← This Week in Global Development
This Week in Global Development
Ebere Okereke believes global health is about power
01:29:56
Global health is entering a period of profound upheaval. As governments reassess foreign aid, donors rethink decades-old models, and African leaders push for greater ownership of their health systems, one question looms over the sector: Who should...
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- [00:05]
A
The Trump administration's decision to dismantle the U.S. agency for International Development sent shockwaves around the world, but they reverberated differently in different places and institutions. There were the acute impacts. Health clinics closed down overnight, aid workers stranded in conflict zones, NGOs facing immediate financial collapse. But there have been other ripple effects that are more difficult to trace, more complex and nuanced. For many political leaders and health policymakers in the countries where USAID operated for years or decades, the agency's sudden withdrawal was also a wake up call, a seismic shift in the status quo of global health cooperation. Dr. Ebere Okereke, a global health strategist and consultant born in the UK and raised in Nigeria, has been thinking a lot about what that rupture means for the future of public health institutions. She's a prominent voice in a conversation that is still just taking shape about how these big geopolitical changes create both risks and opportunities in the quest for a more equitable global health architecture. And at the end of the day, it's ultimately another conversation about power. Here's Ebere. Dr. Ebere Okereke, thank you so much for joining me.
- [01:47]
B
Thanks for having me. It's a pleasure to be here.
- [01:51]
A
Let's start by learning a little bit more about you. I'm curious what led you to a career in medicine, a career in health? What were the seeds of that decision?
- [02:04]
B
Oh, I have to go back for 50 odd years. My father is a physician and so I grew up in a physician household. I think I started carrying around the medical kit when I was 4 or 5. So it goes back that, that far. And so I never really had any alternative career option. I never thought about anything else. If anything, my dad did try to dissuade me at one point because he felt that medicine can be a hard career on women. This is, you know, a long time ago, but I've always wanted to be a physician. But for public health specifically, that was a particular experience. When I was about maybe eight, we had so context. I'm Nigerian, I was born in the UK but grew up. All my former two years was spent in Nigeria and a cousin came to visit and then became unwell. And this is through the eight year old lens. We all got taken across to this community health center. I had chest X rays and skin, skin tests and I heard about this disease called TB and it was, I've been till today still very fascinated and besotted by the challenge that TB poses to humanity. And I very much believe that when we Crack tb, we would have actually cracked equity and inequalities in health because it's such a wide ranging disease in terms of both its pathology. But it's the people who are affected and the outcomes are very much driven by societal and social factors far more than the medicine or. And science. And the interesting thing as well is that the fact that medicine and science isn't cracking, it is also determined by the people who get it. You know, that whole inequities narrative, that's how I ended up in public health in medicine and infectious diseases and then from that through communicable disease, controlled health security and then here.
- [04:15]
A
Fascinating. I find in a lot of these conversations there's an interesting mix for people who engage particularly in global health of that acknowledgement that this is a terrible disease that brings inequity to bear on populations, but also a corresponding fascination with the disease. These are just such a interesting biological phenomenons. It sounds like you were, you were sort of struck by just something interesting about tuberculosis and its sort of role in human society. It is a rabbit hole you can keep digging into, I think.
- [04:52]
B
Indeed, indeed. I was one of those sad people who. My idea of beach reading on holiday was a really fat book called the Greatest Story Never Told, which is the story of the discovery of the first drug treatment for tuberculosis by, interestingly, a soil biologist, not a physician. So I recommend that book is probably out of print, but I have a couple of copies and I'm happy to lend you one. It's a very good read.
- [05:21]
A
So you're a bit of a nerd is what I'm hearing.
- [05:23]
B
Totally unapologetically a nerd.
- [05:28]
A
Let's jump forward a little bit. So a significant part of your career has been spent working within the UK's public health institutions, particularly on infectious disease control, as I understand it.
- [05:40]
B
Yeah.
- [05:41]
A
How has that experience with a public governmental health institution kind of shaped the way that you think about the power and responsibility to keep populations healthy?
