Gaps in Health Equity: Insights From History, Lessons From Covid-19, and Ideas for the Future
- So, thank you so much for joining us for Gaps in Health Equity, Insights From History, Lessons From COVID-19, and Ideas for the Future. This is the 10th in a series, the Yale Development Dialogues, which are virtual panel discussions hosted by Yale's Economic Growth Center, Jackson Institute for Global Affairs and History Department. I'm Catherine Cheney. I'm a Reporter at Devex focused on technology and innovation and global development.
And I really enjoy moderating these conversations. We bring together perspectives from history, economics, and policy to discuss ways to address challenges facing low and middle income countries. And today we're joined by experts who are leading voices in understanding health and healthcare challenges globally.
So, I have a number of questions I'd like to ask them, but for those of you who are joining us Live here on the Zoom webinar, we really encourage you to submit your questions via the Q&A function. And please don't wait until the very end so that I can have a sense of what you wanna hear and make the conversation as useful for you as possible. Transitioning to the topic that we're tackling today. We all know that unequal access to the COVID-19 vaccine has magnified what are really long standing gaps in health equity. And I found this definition of health equity from the Robert Wood Johnson Foundation to be really useful in preparing for this conversation.
So I'll share it with you. "Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health, such as poverty, discrimination and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments and healthcare." So structural power inequities, which the COVID-19 pandemic again, has really highlighted results in different health outcomes based on factors that are outside of people's control, like where they were born. In this webinar will explore whether this crisis will in fact, change the conversation on health equity and propel the kinds of partnerships needed to achieve it.
We'll ask what lessons we can draw from the COVID 19 pandemic and from the past, in order to design a more equitable future. I wanna quickly introduce our panelists who can share more with us. Today, I'm joined by Anne-Emanuelle Birn, who's Professor of Critical Development Studies and of Social and Behavioral Health Sciences at the Dalla Lana School of Public Health at University of Toronto. Pascaline Dupas is the Professor of Economics at Stanford University and Faculty Director of the Stanford King Center on Global Development, which also has fantastic events they've put on. I highly recommend them. Dr. Mesfin Teklu Tessema is Head of the Health Unit
at the international Rescue Committee and IRC Senior Leader in Health. And Sunil Amrith is the Renu and Anand Dhawan Professor of History at Yale, and one of three co-organizers of the Yale Development Dialogue series together with Rahini Pande, Rory Stewart. Thanks so much to all of you for joining us.
So, I wanna begin with you, Sunil. I mean, you've really championed this topic as one that we should take on as part of the Yale Development Dialogue series, bringing these different perspectives together. And I'd love for you to expand a bit on why this topic and why now. - Thank you, Catherine, and thank you all for joining us.
Last year, when we started the Yale Development Dialogues, we were really in the very midst of the pandemic as we still are in many ways. And we had a couple of very successful conversations on COVID, on COVID and inequality, COVID and development. And I think one of the messages that was loud and clear to me from those conversations was this is only the beginning of the conversation that if anything, COVID has highlighted just how deep rooted inequities and health are around the world. As a historian, I've been very interested in the history of moves towards health equity, both as a regional and a global scale. And I think what we've seen is that there are periods when there have been substantive moves towards a greater health equity. You see this after the Second World War where despite mass killing there was also technological innovation and process of decolonization to the point where with the foundation of the WHO with the disease eradication campaigns though they were flawed, they were in some sense profoundly democratizing this was to go back to the definition you gave us Catherine about removing some of the obstacles to the majority of the world's population having better conditions of health.
See a very different movement in the 1970s, which is really coming from the Global South. And this is the movement that leads to that very famous slogan, "Health for all by the year 2000". In the 2000s I think we see a different type of movement that kind of philanthropic movement around the formation of Garvey and the Global Fund. Each of these movements has its moment and of course, we can talk about the weaknesses within each of them, which explains why perhaps they didn't have the impact that they intended to. I think there are three questions that come out of looking at those histories though. One is the question of accountability.
I think we always come back to this question of who's responsible for health equity? Who has in a sense, the right to make these decisions about what will remove the obstacles to the majority of the world, having better access to conditions of health? The second is this constant push and pull between a bottom up and a top down approach. One of the criticisms of the disease eradication campaigns of the 50s but also some of the more recent philanthropic efforts is that they've been very top-down, not really consultative, not really responsive to what people need in different parts of the Global South. And then the third question is, how does one build political support to make health equity a priority, not just at the level of global institutions, but in each individual country where this is a challenge. and that includes right here in the United States. So I'm very keen to hear from our panelists who have such a diverse range of expertise, their perspectives on all of these question.
- Thank you, Sunil. Really helpful framing here. And I appreciate your point that we need to look to history and evaluate what worked and what didn't in each of these movements. Why didn't they have their intended impacts? We once talked about health for all by the year 2000, here we are in 2021.
