By guest contributors: Juliana Soares Linn, Director, Infectious Diseases Department, FHI 360, Emily Headrick, Clinical Technical Advisor, FHI 360, Petra Heitkamp, Community…
By Beryne Odeny (Washington University in St. Louis, Department of Surgery) and Julia Robinson (PLOS Global Public Health)
The first in-person CUGH conference following the emergence of the COVID-19 pandemic took place in Washington, DC, USA in April 2023. This event drew thousands of global delegates providing a platform for meaningful discussions about the definition and trajectory of Global Health (GH). The conference theme, “Global Health at a Crossroads: Equity, Climate Change and Microbial Threats,” resonated with the rise of non-communicable diseases (NCDs), persistent microbial threats, and the triple planetary crises (climate change, biodiversity loss, and pollution) within an inequitable GH ecosystem . Building upon last year’s CUGH 2022 highlights , a compelling question emerged: with GH at a crossroads, is it time to rethink and redefine GH?
The term ‘agathokakological’ aptly captures the dual nature of GH practice that practitioners are grappling with, which is inherently a blend of good and bad. ‘Good’ in that there are tremendous achievements such as the rapid development and deployment of COVID vaccines, improved maternal and child health, and overall life expectancy. However, these positive strides sharply contrast with enduring health inequities and power imbalances both within and between nations, representing the ‘bad’ [3,4]. Does the good neutralize the bad for overall net good, or vice versa? How can the good from GH be amplified or redistributed and the bad mitigated or eliminated?
While GH has made remarkable strides in advancing health technologies and outcomes, the narrative is far from uniformly positive, with many regions and communities continuing to experience disparities in health access, outcomes, and substantial losses in both lives and resources . The CUGH plenaries exposed the bare facts: while some regions have predominantly experienced the gains from GH programming and advances, others have disproportionately faced challenges. Glaring examples include vaccine inequity , inadequate GH funding, unmet Sustainable Development Goal (SDG) targets [7,8], unattained Universal Health Coverage (UHC) , limited pandemic preparedness plans , and the disproportionate impacts of triple planetary crises .
The roots of GH are intertwined with historical power structures that favored privileged populations; hence the emergence of Global Health 1.0—built upon inequitable foundations—has led to an imperative for reform. To address the root causes of GH’s limitations, it is essential to reexamine its origins, redefine its parameters and scope, determine which voices to elevate, and identify strategies for course correction. To this end, CUGH speaker, Arghavan Salles, Clinical Associate Professor at Stanford University, USA, emphasized that the social determinants of health (SoDH) are structurally determined and must be tackled along with the power structures that encroach on citizen sovereignty in public policy and health programs.
The stark tension between the historical underpinnings of GH practice and ongoing reform efforts contributes to the current lack of clarity in definition and scope of GH practice . Conference delegates strove toward a common understanding of GH, and the conference debate revolved around whether GH should ‘broaden’ to include the SDGs or ‘narrow’ its focus for greater positive impact. Advocates for broadening GH contended that the field needs to expand beyond its disproportionate focus on; 1) human health and infectious diseases; 2) low- and middle- income countries (LMICs) as the target for assistance; 3) developmental aid and dependency on high income countries (HICs); and 4) short-term disease-based targets and goals, and towards a long-term system reconstruction of GH at political and socioeconomic levels. Conversely, proponents for a narrower focus emphasized feasibility concerns. A CUGH panelist, Dr. Olusoji Adeyi, President of Resilient Health Systems, USA, pointed to the necessity of first addressing governance, credibility, and financing challenges which perpetuate power asymmetries, before embarking to expand GH’s reach. This debate underscored the intricate balance between ambition and practicality.
An emerging consensus at the conference was the need to adopt a One Health approach to redefine GH. This approach recognizes the interconnectedness of human health, the environment, climate change, and veterinary health. By acknowledging these interdependencies, GH can more effectively address shared health threats, including zoonotic diseases, antimicrobial resistance, and food security . Climate change needs to be more squarely at the center of GH programming, as it affects everything from zoonotic disease emergence to global nutrition to mental health—and public health practitioners need to embrace this paradigm shift of understanding that GH is planetary health. At the heart of redefining GH lies the imperative for equity, justice, and collaboration. Amplifying marginalized voices and adopting an inclusive GH narrative involves addressing structural factors that sustain inequities, including wealth, education, and technology access. To be global, GH must broaden to involve all countries and address inequities between and within countries .
Pandemics like COVID-19, NCDs, and antimicrobial resistance have invariably exposed inequities perpetuated by the structural determinants of health, highlighting health system vulnerabilities that disproportionately affect less-resourced regions. GH will continue to learn from COVID-19 for years to come, with the certainty that more pandemics will follow . While commendable structures for future pandemic prevention are in place, COVID-19 has worsened ongoing NCD and mental health crises, revealing intricate links between health challenges. In parallel, antimicrobial resistance, driven by complex and multifaceted dynamics, has emerged as another global pandemic, creating an enormous need for context-specific and cost-effective strategies to both prevent infection and prevent the emergence of resistance, particularly in LMICs .
These complex challenges emphasize the necessity for robust health systems—with equitably shared power, decision-making, and resources—capable of managing the complexities of both infectious and NCD threats . More crucially, robust health systems require essential political goodwill and support for resourcing the transformation of the health sector to embrace One Health. Dr. Keith Martin, Executive Director of CUGH, emphasized that by leveraging the power of political engagement and advocacy, GH practitioners can foster systemic change that addresses the root causes of disparities.