- [05:54]
B
So this is a really interesting question. Let me think about. So I was very. Like I said, I grew up in Nigeria. I was born in the uk, but my whole formative years were in Nigeria. But the Nigerian health system, the Nigerian system of government is very much, you know, it's a legacy of colonialism, is very much modeled on the British one. Not as well organized the health system or funded as the NHS was. So I was very intentional in wanting to work in a public health system that seemed to have equity at the heart of it. And so working in the NHS was always a destination for me. But then on getting there I realized I. It's not as, you know, it wasn't as perfect as one would have hoped. There were still challenges in addressing the equity issue even within the nhs. There was the politics of health around the balance between what you invest and who benefits and who funds, even within the nhs. But I still think it was, or it is still to an extent an important approach to health and how I got from there into sort of public health and clinical disease. Like I said, I was fascinated by tb, so I was constantly looking for how do we square the circle. So I started in my clinical practice, I was in infectious diseases then. The public health aspect of it now when I went to medical school, it used to be called community health and most of what we did was immunization clinics or what is actually more accurately described as occupational health for so, you know, diseases like minors and people working in high risk industry. So I was doing a Diploma in Tropical Medicine at Liverpool School of Tropical Medicine and had a lesson by the then professor of Community health, as he was called in, who Professor Lucas. He's dead now. I had one of those eureka moments and I thought, this, this is what I want to do. How do we stop people from getting these preventable diseases? So that switched me from clinical practice into public health while still straddling a clinical role with. With public health training. And I think that really opened up my passion for. My passion for medicine and clinical practice is actually driven by public health in the fact that recognize that physicians, nurses, clinicians, health professionals do their best work if there is a system that allows them to work. And so that NHS system, underfunded or, and sometimes not very efficient as it can be, was still, of what I observed, the best model we had at the time for ensuring that people could get access to what they needed at a time cost that was affordable not just by the. For the individual, but for the system itself. And I think that is a constant question that weaves through everything we do today in when we talk about health, system and equity and everything is how do we design a health. A mechanism for delivering access to health that is affordable for the individuals and the system? I'm sure I left your question somewhere around there and went off on another tangent, but.
- [09:20]
A
Yeah, no, not at all. That's great. And so many directions to take it. But just on the piece about the sort of UK institutions first, when you were doing that work, were you focused in a particular area? Were you still focused on tuberculosis or were you working more broadly the UK
- [09:41]
B
Public health system has a role defined by law under the Public Health act from way back when, which was there's a. A requirement to have a role of a consultant in communicable disease control, who has some legal responsibilities around that, deal with staff from the Sanitation act all the way through to modern public health, around the responsibility for developing, leading and shaping the systems that protect the public from communicable diseases. So that role is now more recently called a health protection role. To broaden it for it's not just communicable disease, it takes an environment, hazards, emergency preparedness and response, but it's still defined by law in the uk. And that role for me was the attraction was you needed to work outside the health system to address infectious diseases and communicable diseases like tuberculosis, because most of the determinants are not in the health system, they're in society, in local authority, in housing, in education, nutrition, the whole works. So it was a very interesting way of engaging across the system while still being a physician and a clinician and a doctor. It was the first opportunity to engage with local authorities and recognizing the role of local government in addressing health and working with them as co creators of an environment that enables health to exist. One of, I think the challenges that the NHS in the UK has experienced is that expectation that everything to do with health sits within the NHS to deliver, and that isn't so. The NHS actually is much more of a health care system than a health system, although more recent changes have started to put health back in the center rather than just health service. But you can't get health in any ecosystem just relying on doctors and nurses. You've got to talk to the people who determine the laws, who are responsible for the environment, people live with the opportunities people have for education, for nutrition, et cetera, et cetera. So that role was actually a really exciting opportunity to learn about the role of politics in health from local government initially, and then it's kind of a natural evolution to start looking at it globally as well.