And the sustainable development goals are one of these frameworks looking at really health for all by 2030. Will we get there? What will it take and what can we learn from history? So really helpful framing. Building on what we can learn from history I'd love to bring Anne-Emanuelle into this. So, your work focuses on the history and politics of international and global health, mostly in Latin America. And I wonder if you can expand on lessons from history when it comes to advancing health equity. - Sure. And let me begin by saying that
I don't quite agree with the notion of lessons from history. I think that perspectives, shedding light, contextualizing, understanding are better ways because the context always shifts, right? So you can't have importable or exportable lessons, whether over time or over space, just as some of the very prescriptive top-down health campaigns that Sunil was mentioning are very fraught when Peru is seen as the same as Thailand is seen as the same as Botswana, et cetera. So I just wanted to put that on the table to get us going. - I appreciate that. - And in terms of the Latin American region historically, I think we also need to consider moments of advance progress, but also enormous setbacks not necessarily the same or expected moments in time in terms of international events. So there's also very peculiar or specific situations in different regions.
And one issue has to do with the rise of Social Security systems. Actually fairly early on in many Latin American countries that were industrializing, Chile as one of the prime examples. And so there was an early Social Security system in 1924 set up, but it was exclusive to urban industrial workers, not even their families were included. And so you had this step forward, but then the exclusion of indigenous people, of rural peoples, et cetera, et cetera. And then you have another wave in the...
Well, expectation of wave in the late 1930s when the popular front is elected and Salvador Allende becomes Chile Minister of Health. And yet the expectation of setting up a universal healthcare system fails because it gets embroiled in some of the anticommunist ideology and pressures in the 1940s. So you really have these waves. Then in the 1950s, the leftists are out of government and they do manage to put a universal healthcare system in place with certain flaws and exclusions and so on.
And so we need to think about this heterogeneity as well as kind of narrative flipping, which I'm always concerned with this idea that countries of the Global South are following, are learning in the Bismarckian Model or the British National Health Service Model. In fact, Chileans would argue the opposite that the Brits just got faster to the legislative sausage making than the Chileans did. But also the importance of not having nostalgia for the past. So, no society has ever reached perfect health equity. It's always a process, right? And so even countries that have made enormous strides, such as Cuba have been slower in some realms than others.
I mean, they've worked very hard to bring in rural folks and prioritizing rural folks, but rather later at bringing LGTBQIA folks having their health needs covered. So I think there's kind of a wide heterogeneity there that we need to be mindful of when looking at history and thinking through those perspectives. - Yes, I really appreciate the nuance you've brought to this. Both that no country has reached perfect health equity, it's always a process. And that you can't have these importable exportable lessons context matters. I think that's really valuable.
Thank you. I wanna bring Pascaline into this. So your research has focused on questions related to health equity. There are many examples of this one being for example, why there hasn't been more investment in fighting neglected diseases.
And I wonder if you can expand on some of your research and some of your findings most relevant to this topic of health equity. - So my own research is not so much about why some pieces are neglected I think we know exactly why they are neglected. It's just a matter of like economics, unfortunately, which is that all of the diseases that are specific to really poor countries the pharmaceutical companies would have the incentives to do R&D, well there's no incentive there because the very people who need this medicine, all these vaccines cannot afford to pay for them. And they can't afford to pay very much for them.
And their governments cannot afford to pay very much for them. Unfortunately where the economics versus health comes into play. So my own work has been sitting here well, given that there's no vaccine for Malaria, given that there's not much investments in this negative diseases, what can be done in the meantime? And they have some term like how do we say coping strategies. There are antimalarial bed nets that you can sleep under in order to protect yourself and your children. And so trying to understand what are the barriers to every household in a malaria epidemic area having access to that is what I've been working on. But over the years what I've realized is that there are so many of these issues that poor households in poor countries have to deal with.
There's a bed net for Malaria. There is making sure that your water is not contaminated. There's making sure that you have enough iodine because your salt is not iodized and also stuff like that. And so the honors is really on the people to take so many actions to cope with the fact that their environment is not safe. And to me, it's not sustainable. So going back to the definition you just gave us, Catherine that no one of the key factor is safe environment.
And to me, the biggest source of health inequity in the world is really between higher income and lower income countries. And it comes a lot from the difference in the safety and the environment. The fact that there are some tropical diseases or some issues with environment that that households cannot subject to in a way, unless we try to tackle those big environmental factors, we are not gonna get equity in any way if we think of it from the point of view of across countries, not just within the countries.
And so in as much as I'm sympathetic to Sunil's complain about top-down apertures not being well-tailored, I do think that for these huge environmental concerns, we actually need top down, because it's really about coming up with the technologies, coming up with vaccines, getting the international resources together to get these vaccines out. And it's not something that at the middle level I don't have much as the poor country. I don't have any leverage to make that happen. And so why the disease or inefficient campaign after World War II did not go as far as one would have wished. I'm gonna leave you on this story Anne in the room to speak to that.
