#86 Global Health

Dr. Ngozi Erondu, Senior Research Fellow at the Chatham House Centre for Global Health Security, and Senior Public Health Advisor at Public Health England

December 2, 2020

As we have learned through the COVID-19 pandemic, the health of communities around the world is connected through shared technologies, institutions, and values. In this episode, we explore these connections outside the context of a pandemic. We learn how issues in global health are prioritized, funded, and measured; about the roots of global health in imperialism, and what it means to decolonize global health; and about the importance of highlighting local expertise and youth perspectives to strive for equity and improve health outcomes. We spoke with several leaders in global health, including: Dr. Erica Di Ruggerio, Director of the Centre for Global Health and the Collaborative Specialization in Global Health at the Dalla Lana School of Public Health; Dr. Ngozi Erondu a Senior Research Fellow at the Chatham House Centre for Global Health Security and a Senior Public Health Advisor at Public Health England; Jason Nickerson, Humanitarian Affairs Advisor with Medecins Sans Frontieres (MSF), and Colleen Dockerty, Registered Nurse and gender-based violence consultant, also with MSF; and Habon Ali, a Somali-Canadian community builder, who leads initiatives to improve health equity and remove systemic barriers to engaging youth in global health.

Written by: Stephanie Nishi

Dr. Erica Di Ruggiero - website
Dr. Ngozi Erondu - website
Dr. Jason Nickerson - website
Apathy is Boring (Habon Ali) - website
Doctors Without Borders/Medecins Sans Frontieres (MSF) - website

Noor al Kaabi [0:00] What is global health?

Dr. Erica Di Ruggiero [0:02] It's a study that includes research practice, and focuses on health, but also increasingly a real call out to achieving equity and health for all people worldwide. As I mentioned, when I talked about COVID, it also really emphasizes the transnational nature of an issue, both in terms of its determinants, and also the solutions. It's a field of study. So that means that it actually doesn't just draw on one discipline, but many disciplines, and really calls upon collaboration, not just between and within countries, but also across sectors. Sectors, both in terms of academia, public, private, but also sectors in terms of things that happen within the health sector, but also outside the health sector environment, etc. So of course, we have global institutions like the World Health Organization, we have the World Bank, national governments, nongovernmental organizations, many civil society actors, but we also have an increasing rise in philanthropic organizations that are also really defining that global health arena. And an example of that would be the Gates Foundation.

Dr. Ngozi Erondu [1:13] I think it's really important to start with the successes of global health. It started as international health is what we kind of talked about, like in the 90s. And it has been this experiment in collaboration, this experiment, in achieving collective goals to protect human beings from deadly pathogens, you know, it was very successful with smallpox, of course, and also very successful when you just think about immunization as a whole. Vaccine preventable diseases have decrease significantly. You know, in most parts of the world, we don't have to worry as much as children dying, before they reach the age of five years old. And so it's been like this amazing experiment, in working together in looking for problems that affect humanity, and finding solutions to those problems. It's also given us, you know, pretty large, bureaucratic, but also necessary organizations, you know, like, the United Nations, UNICEF, World Health Organization, World Bank, that really kind of helps us to manage and somewhat coordinate these goals and this effort to kind of bring all of humanity to a certain standard. So I think all of that is part of the history and the story of global health as well. The power dynamic and global health has always been, the power has been within the west, and really wider countries if you look at it, you know, there's this huge divide between white countries and brown and black countries, that the global health is also kind of been like this savior mechanism. And it's been this like, we help you, and you should be grateful type of dynamic, and that hasn't been useful.

Habon Ali [2:51] I do see global health as an area and a space that we can work to achieve health equity for everyone across the globe. And when I think about global health, I like to think of it through a social determinants of health framework. But more importantly, I really like the phrase, think globally, act locally. And I like this phrase, because it makes us think about the actions that we take on a local scale, whether it's in our communities and our cities, and how that can impact the health of our global community at large. And often, I think when we think of global health, or we often think of things that are happening across the world, not necessarily we don't think of Canada, and I'm not saying everyone thinks this way, but it's a common misconception that global health is something that's done abroad. But honestly, there's a lot of inequity within Canada. And there's a lot of areas that we need to work within to improve the health of all communities and not a select few, which is what is happening in our country today.

Dr. Jason Nickerson [3:49] For a variety of reasons, you know, it's people who live in places where health systems just simply can't meet their day to day needs. There are people who are prevented from accessing care because of bad policies, whether that be in the way that health services are designed and implemented, or whether it's that they're specifically targeted and excluded from accessing the care that they need, or whether it's because the medicines and the vaccines that they need are too expensive. There's a lot of reasons why people are not able to access the kind of care that they need. And for me, MSF was an opportunity to shine a light, not just on the problems, but also some of the solutions for for how we can meaningfully close the gaps in access to truly life saving kinds of services.

Noor al Kaabi [4:37] You just heard from Dr. Erica Di Ruggiero, Dr. Ngozi Erondu, Habon Ali and Jason Nickerson, a few of our guests for this episode of Raw Talk. Today, we're exploring the wide ranging and complex field of global health. We'll hear about how global health issues are prioritized, the persistent effects of colonialism and white supremacy which affect this work, and the importance of highlighting local perspectives and youth to achieve equity and advance health outcomes.

Frank Telfer [5:05] Before we begin we wish to acknowledge the land on which the University of Toronto and our podcast operates. For thousands of years it has been the traditional territory of the Huron-Wendat, the Seneca, and most recently, the Mississaugas of the Credit River. This territory is covered by the Upper Canada Treaties, and is within the lands protected by the “Dish With One Spoon” wampum agreement. This meeting place is still the home to many Indigenous peoples from across Turtle Island and we are grateful to have the opportunity to work on this land.

Noor al Kaabi [5:36] We ask listeners to visit indigenouspeoplesatlasofcanada.ca and native-land.ca to learn more about and reflect upon the Indigeneous peoples whose traditional territory they currently occupy and their own role in Reconciliation.