- [12:21]
A
I'm going to, in a second pivot, to apply some of those observations to other contexts that I know that you've worked in and thought a lot about. But before we do that, I want to sort of nail down some of, in some sort of concrete terms, some of these equity issues that you've raised sort of throughout the conversation so far. So let's use tuberculosis as kind of the lens here. Can you explain what you mean that at the end of the day, the challenge of tuberculosis is really a challenge of, of equity. Why is that? How does that sort of play out in terms of people's experience with that particular disease?
- [12:59]
B
Right. In whatever ecosystem you live in, whatever part of the world you live in, there are certain characteristics of the people who get TB and whose TB results in the worst outcomes, who don't recover, who have drug resistant tb, who have the complexities and complications that result in death as well. And those factors are socially determined poverty. And therefore as a consequence of poverty, malnutrition, lack of education, and as a consequence, limited agency to make informed health decisions. Access in terms of being able to access both good food, early access to health care, preventative interventions, therapeutic interventions across the whole spectrum. So wherever those people are, those factors are what determine the first of whether you get TB and whether you survive it. So equity in my sense, and I like Paul Farmer, described global health as basically global health is about equity. Equity is about how do you, what factors can society collectively change to maximize every individual's opportunity to access health. So now it doesn't mean that everybody is going to get good health or the best health or the best outcomes, but it's about maximizing the opportunity to have good health. So whether you look at it through the lens of everybody, as many people as possible, having the opportunity to get enough education to make informed health decisions, enough education and access to have good food resources, of course, is really a big determinant of access to anything. And those resources is whether they actually have capital themselves or the system enables them to afford, afford access to those, those opportunities. So for me, in every thing, it's particularly stark in infectious diseases and for example, we talk about neglected diseases. It's not the diseases that are neglected in my book, it's the people. So but it applies whether you talk about even non communal diseases, the cardiovascular diseases of today, smoking and tobacco related diseases, etcetera, there's still an issue about agency and opportunity to make the best decision to optimize health for yourself. And that's an equity conversation, whichever lens you look at it through.
- [15:36]
A
This is an enormous question, maybe an unanswerable one, but you said that you got to the nhs, you got into the sort of UK public health system, and while it had been sort of held up as this model, and literally was kind of the model for Nigeria as you described, it wasn't perfect. And in particular it sounded like this equity piece was maybe missing from the equation or at least wasn't as prominent as you might have hoped it would be. What is the barrier that you found or what Are the barriers to making equity sort of a more central institutional center of gravity for public health bodies? Why is that something that's hard to put front and center when you're designing a health system?
- [16:29]
B
I think it's twofold and I don't think so. First of all, none of us are likely to ever have the opportunity to design a health system from a blank sheet. We're always building on what exists and whether that is traditional western medicine framed health system. You build on what exists. So the challenge of equity in the health system is the challenge of equity in the human condition. I don't think it's just a health system specific one. But then focusing on the health system itself, we tend to see health, a particular health service as a nice to have and a cost rather than an investment. And that's sort of more recently the conversation's moving more and more about looking at the investment and the economic dividend of investment in the health system. But traditionally we've always looked at this as something you pay for as a social good without necessarily defining the community impact, the population impact and the economic impact impact of having a functional health system that enables you to have a healthy population that can then contribute to economic development and growth of any society. So some of the challenges in talking, I mean even in the more resourced health systems has been seeing health as a sinkhole. You just put money in and put money in and people get sicker and sicker. And we know that healthy was it, the cost of health goes up exponentially at far higher rate than normal traditional inflation. And also because for a very long time we focus on health from the therapeutic end, you know, treating sick people. And the challenge has been, and also I think a necessary move to make health systems and healthcare affordable is to move more upstream into disease program prevention and actually recognizing that the real investment in health is keeping people from getting sick. And most of that investment doesn't actually happen in the health sector. It has to happen elsewhere. Like I keep saying, it's about education, it's about housing, it's about clean air, it's about, you know, legal rules like, you know, indoor smoking, use of seat belts and all those sorts of things which are, by the way, that is public health. That public health isn't necessarily just about the disease. It's about how do you change the laws, how do you influence the environment and the politics to enable people to make the right choices. So the problem, I think even in well resourced and we could talk about the US for example, which I mean the highest spend, yeah, the highest spend per capita on health is in the United States. And you wouldn't have to argue, hard to say that their outcomes are not reflecting that investment. And a lot of that is to do with, with when we look at health as an individual responsibility or when we look at health from the end of when you get sick, then we treat you. If we start to look at health as a collective community responsibility. And I know, you know, with today's extreme politics, we don't like talking about, you know, collectivism, for want of a better term. But just as a country level, you can't do health security without working collectively as a community of countries, as individuals, you impact on health more positively. If we work as part of the community, immunizations work not because everybody can be immunized, but enough people can be immunized to protect those who aren't immunized. Some of the politics, I would say, of the Cold War era may have colored some of our thinking about health and health systems and may have influenced some of the decisions that were made about what do we invest in and what do we do and how the narrative and the rhetoric surrounding health investment and health system development and individual versus community responsibility.