But I do think it's important to try to go back to this and to really not forget about this. It originates in the environment that people face. And within my own discipline economics, I think over the last 10, 15, 20 years has been kind of pushed back against this sentiment that geography matters.
It's all about institutions. And just to bring your geography back onto the table, because I do think it's a very important factor. - Really, really helpful.
And I wanna get back into our conversation as we all jump in about this debate over geography institutions, what are the structures that lead to this inequity? We need to sort that out before we figure out how to tackle it. I also really appreciated you talking about really what this is like at household level, covering global health and international development. I write a lot about groups working on X, Y or Z topic related to health equity, but from the perspective of someone in a household, it's a lot to take on and it has to do with the safety of their environment, as you said. So thank you for that.
So Mesfin, I'd love for you to expand now, kind of even further on the human experience of health inequities because I know you deal with this day in and day out and health equity is very much at the center of your work, the populations that you serve at IRC often lack access to health services. So, I wonder if you can expand on the barriers to access it come up in your work and what that looks like on an individual level. - Yeah. Thanks. Yeah, absolutely. I think that is one of the challenge of all time in terms of equitable access to health. When I think of this I always go back to the 2008 report by that of the commission on social determinant of health, which probably be one of the most articulate document, what are the condition that actually create health inequity? And I think failure to address that is what is leading us to different health outcomes.
And that's true for refugees, that is true for people in low income countries or true for people in high-income countries. So when it comes to refugees and population affected by conflict, these are the people who are the most vulnerable, either directly impacted by disaster or running for their life because of conflict. And even that is growing because of climate change.
And I think that is a growing issue that we see and it's was looking at the numbers, number tells a story. In 2021, nearly 235 million globally get humanitarian aid. That is one in 33 people of the global population. So that is like before the pandemic, that was like 172 million, which was like a jumped by a 100 million. So this pandemic actually has hit hard even those populations who have the little means to cope and as well as survive the impact of pandemic or disease. So the barrier to access to health has multiple factors.
And one is resource despite the growing number of refugees and internally displaced maybe a fall 85% of them live in low and middle income countries who have also limited the resources to provide healthcare for their whole population. So that creates a huge strain when you talk about refugees, what comes on the media and the headline is probably, refugee in the U.S or perhaps maybe a few migration in Europe who have the means actually to handle it. But not to forget that 85% of them are hosted by countries like Uganda, Ethiopia, or Pakistan.
So, understanding the need is a starting point. Of course, the humanitarian system has been generous in terms of providing the resource, but it has not been able to match with the growing need. Today, for population we need direct humanitarian assistance which is under the UN OCHA mandate, only 36% of the needs are met as of September, last month. And which means that people are basically living in a situation where there is no much resource actually to provide the care that they need. And the other thing is these places are characterized by conflict in a way that health facilities are damaged or destroyed.
And healthcare workers are killed. The safeguarding for health coalition who regularly monitor report in 2020 that attack on healthcare system has grown. So in a way that when all these situations are compounding and even the little resource available actually cannot be accessed by the population. And that is the kind of situation people are experiencing. So perhaps maybe this reporting might under count even the really number of attacks to healthcare workers even much larger than what's already reported. And of course, the other issue is that refugees by nature, there are people who are running for their lives.
They are marginalized and there is no political incentive for countries that have tried to provide protection unless they have expressed policy to support or host refugees. And also this politically divisive point. You remember the Peacock European refugee crisis from Syria, a German Chancellor plead to receive one million Syrian refugees.
And we remember how she received a backlash for that commitment. So, really including refugees doesn't gain you electoral votes. And as a result, these are people who are being marginalized, not necessarily included in the national response plan.
And when it come to COVID today, many national plans don't include the refugees in the COVID vaccination rollout. That's why COVAX has created what is called humanitarian buffer stock, which is to meet those population who may not be otherwise included by the national government. And I think, I can go into the policies and the number of people who ratified even the UN convention for refugee, as well as the additional protocol, which provides the legal mandate for countries to provide protection and as well as a kind of assistance that refugees can expect from government. But not every country has a signatory to those convention.
As a result, the population are left at the mercy of humanitarian assistance and kindness, not necessarily that people who have a right to claim. - Great points. Thank you so much. I wanna pick up on one thing you said, which you mentioned climate change, and in terms of the urgency for action, I'm glad you mentioned that because that's gonna only worsen these health equity challenges and really increase that urgency for action.
I wanna pick up on a theme that came up throughout some of your remarks, and that's whether we've kind of talked about what are these challenges when it comes to health equity. In terms of the path forward, and as I said, at the outset, the kinds of partnerships needed to tackle these challenges. One thing that that came up a couple of times, Sunil mentioned it, Pascaline mentioned it, is this idea of whether top-down works, whether top-down is needed, and there seems to be maybe some disagreement on that, which I think is actually interesting in terms of having a discussion here. And Mesfin, you just mentioned policy, policy being critical and a challenge you're facing when it comes to addressing health equity. So, let's talk about that for a moment and a reminder to our audience, keep those questions coming in on Q&A, because I certainly have a lot of questions, but I wanna hear yours. But we'd love to just get your thoughts, any reactions you have on how top-down has or hasn't worked in your work on whether a historical perspective and economics perspective, a policy and practice perspective.
