Nevertheless, while global health’s mission has already expanded from protecting colonizers from disease to improving health equity worldwide, it can be argued that there are still some signs of colonialism lingering in the field. Old colonial powers still very much control the restricted space of global health policy and decision-making – though the rise of China’s Silk and Belt Road and the backlash against globalization as shown by Brexit and Trumpism may also be initial signs of (global health) crumbling empires. Recent decades have seen the birth of neocolonizers – from non-state actors without legitimacy to emerging economies demanding a seat at the table – that rather than offer a new narrative, end up helping perpetuate the status quo. Meanwhile, dissidents and emerging voices from the Global South still largely assume token positions in global health discussions instead of playing meaningful roles in global health operations – though I would be remiss to ignore programs such as the Emerging Voices for Global Health from which I greatly benefited and that are attempting to, borrowing this blog’s tagline, switch the poles in international health policy.

The past months have seen a surge of interest in the idea to decolonize global health. Late last year, I started a hashtag #DecolonizeGlobalHealth on Twitter which generated some initial feedback and suggestions, especially from fellow young Global South voices. Some even reiterated that the growing movement towards advancing women leadership in global health is deeply intertwined with progress in global health decolonization. Last week, my fellow students at Harvard organized a conference on the decolonization of global health, whose slots were not just immediately filled but which was also widely anticipated in livestream worldwide. (I missed the conference because I’m currently based in the Philippines finishing my doctoral thesis. As part of my decolonization project, it was my intentional choice to focus on a community-based action project in my home country rather than write a global health policy paper for an international organization.) In the past weeks, I was approached by some colleagues asking what can be done to move this conversation from Twitter to the real world.

But what do we really mean by #DecolonizeGlobalHealth? In order to prevent this new concept to end up becoming a buzzword that will later fade away, it is vital that the global health community of scholars and practitioners unpack, examine, and reflect upon this idea. From my view, there are at least three areas of inquiry where researchers and policy-makers can ask questions, debate ideas, and find answers.

1) The analysis of global health. All global health action emanates from a certain understanding of the world. There are values, assumptions and premises on which decisions and relational arrangements are based, and frameworks for analysis define the boundaries and dictate who is included and who is not. Just a few years ago, developing countries were still generally seen as mere recipients of charity and generosity, bereft of good ideas and innovation, and possessing limited potential for leadership. Along the same lines, ‘capacity-building’ of poor countries was (is?) a ‘white man’s burden’ of the ‘developed world’. Today, arguably, new narratives are evolving, moving away from the traditional donor-recipient relationship towards country ownership and partnership – though some may feel that this is more rhetoric than practice.

Territorial colonialism may be long over, but the colonization of the mind, of culture, of domestic politics and of the economy continues and reparations are yet to be realized. Meanwhile, colonial powers did not just dominate over foreign lands – the Western mindset of progress and capitalist ‘development’ (copied pretty much everywhere in the world now) also exerted enormous pressures on the very Earth that sustains our health and wellbeing, leading to the climate crisis that puts our future health at great risk in return. The new frame of planetary health offers the best form of hope – but it will require a deep expression of humility from planetary colonizers of all forms – countries and corporations alike.

2) The institutions of global health. Who are the agents of modern-day colonialism in global health? This question requires scrutiny of a wide range of actors – from formal institutions such as the WHO and World Bank, to non-state players such as the Gates Foundation and the pharmaceutical industry, to influential personalities that control what Richard Horton once called (on Twitter) the ‘old boys’ club’ of global health – whether they are in Lancet Commissions, Twitter feeds, or conference organizing committees. One time, I saw an academic tweeting a photo of an all-white global health meeting – I thought ‘global’ was more colorful than that!

Promoting diversity and inclusion in boards and staff of global health organizations is a good first step. For instance, apart from UN agencies and philanthropic foundations, I have always wondered about the composition of global health departments in elite schools of public health. A quick count of faculty members in my alma mater, Harvard Chan School, shows that out of 35 primary faculty at the Department of Global Health and Population, only 13 have non-Western-sounding names and 14 are non-white or white Latin Americans. Only 1 professor worked in a developing country immediately prior to joining the faculty, which may indicate that almost everyone from the Global South stayed in the US or Europe either prior or shortly after graduate school. One piece of good news is that a Brazilian professor just got appointed as department chair, replacing a Sudanese who served for seven years.

But decolonizing global health actors is more than having additional Global South seats in still-colonial organizations. Colorful composition does not automatically mean transformed structures and changed values. To decolonize institutions, there is a need to retell the story, rewrite the rules, and even redesign the system.

3) The processes of global health. Finally, apart from critiquing the starting framework and the cast of characters, it is also important to investigate the processes that animate the global health space. The management of organizations, shaping of rules, making of decisions, generation of knowledge, and allocation of resources are just some examples.

Let me describe two processes that receive little attention. Part of the decolonization of processes is to level the playing field so that emerging scholars and practitioners from the Global South can have a chance. The first are the procedures and requirements governing journal publications. I once had my Global South-perspective commentary about a novel emerging issue rejected not because of it being not well-written but because of ‘oversubscription’ and ‘lack of space.’ Meanwhile, a colleague from the Global North who has clearly penetrated the ‘old boys’ club’ published six commentaries within a six-month period in that same journal – or at a rate of one article per month!

Another area that needs to be examined is the recruitment of global health professionals and how their work is recognized. To illustrate, a year-long stint done in a developing country by a colleague from a rich country will be counted as ‘global health experience.’ Meanwhile, coming from a developing country in the process of health reform, my decade-long contributions at home will be considered only ‘domestic work.’ This means there is a high chance that the development bank, which counts the number of countries an applicant has worked in, will hire the other and not me.

Some initial steps: write, mobilize, reflect

To start global health’s decolonization and rewrite its narrative, more Global South scholars and practitioners must begin writing and talking about global health – its analysis, institutions, and processes – as they see it. There is nothing to fear about sounding politically incorrect – after all, there is nothing politically correct about colonialism. But there is always room for a respectful conversation.

As an indication of the need for alternative global health stories, only seven of the global health books included in a list recently generated from a Twitter survey are written by a Global South author (plus Global Health Watch by the People’s Health Movement, and not counting Harvard-based Amartya Sen). Meanwhile, Paul Farmer – the white Harvard doctor who would cure the world – has six books out of 100 – five written by him, and one about him. (Don’t get me wrong – I admire him and his work.)

Another essential step is to ensure that the decolonization discourse does not only occur in Twitter-verse and global health reunions. Decolonization begins at home, and so movement-building at the country level is crucial. A Global South expert sitting comfortably at a desk in Geneva is not decolonization. #DecolonizeGlobalHealth must inspire a new generation of global health leaders to question the status quo and take bold action at home and elsewhere.

Finally, for us who were educated in schools of public health that are based in former colonizers or were agents of colonialism themselves, we need to be constantly reflexive about our position of privilege. We might not be noticing it, but in our pursuit to decolonize global health, we could very well end up becoming neocolonizers ourselves.

While PMAC has been running since 2007, this is only my fourth time to attend this event. (See my blog about PMAC 2015 here.) Every year, this by-invitation-only conference revolves around a specific theme – and for 2019, it was the political economy of noncommunicable diseases (NCDs). This year’s opening speaker, Harvard professor Michael Reich, lauded PMAC for being the first global health conference to include “political economy” in its title. Inspired by Harold Laswell’s definition of “politics” – “who gets what, when, and how” – Prof. Reich offered a simple definition of “political economy” for PMAC’s audience – “how the allocation of political resources and economic resources affects who gets what, when, and how.”

While the focus of the conference was NCDs, one can’t help but use the same lens to understand PMAC itself as it unfolded. Recently, there has been so much buzz about global health conferences – from declined visa applications among Global South delegates to lack of representation in panels based on gender, nationality, and intersectionality. While a full-blown political economy analysis of “who gets what, when, and how” merits a longer academic paper (though Chatham House’s Rachel Thompson did a good job in a recent blog, drawing from her insider perspective), let’s do a quick-and-dirty description of “who gets invited, who doesn’t, and so what” – PMAC style. Here’s my part-ethnography, part-Twitter analysis:

Voices old and new

One of the biggest annual reunions of global health’s ‘Who’s Who,’ PMAC 2019 was more than a venue for political economy discourse; it was a sneak preview of global health’s political economy in action. As expected, the World Bank’s Tim Evans was there not just for one but two plenaries. Meanwhile, I’m not sure if anyone noticed the absence of Svetlana Axelrod, WHO’s assistant director-general for NCDs, though there was a sprinkling of WHO staff working on NCDs from Geneva and regional offices.

Of course, this is the time to shine for Thailand, as its hardworking public health specialists showcased the country’s impressive achievements from its Universal Health Coverage program to Health Promotion Fund. Various UN agencies, financial institutions, foundations, and nongovernmental organizations, especially those devoted to NCDs (such as the new Bloomberg-funded initiative Resolve to Save Lives led by former US CDC head Tom Frieden), were present as well. Due to Thailand’s location, PMAC also invites seasoned and emerging public health specialists from Southeast Asia – myself included.

While Richard Horton was sorely missed, the Lancet’s imprint was very much felt through the newly-launched Syndemic Commission linking obesity, undernutrition, and climate change. (These Lancet commissions are another agent of global health policy worthy of political economy analysis.) Meanwhile, as one of Global South’s most passionate planetary health advocates, I was elated that PMAC also had a few of us ‘voices in the wilderness’ talking about the more upstream environmental (non-behavioral) drivers of NCDs. (Dear Thai friends, here’s my suggestion for PMAC 2021 theme – “Planetary Health: A New Paradigm for Global Health.” Let’s do it before it’s too late!)

In the spirit of much-invoked and eternally-fuzzy ‘multisectoral collaboration,’ PMAC also invited a few representatives from the ‘industry’ as well. One notable guest came from the International Food and Beverage Alliance, who during the opening panel urged the audience to stop viewing the food industry as a ‘monolith’ and instead begin classifying individual companies into allies and enemies. What the speaker failed to say is under which category does IFBA – which includes Coca-Cola, PepsiCo, Nestle, and McDonald’s – belong. That would have been helpful in guiding how we in public health must engage with them – if at all.

Nonetheless, the presence of Big Food, Big Soda, and Big Alcohol (I suspect Big Tobacco was absent, or perhaps at least present discreetly) allowed NCD prevention advocates to tackle the ‘commercial determinants of health’ – global health academia’s newest buzzword – head on. From the audience, NCDFREE’s Rhea Saksena likened the ongoing interactions with industry to a ‘very tense couple’s counseling session,’ challenging companies to behave in a trustworthy manner if they want to be a ‘partner.’ Meanwhile, Paula Johns from Brazil remarked that “the best public-private partnership is taxation.” During the conference, there was general support for ‘sin taxes’ (which I suggest should be renamed ‘corporate sin tax’ to be precise), which Tim Evans described as a ‘triple win’; it does not only reduce consumption of unhealthy products and raise revenues for health – it also has an equity-enhancing effect.

