Learning from the lobster and making space for transformation in planetary health
Authors: Ben Brisbois, Katrina M Plamondon
Journal: The Lancet Planetary Health (2024)

COVID-19 has revealed deep fault lines of global injustice, motivating WHO to draft a new legal instrument, the WHO Convention, Agreement, or Other International Instrument on Pandemic Prevention, Preparedness, and Response (WHO CA+).1WHOBureau's text of the WHO convention, agreement or other international instrument on pandemic prevention, preparedness and response (WHO CA+).https://apps.who.int/gb/inb/pdf_files/inb5/A_INB5_6-en.pdfDate: June 2, 2023Date accessed: September 14, 2023Google Scholar COVID-19's zoonotic origins inform the draft instrument's “interventions that address the drivers of the emergence and re-emergence of disease at the human-animal-environment interface, including but not limited to climate change, land-use change, wildlife trade, desertification and antimicrobial resistance”.1WHOBureau's text of the WHO convention, agreement or other international instrument on pandemic prevention, preparedness and response (WHO CA+).https://apps.who.int/gb/inb/pdf_files/inb5/A_INB5_6-en.pdfDate: June 2, 2023Date accessed: September 14, 2023Google Scholar When Intergovernmental Negotiating Body (INB) co-chair Precious Matsoso urged participants in the December, 2022 meeting to pay attention to lobsters, however, she was referring not to animal health, but rather to the mental toughness that delegates will need to reach a final instrument. A lobster must lose its shell and survive unprotected while it grows a new one, a fitting analogy for how the international community can challenge established beliefs and ways of working. As non-state actor participants in the INB process, in this Comment we explore its lessons for the transformation of societal structures held to be necessary by many in planetary health.2Jones R Reid P Macmillan A Navigating fundamental tensions towards a decolonial relational vision of planetary health.Lancet Planet Health. 2022; 6: e834-e841Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 3Hoogeveen D Atleo CG Patrick L et al.On the possibility of decolonising planetary health: exploring new geographies for collaboration.Lancet Planet Health. 2023; 7: e179-e183Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar WHO CA+‘s language on health–environment links reflects contributions to INB sessions by non-state actors. Absent, however, are contributions on disease-promoting land use changes stemming from structural adjustment programmes of the 1980s and comparable neoliberal reforms in the 21st century.4Wallace R Dead epidemiologists: on the origins of COVID-19. Monthly Review Press, New York, NY2020Google Scholar This omission is consistent with WHO CA+‘s silence on the inequitable global distribution of resources and power. Civil society actors who are active in global health are present in the INB process, but have failed to derail the so-called right of industry to strict intellectual property protections. Pandemic-inspired resolve has thus been channelled into measures that naturalise the root causes of global health inequity. Importantly, the neoliberal policies conspicuously not mentioned in WHO CA+ have major negative effects on health via a range of mechanisms listed in the table.5Sparke M Health and the embodiment of neoliberalism: pathologies of political economy from climate change and austerity to personal responsibility.in: Springer S Birch K MacLeavy J The handbook of neoliberalism. Routledge, New York, NY2016: 237-251Google Scholar, 6Labonté R Neoliberalism 4.0: the rise of illiberal capitalism comment on “how neoliberalism is shaping the supply of unhealthy commodities and what this means for NCD prevention”.Int J Health Policy Manag. 2020; 9: 175-178PubMed Google ScholarTableNeoliberal economic reforms and their effects on healthPathways to health outcomesFinancial deregulationFinancial instability and resultant reductions in state revenues and capacity; and income inequalityReduced public sector spendingReduced access to and quality of health care, education, housing, etc; and increased poverty and unemploymentRoll back of environmental and social protection measuresIncreased consumption of unhealthy foods, substance abuse, etc; occupational hazards; and environmental contaminationPromotion of primary commodity exportsLand dispossession and contamination from agroindustry and resource extraction; pressure on ecosystems, contributing to zoonotic disease emergence; impaired livelihoods and disrupted cultural continuity among land-dependent and forest-dependent communities; and lack of food security and sovereigntyIntensified greenhouse gas emissionsClimate change-related health issues: extreme heat and natural hazards, drought, spread of infectious diseases, and impaired livelihoods and relationships to landPromotion of entrepreneurship and other market-based responses to problems with structural rootsDecreased social connectivity; increased sense of personal responsibility, competitiveness, etc, with resulting isolation and anxietyAn international trade regime that prioritises corporate rights over the health of the planet and its peopleImpaired livelihoods; environmental degradation; occupational hazards; and reduced access to essential medicinesWe recognise that there are some health benefits from increased economic