I think that'd be an interesting topic to just hear thoughts on. So, Mesfin, I saw you on mute, please jump in. - Sure. Just in a couple of points from me. I mean, it depends on the issue we are dealing of course, there are room for both top down as well as bottom up.
And I think, we need to be very clear when we have a global pandemic, like COVID, we do need whole of society response. And that includes communities, national government, as well as the global system need to function, including the UN system, as well as a pharmaceutical and all of the international system. But unfortunately some of the system are not efficient to respond to pandemic. If you look at access to technology, which is a critical for vaccine and we have a system that basically protect access to technology through the World Trade Organization, intellectual property related agreement, and it's not flexible. And it also give undue influence for people with high-income countries, not to make the system work for equitable access to technology.
So, we should recognize those inefficiencies in the system that may not be deploying the kind of assistance we need to respond. But at the same time, if you look at access to vaccine and demand that's where addressing misinformation, engaging communities from the outset and creating really an enabling environment where even the limited available resource can be taken up. So I would think that we need to pick our tools in the right way. And I'm not in favor of one way works better than the other, but it depends on the situation that we are dealing. Thanks. - Yeah, that makes a lot of sense. Go ahead, Sunil.
- I think it was probably unhelpful on my part at the beginning to sort of frame it as top down versus bottom up. That is often how this is kind of framed as a problem. I think you know clearly there are moments when, depending on the scale of the problem, and I think this does come down to scale. There are different kinds of challenges to health equity that operate on very, very different scales. And we probably need to sort of deal with them well. A global pandemic on the one hand and perhaps much more localized kinds of challenges on the other.
I think one of the questions historically speaking is, it's undoubted that top-down campaigns or interventions have very often had rapid and effective results. What we often find is that those aren't sustained. And I think that's where the kind of multilayered or multi-level sort of intervention that Dr. Mesfin is talking about, I think becomes very important.
After the initial impact, talk about the disease eradication campaigns of the 1950s, initially there were tremendously successful, particularly against malaria, but then partly because of the sort of vertical structure of those campaigns there was very often the sort of diminishing returns to that. And then I think environmental challenges also come into this. I wanted to sort of jump in and ask, Pascaline very interesting what you were saying about how geography matters and you keen to sort of bring that back in. I wonder if there are insights from your work about how countries in the Global South which face similar environmental conditions then have very different trajectories when it comes to health outcomes. I mean, have you found that there are sort of particular so that it's not just the environment, if the environmental conditions or the propensity to certain kinds of tropical diseases are shared, do you nevertheless see significant divergence between different countries as a result of the kinds of policy interventions that are made and which ones are sort of effective there? - I know and I wanted to jump in earlier.
So that's something we should make sure that to give us a mic. Very quickly the dividends that are comparing things across countries is something that I think we try to not do too much because we know that there are so many things that can come into play. So what I can tell you for sure that within a country, there is a clear correlation in terms of health outcomes and the environment that people face depending on the ability to fight disease. But of course, when you move out of infectious diseases and move out of things that are very much driven by the environment, there is an opportunity and there is opportunity in the health system, there's opportunity in access to health insurance, in governance. And that matters about for whether the health workers are gonna be well trained and well motivated and present. So there's definitely a lot of things that can be done on their side.
And I think a lot of the research has been focused on that because it's kind of like easier to think about this approaches and to work on these approaches with individual governments, new organizations, because as Emanuelle said before, it's very context specific. So it's very hard to be prescriptive and say, "This is how you're gonna improve or strengthen your health system. It's really depends on the context." And so doing this localized work to make progress, I think is it's been at least in my field people are, "So this is possible. So let's do that." I just wanna say, there's a ceiling to where we can go with that.
And on the larger environmental stuff we need global effort. - Just building on that for a second, I mentioned earlier the Robert Wood Johnson Foundation, one interesting role I've seen philanthropy play is not just directly funding work to address health equity, but trying to highlight what are some of those exemplars, kind of building on Sunil's question like despite some similar challenges that different geographies might face, there have been better outcomes in this place, and why is that? And funding research on why and sharing that research to inform work in other contexts. But, as Anne-Emanuelle, said earlier contexts are quite different and context matters. So, I do wanna bring you in though, 'cause I know you had a comment to make earlier.
- Yeah. Yeah. It's not just that context matters, it's politics and power that matter. And I think those elements have been under-emphasized in the conversation this far. Even if we're looking at the difference between healthcare equity and health equity, we see this playing out in very, very patent ways.