Frank Telfer [5:50] We are a podcast that focuses on the stories and science of medicine and health. Today we are discussing global health. As we'll learn throughout the episode, the field of global health is founded in colonialism and white supremacy, and has perpetrated violence and oppression on peoples around the world, including indigenous peoples.

Noor al Kaabi [6:10] We hope that throughout today's episode, you'll reflect on what assumptions you might have about this topic and what your role is in the essential projects of decolonization.

Frank Telfer [6:29] Hi, my name is Frank,

Noor al Kaabi [6:31] and I'm Noor. We are your hosts for this episode.

Frank Telfer [6:34] Dr. Erica Di Ruggiero is the Director of the Center for Global Health and Director of the Collaborative Specialization in Global Health with the University of Toronto's Dalla Lana School of Public Health. We asked Dr. Di Ruggiero, how stakeholders identify and prioritize issues in global health, specifically, as it relates to resource allocation.

Dr. Erica Di Ruggiero [6:52] Some of the research I've been doing applies policy theories to try to understand how things get and stay or fall off or get back on agendas, you know, and allocation of resources that are really applied to keeping things like that on the agenda. It's really, really challenging, but I would say that what keeps things on the agenda, you know, in part, evidence contributes so there's a growing body of evidence that we need to address problem x, global actors and their power and the kinds of capital, both political and economic capital, that they can bring to an issue can also raise things on the agenda at the expense of other issues that may be also very important. And so I would say, you know, financial incentives are, as much as I would hate that to be the only driver certainly drive a lot of decisions, and so the amount of resources that get put behind things. So when a Gates Foundation makes something a priority, it certainly helps to elevate it on the agenda, because resources are going into it at the expense of for example, neglected problems. There are many neglected disease, that aren't getting the kind of resources to find solutions to because they only affect certain people in very poor countries. Now, that doesn't make them less important. But you can see where economic incentives and the power of certain individuals and institutions can actually drive an agenda and make something more important even though some things also merit our attention.

Frank Telfer [8:27] We asked Dr. Di Ruggiero, which specific issues in global health are being underserved?

Dr. Erica Di Ruggiero [8:33] I bet you if you ask a question of the next 10 guests, and they may give you a different answer. I'll start with that caveat. However, let me talk about the nature of issues that I think are underfunded, relatively speaking. They tend to be the kinds of issues that really are looking at the social and environmental determinants of health. So how employment, gender influence our health, we have done I think, a really good job at funding specific diseases, not all of them because some are more neglected than others and conditions, but we continue to fund things in a more vertical and disease siloed way. And I would say that what cuts across many of these diseases, whether you're thinking about TB, or malaria, or a growing number of not just infectious diseases, but non-communicable diseases, many of these diseases are actually about the social and working conditions in which people live, and work and paying attention to those, what I call social determinants really, really need more attention. The second has to do with our climate crisis, which we can't avoid anymore, but the incentives aren't currently going in that direction. So I think we have to shift the way in which we fund things towards more of a horizontal way. So looking at what cuts across some of these very important diseases and conditions and issues. And the second area from a health perspective is to focus on the health systems that we need to strengthen to better address some of these issues. So strengthening health systems, and also looking at the social and environmental determinants of health. That is an orientation to how we fund I think is critically needed. And this is what the Sustainable Development Goal agenda is, I actually tried to shift our thinking towards.

Noor al Kaabi [10:32] Dr. Di Ruggiero, is alluding to the Sustainable Development Goals, or SDGs. Seventeen goals set by the United Nations General Assembly in 2015, designed to focus global action towards achieving a better and more sustainable future for all by the year 2030. There are also 169 targets, and 231 indicators to qualify the SDGs. A massive undertaking to track for each of the hundred and 93 nations that adopted the goals. We asked about the data collected to measure progress on global health issues and the SDGs.

Dr. Erica Di Ruggiero [11:07] I would sort of see this as like who, like who's producing the data? And who wants to know, right? Because it's very much driven in part by that right, what gets measured, you know, the geographic location, the context for that the governance level of the development and production of those indicators. So who was consulted on the development of those indicators? The "what for" which kind of speaks to the who, but also, what's the purpose, and who's funding it, because there's work being done, of course, or donors have interest in funding the production of certain measures related to indicators. So what is in it for them? And I'm not suggesting that there is always, you know, less than altruistic motive. But I think that also needs to be taken into account. And when you apply that to try and understand how policies work, I think one of the other challenges from the research I've done is not not all policies are actually well articulated. So it's not always very clear, you know, what was really the objective. And so we have to start making some assumptions. And the other issue is that most of the indicators that we currently have, including many of them that are part of the SDG agenda, are about measuring the problem. So you know, what's the percentage of people who are poor or percentage unemployed, don't get me wrong, those things are really important, but they're not actually about the solutions. And an example of a solution would be social protection policies, we do have indicators like that, but in terms of the balance, I would argue more of our indicators measure the status of the problem, and less so about what are the policy and program interventions aimed at changing that problem or the situation. And so the balance isn't quite right. So then you get a disproportionate number of measurement. And you know, this costs money, too, and resources to actually measure well, and we aren't necessarily always capturing critical data about the degree of implementation of a policy intervention. So I think we have some work to do in terms of increasing the number of indicators and some of the measurement strategies related to measuring the solutions and policies being one of them, and their kind of impact on different groups.

Frank Telfer [13:31] We'll hear next from Dr. Ngozi Erondu. A Senior Research Fellow at the Chatham House Center for Global Health Security, a senior public health advisor at Public Health England, and co-founder of Global Bridge Group. Dr. Erondu, specializes in health systems and global health security, and is a dedicated advocate for increasing health research, autonomy and capacity in countries across Africa. We asked Dr. Erondu about the weak links she's observed in global health.