Global health’s Desaparecidos

Like in any party, attending guests can’t help but look around and identify who were not invited. During the gala dinner, Suwit Wibulpolprasert, one of Thailand’s foremost public health leaders, started doing a roll call of Thai’s Fathers – the Father of Thai Universal Health Coverage, Father of Tobacco Control, etc. My seatmate whispered to me: “So many fathers – but where are the mothers?”

Meanwhile, my friend and colleague Mariam Parwaiz from New Zealand expressed her appreciation in the Twitter-verse: “Over 800 participants from 80 counties at #PMAC2019. One of the things that I really like about PMAC is that it’s a major #GlobalHealth conference that’s in the Global South. The future is Asia!” – to which I rapidly replied: “None of the keynote speakers though is from the #GlobalSouth #PMAC2019 #DecolonizeGlobalHealth.” Of course, I was not counting the Princess of Thailand who welcomed us all to the Kingdom.

Surely, concerns about lack of diversity and inclusion along the lines of gender, race, and nationality are not new but certainly need to be re-echoed. Johanna Ralston of the World Obesity Federation replied on Twitter that there was also an “absence of affected people as speakers other than a couple of side events #plwncd.” And while difficult questions were asked during sessions, another group hugely absent were the dissidents. A colleague told me that Thailand’s activist groups are generally not invited to PMAC each year. Thankfully, we have the People’s Health Movement – which another colleague described as PMAC’s ‘token opposition’ – boldly yet expectedly raising the difficult issues no one else will dare say in sanitized and well-scripted global health discussions. (Full disclosure: I’m a PHM supporter!)

Finally, there’s the big portion of our not-so-big global health family who generally did not see an invitation in their email inbox. My fellow Filipino colleague Gianna Gayle Amul, an emerging scholar from the National University of Singapore who is examining alcohol industry interference in Asia, tweeted her disappointment: “I thought I can just register and still come but apparently you can only do that if you actually have an official invitation… a little bit more exclusive #PMAC2019.” (By the way, Singapore is only two hours away from Bangkok! It should not have been difficult for her to come.)

The return of Margaret Chan

PMAC 2019 also appeared to be a homecoming party for Margaret Chan, former WHO Director-General – or as Suwit repetitively emphasized, DG Emeritus. After 2 years of being out of the limelight, Dr. Chan – herself a 1998 PMAC laureate – introduced herself as the global health czar of the China-led Boao Forum for Asia, which some already call the ‘Davos of Asia.’ Dr. Chan invited the PMAC crowd to fly to Qingdao in June 2019, where she is organizing the first Boao global health forum. (Another topic for a political economy PhD – the emergence of annual global health conferences hosted by countries especially in Asia – where the center of world gravity is shifting towards. Other examples include Taiwan’s Global Health Forum and Singapore’s Raffles Dialogue.)

During the gala dinner, Dr. Chan and Suwit unleashed their hidden talent by pulling off a stand-up comedy stunt, where they jested about whether she is still earning a salary from WHO or not (she said no), being ‘raised’ by her husband post-WHO, and how some physical distance is beneficial to marital relationships. She publicly admitted that her only failure as DG – or perhaps the only failure that she can admit in public – is not having been able to convince member states to pass a resolution on LGBT health. But when Suwit, PMAC’s mastermind, asked her on what the major driving force in global health in the next decade will be, Dr. Chan flatteringly remarked: “PMAC, PMAC, PMAC!” Then the two waltzed to the tune of Carpenters’ “Close to You.”

While she received deferential applause accorded to a former DG, her statements about engagement with industry drew mixed reviews. During the opening panel, Dr. Chan repeatedly emphasized that her stand on NCDs is clear – however, it felt more confusing than clear as she urged tackling the corporate drivers of NCDs on one hand and helping make the industry “good guys” while keeping their profit on the other. She also said she did not want to comment on Tedros’ plan to engage with the alcohol industry since “he is in-charge now.” Harvard professor Jesse Bump then reacted on Twitter: “Shameful performance: Margaret Chan sings and dances to avoid a question about whether @WHO should accept money from the alcohol industry at #PMAC2019, focused on #NCDs.”

Leadership beyond imagination

Given this year’s theme, PMAC was pressured to “walk the talk” by adding “Baby Shark” and other dance exercises at the start of sessions and installing food labels in buffet tables (though with lots of food wasted). This just shows that technical fixes in global health are quick and easy decorations. However, the real battle is how to get things done in a world where economic forces sell junk and the politics of change is controlled by a powerful few. This is what political economy is all about.

So what do we need to tackle the messy political economy of NCDs, of platforms such as PMAC, and of global health at large? I propose that it is strong, visionary, uncompromising leadership. Fellow Filipino Susan Mercado, former NCD head of WHO in the Western Pacific, eloquently articulated this during the plenary: “Leaders don’t work in the space that is easy. They work in the space that is beyond imagination.” I could say there were a few of them at PMAC 2019, but their tribe must increase.

May PMAC evolve into a space for courageous leadership and endless imagination. Kudos to the hardworking PMAC organizers – please don’t forget my invite next year!

Roopa (center) and Renzo (far right) with WHO Director-General Margaret Chan (2nd from left), UNICEF Executive Director Ann Veneman (2nd from right) and other youth delegates during the 30th-anniversary conference of the Alma Ata Declaration in 2008

It has been 40 years since the adoption of the Declaration of Alma-Ata, which reaffirmed that health is a fundamental human right and that gross inequalities in health are unacceptable. We agree.

Ten years ago, we were medical students, and attending the 30th-anniversary conference in Kazakhstan helped us become young global health leaders. It was our first time to participate in a global health conference and we were honored to be selected by the International Federation of Medical Students Associations (IFMSA), a global network of more than a million medical students, as its representatives. Our attendance was supported by the United Nations Children’s Fund (UNICEF), which was the co-architect of the Alma-Ata Declaration along with the World Health Organization (WHO) back in 1978.

Along with the other youth delegates, we stayed in Hotel Kazakhstan, which was built four decades ago for the participants of the original Alma-Ata conference. Beside it is the main hall where more than a thousand delegates witnessed the Declaration being signed by more than a hundred national governments, sealing their commitment to make primary health care – essential, scientifically sound, and socially acceptable health services – accessible to all people.

During that week, we listened to panel discussions and met with public health leaders from around the world. We even had a closed-door roundtable discussion with Margaret Chan and Ann Veneman, then the heads of WHO and UNICEF. As youngsters, we were both new to the global health arena, but we saw ourselves leading the youth delegates to draft a statement calling for meaningful participation of young people in strengthening primary health care around the world.

Renzo and Roopa with Professor Sir Michael Marmot, chair of the WHO Commission on Social Determinants of Health

While we were both students and thus neophytes to global health during that time, we both understood early on that we were there as spokespersons for the world’s youth and therefore should not allow ourselves to be victims of tokenism. We did not want our involvement in global health and the promotion of primary health care to end in Alma-Ata. Hence, we made a personal commitment, not just to remain connected after the conference, but to spread the messages of the conference to fellow young people globally and take on some serious global health challenges moving forward.

We both moved on to become leaders of our respective national medical student associations (American Medical Student Association and Asian Medical Students Association-Philippines), co-organized workshops in several countries, from Jakarta to Geneva, on topics as wide-ranging as the social determinants of health and global health diplomacy, and later assumed leadership roles in IFMSA as president (Roopa) and envoy to the WHO (Renzo), working together to advance youth participation in global health policy.

Ten years later, we are still in the frontlines of global health and there are no signs of stopping. In fact, we are only beginning our journey towards active engagement in global health – not as young students but as young-at-heart professionals imbued with youthful energy and optimism. The vision of Alma-Ata to achieve “Health for All” by year 2000 has already been long overdue, but new global health challenges have evolved, making our mission extra difficult.

Roopa speaking at the New Leaders for Health Forum organized by Renzo in the Philippines in 2015

Having experienced first-hand the challenges of being an emerging woman leader in the global health field, Roopa launched a global movement – Women in Global Health (WGH) – to shift the narrative from women as beneficiaries of global health initiatives to women as leaders and change agents of global health transformation. Global health delivery is diminished by gender inequality – ideas, innovation, expertise and talent are lost. With nearly 10,000 supporters from 70-plus countries, WGH is working to transform today’s environments such that all genders, especially women can thrive and reach their maximum leadership potential. Today, the movement continues to spread around the world, with the new annual conferences, high-level reports, and even major reforms in the leadership composition of the WHO cabinet.

Meanwhile, coming from one of the most climate-vulnerable countries in the world, Renzo has taken on the challenge of transforming health systems worldwide to become more resilient in the era of climate change. He has grown into one of the freshest voices in the emerging field of planetary health, working hard to build bridges across disciplines, sectors, geographies, and generations in advancing the health of both people and the planet. At present, he serves in the editorial advisory board of the new journal The Lancet Planetary Health, is finishing his doctoral thesis on building climate-smart local health systems in the developing world, and is now establishing PH Lab in the Philippines that will generate innovative solutions for the world’s pressing public health and planetary health challenges.

Renzo and Roopa today

When we both set foot in Alma-Ata ten years ago, we had no clue that it would be a launching point for us for an exciting journey in global health – one that would be parallel but at many times intertwining. For instance, the Declaration did not highlight the importance of women participation in primary health care, and it mentioned environmental concerns only in passing, so in a way, we both reinvented Alma-Ata. We claimed it as ours and made it relevant to the changing times since women continue to be undervalued and as the planet endures a slow-burn crisis – both of which are detrimental to the future of global health.

Ten years hence, on the Declaration’s 40th anniversary, we both return to Kazakhstan, this time in its capital Astana, to convey our energy and passion to a new generation of young primary health care leaders. New declarations may be made, but we still carry in our hearts the lessons we learned from Alma-Ata and reaffirm the promise we made – to do our part in making “Health for All” a reality within our lifetime.

Both Renzo and Roopa are alumni of the Emerging Voices for Global Health (EV4GH) program.

However, what makes planetary health unique, as compared to other fields or disciplines, is that the domain that it seeks to address, as Kristof already implied, is bound by a very tight timeframe. In general, the pace of human action has lagged behind Mother Nature’s accelerated environmental change – take for example the 21 years it took for countries to negotiate a climate agreement. A fellow Filipino scholar, Laurence Delina, was even suggesting in his new book that a global crisis such as climate change requires rapid action similar to war-time mobilization. While planetary health carries a more constructive, and not a belligerent, tone, it can become a unique opportunity for catching up for lost time – but only if it wants to.