And so important as it is looking at the symptoms or the end game, the horrific situation of refugees or so-called neglected diseases. What we should be doing is asking who is doing the neglecting, why and how? After all trypanosomiasis was not neglected in the late 19th and early 20th century by German and British and other colonial powers rather it was a huge threat to territorial expansion and acquisition, right? So how and why certain health conditions become more or less important under particular contexts at the global level, and then where politics both local and global play out. And Sunil mentioned at the outset of change in the 1970s, but really this change was coming, starting with decolonization in the 1950s the BANJAN Conference and a non-aligned movement and the largest, the G-77, the largest political grouping within the United nations that was able to push forward the concept and ideally the approach of a new international economic order. So, how is it and why is it that power is distributed so unequally? So yes, the trips agreement and adherence toward a huge issue in terms of vaccine access, right? But then the question is how is it that the WTO gets set up under whose influence, right? And why are the rules of the game so uneven and so unfair in terms of Europe has plenty and North America have plenty of subsidies for agriculture and this has prevented for Global South countries who are not permitted to have tariffs and so on. So I think what we need to do getting back to this health and healthcare equity situation is think through what the structural determinants or societal determination of health as (indistinct) and other Latin American social medicine scholars put it.
And thinks through not just what the factors are, but what are the processes and the rules of the game and the power wielding that takes place. The refugee situation at bottom needs to be addressed by addressing militarism, right? And the fact that the five permanent members of the security council are the largest arms exporters' in the world. It is a massive problem that needs priority now. You could say, "Well, you've got a situation on the ground, how can you deal quickly with structural issues?" But we've been saying this for decades and decades, right? So, if not now when, right? It is time and the fact that so many have suffered in such a great extent, and of course, far greater extent from COVID-19 in countries with a huge asymmetries economic, social, political asymmetries is a wake up call, but certainly nothing new. And so, I think it behooves us all who work in the larger global development field really to be constantly pushing at all ends. And certainly on these structural factors less they be placed in the background as they typically are.
- I totally agree. So let's bring those structural factors to the foreground, any reactions to what Anna-Emanuelle just said. We've had these conversations before, but is the conversation any different this time in terms of the power and politics at play when it comes to health and equity, healthcare and equity? You might wanna jump in. Go ahead, Pascaline.
- So, I think deep down I agree with Anne-Emanuelle but at the same time it makes me to give this comment as pessimistic when I think about the fact that, okay, we are not gonna make any progress if we don't change all this structural problem, I feel like it's gonna have even one extra layer of I already have a saying, it's hard to think about getting agreement to fix the environment. If on top of that, we have to bring in the monetary. I just feel like people say it's not happening and there's just give up. So, I wanna find room for progress in a very short run, but then there's always this tension, like how do we make progress in the short run without forgetting to also deal with these deep issues that are so important.
I hear you, Anne-Emanuelle I just feel like do you see any hope for a change on those fronts? - Mesfin, you wanna jump in? - Yeah, sure. This make couple of thoughts. I mean, when you look at the problem, I think Anne-Emanuelle has came to the picture. You may feel like we are paralyzed, what can you do? I do believe there are effort to address this, when it comes to developmental in equity, I mean, we have seen, for example, how the MGD helps to address child mortality and maternal mortality. And we'll move to the SDG with a mantra of leaving no one behind. That was tested during the pandemic, actually what we mean leaving nobody behind when you are rolling out the vaccine actually we have left everybody behind.
So in a way, I think we have to translate this high level of rhetoric into actionable plan and implementation. And there are a couple of efforts to bring the humanitarian development, peace building initiative through what's called a Humanitarian-Development-Piece-Nexus, recognizing that these are not dichotomy that exist in parallel it's actually the same countries that are going through different level of fragility and also countries affected by conflict and also the same countries where we think we should be doing development aid. So in a way, how do you bring the actor together in a way that we can address the root causes? Not only just sending humanitarian aid when people are starting to move. So, and again, when it comes to health, the pandemic has told us that we need to invest in public health infrastructure and public health infrastructure is not something that is appealing to private sector.
And this is where government needs to invest on disease surveillance. Probably that's not what the private sector would be interested to invest. So in a way I think, see trading where government has a role to play. I think that role has to be enforced through accountability and also we need to measure and show where there is progress so that people can see what's working, what's not working. And translating this broad mantra about how this health coverage or leaving no one behind.
What does it mean in practical sense when you are doing either vaccination or when you are dealing with disease or any of the health issues that we are dealing. So, I do believe that there is a way, but I think what is missing in many ways is lack of political wheel. And of course, unless you have a democratic system where electorate can hold leaders accountable, unfortunately, that's a rhetoric which may not be necessarily translated, but I think we need to measure and show where this is happening and probably from the countries who are doing better.
