Episode 77
Shifting Power in Global Health: Equity, Leadership and Change
Global health systems are built on power structures that often exclude the very voices that should be leading the conversation. Funding, publishing, and policymaking have long been dominated by high-income countries, creating systemic barriers to equity.
In this episode, Dr. Shashika Bandara (McGill School of Population and Global Health), Dr. Moses Tetui (Umeå University & University of Waterloo), and Dr. Joseph Mumba Zulu (University of Zambia) discuss two major initiatives that challenge these structures:
The Lancet article: Shifting Power in Global Health Will Require Leadership by the Global South and Allyship by the Global North and The launch of the Journal of Community Systems for Health, a new platform breaking barriers in global publishing and knowledge sharing.
In this episode:
Dr. Shashika Bandara - Post-Doctoral Fellow, Department of Global and Public Health, School of Population and Global Health, McGill University.
Shashika Bandara is a Sri Lankan post-doctoral fellow at the Department of Global Public Health in the School of Population and Global Health at McGill University. He co-leads McGill University’s research examining policy exemplars successfully addressing structural discrimination with O’Neill-Lancet Commission on Racism, Structural Discrimination and Global Health.
Dr. Joseph Mumba Zulu - Associate Professor of Community, School of Public Health, University of Zambia
Joseph M Zulu is a co-founder and Editorial Board Member of the Journal of Community Systems for Health, a platform dedicated to promoting inclusive, socially accountable, and community-driven health systems research. He is an Associate Professor of Community Health at the School of Public Health and has been involved in community-based implementation research projects in different countries across Africa.
Dr. Moses Tetui - Assistant professor, University of Waterloo, Canada and Umeå University, Sweden
Dr. Moses Tetui is a Health Systems Researcher who specialises in using participatory methods to collaborate with diverse communities and stakeholders to address health system challenges. He serves as a founding board member of the Journal of Community Systems for Health. Moses collaborates with researchers, communities, and decision-makers to explore climate change adaptation strategies for communities living in informal settlements across Africa.
Useful links:
- How to prevent equity efforts from losing steam in global health academia
- Imagining a future in global health without visa and passport inequities
- Shifting power in global health will require leadership by the Global South and allyship by the Global North
- The Journal of Community Systems for Health (JCSH)
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Transcript
Dr. Kim Ozano: Hello listeners and welcome to Connecting Citizens to Science.
Speaker:I'm Dr. Kim Ozano and this is a podcast where we discuss current research and debates in global health.
Speaker:Today's episode really is a must listen for anyone working in global health or anyone who simply cares about the equity within our global health framework.
Speaker:No matter what sector you work in or field of research, the challenge and opportunities we discuss today affect all of us.
Speaker:The global health landscape is changing, but as our guests explain, we also need to start seeing shifts in power, and that shift requires bold action.
Speaker:Dr. Shashika Bandara puts it plainly;
Speaker:Dr. Shashika Bandara: To survive as a planet and as humans, we need to prioritise global health and change the way we do it with equity at the centre.
Speaker:Dr. Kim Ozano: The structures that shape global health, those of publishing, funding, policy making, have long been dominated by high income countries.
Speaker:Often excluding the very voices that should be leading these conversations.
Speaker:So in today's episode, we explore two critical initiatives that were launched in October 2024 that aim to address these global health inequities that we see within our architecture.
Speaker:The first is an article published in The Lancet entitled Shifting Power and Global Health Will Require Leadership by the Global South and Allyship by the Global North.
Speaker:The article exposes the systemic barriers that have long prevented a true shift in power.
Speaker:The second initiative is the launch of the Journal of Community Systems for Health.
Speaker:This is a groundbreaking journal that is designed to reshape and rethink the global publishing landscape, one of the key challenges and barriers that are outlined in the Lancet article.
Speaker:Dr. Joseph Mumbazulu explains.
Speaker:Dr. Joseph Mumba Zulu: We need to change how we approach global health so that we can give space to people that do not have enough resources to contribute towards publication.
Speaker:We need also to allow people at the lower level of the health system to be able to voice out their ideas.
Speaker:Dr. Kim Ozano: In this episode, we speak to one of the authors of the Lancet article, Dr. Shashika Bandara, who is a policy associate from the McGill School of Population and Global Health.
