharan Africa, another worrisome trend, is connected to the global political economy through the impact of structural adjustment programs, declining development assistance for agriculture and trade liberalisation (Bryceson 2009).

Crucially, the crisis was not merely an isolated perturbation in prices or markets. By August 2011, the FAO overall food price index had risen above its previous peak in 2008, and by 26% in the preceding year, despite oil prices far below their pre-crisis highs and the demand-dampening effects of recession (Figure 1b). A UNICEF index of local food prices in 58 LMICs showed comparable increases from 2007 levels as of the end of 2010. More disturbingly, local food prices generally failed to track the post-2007 decline in global indices. Rather, they remained near their 2007–2008 peaks, and in 10 countries food prices rose by more than 25% between May and November 2010 alone (Ortiz ). After a period of decline starting during 2011, early in 2012 world price indices were again rising, with drastic domestic increases observed in some countries (World Bank 2012).

Crucially as well, future food security in many LMICs will be further compromised by ‘land grabs': large-scale purchases or long-term leases of agricultural land (Smaller and Mann 2009, von Braun and Meinzen-Dick 2009, Deng , Mann and Smaller 2010, Cotula ). The transactions in question often involve direct government-to-government negotiations and/or require active government support in the destination country, which may include financial incentives, providing security or relocating existing occupants of the land. Qatari land investments in one province of Pakistan alone were reported as threatening to displace 25,000 villages through mass evictions (Deng , p. 79). Rapid growth post-2007 in the number of such transactions can be seen as a response to the food price crisis by investors, agribusiness firms and governments of food-importing countries alike (De Schutter 2011). Secrecy and the fact that not all planned transactions are completed means that all estimates of the scale of the process are incomplete. The International Conference on Global Land Grabbing in April 2011 heard ‘documentation of land deals amounting to over 80m hectares’ (Borras ), including acquisitions for non-agricultural development such as industrial parks (Goldman 2011, Levien 2011) and ecotourism (Benjaminsen ), as well as export-oriented agriculture. The 80 million hectare figure was much larger than previously supposed, equivalent to about three times the area of the UK.

Contours of crisis: finance

Global reorganisation of production in search of lower costs and more flexible employment relations is probably the most conspicuous and familiar dimension of globalisation: ‘[a] pattern of transnational economic integration animated by the ideal of creating self-regulating global markets for goods, services, capital, technology, and skills’ (Eyoh and Sandbrook 2003, p. 252). The development of a global financial marketplace over the past few decades, through competitive deregulation in some high-income countries (Helleiner 1995, Girón and Correa 2002) and the removal of controls on financial flows elsewhere in the world (Stiglitz 2004) has been comparably transformative of national economies and societies (Schrecker 2009).

National banking and currency crises occurred much more often during the 1980s and 1990s than in the preceding decade (Laeven and Valencia 2008), notably plunging millions into poverty and driving the value of national currencies down by 50% or more in Mexico (1994–1995) and several South Asian countries (1997–1998) – a process that a former managing director of the International Monetary Fund (IMF) described as ‘quite swift, brutal, and destabilising’ (Camdessus 1995). Domestic effects of initial losses of output, employment income and purchasing power (as a result of currency devaluations) were compounded by the fact that employment and labour's share of national income recover more slowly than economic output following crises (Diwan 2001, van der Hoeven and Lübker 2006, Walton 2009), and often by public sector austerity programmes that are necessary to restore ‘investor confidence'. Financial crises also tend to magnify economic inequality because bailouts of financial institutions that commonly follow in their wake socialise risk as they transfer wealth from a broad segment of the population (the national tax base) to a minority of households with substantial deposits, and to financial institution shareholders (Halac and Schmukler 2004, Mannsberger and McBride 2007).

The financial crisis of 2008 resulted neither from the prospect of government default on sovereign debt nor from rapid outflows of short-term investment, which had initiated most post-1980 national and regional crises, but rather from the domestic collapse of the largely unregulated market for securities backed by high-risk US mortgages. Effects of the collapse quickly multiplied through the highly leveraged US financial services sector (Financial Crisis Inquiry Commission [FCIC] 2011, pp. xix–xx) to other high-income countries, and eventually around the world. Worldwide, an estimated 35 million people were thrown out of work by the crisis (Calvo 2010). In LMICs, the initial response of social protection systems was described as ‘limited’ and inadequately directed towards the most vulnerable (McCord 2010). Some of the worst predictions have not materialised, partly because the decline in remittances to LMICs, worth more than three times the value of official development assistance, was less serious than anticipated (Ratha ), but it is too early to assess long-term impacts. A 2011 UNICEF review found that after an initial period of expansionary fiscal policy many LMICs were considering such austerity measures as limiting or rolling back wages for teachers and health workers, retrenching social protection and increasing consumption taxes on basic goods like food (Ortiz ) despite the food price inflation of the preceding years.