- Absolutely. Go ahead. - I was just going to say, the idea is not to feel despondent. In fact, it's an enormous privilege to be able to feel despondent as opposed to needing to take action day to day. I think what's crucial is understanding how the global order, the global political economy operates. And then think through, as Mesfin was suggesting, what are some of the leavers, right? And perhaps some of the best leavers are why not a campaign to ultimately put humanitarian organizations out of business, all due respect, so that we don't need them in a few years, right? So that we have a system where it's safe to live in Sudan, and there's a redistribution of income and resources so that everyone has a decent housing and decent education and piped water and paved roads, and full employment and good employment, right? So that we don't have these hugely inequitable effects and impacts on the most oppressed groups of people.
So, I do think we need to use our own positions of privilege to speak out and to point to these connections and to go beyond, you mentioned partnerships, I really worry about public private partnerships because the private sector and certainly the corporate sector in the business of maximizing profits, not in the business of improving social conditions. So, I think one needs to be quite cautious. And in that and in regard of partnerships, which unfortunately the STGs are emphasizing and also seek to support true democratic movements and efforts and there's been so much intervention certainly in the Cold War, but in other time periods, when people's uprising for a new form of accountable government, and the U.S or other forces have come in and nipped those efforts often very violently in the bud. So, again, big issues, but not ones that we can ignore. - Absolutely.
And I think this is resonating with the audience. I'm gonna share a comment from the audience, and maybe we can kind of gear it into the form of a question, but this attendee says, "Thank you, Anne-Emannuelle for addressing the power dynamics that influence health. I'm very interested in the intersection of health equity and economics equity can not be achieved until root causes, colonialism racism, unfair trade practices, et cetera are addressed." So that's just a comment to give you a sense of where at least one member of our audience is standing and seeing these issues. I have some specific questions I wanna dive into and I wanna bring in more from the audience, but I wanna give space for any panelists to jump with reactions, Sunil. - Yeah. If I might just pick up
to develop the conversation and including that interesting comment from our audience member. I'm gonna pick up on something, Mesfin said, which was the question of political will and particularly the question of what political means in different kinds of political system. One of the things that's always puzzled, I think many of us who work on health in South Asia is how rarely health or health equity have been major political issues, even in India, even in the context of regular democratic competition, things might be changing in India, but let's bracket that for a minute. Some parts of India, this is also profoundly context specific, there some parts of India where governments perhaps do fall over questions of health. But by and large, that has not been the case that never been the case in India since independence.
I'm not sure I have an answer to why I've been thinking about this for 20 years. And I'm not really sure what it is whereby in certain societies. And I think Anne-Emanuelle, your Latin American examples are probably better ones there. There has been mass mobilization for health coming from kind of upsurge of democratic demand. And there are places where that hasn't happened. And I just wanted to put that on the table, 'cause I don't have answers to it, but it is something that has often puzzled me must have been mentioned political will.
I think that's true, not just at the level of the permanent members, current accounts and the global governments, but it also in a sense that continues all the way down even to the level of local government. Where is it and when is it that health equity to use just the topic of our discussion today become something people fight for. - Anne-Emanuelle, do you have a reaction to that? - Well, I was just gonna say I think in South Asia, they're the classic examples of Kerala, the state of Kerala in Southern India and Sri Lanka.
And so in the case of Sri Lanka, a free universal, health free the point of service, universal healthcare system that developed quite quickly in the post-colonial period and was fought for and struggled for and exists to a certain extent to this day. I mean, it's being ratcheted down through another force that we haven't discussed, which is the neoliberal phase of global capitalism. But, in the case of Kerala it's so interesting at times there've been communist governments, at times, not, but the public support for universal public health care and education and housing supports and so on is so strong that even when the communists are elected out of office and another party is in power, those issues remain on the table. So, political will doesn't simply come from politicians, but it comes from those who are holding as was said by Mesfin holding politicians accountable and also seeing what's possible, right? Once that's tasted, then the demands also rise to a great extent. I mean, I think we're seeing that in Brazil with the uprising against Bolsonaro went in prior decades, there's this creation of a fantastic, a single healthcare system and enormous social investments and family wages and so on that would enable 40 million people to be lifted out of poverty and so on. And so people are reacting against that and people in the streets.
So I do think it happens and that including in South Asia, not withstanding repressive governments at times and including now in India. - I think you're absolutely right, Anne-Emanuelle. The point is more that Kerala in Sri Lanka has such outliers in South Asia. The question is why is it happening there? To some extent, but nevertheless, I mean, I think that's why they're so interesting I think, and there has been so much sort of study what it is about those two particular contexts.
And I think there are many other examples around the world, which I take optimism to some extent that there have been repeated sort of mobilizations to hold the powers that be accountable in relation to health. - I wanna bring in a question and this is something I'm personally very interested in. So hopefully audiences is as well. But when we talk about leavers for short-term progress, even as we are addressing these larger structural issues that need addressing. I cover innovation and technology quite a bit, and at least perhaps this is an over-hyped space, but digital is often brought up as something that could advance health equity. It's also possibly something that can worsen health inequities because not everyone for example has access to broadband or smartphones.