Speaker:We also speak with founding members Dr. Moses Tetui, from the Department of Epidemiology and Global Health at Umea University and the University of Waterloo, and Dr. Joseph Mumbazulu from the University of Zambia.
Speaker:Together we discuss what needs to change, how we can rethink power structures, and why shifting the global health narrative is an urgent priority.
Speaker:But before we jump into the discussion, remember if you're passionate about global health, make sure you subscribe so you don't miss an episode.
Speaker:If you find this discussion valuable, please share it with your networks.
Speaker:We want as many people as possible to be part of this dialogue.
Speaker:Let's start off with Shashika, who is going to talk to us a little bit about the origins of the article in The Lancet and what brought about this thinking behind the article.
Speaker:Dr. Shashika Bandara: I think the current status quo and the increasing news headlines really brought this about.
Speaker:Especially when you're working global health, it can be a bit depressing to to learn how governments have been very inequitable and how high income countries have hoarded vaccines, or how their really high article processing charges that essentially keep low and middle income country scientists from publishing, and so many inequities in global health that stop us from reaching the goals like health for all in sustainable development goals.
Speaker:We all talk about this problem, but have you considered, like, how our governments, how our universities, how our journals, who claim to be allies, are not really providing us the pathway to find solutions.
Speaker:In the paper, we talk about how governments have contributed strongly, this is no secret, to vaccine equity challenges.
Speaker:How journals have been a barrier to publishing from low and middle income countries, and how the current funding structure from soft money, meaning that money that is tied to contracts or short term funding, that limits the way we approach equity.
Speaker:We also touch on the anti-diversity equity inclusion backlash that is happening very loudly in the United States.
Speaker:Also in universities, right?
Speaker:They're rolling back these programmes.
Speaker:Facebook rolled back its programme.
Speaker:These are big signals to us to say, 'Look, we have systemic problems.
Speaker:They're going to get worse'.
Speaker:So, let's try to highlight them and also try to work on them.
Speaker:And one of the things I was inspired by last year was the journal launch by Moses and Joseph, which is a part of a solution to improve and bring equity to the publishing structure in academia.
Speaker:I was very impressed by that and yeah, so this is why we wrote it and we are hoping people can take it forward, have more conversations and do more work.
Speaker:Dr. Kim Ozano: That's really great to hear, and it sounds like the article is becoming more and more important every day, especially in the kind of global, political landscape that is arising at the moment.
Speaker:I think this is a good time to bring in Joseph and Moses.
Speaker:Welcome to the podcast.
Speaker:So tell us about the Journal of Community Systems for Health and what it's hoping to achieve.
Speaker:Dr. Joseph Mumba Zulu: Yeah.
Speaker:Thank you so much.
Speaker:So, I just want to pick up from Shashika, the article that they produced is really important and points out a lot of important issues when you start discussing inequities with regards to the architecture of global health.
Speaker:And I want to pick specifically one point that he talked about the issue of publication costs, which links so well to our journal, the Journal of Community Systems for Health.
Speaker:Many researchers, particularly in the Global S outh, find it extremely difficult to publish in most of these journals, because they have to pay huge amounts of money to publish the articles, but also to access that information.
Speaker:And as one of the researchers coming from a low and middle income country, Zambia, I have experienced those challenges when it comes to publication.
Speaker:Now, the point is this, if you can't publish in a journal, then it becomes very difficult to grow in an academic career, because then you don't have the possibilities to have networks, to have partnerships with other researchers from other countries; to be able to access resources, to conduct research, to support PhDs, to mentor postdocs.
Speaker:So, the issue of publication is very crucial as far as advancing is concerned in an academic institution.
Speaker:This is why the development of the Journal for Community Health Systems becomes very handy in trying to deal with the inequities as far as global health is concerned.
Speaker:It offers this space which allows young people, upcoming researchers to be able to publish at no cost to be able to provide their information to the global publishing space so that people can understand what is happening, what knowledge is being generated in different countries.
Speaker:Dr. Moses Tetui: I'll just build on that and I'll also build on what Shashika um, raised.