Officially reported unemployment rose by mid-2011 to 14% in Ireland and 20% in Spain and Latvia, three European countries especially hard hit. In the USA, by early 2012, 46 million people were receiving federal government food vouchers (Supplemental Nutrition Assistance, or food stamps) and millions more were eligible (Food Research and Action Center 2012). In Belarus, Greece, Hungary, Ireland, Latvia, Portugal and Ukraine, IMF conditionalities and associated austerity measures were in place, arguably compounding the damage done during the early stages of the crisis by IMF policies that actually worsened output losses (Weisbrot and Montecino 2010). The UK was committed to a programme of cutbacks and tax increases that will disproportionately affect people at the lower end of the income scale (Browne and Levell 2010, Ramesh and Sparrow 2010, Doward 2011), while on many measures social disparities in health are already at post-Great Depression highs (Thomas ). The financial crisis therefore ‘brought the war home’ to several high-income and transition economies through high levels of unemployment and forms of public sector austerity, external influence over domestic policy and cartographies of inequality more familiar from LMIC contexts. The point cannot be explored further here, but the effect will almost certainly be to magnify the internal social and economic disparities created by more than three decades of labour market integration.

Health impacts of the food and financial crises

The food price increases of 2007–2008 frequently led to a rise in chronic undernutrition (Dawe and Drechsler 2010, Prain 2010, Ruel , Ortiz ). The combined effects of food price inflation and the financial crisis have been found to undermine food security, putting households under strain and increasing social exclusion in Bangladesh, Indonesia, Jamaica, Kenya, Nigeria, Yemen and Zambia, often with disproportionate impacts on women and children (Hossain and McGregor 2011, Samuels ). Further research is likely to show longer-term and more widespread effects, for example, as households were forced to choose between food and children's school fees or access to health care. In general, relying on evidence of short-term impacts is likely to lead to substantial underestimates of the health effects of major economic dislocations, which may be irreversible both within and across generations (e.g., in the case of childhood malnutrition or long-term damage to maternal health).

In a review of research on health impacts of the South Asian financial crisis of 1997–1998, which resulted in one-year reductions in economic output of 20% in some affected economies, Hopkins (2006) described a reversal of past health gains and a deterioration in such indicators as undernutrition, household spending on health care and public spending on health. In 2011, an increase in suicide rates and a decline in self-reported health and in access to health insurance was reported over the very short term in Greece (Kentikelenis ). The most extreme recent example of an economic crisis with major, clearly documented health impacts is the post-1991 collapse of the former Soviet economy, leading to reduction in output of roughly 50%, massive capital flight, official poverty levels of 40%, the disintegration of much health care and social provision and a rapid decline of several years in male life expectancy (Field 2000, Field , Shkolnikov , Leon ). ‘In 2004, a Russian boy aged 15 had about a 50–50 chance of surviving to the age of 60; this was much worse than many so-called developing countries, for instance Pakistan, India and Bangladesh’ (Vågerö 2010, p. 26).

Because financial crises are only one driver of the ‘disequalising’ dynamics of contemporary globalisation (Birdsall 2006), it is useful to consider an innovative econometric exercise aimed at capturing the overall, longer-term impact of these dynamics using data from 136 countries. Cornia identified a range of social and economic variables with a demonstrated effect on mortality, classifying them as: (1) related to globalisation (e.g., income inequality); (2) endogenous, and therefore unrelated to globalisation for purposes of the analysis (the diffusion of medical progress) or (3), describable as ‘shocks’ (e.g., wars and natural disasters, HIV/AIDS). They then carried out a simulation comparing trends in life expectancy at birth (LEB, an admittedly crude indicator) over the period 1980–2000 with those that would be predicted based on a counterfactual set of assumptions in which trends in all the relevant variables either remained at the 1980 value or continued the trend they followed between 1960 and 1980. Worldwide, globalisation post-1980 cancelled out most of the progress toward better health that occurred as a consequence of diffusion of medical progress. Regionally, the most conspicuous declines in life expectancy occurred in the transition economies, where globalisation accounted for essentially the entire decline, and sub-Saharan Africa, where globalisation contributed almost as much as the AIDS epidemic to a decline of nearly nine years in LEB relative to the counterfactual. In other words, even when health gains were achieved, they were often less substantial than they would have been under an alternative set of economic and political conditions in which the gains from growth were distributed more widely, and in some regions the economic and political context has almost certainly contributed to absolute declines in life expectancy.