Dr. Ngozi Erondu [13:58] When I went to London School, I started working on looking at the meningitis surveillance system in Chad, Central African country. And I had the opportunity to kind of look at other countries in the same region that was dealing with how to improve their surveillance system for meningitis, but also just in Africa, there's the strategy called IDSR, which is integrated disease surveillance and response, which is really I mean, it's something that the US, Canada, the UK could actually really use because they really requires people from disease areas coming together and speaking weekly about kind of what they're observing. It has one health component, it's really an important tool. But in some countries in Africa, it's more it's superficial. They don't have the training or the motivation or the political will to do IDSR in an optimal way. But when you talk to people who are really kind of keen to detect diseases, they'll tell you exactly what they need. When you're looking at disease surveillance integration, you have to remember that we have multiple donors, we have a lot of donors, you know, we have the Gates Foundation and Rotary that is funding polio, we have the Global Fund, that is funding TB, malaria and HIV, we have USA ID that is focused more on, you know, this part or PEPFAR, which is focused more on malaria, President Jimmy Carter's Foundation, which focuses on guinea worm, and all of these people require, you know, reporting regularly, you know, some of these some, I mean, some of the reports are super extensive takes months, you know, just to get the data and put it in, and then they say, we don't actually have time to do the work,

Frank Telfer [17:50] The prescriptive nature of global health creates a major disconnect between funding organizations and the people on the ground doing the work. Dr. Di Ruggiero also flagged how the data that's being collected is not necessarily useful data.

Dr. Erica Di Ruggiero [18:05] It's also what we're measuring or not measuring. So without reliable and meaningful data on those things, we can't measure the problem, we can't track progress, and we can't guide planning and policy reforms. So if I take one of the goals, which is SDG 3, which is about good health and well being, it includes a bunch of targets and indicators related to specific diseases and conditions, but it also includes some indicators around health systems. But if we don't have strong health information systems, which is, you know, a challenge in low and middle income countries, it would be really challenging to actually measure progress well. And so I think there is lots of work that can be done to strengthen the information systems that kind of underpin our data collection efforts so that we can better respond and develop strong health systems that meet the needs of different population groups, right? For example, you know, there was a recent review done of of health information systems globally, and one of the major weaknesses that was found was that data wasn't disaggregated enough to monitor equity, right? Or there was a lack of capacity to even analyze data. And so that's why we've started to see more calls for equity data, meaning data that's disaggregated. And where we can actually better monitor the differential impacts on how health systems are responding to different population groups, by gender, race and ethnicity, etc.

Noor al Kaabi [19:41] Sometimes emergencies like outbreaks, national disasters and armed conflicts define an obvious and urgent global health need. Doctors Without Borders or MSF from their French acronym are often amongst the first to respond. Jason Nickerson Humanitarian Affairs Adviser with MSF spoke to us about how data collection to assess the specific needs of each situation is crucial to an effective response.

Dr. Jason Nickerson [20:06] Doing these kinds of assessments are quite tricky, right? You're operating with often incomplete kinds of information, you're in a often very dynamic kind of situation. And so you're trying to do an assessment to make a reasonably well informed decision about where to intervene, and how and so on. But depending on the kind of assessment that you're doing in some instances, there's actually very good kind of field epidemiology kinds of assessments that have been developed over many, many years to assess things like vaccination coverage, and malnutrition, and so on. And so there's agreed upon indicators and thresholds and international standards that, you know, provide some goalposts and guidance for trying to understand what these needs are. But in other instances, you know, it's much more difficult if you're coming into a severely disrupted health system and trying to understand something like what's the available surgical capacity? Or, you know, is there an appropriate number of inpatient beds or something like this. You know, these are really complex kinds of assessments. And so this is really where I think taking time and having quite experienced teams coming in to make sense of this to really make sure that needs are being properly assessed, you're taking into consideration things like sex and age and gender considerations to make sure that interventions are appropriately targeted and reaching the right communities, people and not inadvertently excluding people from accessing services. You know, there's a lot of different layers and factors that come into play in properly designing these kinds of interventions.

Frank Telfer [21:42] As we've discussed how global health projects are funded, inevitably influences how different issues and projects are prioritized. Jason talked to us about how MSF is funded, and what impact this has on their organization.

Dr. Jason Nickerson [21:57] Because we are largely privately funded, it allows us to be able to react into response quite quickly on the basis of needs, as I was mentioning, so we see a need, that's unmet. And we think that we have the operational capacity to be able to respond and provide assistance to address those needs. And then we can actually move very rapidly to be able to do that, because we're not waiting necessarily on, you know, humanitarian funding appeal, or on government grants or something else. So that's one of the things that sets us apart as being quite unique. And there's many other considerations behind the private funding model, including the perception that it allows us to maintain not just perception, but also the direct implementation of our principles, being impartial, being neutral, and being independent. Over the many years that MSF has been operational, you know, we've developed independent supply chains and logistic capacity that's internal to the organization as well.

Frank Telfer [22:54] Joining our conversation with Jason was Colleen Dockerty, a registered nurse and gender based violence consultant who has also worked with MSF on several missions. Coleen expanded on what goes into planning a response at MSF.

Colleen Dockerty [23:08] So when there is an emergency, for example, right now Ethiopian refugees going into Sudan, or if there's a cholera outbreak, in a certain context, our emergency team will go and assess the need, assess the existing capacity to respond either to the government, the Ministry of Health, but also the vast number of many other medical humanitarian organizations, such as the UN. So we look at what are the needs, what are the gaps in the response and decide whether or not to respond, we do have the possibility to immediately and rapidly deploy through these emergency teams. So it might be setting up a rapid cholera treatment center very quickly, or it might be more thoughtfully designing a strategy over a longer term of how to respond to the needs. Or it may be saying this actor has this capacity to respond, or the reports we heard before arriving before assessing in this context, were not what we found on the ground and deciding not to respond. So ensuring that when we do respond we're responding appropriately, to the perceived needs of the population as well in ways that they will trust the medical care that's provided in ways that are accessible to them.