Speaker:One of the things that we have witnessed and continue to witness is how knowledge is seen from the outside and also published as from the outside and how the conventional journals that we have now have very rigid publication formats, which makes it difficult to have a flavour of, um, of knowledge and to have stories or to have knowledge shared from different perspectives.
Speaker:And that's why, as a journal, we want to expand that and break that barrier to be able to have knowledge come in many different forms.
Speaker:We want knowledge to come in the forms of storytelling.
Speaker:We want people to be able to share knowledge in terms of field experiences, but also share it in different formats, maybe in video or audio, so that the stories that different people, community members, not just researchers, but also policy makers, decision makers, want to share with the world is shared, but also that, people from different parts of the world are able to do this without the need to be researchers or to be academicians.
Speaker:Dr. Joseph Mumba Zulu: And the other issue is the issue of language.
Speaker:As you might be aware, most of the journals prefer that material is published in English.
Speaker:Now, many of the countries, low and middle income countries, not all countries, English speaking countries.
Speaker:So then you find that researchers have very nice materials.
Speaker:Very nice data, but they can't have it published because they are not fluent in English.
Speaker:So, that becomes very problematic when it comes to generating knowledge from countries that are not English speaking.
Speaker:So, now how is the Journal for Community Health Systems addressing this language barrier?
Speaker:You'll see now, when you go on the platform, we have allowed articles to be published in other languages.
Speaker:So the first language that we have tried to adopt is Spanish.
Speaker:By allowing articles to be published in Spanish, we are hoping that we can now include researchers from a region that perhaps might have not been allowed to publish in some journals because of this language issue.
Speaker:We are trying to ensure that knowledge is evenly spread across different regions and giving opportunities to researchers from different societies.
Speaker:Dr. Shashika Bandara: I just want to bring in the term in epistemic justice, because what we're trying to do through your journal is to build epistemic justice.
Speaker:And and it's really important both the language aspect and also the, the fact that the different mediums that you guys are allowing to be published in this journal, because I think that's a big challenge when a medical or science publishing journal was founded, they really created this binary between humanities or arts and then science.
Speaker:Allowing all of that to come together is is honouring epistemic justice, I would say.
Speaker:Dr. Moses Tetui: I agree and that brings me to one of the other issues that we are trying to tackle it within our journal, is dealing with the problem of extractive research practices.
Speaker:Too often research agendas are driven from the top.
Speaker:And these are often removed from communities that are being studied, and these, these publications, they disregard what the community, the real community needs and therefore their needs and priorities are secondary.
Speaker:So, what we want to do with the journal is have the voices of the communities and to address inequalities and be able to flip the script a bit and ensure that research is shaped by and for communities that it aims to serve.
Speaker:Dr. Kim Ozano: Hmm, I like this idea of flip the script.
Speaker:I think it's a really good framing.
Speaker:But Shashika, it'd be great to come back to the title of the article again.
Speaker:Shifting Power will Require Leadership by the Global South and Allyship by the Global North.
Speaker:There's a lot of examples of how different stakeholders can shift power, including examples for governments, funders, academic institutions, conference organisers and international organisations.
Speaker:Perhaps you could talk us through a little bit about these structures and the examples within the article.
Speaker:Dr. Shashika Bandara: Yeah, so I want to start off with the quote because I don't want to forget to talk about this.
Speaker:The American abolitionist, Frederick Douglass, said that 'power concedes nothing without a demand, and it never did, and it never will'.
Speaker:I I think there's a lot of narrative around how we need, to not challenge, not cause discomfort and so on and so forth, but I think it's really necessary to do that.
Speaker:This is one of the messages I hope that comes across, is that there is a discomfort and sacrifice that is necessary when we are trying to shift power or give more power to the Global South and be a true ally as Global North institutions and researchers.
Speaker:So, that's something we we focus on in the article and this is why the categories are there, because if we say broadly, let's shift power, we don't know who we're talking about here.
Speaker:We need to talk about, okay, governments need to rethink their selfish ways of hoarding vaccines or, not considering the the effect of selling weapons or making money off of weapons and so on and so forth.
Speaker:For us, I think one of the reasons we wanted to highlight these categories is to highlight the key stakeholders.
Speaker:Look, you guys can do something around this.
