A Sober Reality: Necessary Public-Private Partnerships Have Conflicts

The Twitterati is sounding the warning of health programs being approached by a tsunami of assistance from alcohol profits. The majority sentiment is that the poor public relations perception is not worth the financial support.

First, The Global Fund to Fight AIDS, TB, and Malaria, a multilateral institution benefiting from both governmental and private support, announced a partnership with Heineken to expand the Fund’s efforts to end the three epidemics. The Global Fund planned to leverage Heineken’s “logistics and communications” knowledge to improve its ability to deliver medications and supplies to patients, even in our globe’s most remote areas. The reaction amongst health policy leaders was loudly unfavorable, stating that this is simply an industry that is implicated in the spreading of HIV trying to extend its reach and bolster its brand recognition in emerging markets.

Let me assure you that it is already extremely easy to find a Heineken even in the smallest local pub in East Africa.

Following two months of sustained opposition, The Global Fund declared it was suspending the partnership. But the reason given was to protect “female beer promoters” from exposure to “sexual exploitation and health risks.” If you hesitate to believe that this is the real reason for putting the partnership on hold, and not, rather, the barrage of negative publicity following the original notice, then you are not alone.

Next came the front page spread of the National Institutes of Health (NIH) study into moderate alcohol consumption. A large body of evidence already points to the ability of moderate alcohol intake to decrease cardiovascular disease, the number one killer worldwide. But the NIH is seeking to hone our knowledge on the subject with a statistically powerful and costly randomized controlled trial. The New York Times reported that the future investigators sought alcohol industry funding of a study to be independently designed and carried out under the direction of the NIH. This alliance has a much more direct potential conflict of interest and the response has been just as hostile as the reaction to the Global Fund’s announcement.

It is high time for some talk grounded in reality.

The big problems of ending the aforementioned epidemics and answering if, how much, and in what doses, alcohol prevents cardiovascular disease will require big (read expensive) solutions.

Ideally, yes, some perfect institution would be created that would research problems free from bias, free from human imperfection, and free from financial cost. Potential bias, an inherent part of statistics, is something for which researchers control and report in the final manuscript. Funding all investigation into health problems, and the subsequent implementation of their devised solutions, reliant solely on governmental funding is unrealistic and unsustainable.

Conflicts exist in our daily lives. We, especially in the United States, are surrounded by them. They are written into our laws. They drive our daily behavior. It is naïve for the global health community to think that we can somehow immunize ourselves against any and all harmful conflicts of interest. An attempt to insulate ourselves from financial conflicts and claim purity will be a fruitless pursuit.

Indeed, it is interesting that this particular partnership with Heineken has raised such grave concern when the Global Fund’s private donor pool already contains Chevron, Coca-Cola, banking industry, and the pharmaceutical company Takeda. Do all of these titans not also, in some small way, contribute to poor health, climate change, and inequality while raking in profits? While these private contributions make up a small portion of the Global Fund’s total budget, one could imagine these potential conflicts would raise as much concern as the Heineken collaboration.

Traditional models of economic development in low-income countries leave much to be desired. Building upon massive gains between 1990 and 2015, the lofty Sustainable Development Goals (SDGs) implore us all to aim higher to reduce inequality, champion human rights, and improve the lives of all our fellow global citizens by 2030. In an effort to leverage private resources and governmental convening power, public-private partnerships have been touted as one effective route to strengthening health systems in emerging economies. These such innovative alliances should be encouraged and nurtured.

Wealthy corporations in the US have been the natural piñata for beating following the 2008 recession. Whatever lessons learned have not prompted meaningful enough change to prevent persistently growing inequality. However, the plentiful financial resources stock-piled in the year-end reports of private corporations can support our pursuit of public health answers and solutions – and quickly. Why not let them help their public perception while funding answers to our greatest public health questions and solutions to our greatest societal challenges?

This, of course, forces us to rely heavily on the integrity of the scientists and public health professionals designing these studies and programs. We as a society have been let down plenty in the past by supposed independent scientists and studies show scientists have room for improvement when it comes to disclosing conflicts. We also live inundated by news, both “real” and “fake,” funded by special interests and delivered by algorithms. Thus, we have grown skeptical. The NIH is the leading American scientific research body and this study on moderate alcohol use is led by a physician affiliated with Harvard and a Yale neuroscientist. The Global Fund is a multilateral institution with numerous public and reputable private funders who already demand accountability, especially of such a high-profile initiative. If we can’t trust these professionals and reliable institutions, then who will we rely on for sound scientific investigation and health programming ever again?

Refining monitoring and evaluation (M&E) of programs, improving efficiency, and bolstering accountability ought to be top priorities for health program funders and implementers alike. This is M&E professionals’ time to shine. With the abundance of information and oversight by civil society, there will be plenty of data to support their work.

Noncommunicable Diseases (NCDs) such as high blood pressure, heart attacks, and strokes, are not sexy. Ending AIDS, Stopping TB, Rolling Back Malaria; now those are sexy. These infectious diseases command resources at conferences around the world. But NCDs, which are already the top cause of mortality worldwide and an enormous problem in all nations regardless of income, have not traditionally inspired the same support. Fortunately, the World Health Organization has created an Independent High-Level Commission on NCDs. But how will we finance their recommendations? The SDGs highlight the importance of health, with efforts to reach them underway all around the world. But the UN estimates an additional $2.5 trillion will be required annually to reach these. How will we fill this gap and pay for accomplishing all 17 goals and 169 indicators?

Private investments will be essential.

It is easy to argue that the surface perception is so awful that these partnerships should be abandoned. But in reality, we have epidemics to end and more public health questions to answer. The task is large and the resources to make the mission possible exist on our planet. Government cannot be the only answer, but they can help convene critical stakeholders including researchers from top academic institutions, public health professionals from civil society organizations, and the entities with the means to help fund their efforts, to rapidly solve global problems.

This is an opportunity for science to shine. Demonstrate independence and integrity. Submit to rigorous oversight. Let us welcome private partners and benefit from their resources for health.

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