Astroturfing in global health – why this is a serious problem (for me)

I believe that nearly every person I have met working in the global health sector has joined this sector because they want to save lives, and improve the health of all people. We all work (a lot) to try to make sure that children do not die needlessly from diseases that can easily be prevented by vaccines, that mothers do not pass HIV onto their infants during pregnancy or birth, and that diseases that can easily be treated with cheap medicines do not maim or debilitate the lives of millions of people.

There are thousands of journalists who report about health inequities globally and nationally, and showcase new research or developments that could save millions more lives. There are thousands of humanitarian and development NGOs in each region, trying to advocate for and provide services to those people who do not or can not receive sufficient support from their governments. There are ministries, government agencies, technical experts, academics, campaigners, youth groups, mobilisers, fundraisers, communication specialists, data analysts, evaluation experts, strategy consultants – you name it – all trying to make the world a better place for all people.

“If we didn’t have organisation X, we’d have to invent it,” is a favourite soundbite campaigners and fundraisers use to make the case for their work. The message is clear: by doing what we do, we are saving more lives and enabling more healthy lives than if we would not do what we do.

I’ve worked in global health and in the development sector for nearly 20 years. I’ve worked in NGOs, campaigning organisations, as an independent consultant, and have worked for international organisations, the government, and government agencies. I have been proud to work in this sector, and try to contribute to its mission, and I have been privileged to work with some of the smartest, kindest, and most dedicated people out there.

However, I am also one of the people who think our sector is not healthy. We have unhealthy competition in areas where we should see collaboration, we use immense amounts of capacity and funding for naval-gazing and self-serving turf wars, and we keep reinventing the wheel or try to duplicate mandates if we see an opening to grow our own roles. Some argue in return that this is healthy market competition, in a supra-national space where there isn’t and shouldn’t be an all-controlling leader. Perhaps I’m a bit simple, and am a person who needs order in my life, but instead of seeing an efficient market, where the best entity wins the race to provide the best quality services, I’m increasingly seeing chaos. I know that many of my colleagues who are supposed to fund and hold various organisations accountable to at least the minimum extent agree.

As in politics and economics more generally, I guess there will always been a tension and some back-and-forth between those who advocate for free, competitive markets and those who want more centralised planning and control. As long as the world is becoming a healthier place – and in the longer run all data shows it is – the path is irrelevant, no? There’s a whole debate here on whether we could save more lives, have healthier populations, and also develop more sustainable approaches and systems by choosing one or the other path, or perhaps a completely different way of doing things. But that’s another debate. In this piece, I wanted to raise another question.

Like many other people joining this sector, I found a really cool global health job. I had specialised in global health during a second master’s degree, and worked in development financing for a few years after graduating. But my heart beat for health, and addressing some rampant health inequities was something I started thinking about more and more – in my work and outside. Over the next years, I worked in a number of amazing places, with amazing people. I had four children along the way, and also worked as an independent consultant when my children were small, or between various staff positions.

At some point, I realised something that I at first found to be a coincidence, then amusing, then slightly uncomfortable, and later on worrying. No matter where I worked, whether NGO, consultant, or international organisation, I was paid by one global health donor. At some point, I consciously started looking for jobs that would be paid for by someone else – anybody else – just to get out of the narrow niche I had slipped into. I wanted a broader, more diverse perspective and experience, and to hear more diverse views. I also wanted to have more say on what I felt was the right approach, and the right focus. I’ve written about this a lot in this blog over the past years.

I came across the term “astroturfing” a while back. The definition is “the practice of masking the sponsors of a message or organisation to make it appear as though it originates from and is supported by grassroots participants”. You may consider me paranoid – and some people lump this together with “conspiracy theory” – but this concept blew my mind.

I’m not saying that there is no independence in the global health sector. There are many governments, international organisations, NGOs, academics, youth initiatives, and consultants who do their work, based on the best available expertise and experiences. What I’m saying is that my own experience was that I realised at some point (naively, and very late) that I was not one of these people.

Perhaps I am a naive, young(ish) woman who no longer wants to reply “how high?” when a donor says “now jump”. Perhaps serving a system that saves at least millions of lives is better than questioning this system, which may lead to saving no lives – because no-one else cares, or no-one else can get the job done. Perhaps the only way to see progress is to continue working with the journalists, academics, NGOs, campaigners, champions, initiatives, and organisations – who are all paid by and report the same few sources.

But perhaps not. I’ve for a few years found myself nodding my head at more and more “bottom-up” initiatives (and no, not the ones I know are funded and have been founded by those same few donors…). Some people consider these initiatives naive or call them “radicalistas” (aka super left). But I’ve been intrigued by their questions whether development aid models really are the only and best solution, whether white highly-educated experts living in high-income capitals really do always know best, or whether partnering with profiteering pharma really will save the day (or end a pandemic for all people).

If there’s one thing I’d like to tell my 20-year old self, it’s this: ask who pays for your job. And then keep your eye on this throughout your career. At least be aware of this.

Twenty years later, I’m tired of being an astroturfer. I’m tired of calling myself an independent consultant or claim that I’m working for an independent NGO or organisation when I now know that’s neither true, and increasingly also not the direction I think global health should take. Again, this may just be my niche experience, in a select, narrow part of our global health sector. Then again, I fear it may not be.

8 thoughts on “Astroturfing in global health – why this is a serious problem (for me)

      1. Gawain

        Not to be smart, butbI’m not really a health person. So i would put the question back to you? What is missing in global health sector that current institutions and donors are missing? Is there a strategy or approach that should be tried that is missing?

  1. Shawna

    Thanks for this blog piece. Such an interesting concept and turn of phrase. I regularly see this in practice as a way that major donors attempt colonial redress but get confused and end up perpetuating the problem by manipulating the voice that’s platformed. It might even be another type of structural violence to be aware of moving forward in global health. Maybe astroturfing is an opportunity for patient education in the funder ecosystem.

      1. Shawna

        I meant it in the context of patience. As in having a patient, persistent and pragmatic paradigm for the behavioural economics involved in changing perceptions and practice by funders, recipients, local practitioners, etc within the ecosystem. Because realistically addressing this means shifting perceptions and behavioural and having the implementation and behavioural tools to prompt that because donors do not want to hear about global health ethics.

  2. gawain

    The sole-source of much (most) of global health funding, especially in philanthropy, is indeed a huge problem. You can argue that being so big has crowded out other donors who might otherwise provide funding, but feel they are too small to make a difference. It also creates complacency – with other donors (and governments) feeling that health problems – the whole sector – is already covered. Complacency or even dependence. But I feel this should not be a criticism of the donor, but rather a call to crowd-in additional and alternative donors to take up additional and alternative approaches and strategies. Not an easy thing to do, but that is where the focus should be. I’ve observed at least one other major donor withdraw from the sector in the last couple years and it’s a terrible shame. Let’s figure out a strategy on this.


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