So what should the planetary health community do to accelerate its pace? Kristof proposed that we need to start with the individual. He urged planetary health proponents to curb carbon emissions from air travel, to immerse in local communities (perhaps especially in places already affected by planetary health challenges), and to even take two months off from work (which I suppose is to not just limit personal environmental footprint, but also to give oneself a time for restoring energy and wellbeing). While I do not disagree with these specific activities (and I am sure there are much more), I think what he is implying is that planetary health should be framed as a way of life, not just a novel academic curiosity. We therefore need to think deeper on what actions and behaviors constitute a planetary health way of living, and be the first ones to internalize and practice them and lead the rest of the world by example.

In my young global health (or if you like, planetary health) career, I certainly have emitted way less carbon dioxide to the atmosphere than the likes of Richard Horton or Larry Summers which Kristof mentioned (By the way, Larry Summers is not yet involved in the planetary health community, but maybe we should recruit him.). But as I become more involved in the promotion and development of the planetary health idea, I certainly am learning to appreciate the value of consistency, making sure that I walk the talk. This is to ensure that I do not contribute to global pollution but also to serve as a genuine role model for others and enhance my credibility as a planetary health leader (or simply, planetary healer). We can only convince others to follow suit if we practice what we preach.

For instance, while air travel is not totally unavoidable in our profession, it can be hugely minimized or at least optimized. My most recent flight was a month ago to London, and within a week, I was able to spend time bonding with my aunt, take a short course in Oxford, meet a dozen friends in London, and hold meetings with UK’s leading professors, including the chair of the Planetary Health commission and former director of LSHTM, Professor Sir Andy Haines, who is one of the planetary health leaders I know who is walking the talk. He came to our meeting with his bicycle, biker vest, and helmet, told me that he is skipping the inaugural Planetary Health conference to reduce his travel-related emissions, and preferred to hold more Skype meetings and webinars in the future instead. Leading planetary health thinkers as well as international organizations such as WHO and the Rockefeller Foundation should emulate his example.

To motivate us further, perhaps what should be introduced is a metric that assesses the amount of impact made for every amount of CO₂ emitted, say as a result of international travel. Impact can be measured in many ways and may include various elements, but this is a subject for further investigation. Nonetheless, measuring impact over emissions would mean that planetary health advocates and global health leaders must avoid flying to a country to just give an hour-long lecture, or they should maximize doing impactful activities if air travel is unavoidable. Carbon-negative activities like planting trees can also be pursued by individuals to offset low impact and high emission activities. Of course, this way of tracking individual carbon footprint may be both academically interesting and logistically complicated, but the point is that such formula should be kept in mind especially by scientists who engage in planetary health research and leaders who love giving planetary health prescriptions. Another concrete suggestion is for the planetary health community, along with other related communities such as One Health and EcoHealth, to merge their separate convenings and hold longer, less frequent, and more results-oriented conferences instead.

For sure, leading by example is powerful but not necessarily fast in generating results. And so to complement this, Kristof gave a reminder: “Only if planetary health proponents team up consistently and structurally with the people fighting inequality in the world, we have a chance to pull this off in a generation.” I certainly agree that the planetary health community should reach out to other communities as soon as possible, especially those whom we share the same values with. For example, in 2015, during COP21 in Paris, I already made a case on why #ClimateHealth and #HealthForAll are two sister agendas, and therefore the sustainable development and universal health coverage communities should work together more closely. The Commission’s report already recognized that planetary health challenges are rooted in social, economic, and political arrangements, and so engaging with communities and movements working on these areas is necessary. A question that the planetary health community should answer is, who is the effective messenger of the message and builder of bridges? We need to identify individuals and institutions that can navigate these spheres and build alliances founded not merely on branding and academic achievement, but on inclusivity, diversity, solidarity, and trust.

With all fairness, the young planetary health community has already begun putting together the ingredients of a new field. After the release of a landmark report, the Planetary Health Alliance was established and housed in Harvard (Right now, I interact with them a lot, but I’m not even a member myself since it only allows institutional membership for now); The Lancet Planetary Health – dubbed “a new journal for a new discipline” – was launched (and I was privileged to be invited to the Editorial Advisory Board); and an annual conference, which will be inaugurated this weekend (and I am leading a delegation of Harvard’s Sustainability & Health Student Forum). But now that the scientific foundations have been laid, the equally-important social foundation must be built. Maybe it already exists and therefore there is no need to reinvent the wheel. For indigenous peoples and social movements, the oneness of humanity and nature is not a new concept at all, and perhaps for them, planetary health is old wine in a new bottle and the scientific elite, by coining a new term, have gotten it just now. While introduced by Harvard, Rockefeller, and The Lancet, planetary health cannot remain in these elite spaces, and instead be spread as fast as possible across disciplines, sectors, geographies, and generations. Just like for many innovative ideas in history, the success of planetary health does not merely lie on its proponents, but on people from places far and wide who will accept the baton and advance it. As someone who lives in a country at the heart of the climate crisis, I am personally committed to spread this powerful concept to communities where planetary health challenges are most real.

From the other side of the world, Lawrence Loh from Toronto, who is a fellow alumnus at the International Federation of Medical Students’ Associations (IFMSA), lamented the misuse of the term ‘public health’ by physicians. He noticed that it is becoming ‘more and more common to find someone who is “practicing” public health,’ and therefore proposed to clarify the distinction between ‘practicing public health and incorporating a public health issue into one’s practice’ to avoid ‘further confusion around the role of public health physicians.’

These conversations in social media, at least among my doctor friends, are a positive sign of rapidly growing interest in public health among today’s generation of physicians – perhaps this era can be called public health’s ‘renaissance,’ perhaps more precisely in the developing world. For instance, since I have ‘retired’ from IFMSA after medical school, at least 20 fellow junior doctors from developing countries have sought for my advice on how to shape their public health careers – perhaps they were deceived by my FB posts depicting my public health adventures. What many don’t know is that I had to understand the tricks of the trade myself, learning public health as I do it. It is only now that I am about to pursue a formal advanced training in public health beginning this July.

I would surmise that this resurgence of the field especially in the developing world is brought about by many developments around us – the changing global social and political context (like the recent election of a new president in my country); the general dissatisfaction towards our chronic public health challenges especially persistent health inequities; the increasing anticipation of emerging health threats such as pandemics and climate change; the emergence of ‘hegemonic’ ideas in health such as ‘universal health coverage,’ ‘sustainable development,’ ‘resilience’ and the like; the rapid spread of technology that allows global learning and dissemination of knowledge; the increasing attractiveness and accessibility of public health courses, trainings, and conferences; the recognition that developing countries need to build their domestic capacity for public health and not rely anymore solely on external help, to name a few.

With this acknowledgment of public health’s growing importance also comes the deep understanding that before the abovementioned daunting challenges can be addressed head on, there is a need to put the house in order first. As an enthusiast of history of medicine and public health, I will be citing several enduring messages that still haunt us from the past that can aid us in reimagining public health in our time, in our own settings. For instance, in the United States, the Institute of Medicine already noted nearly three decades ago that their public health system was in ‘disarray,’ which led to the defining of 10 essential public health services, delineating the roles of public health agencies and professionals alike and later adopted by other countries. [Of course, and it is important to make this distinction, that despite this, it took them two more decades to fix their system of financing of personal care services (as compared to public health services) through Obamacare, which remains a work-in-progress until today.]

Today, public health practitioners in developing countries such as the Philippines are also noticing the ‘disarray,’ even triggering one colleague to point out in Facebook that public health first needs to be clearly defined, as doctors themselves do not get solid public health education in medical school. This can be tricky, as public health can be seen as a profession (as in public health professional), a specialty (like an MD specializing in public health), a system (as in public health system), an arena for action, a collection of issues, and ultimately a state of society (as in state of public health).

Nonetheless, since the recent online debates have focused on who should be considered as practitioners of public health, I will cite one definition that I believe still stands until today, even in our era when attempts to  separate global health from public health lead to, in my opinion, wasteful and lengthy academic discussions and even create more confusion. (For me, and I agree with America’s public health deans: global health is public health.) Going back to the definition, here it reads: ‘Public health is the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals’ – according to Charles-Edward Amory Winslow, the founder of the Yale School of Public Health, in his 1920 article in Science.

Recalling Lawrence’s concern about the protagonists in the public health field, and given this broad definition of public health as a ‘science’ and ‘art’ geared towards improving society overall, it is therefore vital to acknowledge that public health is and must be comprised of a diverse variety of people, and therefore these categories need to be identified for the purpose of education and capacity development, but also regulation and accountability. Before, the types of public health workers envisioned for the 20^th century were, I would say, much simpler than our workforce needs for today. “The public health servant may be teacher, research scholar, technical expert or administrator… Public health work is therefore becoming, in fact, has already become, a separate profession. It has split off from medicine just as medicine long ago split off from the priesthood,” remarked in a 1915 JAMA article by Milton Rosenau, who at the time was the first director of the Harvard–Massachusetts Institute of Technology School for Health Officers – precursor to Harvard’s public health school.

Today, public health professionals are not anymore just the ‘teacher, research scholar, technical expert or administrator’ that Rosenau envisaged a century ago. At least in the United States, the core competencies for public health professionals have already been clearly defined, yet are constantly reviewed and updated to ensure that public health education and practice are apt for the rapidly changing times. Furthermore, unlike before when Rosenau and his colleagues envisioned public health professionals graduating solely from a public health school, people in public health today hail from a wide array of disciplines such as economics, social sciences, engineering, environmental science, and international affairs, to name a few. Such diversity is essential because of the increasingly complex nature of public health challenges, as beautifully expressed by Julio Frenk, former dean of the Harvard T.H. Chan School of Public Health and former Minister of Mexico: public health is “a crossroads where multiple dimensions intersect: biology and society, individual and population, evidence and ethics, analysis and action.”

So how do we go forward? Going back to the situation in my home country, these are some of the present realities. First of all, public health is not a professional category of its own. What we have is a wide array of characters playing important roles in the arena of ‘public health.’ We have community medicine doctors (as well as nurses) who do not only render clinical services, but also perform public health tasks such as health facility management, disease surveillance, and health education, to name a few. We have doctors and nurses in the government-run hospital system which spans several levels – municipal, district, provincial, regional, national – who provide hospital care and perform administrative tasks – and by the virtue of them working in the public sector (as opposed to private sector), they are also considered by some as ‘public health’ workers. And we have non-health professionals – those who may have degrees in economics, social sciences, social work, public administration, etc. – who work in policy and research-oriented activities in government, civil society, and the private sector. All the aforementioned groups may not be necessarily trained (at least formally, for example through an MPH program) in public health, but we in the Philippines consider them as part of the ‘public health’ community – which I think is an imagined one, as there is no national body that provides roof for all of them, as Harvy noted in his FB post.