This having been said, the complexity of the connections between macro-scale social processes and individual health outcomes raises an important standard of proof issue. Epidemiologists might prefer to set up elegant (and expensive) longitudinal studies of multiple crisis-affected populations, attempt to control for all confounders and then wait 10 or 20 years in the hope that someone will still be interested in the answers. Here, this approach is regarded as ethically irresponsible and it is taken as given based on available scientific evidence – as in the WHO Commission's report – that events, processes and policies that create, magnify or perpetuate poverty and economic insecurity for literally billions of the world's people (cf. Paluzzi and Farmer 2005) are likely to impair their health. Readers who disagree must recognise their disagreement as one about the values that should be brought to bear on policy choices under conditions of uncertainty (Page 1978, Marmot 2000).

Contours of crisis: climate

The events and challenges described in the preceding sections of the article will play out against the consequences of a ‘best estimate’ rise in global mean temperature of 1.8–4.0°C by 2100 (Costello , p. 1698) as a result of anthropogenic emissions of greenhouse gases. An expert panel established jointly by The Lancet and the University College London (UCL) Institute for Global Health, drawing on the collaborative work of the International Panel on Climate Change (IPCC), describes climate change as ‘the biggest global health threat of the 21st century’ (Costello , p. 1693). Although precision in anticipating impacts is obviously elusive, underscoring the importance of how policy addresses uncertainty, the adverse health effects of climate change are likely to include direct effects on patterns of illness and death, including: an expansion of the range of various disease vectors; effects on food production; effects on water availability, in cities and countries where shortages are already widespread; changed frequency and distribution of extreme weather events; and effects on the drivers of migration (Costello , McMichael 2012). Interactions between climate change and food production are of special concern because of effects on crop yields and water availability (Hanjra and Qureshi 2010, Thornton ). Indeed, an historical overview of impacts on various time scales concluded that: ‘The greatest recurring health risk has been from impaired food yields, mostly due to drying and drought. The fact that drought has been the dominant historical cause of hunger, starvation, and consequent death casts an ominous shadow over this coming century, for which climate modeling consistently projects an increase in the range, frequency, and intensity of droughts’ (McMichael 2012, p. 7, citations omitted).

Climate change unfolds over a much longer time frame than the dynamics of globalisation, but it must not therefore be presumed that health-destructive impacts are either gradual or distant. Some, such as increased frequency of extreme weather events and heat waves that reduce agricultural productivity and increase heat-related deaths, may already be upon us (McMichael and Dear 2010, McMichael 2012) – a cause for particular concern since greenhouse gas emissions appear to be increasing faster than anticipated in the most pessimistic of the IPCC's 2007 projections (Costello , p. 1698, 1701, Harvey 2011). From a social justice perspective, a critical point is that the most serious adverse health impacts will be felt by those who have contributed least to the problem; in this respect, the climate crisis closely resembles the recent financial crisis in the inequitable distribution of negative externalities from economic activities that are highly rewarding for some. It is already possible to map a dramatic inverse correlation between countries’ carbon emissions between 1950 and 2000 and the prevalence of ‘four climate-sensitive health effects (malaria, malnutrition, diarrhea, and inland flood-related fatalites)’ (Patz , p. 400), and the future distribution of vulnerabilities is likely to be even more inequitable (Campbell-Lendrum and Corvalan 2007, McMichael ). As with many other aspects of economic life, even larger intra-national disparities may exist in contributions to greenhouse gas emissions and exposure to the negative effects of climate change – again suggesting a parallel with the financial crisis.