But I did just wanna bring up the role of digital. I'm curious if the panelists have reactions to that. I know Anne-Emanuelle, for example, you did some work on whether digital technology can address health inequities, within and across countries. And you concluded that it can be useful tool, but only under certain conditions. So I wonder if you can just quickly expand on what are those conditions, and then I'd love to hear if other panelists have reactions on how that's come up in your work. - Sure.
Well, you can't consider technology divorced from social and political conditions. So it's not just the (indistinct) drops down. I mean, even if you had, well we have a supposed malaria vaccine now, although it's really an immune booster, but anyway, we'll leave that aside. Even if you had that, right? This quick fix, what would happen then to all of the efforts to improve housing stock, right? So that would end up generating further inequities. And then of course, who would be reached, who wouldn't be reached and so on. So I also think it's crucial, especially with current day technology to think through every step of the commodity change.
So we are using digital devices constantly without taking into account the thousands of child artisanal miners in the Democratic Republic of Congo who were abused, mistreated, exposed to cobalt in the mining process, et cetera, et cetera, not to mention every other step in the commodity chain. So we tend to kind of put technology in this very decontextualized box and, yes, we certainly knew our interactions are all shaped by technology, but technology is also shaped by the very power structures that we've been talking about today. I mean, who owns technological companies? What's the role of metal mining? I come from a country, Canada, that has a heinous record human rights and ill health record in terms of its mining involvement in Latin America, it's extractive industries in Latin America. So I think it's really morally and really analytically bereft to not consider the role of technology, to talk about digital technology and equity without considering all of these implications.
So, it could be a useful tool, but when it's embedded in policies that redistribute power and resources and do not concentrate harms, which technology absolutely does. - Good points on technology things. I should definitely keep in mind in my reporting.
I love your point on not putting it in a decontextualized box. So I don't mean to do that, but any other reactions to the role it might play while considering that complexity go ahead, Mesfin. - Yeah, I think technology has a huge problem is in terms of addressing health inequity, especially in Southern Sub-Saharan Africa, for example, is a place I know well that how much actually mobile technology has thrust movement in people's life, whether it's a mobile payment, for example, access to cash for people who are not traditionally connected to the mainstream banking system.
So, access information of course, it has to be regulated. It has to be in an onwards that's understandable by the local community. And there should be some level of digital literacy as well that go with it. It can be harmful as it is useful it is. And we have seen how misinformation kind of spread very fast through social media and all of those networks, but at the same time, the same platform can be a cause for good cause. So, I mean, it has a lot of potential and in humanitarian settings, this is one of the area where access to information is actually as vital as the life saving as it is like access to food.
I recall during the Syria crisis earlier days, even for people where to seek asylum and knowing their legal rights and what is the safest place to be and for children. So all these kinds of emotions are lifesaving for people when they're on the move. So I do think technology has enormous potential, but as Anne-Emanuelle said it has to be regulated in a way that is used and it can also cause harm if it is not proper to use or utilize. So, in the place where I work it's taking off addressing many of the issue that is related to health inequity.
- Other thoughts on technology? Otherwise I certainly have other questions. Go ahead, Pascaline. - I just want to add one area where it can be useful, which is, did you see any early warning system and actually knowing when there is an epidemic starting like Ebola even COVID has been extremely useful to be able to kind of have a sense of like where there is more or less people being infected.
And technology can definitely help with that with obviously all the drawbacks that that means also monitoring people, and there's like the big brother civilians is a term that can be interpreted very negatively or very positively, whether or not you're just surveilling people or surveilling the visitors. So I'm not saying that this is necessarily always a weight tool, but in some context it shows like, I think it's between contexts where the health system in may not be strong enough yet for people to feel that they can trust during an Ebola crisis, if I go to the healthcare system, am I gonna get Ebola, whatever I'm gonna be able to communicate information about their own symptoms through a phone, for example, would be a great way to help deal with crisis. So that's one extra area where I think it could be useful, but I also wanna say, I don't think it's (indistinct) I got a phone call where Silicon valley, like every student comes and says, "Hey, I got this new app. That's gonna like solve every problem on the planet." And I'm like, "No, I strongly doubt that."
So I tend to have like an outside technology point of view, just as a reaction to the average person around campus here. But so I just wanna say there are a lot of areas where I think technology is not gonna get us there. And I wanna bring us back to comment I made earlier about the fact that they are just like some diseases that we just don't yet have tools for. And malaria is one of them. And when it comes to vaccines, there is now some hope that there is a vaccine that may be partially effective. And the question is how do we make sure that this is all out widely as quickly as possible.
- I wanna come back to each just very quickly and I hate to make you respond in about 30 seconds or so. But if you can, that would be ideal 'cause I do wanna bring in all your perspectives one more time on this question of, this is something Pascaline mentioned as we were getting ready for this call. She mentioned that over the years, she's seen several openings where there is a possibility for action to address health inequity, but then those moments come and go. And I wonder if you're optimistic that this moment might be any different.