Frank Telfer [24:25] We've talked a lot thus far about money and its powerful influence on global health. The power imbalance money creates often leads to poor outcomes when money is shifted away from local priorities. Dr. Erondu talk to us about the essential nature of grounding actions in local expertise and supporting on the ground organizations directly.

Dr. Ngozi Erondu [24:47] I think aid organizations need to fund local organizations directly. I think, of course they should be vetted. Of course you should understand like, which partners you're working with, but there are a lot of amazing on the ground institutions, civil society organizations, advocacy groups that should be funded directly to do whatever that they specialize in. And I think that is how, you know, we work towards a more equitable and successful future full stop. You know, when I was in Guinea, I thought I was coming to help them to strengthen their surveillance, like kind of after they had the biggest kind of shock to their system, I thought I was coming to just like, help them, like, build up a surveillance system that they could use for just kind of routine health. But then we had another outbreak. And so I ended up responding to that. But by the time I came, there was so much more investment in local communities, you know, it's like, you know, as a foreigner, we come in and say, oh, this was a post French colony, we need people who speak French. Okay, well, when you go into the villages, they don't speak French, like only the educated Ghanaians speak French, who have gone to uni and things like that. And so it took a while, but we got there in the end. And obviously, we saw a lot more success with the interventions that we put forth. And if you think about, you know, global health as a whole, it works everywhere, you know, like, I have less experience with Canada, more with the US. But in the US like, yes, there are 50 states, but I'm from the state called Missouri, and I don't look to the capital of Missouri, for my trusty community leaders. I'm from a city called St. Louis, I look at St. Louis like that is my you know, catchment area. That's what I look at. And so I think is, you know, as close to the community as we can be, is important. I think taking the lessons that we've learned from global health, and translating them to a community level all around the world is what we can do to make global health stronger. I think global health needs to be smaller. And that's how it will be more successful by funding these communities, by translating these larger lessons into a specific community context, by working very closely with actual community leaders and kind of multiplying that over like states and provinces and countries and regions. I think that's how we make global health more equitable.

Noor al Kaabi [26:59] Next, we hear from a Habon Ali, a Somali Canadian community builder who is actively involved in initiatives that involve health equity and removing systemic barriers for youth, especially those from racialized and low socioeconomic communities. She also provides an example of how actions may be translated from a global to a local level. But first, Habon shares her personal story about having a younger brother with a developmental disability, and the treatment her parents faced at the hospital. She talks about how these experiences guide her work in global health.

Habon Ali [27:32] My personal story actually guides a lot of what I'm doing here today. So both of my parents are were refugees from Somalia, they arrived to Canada in the 1990s. And growing up as a daughter of Somali refugees in an under resourced, predominantly racialized and immigrant community, I had a unique perspective in policymaking and community building. But there were very few opportunities for folks in our communities, especially youth, to engage in having our voices heard, engage in avenues, where we could be creating sustainable change that we knew our community needed. I also noticed something different in the way my parents were treated at the hospital. When I accompanied my father, health care providers were quick to provide me with a colouring book and say, your kids sit off to the side, he spoke English without an accent. So when I accompanied him, they would give me that colouring book. And whereas visits with my mother, you know, I was required to become the intermediary translator, she speaks four languages, English is the last language she learned. So I realized that with the same health care providers, that dynamic change, her presence was met with like, question of competence and condescending remarks. And I remember feeling frustrated, very angry, sad, when we left those meetings with physicians. And that was my earliest memory of systemic racism coming from the very same systems that were supposed to be sort of supporting a youth, my brother, but it also sparked my interest for community service and health promotion, and science. So I'm really thankful for that time. And I really believe that like, you know, our civic engagement is tied to our health in terms of who is heard, and who is not, and what voices are taken seriously, and who our political leaders and parties have political will for and push the needle for. And like I said to you earlier, I do view health in the social determinants of health framework. So I view that like employment, income, housing, so many different things can impact our health. And so I really do think that BIPOC youth do face a disadvantage in many institutions, including the health care system and our education system, in navigating political institutions that are meant to serve us. And this is one example that I have from my experiences Apathy is Boring. So in this report, they looked at youth engagement and political participation, and they found that there's actually a crisis in Canada's political culture. There's a perception of distrust between public and political decision makers, and few Canadians have strong trust in political systems, such as parliament, political parties and mass media. Many groups are made to be marginalized and vulnerable by systems of oppression. But for me personally, that has been exemplified in the experiences that black and indigenous youth have across this country and even being a part of building Canada's National Youth Policy, you know, going throughout Ontario, Quebec, and I even had the pleasure of traveling to Nunavut and learning about the experiences of youth across this country. While there are very distinct experiences held by black and indigenous youth, you know, these are not monolithic groups of people, there's so much diversity and richness and culture amongst, you know, both communities, there is similar threads in some of the oppression that we face from various institutions. And I definitely think that has negative health impacts.

Frank Telfer [30:51] The history of global health is a history of colonialism and white supremacy. We asked Dr. Erondu about the importance of recognizing this history.

Dr. Ngozi Erondu [31:00] Studying in the UK, I have mostly kind of read about global health history from a European perspective, which is why we use language like decolonize, because as we know, like the British Empire was one of the biggest empires in recent history. And so global health, or as it's known today, really was rooted in this colonial expansion of the Imperial arm of the British system. And so it was to protect the people that were going to the colonizers basically was to protect them, it was like, okay, we don't want our citizens dying in India, we don't want our, you know, from malaria, we don't want our citizens in Nigeria having different foodborne illnesses, so let's, you know, let's create research studies, a whole scientific branch of Tropical Medicine, so that we can really unpack what's happening, and we can protect our own. That's what it was for, you know, if you read some of the histories, even when they started discovering, like quinine, and ways to kind of inoculate themselves from malaria, they weren't sharing that with the population around them, it was for them. And so, colonialism and white supremacy are one in the same vein, you know, I mean, just full stop. You know, the fact that, you know, a group of people thought that it was okay to go to someone else's land, to enslave them or to take the resources or whatever to divide and conquer, to create, you know, false lines and call it a country, to initiate most of kind of the civil unrest, that the sectarian issues that we have in a lot of, you know, previous colonies. That is all out of white supremacy. You know, that is all about this belief that one group of people are better than another group of people, you know, like, yes, Spain and England, they fought, but they also exchanged kings and queens, you know, I mean, they found ways to live in peace, it's just not the same at all. And so I think, unpacking colonialism and global health is key to equity and equality, it's key to trying to write a lot of those wrongs. But the larger issue, I think, that needs to first be kind of unpacked and improved, and, you know, is the structural inequality between the global north and the global south because the global north has all the money.