Political economy of problems and responses

One of the least contested functions of the state involves supplying, or coordinating the supply, of public goods; global public goods (GPGs) have been a major focus of recent work on global health governance. There are, in fact, fewer GPGs than imprecise users of the term would have us believe (Woodward and Smith 2003), but well before 2008 financial stability (the avoidance of financial crises) was recognised as a GPG inadequately provided by existing institutions (Griffith-Jones 2003). At least some policies to increase its supply are not arcane or complicated. Notably, LMIC governments must be allowed more latitude to control capital flows than is consistent with current macroeconomic orthodoxy. The details are beyond the scope of this chapter, but it should be noted that deterioration in living standards and social determinants of health after the Asian financial crisis appears to have been less severe and shorter lived in Malaysia, which explicitly rejected the neoliberal prescriptions of the IMF in favour of capital controls (Cornia 2006, Hopkins 2006), and that Ndikumana and Boyce (2011, pp. 74–83) provide quantitative estimates of the human costs of capital flight from sub-Saharan Africa. High-income countries must not permit financial institutions to become ‘too big to fail’ (Bank of England 2009, p. 10, Hoenig 2011, Johnson and Kwak 2011, pp. 153–188), but the financial services industry had invested much time and treasure to create and defend the unregulated market, without which the 2008 crisis could not have occurred (FCIC 2011, p. xviii, Immergluck 2011).

It is helpful to understand the politics of resistance to strengthening financial regulation in the post-crisis period by way of an historical analogy: in parts of coastal England during the eighteenth and early nineteenth century, the practice of wrecking was widespread. Wreckers appropriated the cargo of shipwrecked vessels and the materials of the vessels themselves, and in extreme cases actually lured vessels onto the rocks (Rule 1975). If financial stability is in fact a public good, then improving its supply in today's global economy through either national or multilateral initiatives is like trying to build lighthouses – the textbook example of an institution that supplies a public good – in a world where a large, wealthy wreckers’ lobby funds national political campaigns and former wreckers are often placed in charge of granting lighthouse permits. Predictably, in early 2012 the (still unregulated) market for mortgage-backed securities was making a comeback (Ahmed 2012).

Climate stability is also a true GPG, although, as noted earlier, one far more important in the lives of some people than in others'. Supplying it adequately will involve nothing less than converting the world economy to low-carbon energy over just a few decades, reducing greenhouse gas emissions by 80% or more in order to stabilise global temperatures and simultaneously supplying the urgent energy service needs of, most conspicuously, ‘2.4 billion people who rely on biomass for cooking and heating and 1.5 billion people who have no access to electricity’ (Costello , p. 1706). This will require reaching agreement on carbon taxes or similar pricing mechanisms, while somehow recognising a distinction between survival or subsistence and luxury emissions (Shue 1993, Costello , p. 1694) – likely to prove highly contentious even within national borders – and mobilising an estimated US$10 trillion of investment in low-carbon energy sources. Costello , p. 1872) point out that much of this cost might be offset by savings in fossil fuel costs and, correctly, that ‘[t]he net balance of US$1.4 trillion is less than half the [value of the] global bail-out’ of financial firms.

This hyper-rationalist view neglects politics, in particular the power of actors standing to gain from the continuation of business as usual. They include not only the oil and gas and automotive industries (and their employees) but also energy-using households and industries in much of the world. Thus, domestic coalitions arrayed in opposition to major reductions in greenhouse gas emissions may be even more formidable than the interests opposing financial regulation. Further, much investment in low-carbon energy will need to take place outside the high-income world, necessitating substantial direct financial and technology transfers both for energy supply and for adaptation. Efforts to identify ‘win–win’ solutions (Costello , p. 1728), while comforting to their proponents, cannot solve the problem of political resistance: think again about lighthouses and wreckers.

The politics of addressing crises of food prices and security are comparably complex. Food is not a public good, and indeed is increasingly commodified by transnational agribusiness and commodity investors. The UN Special Rapporteur on the Right to Food argues that ‘truly responsible’ agricultural investment must ‘benefit the poor in the South, rather than leading to a transfer of resources to the rich in the North. It must be investment that truly reduces hunger and malnutrition, rather than aggravating them’ (De Schutter 2011, p. 275). This is an especially tall order given the ‘emerging ‘North–South–South’ dynamic in the recent global land grab, with economically powerful non-Northern countries getting significantly involved’ (Land Deal Politics Initiative 2012) – including several Middle Eastern nations, South Africa, China and India. Destination country governments are routinely involved as facilitators and promoters of land grabs, motivated by such factors as economic benefits for politically connected local elites (e.g., Ansoms 2011) and what has been described as ‘unwavering faith in the role of foreign investment in national economic development’ (German , p. 2) – faith that has been nurtured by financing from the commercial arm of the World Bank (GRAIN 2010).

