Category Archives: Global Health

The wikipedia pithy definition is: the health of populations in a global context. https://en.wikipedia.org/wiki/Global_health

To share power, someone has to give up power

Over the past few years I have been peripherally involved in various discussions with male colleagues about gender equity. The conversations have had a predictable ebb and flow.

Women’s empowerment. It’s great in theory, but who wants to give up power? Not these men. [source: reddit; https://bit.ly/2wd2AJC]

The consensus, at least among my colleagues, is that gender equity is a good idea. In the abstract, we fully endorse it. The practice is another matter. It is not that we don’t want to share power. We’re enlightened! We know there is a problem, but can it be someone else’s power that is shared?

The reasoning goes something like this. I should not have to share power. I’m talented, I got here on merit, and I deserve everything I achieved. It is an absolute social good when I have power. For me to give up power would not be good, because I wield it benignly and actively promote gender equity. It would be great if another man gave up power because that would support gender equity.

At a fundamental level, power is a zero-sum-game. There are only so many seats around the high tables of power, and if someone gets a seat at the table, someone loses a seat. Sure, we can squeeze an extra seat in here or there — but there are limits. If someone sits on a panel, someone else cannot sit on the panel. If 50% of the world’s population suddenly achieved fair access to power, power that had been largely controlled by the other 50%, competition would increase sharply.

In 2017, the World Health Organization Director-General Tedros Adhanom Ghebreyesus, tried to fudge the arithmetic [it has since changed]. He appointed a substantial number of women to senior positions in WHO. He did this by increasing the pool of senior positions, and he appointed women to the new positions. Unfortunately, many of the new positions were without substantive portfolios, and without real power. In effect he dragged some extra stools to the table. Chairs for men. Stools for newly appointed women.

The strategy had all the right visuals without the structural capacity to support gender equity; i.e., the fair distribution of power.

Gender equity is a good idea. It will be achieved through structural changes that share power and resources, not through appeals to people’s better nature nor through empty gestures. The test of whether one person’s power has increased is whether another person’s power has been diminished.

Indonesia pushes back against trickle down science

A recent article in Science Magazine (July 2019) described changes to Indonesian laws regulating the way that foreign scientists can do science in Indonesia. The laws are, in essence, a push back against “trickle down science“, in which scientist in Global North Institutions engage in colonial science. This is what happens when Global North researchers engage local institutions to provide service scientists and easy access to samples without any genuine consideration for their Global South collaborators.

The implications of the new law are still uncertain, but it may affect one of the studies on which I am in investigator. The change in the law means that

[Foreign scientists] need to get ethical clearance from an Indonesian review board for every study (although some types of studies may be exempted), submit primary data and published papers to the government, involve Indonesian scientists as equal partners, and share any benefits, such as the proceeds from new drugs, resulting from the study. Researchers can’t take samples or even digital information out of the country, except for tests that cannot be done in Indonesian labs, and to do so, they need a so-called material transfer agreement (MTA) using a template provided by the government. (Rochmyaningsih, 2019)

A Bajaut Laut community in Sabah, Malaysia. It was a study in a community like this one in Indonesia that sparked a debate about subaltern science.

It is hard to fault any of the new requirements. Of course there should be ethical clearance and of course the clearance should come from the country in which the science is being done. Lodging the data and the papers seems like a reasonable idea. The Indonesian governments wants papers and data lodged with the them; a bolder and more constructive approach may be for data and papers to be lodged in accessible repositories. Of course Global North researchers should have in-country scientists as partners and of course the collaborators should be equal partners — not pretend equal partners, but actual, equal partners. Of course the benefits of the science should flow to all the countries engaged in the science. These are not high hurdles to jump unless the scientists from the Global North thought they should be able to arrive, collect samples, and run … which would never happen, right?

I could have predicted the kind of response that has already begun with the announcement of the Indonesian law, because I have heard the responses before. Indonesia (or insert the name of your favourite Global South country here) doesn’t have the capacity to do the research that we want to do. It wasn’t the research idea of the scientists in Indonesia, it was our idea. These new laws will destroy science in Indonesia, because any credible Northern researchers will move to a more accommodating country; i.e., a more readily exploitable country. Every single one of these responses condemns the person who utters them, because each one shows a complete lack of commitment to genuine, scientific collaboration.

