‘Greater moral courage’ necessary to transform global health

No country can achieve sustainable development without building capacity in science and technology. So, there’s a need to reinforce science education, to train a critical mass of researchers, and to create research infrastructure that facilitate an environment where innovation can thrive.

This task is enormous, said the South African Medical Research Council’s (SAMRC) Professor Ntobeko Ntusi. It requires government policies, financial backing and well-defined priorities to seed the development of science, technology and innovation. And universities and scientific centres have a massive role to play. They must fund research and development, create inclusive avenues to ensure that the talent pool incorporates women in other marginalised groups and establish robust educational policies that will stand the test of time.

“It must be done in countries where resources are scarce; in which fundamental needs such as food, water, war, famine, government corruption and education compete with research and development for funding. Therefore, in all of this, the voices of scientists, clinicians and indeed all activists must be heard as we define our priorities in the face of urgent challenges,” he said.

These thought-provoking comments kicked off Professor Ntusi’s keynote address during the annual Dr Stuart Saunders Memorial Lecture on Tuesday, 28 January. Titled “Reconceptualising global health and medicine – a time for courage and ethical scholarship”, the lecture paid tribute to Dr Saunders – a University of Cape Town (UCT) vice-chancellor (VC) from 1981 to 1996. Friends and mentees, who included chair and head of the Department of Medicine, Professor Mashiko Setshedi, described Saunders as a colossal scholar, and a kind and compassionate champion of the people whose commitment to social justice was unparalleled.

Before taking up office as VC, Saunders also served as the chair and head of the Department of Medicine. And despite a rigorous VC schedule, he sacrificed every Tuesday and Friday to see patients at Groote Schuur Hospital (a UCT teaching hospital) where he continued to practise his love for medicine with an impeccable bedside manner.  So, it was only fitting that the lecture, held in his honour, took place at GSH and was delivered by Ntusi – the current president and CEO of the SAMRC and a former chair and head of UCT’s Department of Medicine.

Global health gone wrong

According to Ntusi, the current skewed structures and asymmetric, financial, epistemic and power dynamics of global health in its current formation are unsustainable and untenable and are some of the urgent challenges he referred to early on in his talk. Instead of its promise of equity and social justice, he said, global health has been characterised by a demise of the global. But has increasingly been in pursuit of individuals in the Global North.

“All the practitioners of global health are, after all, mostly based in the Global North.”

“All the practitioners of global health are, after all, mostly based in the Global North. Scientists in the Global South rarely describe their work has global health. Features of patriarchy, racism, white supremacy, neocolonialism empower asymmetries between high-income and middle- to lower-income countries,” he said.

Added to that, an increasing lack of diversity, equity and inclusion are some of the dire challenges that lie at the heart of what has gone terribly wrong with global health.

“Therefore, reimaging global health requires that we address these intersecting systems of privilege and supremacy that continue to limit our ability to achieve equity and justice. Inequities are not only about the needs and concerns of the disadvantaged, but also about the systems that create disadvantage,” Ntusi said.

A massive setback

He told the audience that when he suggested the topic for this lecture several months ago, he could not have predicted how ominous it would be today.

“For in a single week since the new United States (US) administration took office, a series of harmful and retrogressive policies that restrict US international development assistance to organisations providing global health have been enacted [and it] threatens to undermine the laudable gains made in global health, achieved over the last four decades,” he said.

These events, he pointed out, represent a significant setback for global, human rights, health justice and particularly for vulnerable communities the world over who already face systemic barriers to increasing health access.

“The rise in nationalism and polarisation spells a dubious future for global health. The events of the last week have been most unsettling. And in any equal and equitable society, no single country should have so much influence on the health of so many outside of its borders,” Ntusi said.

Reimagine global health

As the lecture celebrated Saunders’ legacy, Ntusi took a moment to reflect on his mentor and friend and described him as a man of principle and strong moral conviction and a courageous and ethical leader, who left an enduring impression. He told the audience that he thought long and hard about the lessons everyone could learn from Saunders’ leadership to reimagine global health.

In articulating the difference between global health, public health and international health, Ntusi said several sub-themes emerged: global health is a multiplex approach to worldwide health improvements, taught and pursued by research institutions globally; and it’s an ethically orientated initiative guided by just principles.

“Diversity, equity and inclusion are clearly on the decline.”

Yet, global health is inherently inequitable and is failing dismally on all measures of inequity. The rise of nationalism, right wing politics and the erosion of democracy worsens global health inequities. He said global health continues to be a field where Global North actors see themselves as experts and leaders. And although the decolonising global health movement has exposed some of the deep inequities inherent within the architecture of global health, this movement, prone to elite capture, faces several institutional barriers that prevent meaningful shifts in power.

He noted that the lack of allyship in global health recently manifested as vaccine apartheid led by Global North countries who hoarded vaccines for COVID-19, mpox and Ebola. Further, he argued that the “current posturing” by President Donald Trump’s administration is just another example of absent allyship.

“Diversity, equity and inclusion are clearly on the decline. On global health, all efforts to correct this are increasingly seen as wokeism and reverse racism. Therefore, if we are to move forward, there needs to be a concerted effort to support Global South leadership [on] global health,” he said.

Decolonising global health

Importantly, Ntusi noted that there have been growing calls to decolonise global health, and this process, he added, is only the tip of the iceberg. But what does success look like? To decolonise global health is to remove all forms of supremacy within all spaces of global health practice within countries and between countries, and at a global level.

He stressed that supremacy is not just restricted to white supremacy or male domination or between people from high- and low-income countries. But it also refers to what happens between groups in high-income countries, as well as in low- and middle-income countries.

“Supremacy is there glaringly. And how global health organisations operate, who runs them, where they are located, who pulls the purse strings and who sets the agenda, and whose views, histories and knowledge are taken seriously.”

Ultimately, the goal of global health should not be the survival of its decolonisation. Instead, it should rise up and lead to the present demands of its mission. He said the pursuit of equity, social justice and health justice must be at the centre of all global health efforts.

“Like Stuart Saunders did in his day, we are all called to have moral courage in contribution to the global agenda to transform global health.”

“Decolonising global health is of great interest. But it’s been difficult because systems are entrenched. We need you, all scientists, clinicians and concerned citizens to continually question the skewed ways in which global health is being studied, taught, funded, researched, driven, designed and implemented,” he said.

“The accountability and shaping of power dynamics are at the heart of my proposals for change. But good intentions are not enough. I wish to argue that we need greater moral courage. Like Stuart Saunders did in his day, we are all called to have moral courage in contribution to the global agenda to transform global health.”

Others who contributed to the evening’s programme included the chair and head of the Department of Medicine, Prof Mashiko Setshedi; UCT VC Prof Mosa Moshabela; the dean of the Faculty of Health Sciences, Prof Lionel Green-Thompson; and the Department of Medicine’s Prof Marc Blocman.