Interview with Arianne Shahvisi: On Extractivism and Global Health

Jumanah Younis: Can you start by sketching out the links that you see between the extraction of resources from the global South and inequity in global health? Arianne Shahvisi: Of course. If we think about extractivism conceptually, not in terms of material resources, but human resources, the obvious case is health worker brain drain. Global North systems rely on the extraction of trained health professionals from global South contexts, which generally means getting qualified professionals whose training was subsidised by taxpayers in global South settings. If you start looking at the numbers in terms of how much money global North health systems save, you see that it’s a tremendous extraction of value. Health worker brain drain also means that health workers are moving from a place where there are very few health workers per capita to a place where there are many more, exacerbating a gap that is already there. Clearly we don’t want to look at solutions that block people’s ability to migrate, as that raises other moral issues, so the question becomes how do you make sure that money is getting back to the communities that need it, or how do you incentivise health workers staying in the communities where they train? Another slightly unorthodox take on extractivism is to look at its inverse in terms of waste disposal. The world’s dirty industries produce commodities that are largely consumed in global North settings, while the industries themselves are located in global South settings. When these products are used in the global North, waste is created. Very often, waste is exported back to locations in the global South. If, instead of the direction of flow of resources, we think about the direction of flow of harm, sending waste to the global South is an extractive practice. The logic seems to be that it’s okay to pay somebody to take care of your waste because the money is more valuable to them than their subsequent drop in the quality of life. Yet the assumptions behind such reasoning are utterly objectionable. This is called ‘toxic colonialism’, the same kind of gain-loss relationship is at work that characterised classic colonialism. Toxic colonialism is often preceded by an extraction: you extract raw materials from a global South setting, turn them into products through ‘dirty’ processes (often also located in the global South), then they are consumed in global North settings and the waste makes its way back. The health effects are tremendous. You’ve got people living in close proximity to dangerous toxic waste and, in some cases, picking through that waste to make a living, particularly if it’s electronic waste. The old phones, laptops and tablets of people in the global North are melted down for the precious rare metals that are inside them, and the fumes cause all sorts of rare and fatal cancers among communities that rely on this waste. Essentially, we’re depositing negative value in certain world regions, with all the health consequences that come with that. JY: One of the things you have mentioned before is how there is also an extraction of wealth from migrants coming here in terms of the immigration system. AS: Yes, until very recently, health workers coming to the UK to work in the NHS had to pay to use the very service they were staffing! All visa-holders in the UK are required to pay the immigration health surcharge (a flat payment of around £600 per year for use of the NHS). During the pandemic, the government said that this would no longer apply to migrant health workers. It was presented as being a sort of prize for being on the frontline during the pandemic, as though removing a highly questionable fee would make up for what health workers had been put through. JY: In terms of this international flow of negative value, as you put it, what state or corporate bodies enable it? AS: Extractivism is the central feature of how our global economy works. Corporations, concerned solely with their profit margins, are completely reliant on the extraction of resources that are converted into products – that’s their lifeblood. Governments see the growth of economies as essential to the ‘health’ of a society, i.e. a society that, according to various economic measures, looks like it’s doing well. International regulatory bodies also want to see this kind of growth. The world that we live in at the moment requires resources to be extracted, waste to be created. One of the things that is really critical to this is borders. Borders are administered by states. Borders allow capital to accumulate in particular places and concentrate in those places. Borders control the flow of money and the flow of people. Borders put walls around accumulated value and protect it from the claims of people living in communities that have been extracted from, who have every reason to want to come to places where all that concentrated value has ended up. It is borders which make those journeys dangerous or impossible. Borders also make it possible for people in the global North to fail to recognise the moral claims of people elsewhere, to be happy to have an NHS that serves people in the UK well and seemingly not be at all concerned about the cost that is having on people elsewhere in the world. Borders pose a limit to a person’s moral imagination. I think when we talk about extractivism and the things that facilitate it, we’ve got to keep coming back to this. Personally, I can’t imagine a world without borders where it would be possible to ignore the health outcomes of people globally. I think it’s important to see good health itself as a resource that is unevenly distributed. The reason it is a resource is because it’s completely dependent on things that we do straightforwardly see as resources – diet, exercise, money, education – and all of those things are unevenly distributed. More than that, like other resources, when there’s an increase in health somewhere in the world, it comes at a cost, a reduction in health elsewhere