And if it is to be different, if real progress is to be made, what needs to happen? So just quickly coming back to each of you, how might this moment be different if you're at all optimistic, it can be and what needs to happen? Pascaline, can we start with you? - So, I mean, I just said malaria vaccine as an example. Recently I saw an article by the CDG that I got very unhappy with because it said, "Look, let's think twice about this vaccine, is not as cost effective as other stuff." And it was like, "Oh, it's $200 per daily compared to like 60 for something else." And I'm like, "$200 for daily, there's a bit here, this is left here."
It's nothing like in the U.S we spent like thousands of virus per days, every time. So it is super cost-effective and we just have to move beyond just saying, "There's not enough money and we have to go for the really, really, really, really cheap stuff." We should have more money available for that. And I think there's an opening there because everybody here has seen what it means to be in an environment where you are afraid of getting a disease from your neighbor all the time.
We know that we're willing to make sacrifices, to just like, get rid of damn COVID, okay. Everybody has been doing that. And now we can put ourselves in the shoes of people who have been living in- - Pascaline, you've just cut out for me. Can you hear us? Okay, I'm gonna go ahead and bring Mesfin and hopefully Pascaline connection will improve in one moment. - [Pascaline] For a year and a half.
- Pascaline, I'm so sorry your signal's cutting out for me. Your signal cut out for me right there. But now I think we see you, can you just wrap up, we missed the last little bit of what you said.
- Sorry, let's just move on to the next panelist Sorry about my bad connection. - Oh, I was leaning in and so engaged in what you were saying, but I think I understand where you were going with it. And I think we understood you enough to be able to build on that.
So, Mesfin, can we go to you next? - Yeah, sure. When it comes to the greatest challenge of all time, which we started with COVID-19 pandemic, as well as added climate change. As you know, everyone is talking about the need for building back better, but there is far too little attention in terms of the disparity in terms of access to power and resource between high and low income countries, even the most fragile states.
So I do consider this as a blind spot to addressing the root causes of injustice, whether it is vaccine or humanitarian crisis. So, overlooking those context is a strategic era as well. And I do think, if you want to be serious about building back better probably, for a world that we want to see not the one we left behind.
We need to translate this rhetoric into concrete action and through an inclusive governance system, and which is accountable as well. And the pandemic has taught us that investment in public health should be a public good, that government should not delegate this responsibility to private sector. And we need to look at the whole health governance system, including international health regulations for disease pandemic reporting.
And so that really addressing those issues that are paralyzing now to have a better world. I think we need to look at our governance and accountability mechanism to have a fair world. - Thank you, Mesfin.
And we're coming close to the end of time, but Anne-Emanuelle we would love to hear your thoughts. - Yeah so I agree with Mesfin that power asymmetries are the crucial issue of the day and of many, many years, in fact. And I wouldn't say optimistic, but hopeful in a range of actions that have taken place in different parts of the world. The so-called striketober in North America attempts to unionize at Amazon in Edmonton and here in Canada, even though it failed in Alabama, John Deere strikes, gig worker strikes and so on all of the revelations about corporate capitalism and so on extremely important.
And together with those worker uprisings, there've been some notable indigenous uprisings up and down the America's for example. I mean, Ecuadorean in Cuenca passed a resolution, a referendum for clean water and kicking out a Canadian mining company. That's a huge form of resistance. And I think something to be hopeful for and build upon.
Likewise elections in Peru and finally in Bolivia overturning a repressive government that was supported by North America. So I think there are reasons for some hope and that is in the context of people's struggles, right? Not in terms of experts developing better technologies, divorced from all of that. - Thank you.
Sunil, how are you feeling as we close this conversation and how do we make sure that this moment doesn't just come and go in terms of an opportunity to advance health equity? - One thing I've taken from this conversation is the need for joined up thinking. We didn't talk much about climate change. That is very much been on my mind.
And I think thinking about the ways in which new environmental justice maps on to health equity I think without that I don't think anything that we do will we will succeed because in a sense, I think that COVID devastating though it has been relatively fleeting crisis compared with the climate crisis. And I think the ways in which climate change is sort of supercharges all of these existing inequalities is something that we will have to confront. I wouldn't say I'm optimistic, but nevertheless, I think, there are enough people in particularly young people all over the world who are deeply about the climate crisis to make me think that if ever there's going to be an opportunity to sort of start to connect those dots, this might be as good as it gets for the next little while. - Thank you, Sunil. Well, thank you all so much for joining us. Apologies, we've been a bit over on time there, but there was a lot of complexity to get into.
Again, this conversation was part of a larger series, the Yale Development Dialogues. Our next event which will focus on Afghanistan will take place on Tuesday, November 16th. So stay tuned for information on that. Thank you again so much to our panelists, to all of you for joining and to our co-hosts, Yale's Economic Growth Center, Jackson Institute for Global Affairs and History Department.
Till next time.