- [20:36]
A
I wanted to lay this sort of groundwork of the interrelated, interacting components of not just a sort of health system narrowly defined, but the social structures that feed into and out of, of people's health. Because I think there's a lot happening and a lot of dynamism right now on the African continent in terms of, I mean, you said there's no such thing as a blank sheet of paper for health systems, and that is 100% true. However, we've seen the emergence of some new institutions. We're seeing sort of regional cooperation that is again, not starting from zero, but starting from a place of, it seems like new energy and in some cases, necessity. And that's all sort of a preamble to add a little bit of context here and to get your take on this. So we are almost exactly one year removed from the formal dismantling of the US Agency for International Development. And I'd love to get your take on the implications of that. And let me ask this question in a sort of particular way, which is in the United States, that decision to dismantle USAID and remove most of its workforce and cut a significant number of its programs. I mean, the reaction has been highly charged and highly polarized. I think people who worked with USAID or generally supported its efforts are extremely angry. Some of them remain deeply traumatized by the experience of seeing this entire body of work sort of wiped away. And then you have people who support the Trump administration or Elon Musk and the sort of Department of government efficiency efforts and they're all convinced that USAID was this sort of shadow network that was pushing a liberal agenda around the world or interfering in countries domestic politics. Of course there are also people in between those two ends of the debate. But I think that's sort of, that's how I understand sort of the general shape of the reaction and the disparity that we're seeing within it. Yes, I'd love to get. And look, I'm not asking you to speak for the African continent, but I wonder if you could sort of, could you kind of characterize at least sort of the shape of the reaction that you've seen among African political leaders or African health leaders in the wake of this decision. How does it compare and contrast to that picture that I just kind of painted? And maybe mine's not right either, but I just love your sort of general. It seems like the reaction has been different. That's what I'm getting at.
- [23:27]
B
Yes, I think the reaction has been different, but not as the, but I think understandably so. So globally and the usa, USAID and the whole US architecture in global health and both in terms of what they've invested and their leadership, it touches every part of the globe, not just the African continent, but what is specific about Africa in Africa. And I stress that the impact and the effect varies depending on, you know, in different countries and everything is how direct some of that investment and relationship was in the fact that in the sense that some of the architecture of healthcare health systems were actually being developed, designed and delivered by USAID systems. So by the suddenness of the removal of that framework. So it's like you're still at the foundation level. You haven't quite put up the walls in your vaulted story building and you take away the scaffolding or you literally pull out and be living near a construction site. So I'm thinking of construction and you pull out the metal rods, the steel rods that are actually supposed to hold the building down. So there is an immediate impact in Africa continent in that in some countries clinics did not open the next day. So that's one of the very immediate, acute, obvious impacts on the African country. And in many African countries that you wouldn't have seen in the US or North America. A large proportion of the people employed by usaid, particularly in more senior decision making positions, were US nationals. And so their implication for them, these are people who have dedicated their entire lives, it was their career, the profession, their whole vocation in some cases suddenly taken away from them. So that experience is also very different. We also had significant people employed or paid through USAID interventions who also lost their livelihood on the African continent. But the experience of it was slightly different in that for them it was actually, it's a system that they're constantly vulnerable in navigating anyway, there was a certainty for USAID. Now people work their entire careers, 20, 30 years, then you know, five minutes to retirement, you suddenly realize they've taken, you know, pull this out for one day. So there was, there's a huge shock there. But on the flip side, one of the things that we're all aware of and need to acknowledge and own is that the, and I use USAID as an example, this is not exclusively USAID driven situation or a US government driven situation is that, and African governments also need to take responsibility for some of that, is that they became a dependency or there has been a dependency on foreign entities about what gets funded for the health system, how it's funded, how is it. Decision making is not even, is hardly ever in the countries where the services are being delivered. So even though of late, you