Noor al Kaabi [33:21] The importance of prioritizing youth perspectives in the context of global health can't be understated. Indeed, it's an important component of the ongoing project of decolonization. We'll hear more about the role of youth in global health later on in this episode. But here we ask Dr. Erondu the broader question of what it means to decolonize global health.

Dr. Ngozi Erondu [33:44] Decolonizing global health really starts with it starts in two ways. First, is the global north or Western countries or white majority countries, looking at reviewing the systems that they have in place, and listening to the students in institutions, listening to minorities, in their organizations, minority populations or black and brown populations, listening to women, you know what I mean? And just really, because there are all these structures in place that has been there that continue to marginalize and oppress these populations, and these populations are continuously ignored and dismissed. And in order to really examine and understand the colonial nature of our organizations and institutions, we have to listen to them. I think the second part is more about the global south or less rich countries, but the global north still has something to do with this and is providing them a platform. So I recently wrote about intersectionality. And like, you know, obviously I have a lot of privilege because, yes, I'm Nigerian, but I'm also from the U.S. I also I speak a language not just in English, but in the way that I understand concepts and things because I was, I was raised in a majority white country basically, and I can navigate kind of the systems much more definitely, then somebody that was born and raised in Nigeria, you know what I mean? So that's one part of it. The second part of it is that I'm pretty middle class. Yes, I've worked alongside people that come from poor communities or lower socioeconomic status, but I have not experienced what they've experienced. So while I have a platform, I find it really important that they have a platform as well. And I think that there are a lot of barriers to ensuring that they have apart from one is this, you know, the structural barriers of them just not having the access because they didn't go to the universities, they didn't work for the organizations, they they chose to work for community organizations that are not well known, or well vetted, or, you know, that don't, you know, traditionally meet the standard of what a Western organization would say, is a good partner. That is something that I've noticed, for a lot of my colleagues in the global south is that they're quite hesitant to lean in, because they don't think their voices will be heard, because they're afraid to rock the boat. You know, again, it comes to that inequitable power. But you know, we need both to happen, we need both to happen, we need folks to lean in, we need them to have a platform to lean in, we need to create the environment for them to lean in. But there I think we have to start the next generation or the current generation of global health leaders have to encourage each other and that I think can fall on you and me as well, right? Like, since we do have privilege, how do we how do we share our privilege so that folks from less privileged backgrounds can lean in? You know what I mean? How can they stand on our privilege platforms so that they can have more of a voice? How can we write op-eds with them? You know, how can we amplify their voices on Twitter, on different social media platforms? Because it all matters.

Frank Telfer [36:39] We continued our conversation with Dr. Erondu asking how language and rhetorical substitution contribute to white supremacy in global health specifically.

Dr. Ngozi Erondu [36:48] We talked about like the systems of decolonizing global health, the global north and the global south when we really mean white majority, versus like everybody else, because another thing that happens when you talk about global north and global south, you include the minority and marginalized and oppressed populations of the global north, you know? So there are some funding organizations right now, that if you're like, if you're a black, indigenous, or person of colour, brand organization that wants to kind of work with a global south organization, they'll say, no, you can't, because you're part of the global north. It's like, I'm part of the global north, but I'm not receiving any of the benefits of being part of the global north. I am not a powerful entity of the global north. A lot of people don't look at it that way. A lot of people somehow kind of separate the imperialistic past to current times. I went one time to the Global Health Summit, which is a crazy name for this small group of people who gather every year in Berlin, and I remember saying it would be really good to talk about decolonize global healthcare, because there's a lot of like leaders there like everybody from, like the top leaders of global health go there. And like the the person who was running, it just kind of scoffed at me. So are we just talking about this? Are we actually trying to do something about it? And I think that one of the deeper conversations we need to have about decommonality is, what specifically are we saying? And how can we, you know, think of other words, how can we build a better lexicon that talks very specifically about what we're talking about? Otherwise, we're going to be dismissed all in one when we all could be talking about very different things. Like I talked a lot about, you know, institutional prejudice and discrimination in academia, which is not the same as you know, somebody talking about like, the legacy of colonialism in malaria, or someone talking about, like, you know, how Ebola wasn't actually discovered by Peter Piot, like, you know, there are all these different aspects that I think we need to pull out. And I and I think that's how we kind of upkeep white supremacy. I also think another way that we upkeep white supremacy, is who frames these conversations. So I think we need to have a lot more leaning out of white older men, not to say that they shouldn't be part of the conversation, is that they should be humble enough to include others in part of that conversation as well. And so I just think that type of dignity and respect should be given to, you know, everybody, basically.

Noor al Kaabi [39:10] The theme of humility and vulnerability continues to be a concept that is emphasized as being needed in global health. It's particularly important to have a critical lens towards the work one is doing to reduce harm, and ensure equitable practices. We asked Habon about the importance of teaching this to emerging global health leaders.