Speaker:So, we talk about governments what high income country governments can do, but also if you talk to... I'm from Sri Lanka, so if you talk to someone from Sri Lanka we just went through a massive economic crisis we cannot blame everything on the leaders or on the leaders of the Global North or the current status because we have to hold our leaders accountable as well.
Speaker:One of the things we do in this piece is to say, look, there needs to be allyship oriented action.
Speaker:That is very necessary.
Speaker:But leadership also has to come from within and this is how we can do this.
Speaker:For an example we push the Global South institutions and government to say, invest more in health and be less reliant on donors.
Speaker:Make that a strategy of your five year, 10 year strategic plans.
Speaker:One of the key things I think we really need to address is the funders and donors in global health.
Speaker:Some things that Moses and Joseph talked about, right?
Speaker:The way the funding flows.
Speaker:If a low and middle income country wanted to build a research project or a partnership, they had to align with a high income country.
Speaker:And a lot of the overheads go into this high income country institution So relatively less amount goes to this low and middle income country institution.
Speaker:So these are the things we are asking to change.
Speaker:Demand change as a Global South institution, but also as a Global North institution.
Speaker:Think about it.
Speaker:Yes, you're getting money, but, is this taking to the goal that you said you want to achieve?
Speaker:We have all these nice mission statements and vision statements, but are we living up to it, right?
Speaker:So these are the questions we ask, and I won't go into the publishing industry because Moses and Joseph really touched on it really well, but I would say, starting a new journal and having that epistemic justice as a principle is really important, one key solution, but we also need to look into the existing journal structures and see how they perpetuate this.
Speaker:Dr. Kim Ozano: Thank you very much.
Speaker:I think that's really comprehensive.
Speaker:So Moses and Joseph, simply by launching the journal, and I know you're, you're quite a new journal and you have a lot of milestones that you hope to achieve, but I wonder, has it already started stimulating conversations and debates around structures of publication and some of the barriers that that is presenting.
Speaker:Dr. Moses Tetui: That's a big question.
Speaker:Yeah.
Speaker:First of all, I think it's important that we exist.
Speaker:Dr. Kim Ozano: Mm hmm.
Speaker:Dr. Moses Tetui: You might recognise, one of the biggest injustices that we have around the world today is denying the existence of others.
Speaker:So, I think it's important that we are in this space and we are challenging the status quo.
Speaker:We've launched our first issue and we continue to receive a lot of support submissions for publication, but the most important thing that we're trying to do is to build up this space as a place that is for active engagement, not just redundant publications, but active engagement that is going to be shaping the way things move forward in the world.
Speaker:If you look at the way the world is built today, it's very much in a sense of extraction from the other.
Speaker:So there's a lot of extractive relationships, be it in trade, be it in publications.
Speaker:It's always extraction.
Speaker:And it's even though it can be termed and dressed as, international aid or trade, it's been in, in many ways, very extractive.
Speaker:It's important that we have this kind of conversations.
Speaker:They are difficult.
Speaker:People don't want to have them, but it's important that we hear voices from different parts of the world and different structures of society.
Speaker:Dr. Shashika Bandara: Yeah, I just want to jump in and say I completely agree on the fact that we have an extractive essentially a capitalist system that is extractive, and they continue to extract, especially from the African region, but also from many of the low and middle income countries.
Speaker:Madhu Pai, one of the co-authors recently gave a guest lecture in one of the classes I teach.
Speaker:And he said when you talk about poor countries or, underdeveloped countries, you have to ask the question, why are they that way?
Speaker:And so they are intentionally underdeveloped because of the colonialism and the extractivism.
Speaker:That came before and that continues even today we don't have to look that far, right?
Speaker:We can look at COVID-19 vaccine.
Speaker:We can look at how high income countries didn't share the mpox vaccines.
Speaker:We talk about this in our paper too, but also a lot of the questions has been asked about immigration, crisis, and also refugee crisis, whose lives matter more in a world?
Speaker:Why are neglected diseases neglected?
Speaker:Is it because they only affect low and middle income countries?
Speaker:So I completely agree with Moses's point about extractivism.
Speaker:I do believe, though change needs to happen as a collective.