know, last decade or so, we've been talking about localization a lot, we haven't really localized decision making. So the what gets invested in, what's been prioritized, the decisions tend to be made outside those countries where the interventions are then put into play. So some of the response was, okay, if this, it's hard to change. Like I said, we touched about, you know, you can't build something from a blank sheet. It's harder to change something. Particularly start to bring in local agency and decision making. When a system is working, it's funded, decisions are clear, the logistics, the pipeline works and everything. When it's not there, it becomes slightly easier to say, okay, this is the time to start thinking about what we should be doing and what we should be doing differently. So there is, and I am not by any definition a supporter of some of the rhetoric coming out of the current government in the U.S. but that dependency did exist. Responsibility for that dependency is twofold, both in terms of those who are funding the donors and those who were receiving it, the African leader, governments and countries and their leadership. But it was actually hard to change the status quo even with the best will. Now that that sort of very shocking and sudden dismantling has happened, there is a forced opportunity and A vacuum that countries need to step into and say, okay, we have to do things differently. I don't think that the way it was done is what did too much damage. And some of the risk is now being transferred to governments who have not been allowed the space to actually grow into and develop the systems that they want to run. So there's a difference. It's not all good or all bad. There is some opportunities that emerge out of any crisis anyway. And those countries and those governments who had already started thinking about how do we address this issue of dependency and lack of agency and sovereignty in health have now accelerated those conversations and started thinking much more constructively rather than just ideologically about what do we need to change. But it's not a switch one off turn on the other. We need to build the institutions, we need to build the leadership, we need to find the resources. And we're doing all this in a time when the truth, you know, global economic space is shrinking, not just in terms of aids, but even in terms of trade and investment. There is no agency, there's no sovereignty without funds. And no matter how much, how good the rhetoric sounds, if you can't fund it, you still have a problem.
- [29:43]
A
Let's talk about health sovereignty. You've mentioned that word a couple of times. What does that mean to you in this context particularly, you know, in sort of comparison or juxtaposition to that sort of donor funded health system that you were describing.
- [30:03]
B
So, so health sovereignty. So I'll say what it's not, it's not about pulling up the drawbridge and saying we rely entirely on ourselves. Like I said, there is no health without collaboration and cooperation globally. There are some things that must be done collaboratively. But for me, health sovereignty is really about capability. It's about the capability of countries, the governments, to define their own priorities, to have their own institutions that lead and deliver the health system, to finance a defined core set of functions that they believe are their priorities for their own people to be able to access the products, whether that means producing them their self, manufacturing, regulating products to use, to generate and use information, data to manage their own priorities. That soul sovereignty is, it's also about then determining which partnerships, and I mean true partnerships, which means mutually beneficial, mutually respectful, support them in that agenda towards their own definition of priorities. And so it's, it can happen overnight because we still have even today conversations where quote, unquote, donor countries turn up and lecture recipient countries. And I put those in inverted comma, because Gavi will tell you, and I was listening to your podcast with Seth the other day that Gavi recipient countries are donor countries as well. So there isn't any sort of group of countries who only contribute and the group of countries who only receive. But in the way that the funding dynamic exists now, we still have an inequality of power. Balance of power is inequitable. So the relationships are skewed towards the ones who tell you what you do rather than actually sit with you to co create a solution and support your own primary agenda. So the discussions and the conversations around health sovereignty, most visible and I think effectively articulated by the Accra reset led by President Mohammad, is really about how do we start to do that in a much more equitable way. How do we start to form communities of interest that might be Africans seeking support from Africans using our regional architecture. And the regional architecture is not just an African opportunity. I think regionalization is one of the consequences, but also potential solutions to the current fragmentation of the global health ecosystem. So part of that conversation around sovereignty is also sovereignty as a regional or sub regional community as well.