Habon Ali [39:30] A concept that I think needs to be emphasized more is vulnerability and justice in global health. And I think a couple of our professors have touched on it, but unfortunately, I haven't gotten it in the depth that I've wanted to learn. And hopefully, I don't know if I'll get that next semester, but it's definitely something that we haven't explored enough this semester. But just to think that, you know, as we're going through this program, we're learning how to be global health leaders, and we're going to all go different ways, whether that's continuing education or whether that's policy making, or whether it's community building efforts are working in various different sectors. But to know that historically, you know, there has been a lot of harm done in the name of science, there's been a lot of harm done in the name of humanitarian work, there's been a lot of harm done in global health, and how do we assure that when we conduct work, whether it's across Canada, or across the world, that we are reducing the harm that we have, or that we are shifting the power and even amplifying local communities to lead the work that they need to do. So that like, you know, we're not perpetuating that white savior complex that I see in a lot of global health work, but also in the principles of our research as well, ensuring that there's equity and that we don't create more harm than good when we enter communities that we are not a part of. So that's something I want to explore more, I haven't gotten the chance to do it. But I have a lifetime. So hopefully, I get the chance to do that.

Frank Telfer [41:02] As we seek to decolonize global health, we must also ensure multidisciplinary participation from a wide range of different sectors in society. Advancing health requires everyone. Dr. Di Ruggiero discuss this in the context of global health, diplomacy, an emerging field at the intersection of health, public policy and global affairs.

Dr. Erica Di Ruggiero [41:22] In the last, I guess, 10 to 15 years global health diplomacy has started to gain more and more attention. And it's a process of engaging many actors to try to shape the global policy context that I described earlier in this podcast interview, and how it influences health or how health gets positioned in foreign policy negotiations. So we've seen this kind of expansion and the number and diversity of public, private and nonprofit actors, in part because of globalization. They're all competing for attention and resources. And many are trying to like influence these policy agendas. And so there's this real need to figure out how to best negotiate in this very complex space. And the second reason global health diplomacy is you know, gaining traction is that there's this recognition that sectors: trade, environment, labor, which was the example I just gave earlier, are operating outside of the health system, but they have a direct impact on health. And so this is where global health diplomacy sort of plays a role. And we've got lots of examples of how it plays out in different negotiations, led by governments, but influenced by civil society, by the private sector, by researchers, etc. But, you know, none of these actors are really all on the same page. Some have shared agendas. But in the global space, we're negotiating for resources, attention. I mean, earlier in this discussion you talked about, well, why is something not getting as much attention as others, you know, that's a negotiated process or set of processes. And I think, because we're talking about global health diplomacy, or also comes from a recognition that health is not always in the center stage, you know, it can be an afterthought, yet many of the decisions and actions that are taken in sectors outside of health can have a profound impact on public health. Because even though a vaccine may seem like a health driven initiative, you know, it still needs to engage many sectors from purchasing to procurement, the R&D and innovation sectors industry, obviously, because many of the pharmaceutical countries need to be invoked. But also bringing a health or health equity lens to the forefront so that at the end of the day, we're going to have fair and equitable access to vaccines, which is the the end goal here, I think, is absolutely critical. Because, you know, we know we're as strong as our weakest link here. But not everyone believes that or buys that argument in the same way, and revert back to wanting to protect their own interests, their own citizens, and not cooperate. And global health diplomacy, I think is really trying to encourage that the multilateral negotiations and discussions. And the vaccine, you know, topic is still evolving, right? But there are many other examples where this is really, really been critical. And you know, health, while it's not always at the table is starting to become an instrument of diplomacy, actually. And so it kind of gets brought in from behind sometimes just, but isn't always you know, the number one focus.

Noor al Kaabi [44:45] This question of who's at the table is central to how global health policies are developed. But it also impacts what value we put on perspectives from around the world and how different ideas are shared. We asked Dr. Erondu about the structural inequities faced by African scientists and scholars, in particular, seeking to advance global health knowledge.

Dr. Ngozi Erondu [45:07] I'll just talk about it from my experience in academia. So, like the structural inequality in academia, like when it comes to, like global health research has to do with visas, you know, like, who has access to the best public schools in the world? Do you got I mean? Even conferences, you know, there's been so many times that some of the most intelligent and most prolific authors and scientists in poor countries can't come over to talk to us about these so they don't have a voice. And so their prominence actually diminishes because they have less visibility. You know, I think it was like less than 1% of first authors are from African countries. But if you look at the amount of research done in African countries Republica, that doesn't make any sense at all. COVID-19 is kind of like, not the great equalizer, but a little bit of the great equalizer, because rich countries are suffering as well. And yet you have research papers coming out with all the authors 20 authors being from you know, let's say Canada, the US, and the UK, about COVID-19 in the Democratic Republic of Congo, and it's like, okay, not one Congolese author, like that's crazy, like the structural imbalance there is what journal editors thought it was okay to even publish them. Can you imagine a 20 author paper from Congolese researchers, Nigerian researchers, Ghanaian researchers about how political madness in the US is leading to higher or poorer COVID-19 outcomes? Do you think anybody would publish that? Do you know what I mean? They wouldn't? They simply wouldn't I've been on papers that are just African authors, and I recently in Twitter asked, "How many people have had eight reviewers for a paper?" like I've written a lot of papers, I've never had eight reviewers like it like, and it's because there's this assumption that if an African group of authors wrote a paper that is not as solid or it's not as good, you know, which is crazy. So that has nothing to do with, you know, our behavior or anything like that it has to do with how these journals were set up.

Frank Telfer [47:15] Dr. Erondu expanded on the structural determinants of health, and explained how the global north unwillingness to recognize non white expertise is detrimental to health outcomes.

Dr. Ngozi Erondu [47:26] Medecins Sans Frontieres, which I highly admire, their staff has really been speaking out on the colonial nature of the organization, and how that is detrimental to the people that they're supposed to serve. A lot of people that are being treated by Medecins Sans Frontieres, they don't have a choice, even if the the doctors are rude or dismissive. And the structural barrier is this power dynamic that not even the local staff can really speak up against, you know, the supervisors and that all the supervisors are white, all the supervisors are imported from other countries. And you can be doing everything wrong. Like you might have read that in Islam, you wash the body of people who die, clearly, you know, that is a transmission route. And it took months before practitioners on the ground were like, oh, we need like, you know, safe burials, like, how come there wasn't someone from Guinea that was there to tell them or even if you can't be from Guinea, there are other countries in that region that have very similar customs. And I just feel like you know, global health really dismisses the local expertise.