I think that public health schools have a critical role to play in ushering the needed transformation, and the recent FB conversations prompted me to dig from my treasure chest (aka external drive) a reflective essay I wrote in 2010 which I gave as a gift to Dr. Nina Gloriani, former dean of the University of the Philippines Manila College of Public Health. The College was one of the first public health schools in Asia established by the Rockefeller Foundation, which considers itself the inventor of modern public health, having funded the first schools of public health in Hopkins and Harvard, among others. I was a 4^th year medical student then, but having interacted with public health colleagues early on, I already knew that my mission is not in clinical medicine but in public health. And so, with my numerous engagements with the College across the medical school, I began to formulate at a young age my personal vision for the practice of public health with the leadership role of the College in mind. Some of my ideas articulated in the essay have already evolved since, yet I never imagined that this essay of a 22-year old medical student would still hold true and be relevant today.

The FB threads as well as my dusty old essay have articulated some common proposals, such as the creation of a national association of public health and formulation of a document that lays down what constitutes the practice of public health (similar to the Philippines’ Medical Act governing the practice of physicians). Such institutions and frameworks can aid public health workforce planning, including the establishment of new agencies that address persistent public health gaps, possible creation of new job items for public health in government, and unloading of public health-related tasks traditionally assumed by clinicians (doctors and nurses alike) who already have enormous responsibilities in healthcare delivery. Ultimately, perhaps an endeavor that can be considered is a comprehensive report to be written by a national commission of experts and leaders, which will examine the future public health needs of the country, determine the kind of public health system we need, and identify the competencies that public health professionals should acquire, similar to the landmark Welch-Rose Report of 1916 that served as the basis of American, and later international public health.

For us in the communities of global health and health policy and systems research (HPSR), our active participation in this global discourse about the future of public health is very critical. Such definitions and debates have huge implications in the way we conduct our research, design health infrastructure, influence health policies, and ultimately strengthen health systems around the world. We should not let pass this rare opportunity to help reimagine public health in the 21^st century.

Last January 29-31, 2016, I was blessed to attend the Prince Mahidol Award Conference (PMAC) – Thailand’s annual global health event – for the third time, and I felt very elated that this year’s award for public health went to Sir Michael Marmot – a global health icon who of course needs no introduction. This news did not come as a surprise though – I remember, it was December 2014, during a meeting of our committee on social determinants of health and transformative health workforce education at WHO in Geneva, a few of us were pondering about the possibility of the Prince Mahidol Award being given to Professor Marmot. Months later, I met Sir Michael in Kolkata under what looked like a banyan tree (making him appear like a true guru!), and to my surprise he exclaimed: “Thank you for suggesting my nomination!” I’m sure it was an idea of many and not one, but my shock was towards my discovery that he already knows! (Of course he would know, as he was asked by the awards committee to submit many documents.)

Actually, on my way to PMAC, I was reading his latest book, “The Health Gap.” I made sure to bring my hardbound copy to Bangkok, and even dropped by Kinokuniya (a bookstore) to buy two more, so that I have back-up copies should my first copy get drenched in the rain (in tropical Manila of course!). On the first day of PMAC, Sir Michael had a book signing session. Because I was busily interacting with colleagues, I ended up being at the end of the queue. Then, it was the end – the staff are pulling him out as he was expected to meet the Prime Minister that afternoon. To catch his attention, I shouted “Congratulations!” and ran to him. We had a bit of chat but he was already being literally pulled by the Thai guards as if a prisoner. I saw his beaming smile turn into an apologetic grin, as he cannot anymore stay upon orders from the palace. Because he was not able to sign my three copies, I will have to wait – and I told him, I’ll bring them all should I drop by London in the unforeseeable future. Meanwhile, I decided to return the favor – and so I wrote this essay!

Going back to the book, “The Health Gap” is indeed an enthralling read. I am notorious for not finishing my books, but this one couldn’t slip away from my hands. Certainly I am biased – my dedication is partly because of my personal admiration for Sir Michael and his contributions to public health. But in this book, one will see a different kind of Sir Michael, which makes it mesmerizing. I am used to reading his journal articles such as the Whitehall II Study, or the 200-plus page report of the WHO Commission on Social Determinants of Health which he chaired from 2005-2008, or the Marmot Review of health inequalities in England, or his Lancet commentaries, or his book “The Status Syndrome” which could be described as the “laymanized” version of all the other things I just mentioned.

Meanwhile, in “The Health Gap,” it is not only Sir Michael the social epidemiologist who is speaking – I was hearing Sir Michael the philosopher too. For instance, his accounts of his personal journey trying to reconcile his public health evidence with philosophical theories were enlightening as well as inspiring to a young physician like me who learned very little philosophy in the confines of the medical school. Quoting philosophers such as John Rawls and Amartya Sen is surely taboo for the world’s most rigid medical journals, but in his book, Sir Michael was free to converse with these great thinkers, albeit imaginatively, through his musings about health equity and social justice.

In one part, he even suggested that health could be the answer to many of the age-old philosophical debates that still persist today – no one wants to be un-healthy, and health can be viewed as the ultimate manifestation of justice in society. I’m not quite sure though if the technocrats from the World Bank and other international agencies – who, by the way, were also present in PMAC, if not dominating the speakers’ list in the conference sessions – are ready to cut their addiction to Gross Domestic Product and other economic measures of “development” and instead heed the proposal of Sir Michael and use health as the real indicator of progress. (By the way, the book also narrates Sir Michael’s experience being trapped in a room full of economists, witnessing their irrational devotion to “rational choice” and “utility” – but I will not spoil it for your ultimate reading experience!)

A global health rockstar’s autograph. Sir Michael Marmot signing a copy of the report of the WHO Commission on Social Determinants of Health as Renzo looks on, Copenhagen, August 2011.

Nonetheless, Sir Michael acknowledges the importance of improving the economy and all things that comprise “the conditions in which people are born, grow, live, work and age” – in short, the social determinants of health. And he is pretty consistent about this in his book, as the bulk of the chapters delved into specific priority determinants that need to be addressed such as early childhood development, education, employment, and community resilience. He and the Commission that he headed had repeatedly emphasized that it is not just the healthcare system that enhances health and closes the health divide – it was ironic though that this year’s PMAC, where his advocacy for social determinants was recognized, focused on the theme “Priority Setting for Universal Health Coverage,” looking into things such as assessments of health technologies using cost-effectiveness tools and decision-making processes for who gets what in terms of health services.

These are all important, but not sufficient, as action on the social determinants of health is what is truly needed to close the health gap. Sadly, in one panel during the conference, a World Bank representative even said that while he acknowledges the importance of social determinants, they are difficult to measure, and therefore difficult to fund. He even admitted that the myriad departments of the World Bank, which I believe is the world body that covers the greatest number of social determinants, find it difficult to even talk to each other. I felt sad upon hearing this, my idealism and longing for a “World Bank” of ideas and solutions to social determinants being temporarily crushed.

But it seems there is hope. Nearing towards the end of the book, I got personally moved when Sir Michael wrote about the World Conference on Social Determinants of Health held in Rio de Janeiro in 2011. He was particularly proud about that conference, which was in a way a gift to him by the Brazilian government and other Member States and a concrete expression of their commitment to addressing the social determinants of health. However, the Rio Political Declaration that came out of the conference lacked the ambition of his Commission’s report, and here Sir Michael talked about the statement that was distributed to the conference delegates at the closing plenary by the International Federation of Medical Students’ Associations (IFMSA), “[pointing] out [that] inequities in power, money, and resources were airbrushed from the Rio Declaration – too strong for ministerial stomachs.”

This portion gave me goosebumps, because, as the head of the 10-member medical student delegation of IFMSA – the only 10 young people in a sea of a thousand ministers, public health experts, and advocates – I was blessed to have been given the opportunity to lead the drafting of what Sir Michael once called the “alternative Rio declaration.” By putting it in his book, he made that simple gesture historic. And he did not just do it once – he also wrote about our statement in his chapter in the second edition of “Social Epidemiology” by Berkman, Kawachi, and Glymour – the official textbook of the discipline. I never imagined that such a statement coming from the youth would make a huge impact on him.

I now look back at 2011, the first time I met Sir Michael in person – it was in Denmark, during the 60^th anniversary conference of IFMSA. My task was to moderate the session in which he was our keynote speaker, but the energy in the room, the passion of the medical student audience, and the inspiration of Sir Michael were just so difficult to moderate that the session extended for 3 hours! Certainly, that was bad moderation, but the impact that session made on IFMSA and the world’s medical students is certainly not bad at all! Sir Michael would repeat to me during several encounters that followed that one Minister of Health even approached him during a WHO conference, saying that he learned about him through his daughter who listened to his inspiring lecture on that cold morning in Copenhagen. That IFMSA event turned Sir Michael the epidemiologist and philosopher into a global health rockstar! (And these blogs by medical students who attended that conference are enough proof – here and here!)

And of course, among the world’s medical students, there was me, whose career as a doctor and whose views on health and society were helped shaped by Sir Michael and his scholarship. Our several encounters between IFMSA and PMAC, our various indirect engagements (through the Lancet-University of Oslo Commission and the WHO committee on transformative education), and his writings such as “The Health Gap” were all transformational. Amused by my eclectic concern for all things public health, someone asked me recently, “Why don’t you stick to working on social determinants of health? Why do you still dip your feet into a variety of issues, from universal health coverage to migrant health to climate change?” My response was simple: “Aren’t these the arenas where the social determinants of health operate?”

The social determinants of health approach, further advanced by the works of Sir Michael and many other public health thinkers who went before and who followed him, reminds us all that the challenge of the 21^st century is health inequity, the solution to this challenge cannot be siloed into disciplines anymore, and the vision for global health should that be of social justice. But as I implied, this is not a brand new idea – Hippocrates and Virchow have articulated it, Alma Ata put it on paper, and now, scientist-philosophers such as Sir Michael Marmot are telling us through a combination of rigorous evidence and deep philosophy the concrete ways for turning these visions into reality. Maybe soon we will be witnessing a great revival of these ideas and values, now that Sir Michael is the leader of the world’s doctors as the new president of the World Medical Association. Hopefully, this is the time to reorient the global health community to look to health equity and its social determinants and to listen to the gospel of Sir Michael. Just like his Prince Mahidol Award, which I think is long overdue though, change is never too late.

A 2014 Emerging Voice for Global Health, Renzo Guinto, MD is the campaigner for the Healthy Energy Initiative of Health Care Without Harm (HCWH)-Asia, director of #Reimagine Global Health, and co-investigator at the Universal Health Care Study Group at the University of the Philippines Manila. Recently named 2016 Aspen New Voices Fellow by the Aspen Institute, he played a leadership role in institutionalizing the social determinants of health approach in the International Federation of Medical Students’ Associations as the founding coordinator of the IFMSA Global Health Equity Initiative and later Liaison Officer to the WHO back in his student days.

