My problem is that I have become a cynic. And not in the charming, world-weary way of a philosopher. I simply no longer believe that the world will get better in any fundamental way. Between climate change, antimicrobial resistance, deepening inequality, and whatever geopolitical crisis is trending this week, we seem to be running a full buffet of existential threats. If ever there was a time for global solidarity and collective action to reform global health in ways that can tackle these threats, this would be it. So naturally, we’ve chosen this moment to also experience what I consider to be a crisis of global leadership.

I realise this commentary sounds rather dramatic; but perhaps my cynicism is indeed warranted? My work has nurtured this cynicism. I spend my days in the space between research and policy, where evidence and reason are apparently supposed to lead to better health policy decisions. But years of working and studying this space have shown me how little evidence matters when set against power, interests, and values.  Watching that up close can hollow your optimism. After a while, it becomes difficult to believe that anything really changes.

Cynicism is seductive. It feels like honesty. It feels smart seeing the world “as it really is”, particularly when you work in global health and witness how reforms fall in the gap between press releases and practice. But cynicism is also a constraint. Have you ever read Ursula K. Le Guin’s The Ones Who Walk Away from Omelas? It’s a short story about a city named Omelas. Omelas is full of joy, beauty, and prosperity. Everything about it is perfect. So perfect in fact, that the narrator senses our scepticism that such a place can exist. “Do you believe? Do you accept the festival, the city, the joy?” the narrator asks. “No? Then let me describe one more thing.” And so, they do. Beneath the city, in a locked cellar, there is a single child who is starved, neglected, and afraid and whose suffering sustains the happiness of everyone above. Only then, Le Guin writes, does the story become plausible. “Now do you believe them? Are they not more credible?” It’s quite the narrative turn. But what strikes me is not the moral dilemma of staying in or walking away from Omelas, but the narrator’s certainty that we never believe in utopia unless there’s a catch. This, Le Guin seems to suggest, is our imaginative failure.  

My own cynicism mirrors Le Guin’s point. I easily accept the politics of reform, the bureaucracy that slows progress, the shifting priorities, and the “realities” of feasibility as fixed features of the global health landscape. But imagining real reform (the kind that redistributes power and shifts incentives) is difficult. This mindset isn’t personal, I’m sure. It’s almost professional. Global health has developed a refined vocabulary for low expectations… “realistic” “practical” “feasible”. Transformative change is reduced to “adjustments that don’t upset anyone important”. Of course, when it comes to technological imagination and innovation, global health has no shortage: new diagnostics, platforms, AI tools, mRNA pipelines, you name it. These are the kinds of innovation that fit neatly within existing power structures. But when imagination requires redistributing authority or changing decision-making structures, the community becomes far more cautious. Perhaps because it is technically difficult or perhaps because it challenges the arrangements that stabilise the global health system itself. Either way, that’s the kind of imagination we most need.

While cynicism sharpens our diagnosis of what’s wrong, it shrinks our sense of what could be truly different. Reform, at its core, is an imaginative act. It begins with a belief that the world could be arranged otherwise and that we have the power to help arrange it thus. If global health is to reform, it requires the capacity to imagine a new world and the optimism to take it seriously. And if imagination feels indulgent, there are real cases that show what it can make possible in global health and beyond. South Africa’s Treatment Action Campaign (TAC) demonstrated how organised collective action could force a national government to rewrite its approach to HIV treatment. Brazil’s participatory budgeting, first developed in Porto Alegre, included residents to directly decide how portions of the municipal budget were allocated, shifting authority to ordinary citizens. Both examples required people to imagine institutions that did not exist and work towards making them real. They are reminders that our dominant models are choices, not inevitabilities. Such imaginative work is not about inventing the impossible but about recognising that the possible is wider than current orthodoxy allows.

I begun this article by admitting that I am a cynic. That part is still true. But I am trying, (against all my instincts, reader) to recover a sense that things can improve and the discipline of refusing to accept that they cannot. Perhaps we should all put some effort in holding open a wider horizon long enough for true global health reform to have somewhere to go. Perhaps we should learn to imagine Omelas can exist without the suffering child.