Noor al Kaabi [48:30] Colleen and Jason talked about MSF's, reflective and self critical culture and the work they're doing to elevate local voices.

Colleen Dockerty [48:37] I think we're also having difficult conversations about who is pushing for that change. And we know that there are limited opportunities for people from the global south within the current ways that humanitarian system is structured. And so I think we are needing to really look at our own organization, and many other organizations are doing this about who is experts whose voices need to be listened to, and how can we amplify the voices of our national staff, of our colleagues from the global south who have that on the ground experience, more on the ground experience and myself. Not only the individual voices, but how to change structures so that we can amplify those voices more and have more effective ways to then advocate for change.

Dr. Jason Nickerson [49:28] Yeah, I mean, that's exactly what we're trying to do more of to make sure that the voices that we're bringing to the table are people who are directly affected by the issues that we're talking about. So Sudanese or a Congolese physician is going to be able to talk about health care in those countries in the way that I'm never going to be able to. They are the experts. They're able to speak with, you know, additional insight that I just don't have,

Noor al Kaabi [49:56] As we briefly discussed earlier in the episode, one essential step towards the the goal of decolonization and equity in global health is advancing the perspectives of youth who are challenged not only from not having a seat at the table, but also by stereotypes about disengagement with political processes. We hear Habon's take on this.

Habon Ali [50:15] We made the first address why young people, especially young Canadians, feel disconnected from traditional political processes. It's not that young people, it's not that they're not politically informed. Young people are a lot of these things. It's just that there's a lack of trust with government, there's a lot of youth who have different and employment and socioeconomic outcomes that really impact how they engage with civic and democratic institutions. And a lot of young people don't feel like they have a say in what the government does. And the way young people participate are shifting, you know, as a lot of young people are swapping to forms of participation that they see as community based, non-institutional social movements, and that form of engagement. And that comes from young voices not being respected and not being heard or being tokenized in spaces of power. So I really think that it's important to give young people power and space, you know, there's a myth that young people are apathetic and that they're not engaged in democracy. But we are and we're leading, non-conventional forms of action. We've seen the political demonstrations that are currently ongoing; protests, marches, petitions, information sharing, that's like taking over all over Instagram feeds, you know, people are informed, and they want to be involved. But we have to make space. And I think, for youth, a lot of us want to have a seat at the table, because we have high stakes in the decisions that are being made, you know, we're going to be living with them for the rest of our lives. So because of these stakes, you know, young people tend to have, you know, radical forward thinking views. But we are not mistaken in having that, especially when we're looking at the magnitude of the crises facing our generation, these perspectives should be welcomed and respected and acted on. I really think youth, and we're not obviously, we're not a monolithic group, youth come from rural, urban areas, different cultures and gender identities, everything, we're coming with all of our, you know, different identities to the table. So definitely different youth have different perspectives to bring to the table. But I think the unique perspective of the entire youth group is that most of us tend to be forward thinking, we want action, and these voices should be heard, I think, because like I said earlier, you tend to be radical thinking. And this isn't necessarily bad, it's that we're young in the decisions that are being made. So to give you an example, we're currently in a climate crisis, we're living through a pandemic. We're living through a racial justice crisis. There's a lot on the table right now. And young people who hopefully, we're gonna hold space on this earth for the next 50 to 70 years. You know, if our life expectancy you know that that's different for different young people in the world, unfortunately, but we have high stakes in the decisions that are being made. And we will live with the repercussions of those decisions that are being made for the rest of our lives. So whether there's political precedents, or whether there's projects that are not aligned with climate just future, or whether it's that we're losing generations of young people because of systemic racism, and that they're being left out of educational systems, employment opportunities, they're not being allowed to shift in this future that we're building, they're excluded from the features that we're building. And that's really scary. So I think that unique perspectives that youth bring to the table is that we bring fresh eyes, we're really not bogged down by life, by the world, by red tape, by bureaucracy, we see things for what they are and we have often a moral responsibility to say and to act on things exactly as how they are. But we also bring the perspective of innovation and of that forward thinking for the future and the responsibility that we have for the earth that we'll be inhabiting for decades to come.

Frank Telfer [54:01] As we've alluded to, in addition to listening to and learning from youth, there's also an essential opportunity to learn from actors around the world. As Dr. Erondo explained, health systems in the global north have a lot to learn from the practical experiences of those in the global south, in addressing health challenges.

Dr. Ngozi Erondu [54:21] I've worked mostly in Sub Saharan Africa, where a lot of disease surveillance successes have been funded by USAID yet in the West, we actually don't have very good disease surveillance in some of our countries, you know. For example, in the States, because it's so fragmented, because it's a federal system, the CDC requests data but they don't necessarily always get it. The West can learn a lot from mostly Africa when it comes to the surveillance to be honest as they're very ahead of Asia, and even Latin America when it comes to disease surveillance because they're always dealing with kind of emerging or reemerging infections, but also because they've been invested specifically in you know this idea SARS strategy I think we need better systems for mandatory reporting. I think that a lot of our reporting systems in the West are delayed. I think that we also need to find ways to reach communities. In Africa, we call it sensitization. So you talk to the mothers, and you talk about the vaccines and things like that. So you educate them, and they understand it for themselves that it's important, and they're more likely to bring their children to get vaccinated during the appropriate immunization schedule. Whereas in the West, we've kind of just taken that for granted. And so we've seen a rise of anti-vaxxers, we've seen a rise of measles, and all these different things, and part of disease events isn't just monitoring the diseases, but it's also preventing the diseases, you know what I mean? It's actually surveillance doesn't happen without action. Whereas a lot of times, I think, in the West, because of power struggles, politics, all this other stuff, it does happen without action, we have like these huge surveys, but we're not able to do anything about them on a regional or even a state level, but definitely a lot of times not on a federal level, we're not able to act very quickly on things in order to, to stop the increase of certain diseases, the incidence of measles, for example. So we've been having more and more measles outbreaks for the past five years in the States, but the anti-vaccination movement has just gotten stronger. You know what I mean? And that's very scary. And I think we need to be more creative about like, how do we really engage with these communities because we have been successful as a public health community, global health community in other countries, like, people, people, like people from the west are not like markedly different from people from Sub Saharan Africa, or from Southeast Asia, people are people. So it's about finding ways to talk to those communities so that they can adopt healthy lifestyles, or agree with the need for vaccinations and different preventative measures for themselves so they can actually appreciate it and value it themselves. So I think that's one way to make our system better, other than just improving the system in itself, but also improving our actions to reduce disease prevalence.