The issue of #trickledownscience seems to have come to a head in Indonesia with the publication of an article in Cell — the high impact factor (36.2) journal in experimental biology. The article, reported a study of genetic adaptations to hypoxia in the Bajau Laut people, a nomadic, sea-dwelling community in Southeast Asia. The article is fascinating and well worth a read, and the authors should be congratulated on a great piece of science! The problem is not with the findings, it is with the process of Northern Scientists going to far flung places to do their research without any genuine engagement or collaboration with local scientists. There are 17 authors listed on the paper and with only one exception they come from Denmark, Germany, the Netherlands, the UK and the US. The exception is author #15, an Indonesian who is and education researcher and has no background in genetics or cell biology, and whose contribution was to “provide logistical support”. Author #15 comes from Tompotika Luwuk Banggai University — a small, private institution in Central Sulawesi; underscoring the lack of genuine collaborative intent, Tompotika’s university ranking is 498 in Indonesia and 12,999 in the World. This is a far-cry from, to give one example, the more relevant and credible Eijkman Institute for Molecular Biology in Jakarta.

The publication of the article received good coverage in The New York Times, and less desirable coverage in Science Magazine. The heart of the problem is revealed in a comment by Melissa Ilardo, who was the doctoral student on the study and the first author of the Cell paper. Commenting on the controversy, she said, “I did everything I could to conduct this research ethically and properly, and this is breaking my heart”. I truly feel for her. To be a young (post-)doctoral student and have to go through this kind of scrutiny would be awful. But just think about Ilardo’s idea of “doing everything” to conduct the research properly. What does it mean to conduct oneself properly when the #trickledownscience relationship is a profoundly colonial one. The study looks a lot like the modern day equivalent of the Elgin Marbles; however, instead of retrieving (stealing?) ancient artefacts, Global North reseaerchers  collect biological samples.

The new Indonesian law is probably too heavy handed, but it is in the right direction. There is little doubt that there is a problem with #trickledownscience, and governments in the Global North, funders, and institutions need to push the nascent dialogue with the Global South about how appropriate, collaborative science can develop that addresses the needs of the Global South and not the whimsies of scientists in the Global North.

I predict it will be those Global North institutions that tackle this issue head-on that will be the most successful. It does require that they give up a little power to retain a little power, and it begins by negotiating genuinely, collaborative arrangements that address (1) the most pressing scientific questions in the Global South, (2) the building of capacity in the Global South, (3) sustainable funding for research in the Global South, and (4) sustainable, collaborative research relationships between the Global North and the Global South.

I was trying to imagine what the response in the US would be if a group of Indonesian, Nepali, and Tanzanian scientists arrived in the US to collect saliva samples from a Hasidic community in upstate New York or an Amish community in Pennsylvania. A young academic at a local community college would provide “logistical support” and facilitate obtaining ethical clearance from the college’s Institutional Review Board. The samples would be collected from the community and shipped back to the Eijkman Institute in Jakarta for analysis. A paper would subsequently appear in Nature detailing some interesting genetic variations associated with the communities. Would the science be celebrated in the The New York Times or would someone have a WTF moment and question how this could ever happen?

I am looking forward to that studying being done. Will NIH fund it, I wonder?

Public Health is not a specialisation of medicine

Medicine saves lives one at a time. Public Health saves lives by the millions.

In many countries, the guilds of the medical fraternity provide for specialist membership. Attached to membership is prestige, promotion, and increased earning potential. In almost all cases, membership or fellowship of one of these guilds, typically titled “Colleges”, indicates increased expertise in the management of classes of disease in individual patients.

If you have diabetes, atrial fibrillation, Parkinson’s disease, major depression, etc., or you need more or less specialised surgery, you may well want to consult a member of one of these guilds of medicine.

 

Vaccination programs are critical to Public Health, but they do not require a medical specialisation in Public Health. [Image source: pixnio.com]

The focus of Public Health is the protection and improvement of the health of populations. The breadth of public health practice is enormous with individuals working in disease specific areas (e.g., HIV, TB, or mental health); settings (e.g., schools, workplaces, markets); social policy areas of the social determinants of health; health systems; health financing and market regulation; urban design; and health data analytics, to name just a few. Although there are commonalities between them, Public Health may be contrasted with Community Medicine and Social Medicine by the fact that Public Health practitioners do not spend their time treating individual patients, although they may guide services for the better and more efficient treatment of populations of patients.