Let me pick some of the titles from this collection that caught my attention: “Paris deal: Epic fail on a planetary scale”; “At COP21, the world agreed to increase emissions”; “COP21: in spite of the show, the glass is 80% empty”; “Talks in the city of light generate more heat”. The Guardian’s George Monbiot perhaps sums up best the perspectives and interpretations of the essays in the collection: “By comparison to what it could have been, it’s a miracle. By comparison to what it should have been, it’s a disaster.”

The articles are in sharp contrast with the celebratory tone manifested in reports made by traditional media. Certainly, the authors cannot be blamed for the mixed emotions, perhaps more accurately leaning more towards the side of disappointment and despair. Of course, as early as now, many are doubtful of the accord’s implementation, especially with a global governance system that is notorious for flowery declarations, inconsistent enforcement, and weak accountability. But the text in itself is enough a cause for grave concern, from its weak references to human rights (the right to health is mentioned only in the preamble) and vulnerable groups (such as indigenous populations) to vague implementation mechanisms (such as raising the 100 billion USD commitment for climate finance). (For an easy-to-read analysis, see this infographic.) Countries may have reached an agreement at last, but we also know that the treaty did not reach the kind of ambition that science is prescribing and people are demanding, especially that “we aren’t just talking about the weather,” as this powerful poem delivered at the Climate and Health Summit says.

Fast forward, two days ago, I opened the New Year by giving a 2-hour lecture on climate change and health to an audience of around 500 medical students and faculty. In my talk, I discussed the projected health impacts of climate change (250,000 deaths annually beginning in 2030 and 7 million annually due to short-lived climate pollutants, according to WHO; reversal of 50 years of global health gains, says the 2015 Lancet Commission); shared my thoughts on how the health sector can, recalling the Hippocratic commandment, “do no harm” on both people and planet (Learn more about my organization, Health Care Without Harm, and our two flagship programs: Global Green and Healthy Hospitals and Healthy Energy Initiative); gave updates about the health sector’s presence at COP 21 (especially the successful Climate and Health Summit, along with numerous health-related side events); and even showed our selfie with WHO Director-General Dr. Margaret Chan, who after a climate and health side event that Lancet Editor-in-Chief Richard Horton hailed as “COP 21’s most important side event,” ordered us young doctors to actively engage with climate negotiators to ensure that health is central in the climate treaty. (In fact, the climate treaty is a health treaty!)

Do we look depressed? Renzo takes a post-COP 21 selfie with WHO Director-General Dr. Margaret Chan and fellow health professionals

During the open forum, a medical student asked me a question, quoting the eminent environmental scientist James Lovelock (originator of the Gaia Hypothesis, saying that the Earth is a single living self-regulating system): “He expressed early on that we should have addressed climate change decades ago, that it’s already too late to solve it, and so should we give up?”

Of course I was impressed that at least one medical student in the audience had been tracking climate-related literature (and I hope more health professionals will follow suit, and that climate change be incorporated in health professions curriculums), but also acknowledged that his was a difficult question. But I then used my doctor’s hat and responded: “When we are in the emergency room and faced with a severely sick or injured patient, perhaps with unstable vital signs, a large open wound or even two, we do not give up on the patient, right?”

I know it may appear a lousy attempt to answer a challenging query, but my fellow health professionals will understand where I am coming from. That is what makes the profession of medicine and public health, the vocation of healing, unique – we never give up. And in my work so far, I have personally engaged with health systems, hospitals, and communities, all never giving up and trying to tackle climate change to protect people’s health. For instance, we in the Philippines have started mobilizing the health sector for what we call “The BIG SHOW” – the transition to healthy, renewable energy that is not only necessary, but possible. Prior to Paris, we launched the Paris Platform for Healthy Energy, which laid out our proposals for addressing the climate-energy-health nexus. On the other hand, integrating climate resilience in health systems is very compatible with the universal health coverage agenda.

Members of the Global Climate and Health Alliance present at COP 21

Indeed, much can still be done. I could say that the global climate and health community left Paris much stronger than ever before. Good thing that before we split ways, Dr. Maria Neira, the energetic director of WHO’s Department of Public Health, Environmental and Social Determinants of Health which manages WHO’s work on climate change and health, gave us a reminder in order to allay our fears and worries in advance: “After COP 21, we cannot have post-partum depression. We must begin developing a post-COP 21 plan for the health sector now.”

And so, to begin my personal post-COP 21 plan, shortly before flying back home, on the day after the adoption of the Paris Agreement, I immediately made a brief “side trip” to Rome to attend the Sunday Angelus at St. Peter’s Square to hear from the world leader who reminded us that climate change is, first and foremost, humanity’s moral crisis. From his small and distant window in Vatican’s Apostolic Palace, Pope Francis said: “With the hope that special attention for the most vulnerable populations is guaranteed, I exhort the whole international community to proceed on the path undertaken in the name of an ever more effective solidarity.” That in itself is enough a marching order for the future ahead of us.

Without post-COP 21 depression and with post-COP 21 inspiration, let us begin the grand work anew. Happy New Year to us all!

A 2014 Emerging Voice for Global Health, Renzo Guinto, MD is the campaigner for the Healthy Energy Initiative of Health Care Without Harm (HCWH)-Asia, director of #Reimagine Global Health, and co-investigator at the Universal Health Care Study Group at the University of the Philippines Manila. He attended COP 21 as part of the Philippine and HCWH delegations, and spoke at the Climate and Health Summit of the Global Climate and Health Alliance.

Renzo speaking in a panel on “Energy and Air Pollution” at the Climate and Health Summit

On one summer day in Cape Town, on the last day of the Third Global Symposium on Health Systems Research, two Emerging Voices from the Philippines, ignited with a burning desire to share new knowledge and skills with others, made a commitment to do something similar when they return home.

Just a few months after, a rare opportunity for the Philippines’ Emerging Voices then emerged. Renzo was invited to join the Scientific Committee of Forum 2015, and was appointed chair of the subcommittee for the “Health in Megacities” thematic track.

However, during the first meeting of the committee, Renzo noticed that something was missing in the program – a venue for young leaders in research and innovation for health to let their voice be heard in a global conference expecting nearly 4,000 delegates from around the world.

Fresh from the EV4GH program and having understood the importance of meaningful engagement of emerging voices in such fora, Renzo immediately called Mai for a mission. They also recruited other colleagues from various networks, professions, and disciplines to comprise the ‘dream team’ that would organize this gathering for new leaders (yes, it was decided to not call it ‘young leaders’ to transcend age boundaries, and definitely not ‘emerging leaders’ due to other similarly-named programs).

And so, the New Leaders for Health (NL4H) Pre-Forum was born.

Organizers of the New Leaders for Health Pre-Forum

Indeed, we were both inspired by our EV4GH experience, and while we cannot replicate yet this intensive two-week program, the three-day program that gathered nearly 500 new leaders was already a great start to generate momentum and drive inspiration within the youthful yet growing health research and innovation community in the Philippines.

We are already more than a week from the NL4H Pre-Forum, and we still can’t get over with the fever – surely a positive one – that it has caused. Some of the participants even posted in Facebook that it was the “most meaningful weekend I had so far,” and that it “was an inspiring experience to meet colleagues who are also up to the challenge to take on global health issues.” During that weekend, the hashtag “#NewLeaders4Health” even trended in social media. As organizers, we certainly feel elated and touched.

The NL4H Pre-Forum served as a beautiful opportunity to retool new leaders and reimagine global health. This is very timely especially for our country, at a crossroads on the journey towards universal health coverage, yet is now confronted with new challenges such as climate change, increasing natural disasters, rapid urbanization, food insecurity, among others.

Many have expressed that they did not just enjoy the sessions, but that they also made them rethink the way they view health today. They were triggered by ideas coming from our amazing selection of panelists, like Dr. Mojgan Sami of University of California Irvine, who, in a session on “Health in Megacities,” exhorted everyone to “decolonize the way we design our cities,” and Dr. Anurag Mairal of Stanford University, who, in his closing talk entitled “The Future of Health,” reminded young innovators about the value of empathy – making designs, whether of a device or a procedure, with the end user in mind.

The Pre-Forum also served as a moment for reflection for new leaders. Professors from our alma mater, the University of the Philippines (UP), provided emerging leaders with nuggets of wisdom. Health social scientist Prof. Nina Carandang reminded the audience that “Social accountability begins with personal accountability.” One of the Philippine’s national scientists, hepatologist and universal health care advocate Dr. Ernesto Domingo, reiterated the words of German physician Rudolf Virchow: “Medicine is a social science.” UP Manila’s chancellor, leading geneticist Dr. Carmencita Padilla, advised new leaders to “Do not work alone” to achieve one’s goals in health research and innovation.

The most compelling remark came from another national scientist, the 87-year old rural sociologist Dr. Gelia Castillo, who was the deputy chair of the 1990 Commission on Health Research for Development, the origin of COHRED and the Global Forum. The Commission popularized the ‘10/90 gap,’ which means that 10% of the world’s funding for health research occurs in countries having 90% of the world’s disease burden. Referring to the “brain drain” that has confronted the Philippines for decades, Dr. Castillo told young Filipino health researchers and innovators: “I have only one plea – please stay.”

Through a total of 36 interactive parallel sessions, the Pre-Forum also showcased a wide range of topics, from emerging fields such as digital health care and implementation science, to neglected issues such as the role of nurses in global health, to novel approaches such as design thinking and social network analysis, to pressing health challenges such as Ebola and trade agreements, to more practical skills such as translating evidence into policy and publishing in journals for the first time. Together with Renzo, the Emerging Voices alumni present at the Pre-Forum, Nasreen Jessani, Baskhar Purohit, and Beverly Ho, even had their own panel introducing the EV4GH program and discussing the future of health systems research. The participants found the session “very inspiring” and said that it “encouraged them to pursue health systems research.”

The attendees of the Pre-Forum, from the speakers to the participants, came from a diverse array of disciplines and sectors – public sector researchers and policymakers, medical professionals, students, members of the academe, as well as representatives from civil society organization and the private sector. This presents an exciting opportunity for reechoing and forging potential collaborations across multiple sectors. In fact, according to the recent evaluation of the Pre-Forum, 90% were motivated to take action and bring back their learnings to their respective organizations/institutions, while 80% intend to contact the people they met at the Pre-forum to follow-up on ideas discussed.

Of course, we wanted to seal everyone’s commitment before leaving the mammoth PICC, and so the highlight of the Pre-Forum was the reading aloud of the New Leaders for Health Statement, which captured the ideas and recommendations raised during the three-day convening. In the statement, we New Leaders for Health embraced “reimagining global health in the 21^st century” as our collective imperative, and called for greater investments, upholding social accountability, and developing domestic capacity for health research and innovation.