Frank Telfer [57:06] And concluding our conversation, we asked Dr. Erondu, what advice she would have for people who are interested in meaningful engagement with global health.

Dr. Ngozi Erondu [57:16] So sometimes like speaking with you, you're a young white man who is interested in decolonizin global health, and some of the things that I have said, may sound like you don't have a place. But the truth is, we all have a place. And that's what decolonize Global Health is about full stop, we all have a place. But for a long time, you and me actually, because I'm from the west, we've taken up way more places than we need to. And the truth is, is that we need to share that space. And so anybody that's trying to come into global health, I think it's important to understand your privilege, understand, like your skills, but are also understand your weaknesses and understand the gaps in your knowledge. And it's not about you having to know everything, it's about you working in a complimentary fashion. So that we can actually achieve, quote, unquote, global health. Like I think what I want to achieve is collaboration with partners from all around the world, to fight against infectious diseases, that's what I want to achieve. And I think we all should kind of have this personal statement of what we want to achieve in our careers. And it needs to be towards human progress, not necessarily towards you know, dominating a region. That's not where you're from, or even one that's where you're from, like, even in Canada, like you're, you're not an indigenous individual in Canada, like there's so much you can learn. So it's like, what are we working towards in establishing what you want to work towards, and who you need to work with, to get there, I think is very, very important as you start your career in global health, and also just realizing all the ways that global health has benefited us in the west, or us as you know, white people or us as men, I think, if you can realize how it has benefited you and how you have kind of unmerited privilege, you can do different things to correct it. And I always think that, like people don't think that individual actions matter. But they matter so much. You know, I had this one supervisor at CDC, who when we would go to different countries, he would stand in the back, and I would sit in the front and it forced the people to talk to me, because if he sat where we sat, there's no way they would even look at me and like, what he's done for me, and maybe even for them, you know, it's been life changing for my career. Understanding like, because you give power or the you allow other people to gain power doesn't mean that it takes power away from you, meaning like it doesn't make you less when you give more room to other people, but I think it actually increases who you are as a person and what we can do together as a global health community. So really understanding your privileges and finding ways to leverage that for other people I think is really important. And then finally, I'll say like whatever you're passionate about, you should do it. Don't use anything from decolonize global health to, you know, count yourself out, count yourself in, but just do it in a more collaborative way.

Noor al Kaabi [1:00:12] And as we've heard throughout this episode, global health is local health. Habon leaves us with some parting words, emphasizing the importance of local engagement, and collaboration,

Habon Ali [1:00:23] Global health and Sustainable Development Goals are not things that just happen abroad, they are things that are relevant to Canada. They are goals that are relevant to Canada, principles that are relevant to Canada, and work that we need to do in our local communities as well. So I would say like, just in your own neighbourhoods, or your city and your communities, who does not have access and who does not have what they need to be home, or have a home, have access to homes, have access to employment, have access to education, you know, because of the financial barriers, socioeconomic barriers, and different systems of oppression, I would say, look within your local spaces and see what organizations, communities that you can support in meaningful ways. And don't limit yourself to just the health perspective, because I think like we we've discussed in this discussion, there's so many aspects of a person's life that impact health, that we need to focus on, as well. There's so many things that allow someone to be healthy and to lead a good life and to meet the full potential of their lives. So I would say if you're interested in global health, definitely go listen to the academics and read seminal papers and do the important work, I guess, but also connect to people. And I think that's what drew me to this program and connects to the human experience. And reducing health inequity was one of the major challenges that I'm focused on, so I want to look at all the aspects that impact a person's health and create disparity and see how I can push back against that, create solutions with others and you don't have to do it alone. I've never done anything alone. Do it with someone do with a group, you know, we go further when we're together.

Frank Telfer [1:02:07] Thank you to our guests. Dr. Erica Dr Ruggiero, Dr. Ngozi Erondu, Jason Nickerson, Colleen Dockerty and Habon Ali for taking the time to speak with us and share their insights. And of course, thank you for listening.

Noor al Kaabi [1:02:20] This episode was hosted by myself Noor and Frank Telfer. Nathan Chen helped conduct interviews, Steph Nishi helped develop content. Jesse Knight was our executive producer. Alex Jacob and Richie Jeremiah, were our audio engineers. Keep an ear out for our next episode in two weeks on water. Until then, keep it raw!

Nathan Chan [1:02:41] Raw Talk Podcast is a student presentation of the Institute of Medical Science in the Faculty of Medicine at the University of Toronto. The opinions expressed on the show are not necessarily those of the IMS, the Faculty of Medicine, or the University. To learn more about the show, visit our website rawtalkpodcast.com and stay up to date by following us on Twitter, Instagram and Facebook @RawTalkPodcast, support the show by using the affiliate link on our website when you shop on Amazon. Also, don't forget to subscribe on iTunes, Spotify, or wherever else you listen to podcasts and give us a five star rating. Until next time, keep it raw!