The most significant distinction is that Public Health draws its expertise from a wide range of disciplines: behavioural sciences, nursing, management, geography, history, politics, anthropology, environmental sciences, urban planning, sociology, pharmacy, economics, biostatistics, microbiology, ecology, mathematics, parasitology, computer science, entomology, engineering, veterinary science, … and medicine. Some of the best public health people I have ever worked with have come from history and geography. It is not that history and geography are peculiarly crucial to Public Health. It is that good Public Health requires interdisciplinary teams that can bring new perspectives to problems. It is relatively unusual to find historians and geographers in Public Health, so they bring novel solutions that are quite different from those one might otherwise see.

Postgraduate Public Health training, such as a Masters of Public Health (MPH), is a useful way of providing the diverse disciplines involved in Public Health a common language with which to share problems, ideas, and solutions. There is no one best discipline for Public Health, and there is no reason that one has to study Public Health formally to make a valuable contribution to Public Health practice. I speak here as a person who has no formal qualification in Public Health but one who has been a Professor of Public Health, has lead Public Health teams, and has advised governments, UN agencies and international NGOs on Public Health.

I return to my titular point. Public Health benefits enormously from the input of people with a diverse range of qualifications. What then is the purpose of a medical specialisation in Public Health, if Public Health is not a branch of medicine?

The answer is historical and political. The historical answer is that Public Health is traditionally located within the Ministry of Health (MOH). There is a logic to this. So much of the practice of Public Health is about the coordination, regulation and efficient delivery of health services that it must be coordinated with MOH activities. The obvious down-side of this historical location of Public Health is that, as it has become increasingly evident that population health problems require whole of government approaches, any attempts to transcend the departmental pillars of government are regarded by other Ministries as a MOH power-grab.

Politically, power within MOH is typically vested in people with membership in one of the specialist guilds of medicine. The only way for Public Health to have status in MOH (and let’s face it, Public Health has never been as sexy as clinical medicine) is for it to be lead by people with a medical qualification and membership of a specialist guild. Thus, specialist guilds of Public Health medicine were born.

This historical and political strategy protected the status of Public Health within MOH. It provided a career pathway for medically qualified personnel interested in pursuing a career in Public Health. Unfortunately, it also limited the capacity of Public Health practice to deliver the best population health outcomes.

Governments need to improve the way they approach the protection, promotion and improvement of the health of their populations. A good start is to recognise that medicine is a part of the practice of Public Health (just as history, geography, etc. are), but Public Health is much bigger than a specialisation of medicine.

Globalisation and health

The past has already been written and the accolades distributed. We now need to decide whether the next century is going to be good or bad for our health, and the role of globalisation in helping us to determine our destiny. People living in failed states do not enjoy utopian, anarchic freedom. They die young. Healthy populations need the goods and services of society to be shared in a broadly inclusive fashion. They need health systems that can respond rapidly and flexibly to emerging disease. They need environments that support human life.

 

The zombie apocalypse is our least likely but most entertaining future. [image from proprofs.com]

70,000 years ago our ancestors took their first steps out of Africa. With those steps they initiated the binding link between globalisation and health. The difference between then and now is a matter of temporal and geographical scale. Then, nothing moved faster than a walking pace. Now, a person can traverse the globe in 24 hours. A city thousands of kilometres away can be destroyed in 30 minutes. An idea can be everywhere in seconds.

The technological advances of the last century have been kept pace by extraordinary improvements in human health. Average life expectancy barely moved until the beginning of the last century, and over the next hundred years, it doubled. In 2016, the global average life expectancy was 71.4 years of age. We had achieved the biblical entitlement of three score and ten years promised in Psalm 90. The improvements in health were achieved because of globalisation. Reductions in poverty. Improvements in food supply. Advances in healthcare. Sophisticated infrastructure was delivering clean water and carrying away waste. Those advances have also been accompanied by large inequalities in health outcomes and significant environmental degradation.

I suggest there are three broad intersections between globalisation and health. First, there is the real (and sometimes imagined) disease outbreaks: Ebola or the Zombie apocalypse. Infectious disease, however, is only one part of the health and globalisation relationship. The second, very modern concern is the interconnection between our global activities and environmental change, and by extension the impact on human health. The final idea is our relationships with each other, and how these relationships can shift, and the effect the changes may have on the availability of health supporting resources.

I sketched these ideas out in a 3,000 word essay in early 2017 at the invitation of the Editors of “Vaguardia dossier” a Spanish language, Catalan magazine. Many people (including myself) cannot read the published, Spanish version, but you can get the slightly rough, English language preprint here.

Reidpath DD, Globalización y salud [Globalisation and health]. Vanguardia dossier. 2017; 65:76-81