Speaker:So we need agents of change that come from Global North and agents of change that come from the Global South and challenge their government to take more leadership role.
Speaker:I feel like we have a lot of creative activism ahead of us, especially given the government change in the U. S. and a lot of the shifting to the right in the world.
Speaker:So, we will have funding problems, right?
Speaker:Especially sexual and reproductive health rights, climate crisis, and so on.
Speaker:All of us needs to build a community that is stronger now and move towards creative activism, recognising what Moses said, and what Joseph has been saying, and understanding that global health is built on a neocolonial system, but a lot of aspects of it is also making a return.
Speaker:And that framing still exists.
Speaker:So I feel like this is a call to action, so to speak let's get together and do some creative activism.
Speaker:Dr. Kim Ozano: What is creative activism?
Speaker:Dr. Shashika Bandara: I think the journal is a very good example of creative activism.
Speaker:It's a, it's also a significant amount of work.
Speaker:So, maybe not everybody can do like that level of work.
Speaker:Even the littler contributions can help like writing commentaries or speaking out, even doing this podcast, for an example, like the fact that you guys have us on your platform is creative activism, I think.
Speaker:One thing I do want to add, I would kick myself if I didn't mention this, is publishing and getting your articles out is one aspect.
Speaker:But also being able to be present at conferences and attend meetings in high income countries or wherever in the world is also really important.
Speaker:Right now, because of visa inequities and passport inequities which kind of has created a walled world where especially low and middle income country citizens, they cannot come and present their work in a timely manner in these big conferences.
Speaker:And that itself breaks opportunities to collaborate or even to build a new solution to a problem that we are facing globally.
Speaker:Something we need to think about if you're really serious about epistemic justice, bi-directional flow of knowledge, all of these things we need to survive as a planet at this point, right?
Speaker:A lot of the problems we are facing are global and to the point it could wipe away part of our population.
Speaker:We need to come together and recognise the equity centered challenges are holding us back from finding real solutions.
Speaker:Dr. Kim Ozano: Thank you for, for raising that very important point.
Speaker:One last area to explore.
Speaker:You know, we've already mentioned that the changes in the U.S. that we're seeing.
Speaker:Does anyone have any comments around the backlash?
Speaker:Especially, policies that are against diversity, equity, and inclusion, and how is a global health community we're going to withstand that together where there's lots of collective responsibility.
Speaker:Any comments on that?
Speaker:Dr. Shashika Bandara: I can start off because this is very close to my heart.
Speaker:When I was a student and an employee at Duke University, we started this task force to say, okay, how can we do better?
Speaker:And a lot of the times when you talk to the community, when you speak to everybody, what they want is more equity oriented efforts than less.
Speaker:And this is true at McGill, this is true at many universities.
Speaker:And I think it's really important to recognise that the governing bodies the political will is to break this down, especially in the U.S.
Speaker:So U.S. has been signaling this.
Speaker:Their individual states have been suing and changing curriculums like Florida, for an example, right?
Speaker:We know the problem.
Speaker:So we need to make sure if you're an education institution and it has a leader that is brave, then you can ask that brave leader to say, okay, let's keep it going, right?
Speaker:Let's invest more money into DEI.
Speaker:Let's be an example in a time of crisis, rather than trying to align with all those people who just say yes.
Speaker:So that would be my approach, I have a human rights background, so that's a very activist centered approach.
Speaker:I wrote this piece about how not to lose equity, how not to lose steam in equity centered efforts in academia.
Speaker:One of the things we highlighted was to, one, to put money where your mouth is.
Speaker:So that's, a big thing that the schools can do right now, and then to communicate your wins and losses.
Speaker:So, in this stage, the schools can come out and say our equity efforts are suffering because of the government, right?
Speaker:But we are going to face this in X, Y, and Z way.
Speaker:And I think that would bring a lot of faith into the younger generation, give them hope, because I think the younger people are ready to go.
Speaker:And just supporting them through efforts like that is really important.
Speaker:Dr. Moses Tetui: Building on what Shashika just said about human rights and how that is being challenged today, I just want to bring to our attention some of the words that the bishop at the inaugural prayer service for President Trump, that she is urging Trump to have mercy on LGBTQ, children and immigrants.