Now the challenge is to turn the statement into reality. There is enormous enthusiasm to turn the Facebook group of Pre-Forum participants into a real, long-term movement that will make a dent in Philippine and global health research. Already we feel that we are gaining momentum, with a resounding 97% of participants expressing interest to join the New Leaders for Health network or movement should it be officially formed, and 80% already volunteering to be part of the organizing committee for future NL4H Fora.

There is also clamor for the NL4H Pre-Forum to be held at more local levels as well as in other countries. Ninety four percent of participants even hope that it becomes an annual event. In this regard, we are optimistic, now that some organizations have expressed commitment to support our gathering next year. We are glad that the Philippine’s Department of Science and Technology, particularly its Council for Health Research for Health and Development, provided the venue and food for the Pre-Forum, and is showing signs that they might be keen to support  this in the long run, as this forum is essential in building a new cadre of health leaders, researchers and innovators for the Philippines and the world entire. Finally, through the new community we have formed as a result of the Pre-Forum, we will be able to check upon each other on how we as individuals and as a community are translating the inspiration generated into real action.

After the NL4H Pre-Forum and the Forum 2015 that followed, we both felt relieved, but also we realized, it is a great time to be a Filipino health researcher and innovator. Forum 2015 has put the Philippines firmly in the global health scene, and the NL4H Pre-Forum has kindled the passion of new leaders who will sustain the positive momentum that was built. Indeed, new leadership for global health begins not just in Geneva or in another country, but at home. The future of global health is exciting indeed!

Nearly 500 participants of the New Leaders for Health Pre-Forum

About the Authors

Renzo Guinto (EV 2014) is the Campaigner of the Healthy Energy Initiative of Health Care Without Harm-Asia and director and co-founder of #Reimagine Global Health.

Mai Valera (EV 2014) is a Health Economist and a Monitoring & Evaluation Practitioner based in the Philippines.

In last week’s New Leaders for Health (NL4H) Pre-Forum in Manila, four Emerging Voices alumni – three from Class 2014 (Renzo Guinto, Nasreen Jessani, Bhaskar Purohit) and one from Class 2012 (Beverly Ho) – participated in a panel entitled “Emerging Voices for Global Health: The Future of Health Systems Research.” The panel aimed to not only introduce the Emerging Voices for Global Health (EV4GH) program to young health researchers and innovators, but also to showcase the experiences of Emerging Voices (EV) alumni post-training and their visions for the future of health systems research across the world. We asked the four alumni to summarize in ten points the key messages that arose from their exciting ‘Manila conversation’ – and below are their answers:

1. Novel and innovative opportunities such as EV4GH help prepare the new generation of health system researchers for greater impact locally and globally. Many of the ‘soft skills’ essential to success in global health systems research are not taught inside the classroom – they require innovative approaches that allow peer-learning and ‘learning-by-doing’ modalities for example. The impact of EVs goes beyond conferences – for instance, because EVs were prepared on how to better package their research findings for evidence to policy translation, Bhaskar’s research on role-related stress among health workers in India and Bev’s study on health insurance coverage and healthcare utilization in the Philippines have been considered in policy development by government agencies and decision-makers. On the other hand, Renzo’s paper on migrant inclusion in universal health coverage in Southeast Asia has been cited several times by other researchers in articles and presentations. Clearly, programs such as EV4GH both enhance traditional presentation skills (i.e. posters and lectures) and develop contemporary public outreach skills (writing blogs and op-eds), among others. More capacity-building programs that are both innovative and impact-oriented are therefore encouraged to complement traditional education in schools of public health.

2. Posters should be in no way treated as inferior to oral presentations. Posters are essential and effective ways of communicating research to the scientific community. Often however, researchers are guilty of copying and pasting bits and pieces of their manuscripts into the poster, and of not seeking help even for seemingly minor aspects such as font, color, layout, and photos. During the EV4GH program, we alumni have witnessed how our posters dramatically evolved and transformed from Day One to poster session day. In fact, during the Third Global Symposium on Health Systems Research held in Cape Town last year, EV4GH 2014 alumni won in the poster competition in 2 out of 3 days – up against tenured researchers some of who had been creating posters for over 30 years! The EV4GH program enhanced our skills in creating powerful scientific posters for conferences – not just for the prizes as demonstrated earlier, but also for capturing the attention of interested colleagues and target audience. For instance, Renzo recalls how he got connected with fellow Southeast Asian researchers as well as enthusiasts in migrant health who visited his poster in Cape Town. Nasreen’s poster on the use of social network analysis (SNA) to identify key knowledge brokers in linking research to policy led to requests for her to conduct workshops on SNA at the ResUpMeetUp symposium in Kenya and the NL4H Pre-Forum in the Philippines.

3. It is important to distinguish advisors from mentors. Oftentimes, we come across well-established and impressive professionals who are willing to provide advice but have neither the time nor the inclination to provide constant support to aspiring early careerists. During the panel discussion, we urged participants to look for people who have a stake in their success: those who are willing to walk the path with them and willing to coach them along the way. The best mentors may not necessarily be the ones occupying the highest posts, but they are the ones who may be willing to dedicate time, the proclivity and the passion to guide the next generation.

4. Be strategic in using professional networking sites such as LinkedIn. Our generation is blessed with online networking platforms that can help emerging researchers identify and reach out to professionals locally or globally who could serve as mentors and/or collaborators. There are several mid- to advanced-career professionals engaged in relevant health research activities who have also traversed the same path as these young students, and may be interested to serve as mentors to young people whom they have same interests or can identify with. For example, during the panel, Renzo shared that through LinkedIn, he was able to meet Professor Phua Kai Hong of the National University of Singapore, who later provided invaluable inputs for Renzo’s paper on migrant health coverage in Southeast Asia. To top it off, Prof. Phua accepted the invitation to be the keynote speaker for the NL4H Pre-Forum!

5. Never commit the folly of underestimating your peers. In our pursuit for linking with those more experienced than ourselves, we forget the value of social and intellectual capital inherent in our own networks composed of fellow emerging leaders. Leveraging peers to test our ideas, practice our presentations, and critique our papers is an important part of not only enhancing our skills but also nurturing our networks. We encouraged participants to benefit from the strengths and experiences of their friends and colleagues, and to invoke principles of peer learning and feedback. Furthermore, a bit of healthy competition within our networks may drive more creativity and innovation, as long as at the end of the day, we remember that we are united under common goals of improving health and achieving health equity, no matter how diverse our backgrounds and skills may be.

6. Building capacity in institutions is critical. During the panel, we were asked by a technical staff from a government agency if we EV4GH alumni are available to work as consultants to support the creation of posters, presentations, and communication strategies both for the health research and policy community as well as the general public. First, we clarified that it is important to make a distinction between public health communication (whose aim is to modify behaviors, inform about health threats, etc.) and communicating research to decision-makers and fellow researchers – nonetheless, both forms of communication may follow similar principles. However, while the request was flattering, we emphasized the importance of institutional capacity building so that there will be no need for external consultants to perform these routine yet essential tasks. What would be perhaps worth exploring is replicating some of the EV4GH methods of training and coaching for these organizations. In this vein, multiple employees would benefit from enhanced research communication skills, a system of embedded capacity strengthening could be instituted, and a culture of effective knowledge translation could be fostered.

7. Emerging voices should demand for strengthening of national health research systems. In relation to our thoughts about institutional capacity-building, the vitality of local health research also boils down to strong health research systems that ensure long-term professional development, provide incentives for the conduct of effective and relevant research, ensure sustainable funding support and other resources, among others. There was huge enthusiasm among the attendees in the room for research; however, there was also enormous concern about low salaries, ‘contractualization’ of research positions, lack of mentors and role models, limited opportunities for postgraduate training opportunities, and in general the uncertainty of their future research careers. We urged the young leaders to proactively advocate for reforms specifically in the Philippine health research system, so by the time they have graduated, they can be guaranteed fulfilling opportunities in their journey in health research.

8. Be creative in finding resources for health research and innovation. One participant asked a very practical question – how did EV4GH panelists fund their research projects? Nasreen’s study was funded partly through a grant by DfID Future Health Systems Project, partly through awards and partly through work-study; Bev and Renzo’s research used data they collected as part of their paid work, and Bhaskar’s project was funded through his home research institution – in short, there is no single funding source for research. However, while financial resources may be limited, there is a need for new leaders to look at innovative mechanisms and novel sources for research funding, such as by tying research with social enterprise. We also encouraged the attendees to maximize online platforms such as Asia which regularly publishes funding opportunities for research projects. Finally, as demonstrated by Renzo’s research paper, one can conduct, for instance, desk reviews with collaborators from overseas even without meeting them face-to-face, thanks to e-mail and Skype (Note: His paper was published even before he has met in person two of his co-authors!).

9. Building research and innovation programs, not projects. In the panel, Bev and Renzo raised their concerns regarding “projectization” of research particularly in the Philippines, which is also happening in many low- and middle-income countries. Most of the research projects are commissioned to individuals rather than institutions; therefore, there is the tendency to commission more projects, with smaller budgets per projects rather than larger multi-year contracts. There is also often the misconception that qualitative work is cheaper and can ‘replace’ more expensive quantitative nationally representative research studies. Such a lack of holistic approach leads to unusable work (or at least inconclusive, hence cannot be used to arrive at generalizations for policy-making), poor databases (because sample sizes are small, etc.) and lost opportunities for institutional research capacity building. Moreover, it is difficult to encourage promising researchers to build a long-term research career. Therefore, thinking of research in terms of programs instead of projects is beneficial in order to avoid fragmentation, ensure coherence among component research projects, and build long-term sustainability overall. While existing research programs and consortia in health systems are predominantly funded by organizations from high-income countries (such as RESYST, REBUILD, and Future Health Systems), countries which recently allocated significant amounts for health research such as the Philippines (at around 200 million Philippine pesos or 4.3 million USD per year) already have the initial resources to build long-term impact-oriented research programs that may eventually encourage other stakeholders such as the private sector to top these resources up with additional investments.

10. Health systems research and innovation is an exciting field for those who want to make a difference. Today, there is a worldwide recognition that in order to improve health outcomes and achieve health equity, strengthening health systems is the way to go. The emergence of networks such as Health Systems Global is a manifestation of this sea change in global health. What is exciting about health systems research is that it requires multiple disciplines and perspectives – this is the beauty of conferences such as the NL4H Pre-Forum in which students and young researchers and innovators from a wide range of disciplines and professions were gathered in a weekend conference. It was also raised that health systems do have a complex architecture and even fuzzy boundaries, thus opening new arenas for inquiry, and therefore there is always room for emerging researchers and innovators to explore, even experiment, and examine health systems beyond the traditional ‘six building blocks.’