in the world. I think that’s often one of the things that we forget: if we want other people to have better health, there are things we’ll have to give up. JY: What are the climate implications of the extraction of resources – natural and human – from the global South, to fuel overproduction in the global North? AS: Extractivism and climate change are inextricably linked. Extraction is all about addiction to growth and the belief that as long as things are growing, we are heading in the right direction. And yet, to do so requires us to be continually wrenching resources out of the earth – but also out of people – at whatever cost, and then moving that value to particular world regions where it’s already very concentrated. The places where resources are being extracted from and processed into products are not the same as the places where most consumption is happening. That can lead people to blame certain countries for climate change when what they are looking at is where industry happens, not where products are consumed. Climate change has huge health impacts. What we’re seeing when we look at maps that depict vulnerability to the effects of climate change are places where there isn’t the wealth or the infrastructure to have the buffers to protect against warming and extreme weather. Climate change affects the quality of air, water and soil; the security of food and shelter; and the temperatures to which we’re exposed, and also it is going to have an impact on climate-determined disease. It’s highly differential. It is already destroying the lives of some of the poorest people in the world while the causes of rising temperatures are located elsewhere, and, again, borders make that differentiation possible. There is no such thing as a climate refugee in international law: in order to be able to claim asylum somewhere it has to be as a result of persecution. That has always been a problem because it means someone living in abject poverty cannot come to the UK, though it is understandable that someone should want to do so, and seems morally right that we should meet their need. The same goes for people whose lives are affected by climate change. It strikes me that if it wasn’t so easy to keep people out, we’d have to think harder about poverty and climate change. JY: There’s also a differential impact of climate change for different types of people within a global South context. How is extractivism gendered? AS: We’re defining extractivism as the patterns of stripping the land, resources and even the care of particular countries in global South settings (nurses and doctors, for example). If the people who care for communities are leaving, what you end up with is a tremendous care deficit. Alongside a health system that is decimated, there is soil degradation and pollutants in the air, which means increasing health problems. So not only have you got a weaker health system, you’ve got more health issues. In those cases, because of gender norms and socialisation, it’s invariably women and girls who end up trying to hold what remains together. Rather than care being provided at the level of the community it is individualised, and each household has to care for itself. Women and girls have the double burden of not only belonging to an impacted community, but of labouring to make that community a liveable one. That has huge mental health effects as well as meaning that many young women are denied an education. It is incredibly gendered, as all extractive processes are, because once you start taking away the essential things that make a society work, it is the most oppressed people in the society who are going to end up with the worst outcomes, and it’s the care-givers who will shoulder the responsibility of keeping people alive and healthy. JY: With that in mind, it’s interesting to think about the predominance of women as leaders in resistance to capitalist mega projects in the global South. Are there any examples of resistance to corporate and state extractivism that are particularly inspiring for you? AS: There are some obvious examples: anti-extractivist movements in Ecuador against the mining of oil and minerals there; the resistance to the Dakota Access Pipeline, in which Native American ‘Water Protectors’ objected to the destruction of sacred lands by the construction of the pipeline, and also the ways in which it would contaminate the Missouri River. There’s also the project of democratic confederalism in the autonomous region of Rojava. I am half Kurdish (my father is from Iran). The Syrian Revolution presented an opportunity for Kurds to establish an autonomous region, the political ideals of which are based on the work of a revolutionary thinker called Abdullah Öcalan, currently in prison in Turkey, who has written extensively on a political ideology called democratic confederalism, which is a multi-ethnic, anti-state, feminist, ecological movement. Ecological and feminist principles are a big part of how that region is being run. People of all genders are encouraged to think about the way that patriarchy has impacted on them and how they see the world. I find it inspiring the way that this autonomous region has put ecological and feminist principles at the centre of its constitution. For me, that’s the most exciting and radical project that is opposed to the idea of a state and to the idea of extractivism. JY: There are a lot of parallels with the Zapatista movement, which conceives of itself as anti-state and anti-extraction. In the UK we have a disparate collection of climate justice movements but nothing that is particularly rooted in thinking outside of the state. AS: We have such a different relationship to the state here, there’s so little mistrust, despite us having very good reason to question the government’s decisions and motives. Things like having a generally well-functioning NHS makes people think the state is an obviously good thing. A lot of the climate activism that gets coverage in the UK is not very radical and is often rooted in this idea that