Avoiding recurring crises of food insecurity is likely to require that high-income countries adopt coordinated (or at least congruent) and largely altruistic interventions involving financial markets, development assistance (to reverse a long-standing decline in aid for agriculture) and trade policy. The land grab phenomenon further suggests that both source and destination country governments need to resist domestic self-interested coalitions of producers/investors and consumers in the interests of equity. The situation in some respects resembles the politics of climate change, but a parallel also exists with conflicts over valuable locations in metropolitan areas, as ‘the prime resources of the city are increasingly appropriated by the affluent. And globalisation is inflationary as the new rich are able to pay more for a range of key goods, especially land’ (United Nations Human Settlements Programme 2003, p. 43). The profits to be made from real estate development by both foreign and domestic investors create powerful incentives to displace the poor or otherwise marginalised, who are simply in the way (Davis 2006, Goldman 2011). Thus, if one defining element of the health policy environment in an age of multiple crises is cross-border generation of major negative externalities (in the case of financial crises and climate change), another is cross-border bidding wars.

Responding to crises: future politics uncertain

Progress has been made in advancing policy attention to global health issues. Development assistance for health roughly quintupled between 1990 and 2010 (Murray ). The Millennium Development Goals (MDGs) are modest when viewed against the global abundance of the era, but most are health-related and they represent an unprecedented commitment to measurable development accomplishments by the nations of the world. Major reductions have been achieved in mortality from measles; the number of people with HIV/AIDS receiving antiretroviral therapy has increased 10-fold; and in September 2011, the United Nations held a landmark high-level meeting on non-communicable diseases, or NCDs, responding to their rapidly increasing contribution to the global burden of illness. On the other hand, at least in sub-Saharan Africa (the world's poorest region), new development assistance may have been more than offset by capital flight (Ndikumana 2010); even before the setbacks that followed the 2008 financial crisis, it was clear that some MDGs and targets will not be met (World Bank and International Monetary Fund 2011) and that these goals have had limited impact in reducing inequities (Vandemoortele 2011); and the high-level meeting on NCDs appeared to proceed in blissful isolation from the facts of multiple crises as presented here.

These observations are not counsels of despair, but they serve as a warning in several respects. Multiple or recurring crises have the potential to slow and even to reverse progress towards improving health and reducing health disparities, as shown (for example) by the Russian experience and the simulation conducted by Cornia with respect to the incremental effects of globalisation. Many global health researchers and practitioners remain poorly informed about the origins of such crises in macro-scale social processes and the evidence connecting these with health outcomes. They need to overcome a certain learned helplessness with respect to economic and social policy, to the point where basic familiarity becomes recognised as a core competency. Beyond these individual limitations, most organisations and institutions with remits primarily related to health are ill adapted to engage in the policy debates, alliances and forms of resistance necessary to address the crises described here. For example the WHO, despite the initiative in social determinants of health, really remains the World Medical Organisation. These shortcomings assume greater importance as the unfolding of crises threatens past progress and in the context of (what one hopes will be) the formulation of a new and more ambitious set of development goals post-2015 (the endpoint of the MDGs).

A further note of caution: Recent research on global health politics emphasises the proliferation of complex institutions involving both governmental and non-state actors, to the point where several authors refer to the emergence of ‘post-Westphalian’ governance (Fidler 2004, Hein ), or even suggest that a ‘transition from state-based to global institutions’ (Lee 2010, p. 12) may be desirable if it is not already in progress. This is a misdirection. The proliferation of complex international institutions, and the urgent need for new ones to address such challenges as climate change, in no way reduces the centrality of the nation-state in the operation of such institutions. National governments as regulators or facilitators of activities within their borders (and the negative externalities they create elsewhere), as protagonists in activities outside them (e.g., land acquisitions), and as participants in multilateral institutions, will be central to the course, severity and prospects for avoidance or resolution of future crises. It is difficult, for example, to envision functioning regimes of carbon pricing or controlling capital flight that do not rely on active commitment by national governments, including agreement to create supranational mechanisms of accountability. The core question is, rather, how ability to influence and set the agenda for national governments is distributed, within and outside their borders – in other words, whose interests the nation-state will serve. The specifics of institutional design and the political economy of alternative policy prescriptions in detail would require (at least) several more articles; this one has accomplished its purpose by demonstrating their importance to global health politics.