In terms of tools for the next version of GH, practitioners emphasized the importance of embracing Implementation Science. The lack of skills in translating and implementing GH evidence—for example integrated disease and NCD control—into practice was recognized as a barrier to achieving health equity. At a plenary discussion, Dr. Ala Arwan, former Minister of Health in Iran, highlighted the challenges policymakers face that require this type of Implementation Research. There is a desire to expand Implementation Science beyond academic settings to collaborate with ministries of health and other non-academic stakeholders. GH thought leaders proposed democratizing Implementation Science by making its tools widely accessible as a potential pathway to address inequities, fulfill SDGs, and achieve UHC, leveraging the knowledge gained in the conference and through research .
To conclude, the discomfort with the status quo is mounting and much more will be required to tilt GH practice from being agathokakological to being truly beneficial to all. The plenary discussions delved into the dual nature of GH and underscored the necessity of redefining GH and its scope, along with the vital role of politics and advocacy in the transformation towards One Health. Panelists were optimistic that as the GH field navigates ongoing global health crises, academics, researchers, practitioners, and advocates have the potential to truly transform the field for the better. A universal commitment to SDGs, venturing the unchartered waters of politics, and deliberate redistribution of power and resources will be fundamental pillars for GH 2.0, and the potential for this shift is palpable.
About the authors:
Dr. Beryne Odeny, Assistant professor of Surgery in Washington University in St. Louis (WashU), is a physician-implementation scientist. She has held editorial roles at PLOS Medicine and PLOS ONE and will be joining PLOS Global Public Health as an Academic Editor. She is committed to promoting diversity, equity, and inclusion in scholarly publishing as evident in her article titled “Time to End Parachute Science.” Dr. Odeny’s research centers on Implementation Science to understand and address health disparities, population-level health access gaps, and health system challenges with a special focus on electronic health information systems. At WashU, she is leveraging Implementation Science to address inequities in the cancer care continuum. She is passionate about rapid and equitable discovery of scientific evidence from, and across, low resource settings.
Julia Robinson is the Executive Editor of PLOS Global Public Health, an Open Access journal that addresses deeply entrenched global inequities in public health and makes impactful research visible and accessible for all. Prior to joining PLOS in 2020, she worked with the University of Washington implementing HIV and health systems strengthening programs in many countries, primarily in Cote d’Ivoire. She is also involved with various global health activist organizations, including the People’s Health Movement.
1. Consortium of Universities for Global Health (CUGH 2023). Global Health at a Crossroads: Equity, Climate Change and Microbial Threats. Available: https://www.cugh2023.org/ [Accessed July 14,2023]
2. Odeny B, Davidson C. Social justice now for an equitable tomorrow: Reflections from the Consortium of Universities for Global Health Conference 2022. PLoS Med. 2022;19: e1003995. doi:10.1371/journal.pmed.1003995
3. Rackimuthu S, Narain K, Lal A, Nawaz FA, Mohanan P, Essar MY, et al. Redressing COVID-19 vaccine inequity amidst booster doses: charting a bold path for global health solidarity, together. Glob Health. 2022;18: 1–4.
4. Binagwaho A, Mathewos K. Infectious disease outbreaks highlight gender inequity. Nat Microbiol. 2022;7: 361–362.
5. Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020;396: 1204–1222.
6. Vaccine equity: A fundamental imperative in the fight against COVID-19. PLoS Med. 2022;19: e1003948. doi:10.1371/journal.pmed.1003948
7. United Nations. The 17 goals. Sustainable Development Goals. Available: https://sdgs.un.org/goals [Accessed July 14, 2023]
8. Zhao W, Yin C, Hua T, Meadows ME, Li Y, Liu Y, et al. Achieving the Sustainable Development Goals in the post-pandemic era. Humanit Soc Sci Commun. 2022;9: 1–7.
9. Debie A, Khatri RB, Assefa Y. Successes and challenges of health systems governance towards universal health coverage and global health security: a narrative review and synthesis of the literature. Health Res Policy Syst. 2022;20: 50.
10. Medicine TLR. Future pandemics: failing to prepare means preparing to fail. Lancet Respir Med. 2022;10: 221–222. doi:10.1016/S2213-2600(22)00056-X
11. Global Sustainable Development Report 2023. Advance, Unedited Version, 14 June 2023. Available: https://sdgs.un.org/sites/default/files/2023-06/Advance%20unedited%20GSDR%2014June2023.pdf [Accessed July 15, 2023]
12. Garcia-Basteiro AL, Abimbola S. The challenges of defining global health research. BMJ Glob Health. 2021;6. doi:10.1136/bmjgh-2021-008169
13. Sinclair JR. Importance of a One Health approach in advancing global health security and the Sustainable Development Goals. Rev Sci Tech Int Off Epizoot. 2019;38: 145–154. doi:10.20506/rst.38.1.2949
14. Walsh TR, Gales AC, Laxminarayan R, Dodd PC. Antimicrobial Resistance: Addressing a Global Threat to Humanity. Plos Medicine. Public Library of Science San Francisco, CA USA; 2023. p. e1004264.
15. Odeny B. Closing the health equity gap: A role for implementation science? PLoS Med. 2021;18: e1003762. doi:10.1371/journal.pmed.1003762