For instance, Renzo expressed that his research interest is investigating the interface between health systems and the broader transitions in health such as climate change, migration, trade, and urbanization, among others. Bhaskar, on the other hand, took a unique perspective on human resources management by looking at the micro level, and emphasized that understanding roles and role-related stress experienced by health workers can be a useful framework to gain better insight into health workforce issues. Nasreen’s unique approach to understanding the flow of knowledge in health systems using SNA illuminated the complexity and multidirectionality of the various elements of a health system.

Conclusion: The ‘Emerged Voices’ should reach out to the ‘emerging’

During the session, it can be noted that the demand for enhanced skills in knowledge translation and research communication was clearly high – from students as well as from institutions. The value of tailored, timely, and context-specific research uptake mechanisms that promote a variety of voices was also clearly demonstrated. It is therefore important to strike while the iron is hot and start creating opportunities to meet this demand.

The EV4GH program also evoked much enthusiasm from the floor, with many participants wondering not on how they can apply for the next edition in Vancouver in 2016, but on how such a program can be replicated in their home countries. Hungry for innovative ways of training and capacity development, the participants challenged the panel to make the global Emerging Voices program one that is more local.

We therefore call upon all fellow EVs to become mentors and trainers, and to reach out to the young voices in their respective communities. Let us capitalize on the momentum by sharing our learnings and skills with peers and fellow colleagues. We can arrange brownbags in our institutions, panels at conferences (or even separate events such as the NL4H Pre-Forum), student groups, professional committees, deliberative dialogues… whatever it may be, let the knowledge gain power, let the skills gain traction. Create an EV legacy by being the mentors that those ahead of us, behind us and beside us all seek when it comes to being a resounding voice for better health for all.

Renzo Guinto, Nasreen Jessani, Bhaskhar Purohit and Beverly Ho

About the Authors/Panelists

Renzo Guinto (EV 2014) is the Campaigner of the Healthy Energy Initiative of Health Care Without Harm-Asia and director and co-founder of #Reimagine Global Health. He is a co-investigator at the Universal Health Care Study Group of the University of the Philippines Manila, and member of a WHO steering committee on social determinants of health and health professional education. He is also the chair of the New Leaders for Health Pre-Forum and of the ‘Health in Megacities’ track of the Global Forum on Research and Innovation for Health.

Nasreen Jessani (EV 2014) is a consultant in global public health policy and systems based in Johannesburg, South Africa. Her work spans health system strengthening through evidence-informed decision-making. She recently received her DrPH from the Johns Hopkins Bloomberg School of Public Health and is on the advisory board of Academy Health’s Translation and Dissemination Institute and a WHO Foodborne Diseases Burden Epidemiology Reference Group (FERG) task force on knowledge translation and policy.

Bhaskar Purohit (EV 2014) is an Assistant Professor at the Indian Institute of Public Health Gandhinagar, which is part of the Public Health Foundation of India. He received his MPH from the Harvard School of Public Health.

Beverly Ho (EV 2012) is a faculty at the Ateneo Loyola School’s Health Sciences Department. She co-founded the Fellowship of the Pump, a mentoring/support group for health professionals and medical students passionate about health systems. She also co-founded Alliance for Improving Health Outcomes, Inc. She recently received her MPH from the Harvard School of Public Health.

There is no doubt that the conference itself was as entertaining as an elephant circus, with all the sumptuous food, festive dances, and royal ambience that are the hallmarks of Thai hospitality. On the other hand, the discussions were both agitating and depressing (Okay, at times a bit inspiring too!), as the ‘old elephants’ paraded in Centara Grand’s conference rooms – I said ‘old elephants’ because quite frankly, not many new ideas were raised – clearly, a proof that many of the problems that plague the world’s health remain unsolved.

As the WHO Executive Board (EB) meeting in Geneva, which usually happens on the week before PMAC, coincided with the conference, some key global health personalities and leading thinkers of the post-2015 agenda were notably absent. (Good thing, this year’s EB meeting came up with more concrete outcomes than ever before, as proposals for overhauling its capacity to respond to crises such as Ebola were approved – indeed a valid excuse to skip PMAC!)

For example, I even tweeted, “Where are you, @IlonaKickbusch?” (and she probably is one of those who, for years, have been keenly monitoring the position of health in the Post-2015 agenda – see her papers here and here), to which she replied: “@RenzoGuinto I am at the #EB136 – very bad timing for Bangkok meeting!” Nonetheless, her presence was still very felt, as Ole Peter Ottersen, chair of the Lancet-University of Oslo Commission on Global Governance for Health, quoted her in his presentation: “We are challenged to develop a public health approach that responds to the globalized world. The present global health crisis is not primarily one of disease, but of governance…”

Global health governance and the role of WHO

And indeed, governance was the first elephant to be tackled in the room. Probably the WHO EB meeting was a blessing in disguise, as there was no high-level official present (unlike last year when Assistant Director-General Marie Paul Kieny joined to discuss the theme “Transformative Learning for Health Equity”), and so PMAC provided an excellent platform for frank, no-holds-barred conversation about WHO’s continuing relevance in the 21^st century.

Thailand’s Suwit Wibulpolprasert, perhaps Asia’s most exciting global health leader, moderated a lively panel during the opening dinner. It was written in the program that the original topic was “Ebola – do we need a new global health institute?” However, Suwit wittily rephrased it by asking the panel “Do we still need the WHO?” His provocative way of questioning gave him answers that he jokingly described as ‘disappointing’: former WHO assistant director-general and now World Bank’s head of global health practice Tim Evans recommended to remedy the disconnect between the Geneva headquarters and the regional offices; Bridget Lloyd of the People’s Health Movement (PHM) proposed a revival of the old financing scheme which predominantly relies on Member State assessed contributions (in contrast to voluntary contributions from donor agencies, which comprise roughly 80% of WHO’s budget today); China Medical Board president Lincoln Chen hoped to fix the internal politics first before instituting organizational reforms; and THE Paul Farmer of the world-renowned NGO Partners in Health suggested a return to 19^th century public health ethic which emphasized on higher standards in the provision of individual care and public health services. Suwit easily dismissed all the proposals as not feasible!

If I were asked, I would also recommend another equally ‘disappointing’ yet highly ‘feasible’ measure – enhancing the democratization of WHO by improving on its engagement with civil society and in general, the people that it ought to serve. In one plenary, I even thanked the PHM and Lancet-University of Oslo Commission for including the youth in its work (I myself am part of both PHM and the parallel Youth Commission). However, I also raised that in contrast, WHO remains to be one of the few UN agencies without an established platform for youth engagement (others such as UNAIDS, UNFPA, UNICEF, and UNESCO have institutionalized spaces for young people). I even remembered one WHO official telling me before that their official youth arm is their Department of Child and Adolescent Health! In its youth engagement strategy, WHO should definitely go beyond highly competitive and expensive internships. For now, we can continue relying on organizations such as the International Federation of Medical Students’ Associations (Sorry for the shameless plug – I’m just being one proud alum!), which for more than 60 years has been advocating that, in global health governance, we young people matter too!

Nevertheless, while the discussions during the PMAC appeared overly critical of WHO, it must be noted that the intent is to safeguard WHO’s integrity and defend it from private interests. Currently, it is the only democratic institution available where every country, even a poor country such as Sierra Leone, has a voice and a vote – albeit only ceremonially, since World Health Assembly resolutions are legally non-binding. Sadly, the WHO reform that Dr. Margaret Chan introduced during her first term remains an unfinished business – and probably this gives Dr. Suwit a sense of hopelessness, making him recall a statement made by a Thai health diplomat during the 64^th World Health Assembly urging Member States to boycott WHO until it enters a stage of “rebirth.”

Governing the political and social determinants of health

Since the achievement of health equity post-2015 is a goal not just of the WHO or the conventional global health system, the PMAC tackled the second elephant – the ‘political determinants of health.’ Aside from the presentations echoing the findings of the Lancet-University of Oslo Commission, the open forum allowed participants to raise burning questions about the roots of rising global inequality that result in gross health inequities within and between countries. For instance, PHM’s Fran Baum pointed out that contrary to the theme, the current world order is actually ‘accelerating inequities’ (and proof of this is Oxfam’s report last month stating that by 2016, the world’s richest 1% will own more than the rest of the world population), and therefore remedies outside the health sector have to be put in place, such as strengthening the international tax regime in order to collect funds for global public goods such as health (because, as Fran said, taxation is national but businesses are global) and examining health impacts of ongoing trade negotiations such as the Trans-Pacific Partnership (and last week, the Nobel laureate Joseph Stiglitz himself pleaded not to ‘trade away our health’). These topics were only discussed superficially, and I wished there were specific sessions devoted to discussing priority health determinants such as climate change, food, migration, trade, and poverty to complement the more general thematic sessions on topics such as accountability, monitoring, and foreign policy.

As expected, the conference began with direct reference to the still-ongoing Ebola epidemic in West Africa, and there was general consensus that the crisis has social, political, cultural, and economic roots. While in his opening speech, Tim Evans listed down 10 lessons from the Ebola crisis, many of which pertain to strengthening health system ‘building blocks’ such as the health workforce and sustainable financing, Paul Farmer on the other hand, noting that “the worst hotel in Africa is so much better than its best hospital,” expressed alarm at the broader social injustices in Africa that served as the backdrop for the crisis. PHM’s David Sanders then called for a deeper interrogation of the political economy of the current epidemic. He gave the example of Sierra Leone, which has one of the highest GDP growth rates – 15% in 2012 – as a result of its huge extractive industry, yet just like neighboring Guinea and Liberia, has been ranked one of the lowest in the Human Development Index in 2014 (183rd, 179th, and 175th, respectively).

Clearly, the entire room nodded to the importance of addressing the social determinants of health to achieve health equity. In the opening video, Margaret Chan herself referred to one of the important health determinants – education. “For equity, health and education are sister sectors,” she uttered. Out of curiosity, I tweeted: “#PMAC2015 on @WHO’s Dr Chan’s statement: Are @UNESCO and education ministers in the crowd?” This time, I did not get any reply (Insert sad face here). The following day in the plenary, I brought to attention WHO’s constant reference to social determinants in its outcome documents and guidelines, while it dramatically downsized its Department of Trade, Ethics, Equity, and Human Rights into a Social Determinants of Health Unit, now with less than five technical staff and merged with the much bigger Department of Public Health and the Environment. How can WHO monitor processes outside the health sector that govern the social determinants, such as trade negotiations? Bridget Lloyd happily tweeted my closing remark: “@RenzoGuinto we pay lip service to SDH. #PMAC2015 @PHMglobal.”

Sustainable Development Goals and Universal Health Coverage

Speaking of social determinants, the Sustainable Development Goals (SDG) give the global health sector another opportunity to incorporate this broad philosophy into the next development agenda. Chatham House’s Robert Yates stated that the health goal should address the social determinants as well as health services, but also there is a need to link different SDG agendas with the health goal, such as by earmarking fuel taxes to fund public health services, both in support of Universal Health Coverage (UHC) and climate mitigation.