Speaker:And we should look at this as problematic, that is not the the direction that we want to go.
Speaker:All humans and all immigrants have the same rights as everyone else, and we should be able to respect that regardless.
Speaker:We need to think very carefully about global crisis and how interconnected we are across the world.
Speaker:One thing might be happening in one part of the world today.
Speaker:And, you might think that you're safe in whatever corner that you're in, but that is not the case.
Speaker:And it's ironic how we know we've just gotten out of COVID-19, you could think that maybe we have learned something, but not much it seems.
Speaker:So we need to be more reflective, think about some of the actions that we are taking and how we are, um, supporting some kind of a crop of leaders, or ways of leading, that might not be in our best interest.
Speaker:Dr. Kim Ozano: We could talk all day.
Speaker:There's so much to unpick here, but we're sadly running out of time.
Speaker:So, let's go to the point of our podcast where we ask for that call to action.
Speaker:What do you really want our listeners to take home from today's discussion?
Speaker:And I think Joseph, it would be great to start with you, please.
Speaker:Dr. Joseph Mumba Zulu: It's important that community voices are lifted up in research, in science, in funding.
Speaker:More resources need to be channelled towards community driven research, community participatory research approaches.
Speaker:And hence, the journal and the platform like ours becomes very essential because then you're allowing communities to give out indigenous knowledge as it exists, not knowledge that is superficial, but knowledge that speaks to context, knowledge that speaks to realities and needs of the people.
Speaker:As we go forward let's allow communities to bring out knowledge as they experience it, as they live it, and as the way they feel it.
Speaker:And hence, we need to allow different ways of publication and different languages and different approaches to be put across so that many people can learn in different contexts.
Speaker:That would be my central message today.
Speaker:Dr. Kim Ozano: Thank you.
Speaker:And I understand the journal has a call right now on indigenous communities and indigenous research.
Speaker:So, anyone who's interested, please visit the journal and submit your articles.
Speaker:Moses, a call to action, please.
Speaker:Dr. Moses Tetui: One thing that I think is very important for us to remember is that we are very interconnected.
Speaker:We are very interconnected as humans.
Speaker:And one thing that happens in one part of the world will have a spin off effect in other parts of the world.
Speaker:Climate change today, as we know, there's many people trying to dip their head in the sand and say this is not happening.
Speaker:Health inequalities and pandemics, they do not respect borders.
Speaker:So, journals like the Journal of Community Health Systems play a critical role in highlighting that collaboration across regions or systems is not just ideal, it's essential.
Speaker:By emphasising interdependence, we can conquer isolate narratives, and showcase the power of collective action.
Speaker:Dr. Kim Ozano: And finally, to take us home with a call to action, Shashika, we've already had a few from you already, but anything that you would like to add for our listeners to take home?
Speaker:Dr. Shashika Bandara: I think I jumped the gun earlier, but I really want to say this, though, I think perhaps the biggest thing we can do is to read journals like the journal that Moses and Joseph has started, and also everything, that we write and others write on equity and come to the realisation that global health field is inequitable.
Speaker:I feel like in an echo chamber where all of us are equity focused, we all feel like everybody is equitable, but coming to that realisation would be super helpful for us to make change.
Speaker:And then we can come together and see how can we challenge visa equity, how can we challenge journal inequities and so on and so forth.
Speaker:So my biggest take home would be to learn the history of global health, learn how it's neocolonial see how it's perpetuating to this day, look at COVID-19 vaccine inequity and learn about that inequitable status quo, and then let's come together and do something about it.
Speaker:Dr. Kim Ozano: I think that brings us back to the beginning of the discussion, where we talked about the fact that the inequities have been exposed within global health.
Speaker:We know they're there, we know about them, they've been made visible, but it's what do we do together to start removing those institutional barriers so that they can be acted upon.
Speaker:Dr. Shashika Bandara: And Moses and Joseph, I was inspired by your chat to, to submit an article to your journal, so I will try to work on that and get something in the works you for.
Speaker:Dr. Joseph Mumba Zulu: Awesome, we will look forward to it.
Speaker:Dr. Kim Ozano: Well, that's it for today's episode of Connecting Citizens to Science.
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