growth, but they are not included here because they are generally distributed unfairly across social groups, exaggerated by apologists for neoliberalism, and already very well represented, or arguably over-represented, in public discourse. Open table in a new tab We recognise that there are some health benefits from increased economic growth, but they are not included here because they are generally distributed unfairly across social groups, exaggerated by apologists for neoliberalism, and already very well represented, or arguably over-represented, in public discourse. As the INB attempts to finalise WHO CA+ by May, 2024, advocates can continue efforts to protect its equity measures from the corrosive self interest of powerful member states. We can call on those determining the outcomes of this monumental global governance effort to give the instrument teeth to achieve its equity ambitions, but although health diplomacy in the past has achieved wins on issues such as access to essential medicines and tobacco control, such efforts have been pushed into narrow, issue-specific channels by competitive funding and multilateral processes, and overshadowed by industry influence on policy makers.7Koivusalo M MacKintosh M Commercial influence and global nongovernmental public action in health and pharmaceutical policies.Int J Health Serv. 2011; 41: 539-563Crossref PubMed Scopus (12) Google Scholar Even if herculean efforts succeed in relaxing intellectual property restrictions on vaccines, diagnostics, and therapeutics in response to future pandemics, without specific language to address structural inequities in areas such as access and benefit sharing, the instrument will still fit comfortably within the inequitable global political economic order.8Hampton AR Eccleston-Turner M Rourke M Switzer S ‘Equity’ in the pandemic treaty: the false hope of ‘access and benefit-sharing’.International and Comparative Law Quarterly. 2023; 72: 909-943Crossref Scopus (1) Google Scholar WHO CA+ has served as a kind of lightning rod for health sector outrage over pandemic-related inequities, but WHO legal instruments have little potential to change structures such as global trade rules that shape social and ecological determinants of health. The INB process therefore shows a need to go beyond typical social change strategies of health professionals and researchers, which assume functional policy processes amenable to evidence-based arguments, and the ability to address relevant determinants of health through work within health institutions.9Brisbois B Burgos Delgado A Barraza D et al.Ecosystem approaches to health and knowledge-to-action: towards a political ecology of applied health-environment knowledge.J Polit Ecol. 2017; 24: 692-715Google Scholar More politically savvy and assertive approaches are required to address what planetary health scholars have termed “colonial, white supremacist, patriarchal systems”2Jones R Reid P Macmillan A Navigating fundamental tensions towards a decolonial relational vision of planetary health.Lancet Planet Health. 2022; 6: e834-e841Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar that see “specific groups wielding power at the expense of other people, other species, and the Earth itself”.2Jones R Reid P Macmillan A Navigating fundamental tensions towards a decolonial relational vision of planetary health.Lancet Planet Health. 2022; 6: e834-e841Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Rather than accepting contemporary inequities as inevitable and unavoidable, world leaders could be strongly pushed to transform social institutions. Such a push can be informed by the examples of transformative or even revolutionary social, environmental, and Indigenous movements. Obstacles to such activism include norms of purported objectivity and a tendency to view existing state structures and the global distribution of power and resources as natural and functional. Such beliefs function as a kind of armour—somewhat like the lobster's shell—that repels challenges to entrenched political ideas. Efforts to trouble such beliefs can draw on transformative planetary health pedagogy, applied to trainees, but also to established scholars and practitioners.10Webb J Raez-Villanueva S Carrière PD et al.Transformative learning for a sustainable and healthy future through ecosystem approaches to health: insights from 15 years of co-designed ecohealth teaching and learning experiences.Lancet Planet Health. 2023; 7: e86-e96Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar These efforts will require a disorienting period of reflection on what it would take to transform the inequitable global economy. Although the discomfort caused by transformative learning is well known to antiracist educators, the benefits of shedding an old and worn-out carapace should not be underestimated. As co-chair Matsoso put it: “Let's cast off—like this lobster—this shell and allow ourselves to become vulnerable. Allow ourselves to come through this process and come up with solutions that will make this a better and safer world.” We declare no competing interests. Both authors contributed fully to this manuscript. BB was the lead writer. KP provided conceptual and writing feedback. KP would like to acknowledge that this work is made possible through an operating grant for the Solidarity for Vaccine Equity (SOLVE) study from the Canadian Institutes of Health Research.