Some people working in global health want to leave a legacy. Some want to save lives. Twenty years into my career, my hope is that I am not wasting my time and that I am doing no harm. These are my hopes – my own personal global health manifesto – for 2023.
What are we doing?
I have been working in global health for nearly twenty years. I have seen a lot. Ten years ago, in Zambia, I was asked by an HIV-positive woman why we kept fundraising for medicines that kept her alive, but weren’t investing similar efforts into finding a cure. Five years ago, in Washington DC, I was asked why we were working to reduce child mortality, but not stillbirths. A year ago, in Berlin, I was ask why we weren’t doing more to end the Covid-19 pandemic. I had been told to deprioritize ending the pandemic in my work, because others before us had already failed, and we wanted to showcase successes.
The longer I work in global health, the more I think that large global health organisations and funds have given up on delivering on their mission. Many governments, including heads of state and ministers, have given up on their responsibility to provide health.
In 2022, we’re left without direction, without leadership, and with the same people who rotate from one top position to the next, fundraising for the next new or old initiative they lead.
Global health is broken. It’s a mess. And it’s not delivering what it should – what it has to: health for all people, globally. As more people are speaking out, it’s clear that global health is not only failing, it is doing harm.
We have created a structure that feeds dependency, where the buzzword “catalytic” is dangled like free opioids. We are patriarchal and at times outright racist, telling people and entire continents what they can get, and when; not allowing them what they need, when they need it.
We have developed systems that burn out underpaid or unpaid health workers, and where the newest cadre of young global health staff rotates through organisations that suck them dry, knowing public health schools will serve them with new, motivated staff.
In 2023, something has to change. I have to change too. I’m still part of the problem that is doing more harm than good. Global health isn’t some abstract institution, or an organisation: it’s us. If we don’t change, if I don’t change, I realise that I am wasting my time.
What are the goals I am working towards?
1) Health for all, not just for some. Health for children. Health for diabetics. Health for pregnant women. Disabled people. TB patients. People in Africa. Homeless people in my local community. Old people. People in war zones. All lives matter, and they all matter right now. We need to work together and not against each other; for all people and not just for “our” people and populations.
2) A healthy person. Eyes. The brain. Reproductive organs. The whole person matters. Saving an arm to die from a diseased lung, or avoiding malaria to live with debilitating mental health problems is just not good enough.
3) Healthy. Some diseases are not preventable. But many are. It is ethically and economically absurd to focus on diseases and ailments only when they cause serious disruption. As much as possible, our focus in global health must expand from “saving lives” and curing or managing disease to doing our utmost to ensure that people stay healthy.
4) Impact. In global health, there are non-profit and for-profit stakeholders. If our bottom line is not impact on people’s health, we have no direction, and no moral compass. We have to be able to justify our investments and actions – and the entire continued existence of global health organisations and partnerships – by more than funding, followers, and board roles. Impact is what justifies our entire sector.
What are my values?
1) Do no harm. If we make promises, we need to deliver, fully. If we seek partners, we must treat them as partners and with dignity. End dependencies. Listen to what people need. Protect and help heal our planet. People’s time and money is precious, we must use it well.
2) Informed by science, but designed for all people. Three main interventions for an entire country don’t cover a population’s needs. Tested only on men means not tested on women. In global health, we need to expand our focus from medicalised science to see how we can bridge this science to where people are at: evidence without implementation doesn’t lead to impact. We need to stop arrogant lecturing and work together with people to ensure we serve their needs.
3) Urgency and equity. Now for some, and later for the rest (maybe) can not be our credo. We live in a digital world where capital moves around the world in nanoseconds, training and even many health services can be managed online, and global supply chains reach every corner of our planet. We have to act and deliver for all people with a sense of urgency.
4) Global health is us. Global health is not a machine that chews up and burns out people. We chew up and burn out people by treating people badly, not recognising their value, efforts, and work. People are global health’s greatest and most critical assets. We need to speak out if we see or experience wrongdoing. We need to apologise if we do wrong, and never repeat our wrongdoing. We need to take better care of each other, and ourselves.
5) Honesty and humility. If we fail, we must admit failure, trigger a sunset clause, and learn our lessons to be better next time. Let‘s be honest enough not to continue to sell what we know doesn‘t deliver.
Everything goes is not possible. What are my criteria?
1) Capacity is finite. Our global health industry may be growing rapidly, but many parts are duplicating into absurdity, or stretched to the point of breaking, no longer being able to do real work. If we found something new, let‘s close down what failed to deliver. Let‘s pull the emergency breaks more often, to take stock of how we are using our time and money.
2) Real demand. If we have to pay for demand, or tell a beneficiary what to say for our promotion video, we are instrumentalizing people and abusing power imbalances. To deliver health for all people, we need to shift power, and we all need to learn to listen. Our aim should be to adapt our supply, not create a false sense of demand.
3) Living partnership. We need partnerships to co-create what is difficult, or to deliver simple things in complex situations and contexts. We need to sunset partnerships that are empty shells, or where partners only convene and symbolically focus for a board meeting.
4) Moving on. When we know we are no longer able to contribute or add value, we must move on, and create space and opportunities for others.
Thank you to all readers of this blog, and to those of you who have provided feedback over these years. I will be going on a blog (and social media) break. I’m not sure what 2023 will bring, but until then, I will spend my break pondering on the last point (4) in my criteria list.
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