Now that the SDG process is drawing to a close, all the more the global health community must unite behind a universal virtue. In a plenary, former Norwegian AIDS ambassador Sigrun Mogedal offered the concept of ‘dignity’ as a potential unifying theme, as already resounded by the synthesis report of the UN Secretary-General released last December. She noted that the report represented the ‘voice of the people’ and is compatible with the goal of global equity and social justice. (Here’s more to why dignity is a worthy candidate, since it’s something that everyone longs for, and that no one possesses if others are also lacking of it, as explained by Jonathan Glennie.) Sigrun also challenged everyone to perform an ‘equity test’ not just for the health goal, but for all the proposed Sustainable Development Goals (17 in total, with 169 targets!!).

Focusing on the health goal, it seemed that UHC will become its main highlight. In its current form, the health goal hopes to “Ensure healthy lives,” with UHC as just one of its subgoals/targets. However, several  speakers during the conference emphasized that UHC should be included in the phrasing of the goal itself, especially now that UHC has already become an ‘uncontroversial’ concept as one speaker from WHO stated.

Thai health policy expert Viroj Tangcharoensathien proposed alternative phrasing as articulated in the conference summary: “Ensure healthy lives and achieve progressive universal health coverage.” The message is clear – universalisms such as UHC contribute to global equity, and therefore should be a prominent feature of the SDGs. However, one thing is not yet clear though – the meaning of UHC itself! PHM’s Claudio Schuftan cautioned about blind devotion to UHC as a goal, given that countries, international organizations, and academics themselves are still debating about UHC’s diverse definitions and metrics. He also warned that the UHC ideology that is now spreading worldwide might open the floodgates to more privately-funded and –provided health care that will further limit access among the poorest of the poor.

Overall, I was sharing with fellow youth colleagues that the conference theme seemed a bit late, if the aim is to provide inputs to the post-2015 discussions. Perhaps this should have been the theme two or three years ago. Nonetheless, while we may think that the conference would probably not make a dent on both the process and the outcome document, it is still worthwhile to discuss the much-needed transformations in the global health system and global governance as a whole for the post-2015 world, regardless of how the SDGs are phrased.

A quick note on the role of Asia in global health

Before I close, let me give some thoughts on PMAC as an Asian global health advocate. It is my second year to attend the PMAC – and I told fellow attendees whom I also met last year that this yearly conference is becoming our “annual pilgrimage to one of the Vaticans of global health.” Clearly, Thailand is turning into an important global health hub – and it certainly has every right to become one, being global health’s poster boy for different things such as UHC, health promotion, global health diplomacy, etc. Commentators of international affairs say that the center of gravity is shifting eastward, yet despite Thailand’s hosting of the PMAC, I am still yet to hear from Asians themselves their critical role in and perspectives on global health. I can roughly estimate that 80% of the speakers were not from Asia, yet I’m pretty sure Asians like me have lots to contribute to the ongoing global debates.

(Well, in addition, I just wished there were more novel voices represented, such as some emerging global health leaders and even perspectives from non-health sectors. I noted that some speakers were just rotating in various sessions, or rotating roles – as moderator or speaker or reactor. No offense meant to these experts – but they were also just repeating the same ideas they already expressed in different rooms and sessions! Perhaps a tactic for ideological domination?)

Nevertheless, there was some time during the conference to reflect upon Asia’s rise in global health. For instance, in the pre-conference panel I participated in, we discussed about the health implications of regional integration in the Association of South East Asian Nations (ASEAN), once described by The Lancet as a “microcosm of global health.” A series on the subject in Global Health Action was also launched, which featured papers that explored migrant inclusion in UHC, mobility of health professionals, disaster resilience, and medical tourism, among others. I will write more on ASEAN integration and its health impacts in a future article.

Imagine there are no elephants

Like in any conference, there was an end – but unlike other conferences that close with a reading of an (sometimes dry) outcome statement or declaration, PMAC does it in a unique and heartfelt fashion. Images of poverty, disease, and misery were flashed onto the stage, and then a visually-handicapped girl started singing:

Imagine no possessions

I wonder if you can

No need for greed or hunger

A brotherhood of man

Imagine all the people

Sharing all the world

Obviously, she cannot physically see the people watching her, who just got exhausted in exhausted in trying to find lasting solutions to the world’s chronic problems. Yet she and the billions more who were not PMAC participants – children, women, people with disabilities, minority groups, the poor, the marginalized, etc. – are the ones who truly feel the pressure exerted by the stomping elephants in the room.

I saw a couple of participants shed some tears – indeed a testament that the conference’s theme had a profound effect on the individual participants. I just hope that these tears would turn into concrete action. Sigrun cautioned the audience at the start of the conference: “Let’s not make complexity an excuse for inaction.”

Finally, on the walls of the conference venue  and inside the souvenir notebook  was printed a powerful reminder, this time from Prince Mahidol of Songkla, to whose memory this conference was dedicated: “True success is not in the learning, but in its application to the benefit of mankind.” I hope the people noticed it as they gazed at the elephants.

ABOUT THE AUTHOR

An Emerging Voice for 2014, Renzo R. Guinto, MD currently works as Campaigner for the Healthy Energy Initiative of Health Care Without Harm-Asia, and previously served as migration health consultant for the International Organization for Migration and Department of Health, Philippines. He is involved in many initiatives on universal health care, transformative health professional education, social determinants of health, and Southeast Asian affairs. He is a co-convener of ASEAN Youth Dialogues, and co-founder of #Reimagine Global Health, a think-and-do tank for the world’s health.

On May 26, 2014, after more than two years of intense online discussions, thousands of email exchanges, and one face-to-face meeting in Kuala Lumpur, the Youth Commission released a report (which was also announced in the Lancet) that seeks to add a fresh and youthful voice to the ongoing discourse about global governance for health. The report arrives three months after the main Commission published their analysis of the “political origins of health inequity.”

While separately developed, the two reports – ours and that of the main Commission – share some key messages. Admittedly though, through this research exercise, the two Commissions provided structure and illustrations to ideas and analyses of global governance that are already widely known but which require further reiteration. For example, both reports agree that health “should be adopted as a universal value and a shared social and political objective for all.” The asymmetrical distribution of power among actors, along with other “governance dysfunctions,” is strongly acknowledged and thoroughly analyzed by both Commissions, albeit through different styles (The main Commission adopted a case-study approach, while the Youth Commission examined power in global governance by deconstructing its varied forms and facets.).

However, there are major differences in our recommendations, although they do not necessarily contradict each other. The main Commission proposed the establishment of two international mechanisms – a Multistakeholder Platform that will provide space for “framing issues, setting agendas, examining and debating policies… that would have an effect on health and health equity”; and an Independent Scientific Monitoring Panel that will, among others, “investigate the complex interaction of forces that lead to health outcomes.” In a way, the Commission recognizes that matters of global governance cannot be resolved in a single Lancet report, and therefore formal spaces need to be established in order to carry on this examination. However, not everyone is happy though, as the Commission has met fierce criticism from various corners for not being able to “move beyond conventional wisdom” as it earlier aspired to achieve. One even bluntly asked them to withdraw their “tame recommendations” of “a talking shop and monitoring mechanism.”

On the other hand, the Youth Commission took a pragmatic stance by acknowledging the potential (and already-ongoing) tensions between health and other equally-important societal goals, as well as the difficulty of health being adopted by other sectors as a “shared social and political objective for all.” The solution to this practical analysis remains idealistic nonetheless. Instead of proposing the creation of new institutions outright – institutions that are “likely to be influenced by the same diverging interests and power asymmetries described by the Commission”, we emphasized the need for a strong philosophical foundation as basis for global governance for health – “a larger framework in which we relate the value of health to the value of other goals that a society wishes to pursue.”

This is where what I consider as the gem of our report comes in – the proposal to adopt Amartya Sen’s “capability approach” as a guiding framework for global governance for health. Briefly, this concept provides an approach to evaluating social arrangements – including policy decisions in global governance – as to the extent by which they promote “freedoms” that people have to pursue and allow them to lead lives they have reason to value. The capability approach therefore expands the discussion from mere “global governance for health” into “global governance for the promotion of human freedoms,” which in turn promotes health and health equity – in short, “advancing health by enhancing capabilities” as the title of our report says. While one major limitation of our report is that we did not fully explore the concrete ways by which the capability approach can be embedded in current global governance, there is huge potential for it to guide the still-unfinished discussions on the shape of the post-2015 development agenda.

Finally, given our unique position as Youth Commissioners, we also drew attention to the gross disconnect between the chronic nature of global challenges and the short-sighted responses of existing global governance. This mismatch can be observed in many current examples – climate change, non-communicable diseases, and socioeconomic inequality, to name a few. Therefore, our report called for fostering “intergenerational solidarity” in order to ensure the utmost consideration of the needs of “unborn” generations in current global policy decision-making. While such paradigm can be incorporated in existing global governance institutions that are predominantly administered by the “adult” generation, intergenerational solidarity also entails expanding the democratic space in global governance platforms to promote meaningful participation of children and young people. Some of the concrete recommendations offered in order to achieve this include appointing national ombudspersons for youth and establishing an international High Commissioner for Future Generations.

I admit that it is a report far from being comprehensive, but that is partly because global governance challenges are complex and therefore will require a much broader engagement with the world’s youth. In retrospect, we could have recruited more young academics and practitioners from other disciplines, ensured greater regional and gender representation in the Youth Commission’s composition, and, if resources would allow, even conducted more consultations in various universities and communities across the world.

Nevertheless, what makes this collaborative project meaningful is that it is more than an academic exercise – it is a conversation between generations. During the course of the project, the Youth Commissioners were given opportunities to provide feedback to the main Commission’s drafts, and some, including myself, were even invited to attend their meetings, in a way “shadowing” their discussions and offering alternative perspectives. Whether at the level of the United Nations, academic institutions, or local communities, such intergenerational dialogue should be encouraged and propagated.

I feel blessed to have been part of this ambitious project, and we young people certainly feel grateful to the Lancet and the UiO for making sure that the voice of young people does count in global governance. But the publishing of these two parallel reports is definitely not the end; rather, it is just the beginning of more substantive reflections and debates to come. As a Youth Commissioner, I am personally committed to spread our ideas to and even gather new ones from my fellow youth, as the quest for health justice in global governance continues.

An Emerging Voice for 2014, Renzo R. Guinto, MD currently works as a consultant for the International Organization for Migration and the Bureau of International Health Cooperation, Department of Health, Philippines. He is also a member of the Universal Health Care Study Group at the University of the Philippines Manila.

The Lancet-University of Oslo Youth Commission during its meeting in Kuala Lumpur, Malaysia