if you consume in a conscious way you’re doing something good for the environment. I find that idea utterly ridiculous, but I think a lot of people are stuck at that, and think of themselves only as consumers. Maybe it’ll take a really exciting movement to convince them otherwise. JY: How has the covid-19 pandemic impacted on already entrenched global health inequalities? AS: Once people had got beyond the initial panic there was this moment when it suddenly became apparent even to those who hadn’t thought about it before that while this disaster was going to hit everybody, it would be experienced differently depending on where you were in the world, and would come down to what your own personal resources were, and what kind of a society you were living within. Interestingly, about a year ago this coincided with a moment when lots of people who hadn’t thought about it before were starting to think about health inequalities due to race, both as a result of global wealth inequality but also, in places like the UK or US, the health inequalities due to racism. It felt like there was a moment of possibility: that surely now, as we all experience this awful time together, there has to be a reckoning with these patterns of global health inequalities which have existed over many decades. It made me sad, disappointed and scared to see the direction things took when the vaccines became available. This thing that could give us protection was the result of the work of scientists—a collective, international enterprise—yet there was no solidarity whatsoever. Global North states immediately started hogging vaccines, which makes no sense from a health perspective or an economic perspective. The fact that people could do that even though it didn’t make any sense revealed the power of particular ideologies: that we want to win, that we want our country to do better than others. Then there was the attempt led by South Africa and India to get a waiver on intellectual property rights, not just for the vaccine but treatments, so that anybody who had the capacity to, could make them and distribute them. This was blocked by the wealthiest countries in the world. I found all of this staggering. Here was the moment where we could learn this lesson and start challenging intellectual property in ways that might set precedents for other situations. I feel like it is an enormous and fatal missed opportunity. If the past year couldn’t bring us to these realisations, what is it going to take? JY: What would you say the three next steps are to help get us onto the path of achieving global climate justice and health equity? AS: The first thing is that we have to decouple health and profit. There is a glaring contradiction between wanting to make profit and wanting people to be healthy. If the whole world was healthy right now then how would the various healthcare industries generate any profit? It is in the best interest of healthcare corporations that people aren’t healthy. This idea that there can be life-saving vaccines and they aren’t getting to the people who need them, and that this comes down to money and accidents of birth, strikes me as utterly ridiculous. In the same way that the air that we breathe is free – though we have spoken about how the precise quality of it varies – healthcare is not something special or luxurious. It should not be subject to the ravages of profit. It should be set entirely outside of that system. It is not something we choose, it is essential. Similar arguments can be made about things like water, food and shelter. These are just things we need to get from one day to the next, and to me it’s immoral for anyone to make money from that need. Another thing is addressing this growth imperative, the idea that everything has to keep growing. The idea that we’ve accepted as being utterly normal that the phone you buy now will not be your phone in a few years’ time. We think that’s just the way it is with technology, but that makes no sense whatsoever. A century ago it would have been very strange to think about the idea that the object you get is designed to break or no longer be desirable in some way in the future. We’ve got to put the brakes on this and realise that manufacturers should be making things that last. In general, we should be making less stuff and protecting what is left of the natural world. This comes back to profit. If companies are thinking about profits that means keeping their markets open, which means making sure that they are not making things that satisfy us too much because then we won’t want anything new. We have got to stop this idea that we constantly need new and better and faster. It is not making anybody happy, it is certainly not making anybody healthy and it is destroying the planet. At the moment it is an axiom of our global economy. The last thing is borders. They enclose wealth and in doing so, they make it easier to have wealth polarities, disparities and inequalities. I think of it like water: without a dam, it flows everywhere. Borders stem wealth; they collect it. Get rid of borders and wealth will necessarily be more evenly distributed. Then you’ll find that it’s in everybody’s interests that everywhere on earth is a good, healthy and safe place to live in. I think it is critical that part of our radical imagining for the future is a world without borders. What would that look like, what possibilities would it open up to us and for all of our health? Arianne Shahvisi is Senior Lecturer in Ethics at the Brighton and Sussex Medical School. She has broad philosophical interests, including feminist philosophy, bioethics, and philosophy of science, and has published articles and book chapters across these areas. Arianne writes regularly for the London Review of Books and has also been published in The Independent, HuffPost, Aeon, Prospect, and Jacobin. She is writing a book on the philosophy of social justice, which will be published by Penguin in 2022. Arianne was recently featured on the Global Health Lives Podcast. Listen for free here.