- [32:54]
A
At the end of the day, is it just about power?
- [32:58]
B
Everything's about power. Everything is about politics, but it's also about understanding what power you have. There is a power. There's a lot of the historical power, like who sits in the Security council, in the UN. That's one definition of power. Who sits on G7, G20, that's one definition of power. But I would say they, a lot of regions and countries actually underestimate and don't appreciate the level of power they have because like again, comes up to what I said earlier about health being this siloed thing as something you just pour money into, but actually not recognizing that health data itself, health information is power, wherein we move from the sort of, you know, the global economy driven by oil now to the global economy driven by data you have. Health. The health system is a huge source of data. Production of, you know, the newest technologies for health, pharmaceutical interventions, et cetera, et cetera, relies on a lot of information. Now as African countries, the continent is sitting on the youngest population in the world and the most genetically diverse population in the world. All the big stuff that's going to come out in pharma in the future is going to need that information. So there's actually recognizing the power we do have and using it effectively. We need to get finance ministers and health ministers and ministers for development and economic growth, et cetera, et cetera. Presidents cross government to recognize what resources you have in one sector that can be leveraged for Negotiation in another and to do that much more collegiately and as a group of countries. The pandemic agreement was one of the, I said most recently, but was one of the first times where we saw the Africa group really negotiating very effectively, a group of shared interests. Now those communities of shared interests are part of a new power dynamic that we are now leveraging better and should continue to leverage better because we have common challenges, common opportunities and common goals. So the definition of power needs to broaden. Another one to look at, I mentioned the youngest population in the globe and by 2050 the world's workforce is going to be in Africa. So that is again an opportunity for power, which I feel very strongly we're currently giving away. We are training in the health sector. The Africa trains people for the world and we don't get anything back for it. Now we need to start thinking about that as a resource, not just for ourselves, but if others want it. They have aging populations, they can't, you know, they're not going to man their services. How do we leverage that? So that is a win, win. So we need to start thinking about power differently. It's not just about who sits in the UN or who has the largest gdp. And I won't go in there because that takes me down a rabbit hole. But I think GDP is a very, very useless measure for the well being and economic, you know, the health of a population. And I use health in the broader sense here. So yes, power is absolutely important, but we need to actually start thinking about it differently.
- [36:38]
A
This also seems to connect very clearly back to the earlier point that you made about understanding health as an investment rather than a cost. I mean the things that you're talking about are assets. They're not, they're not costs.
- [36:49]
B
They're not costs. Yes, absolutely. Yeah. And we need, the more we start to see, I mean, when Covid happened, we all thought, aha, the world will now see how important keeping people healthy is because we effectively ground the global system to a halt. Because we had to shut down various ways, different countries do different things. But it shut down business as usual. So what one had hoped to come out of that and has to a degree. But being a sort of pragmatic optimist, I knew that with a given enough time we were very good at forgetting. It's a coping mechanism for humanity to forget what was traumatic. But it should have made us very clear about the primacy of investment in health. And I say health, not necessarily the health system in health in this broadest sense as a prerequisite for economic growth, for development, for whatever else we think we want to be and to do how well some of that, some of that has landed. So we see more and more particularly in African countries where the private sector recognize the importance of understanding and engaging in what government is trying to do to maintain their healthy workforces, because they know that if they don't, they end up with a situation where their businesses are shut down because, you know, people can't function.
- [38:16]
A
I want to return quickly to this contrast between dependency and sovereignty in a health system. I'm struck that the way that you sort of defined and described health sovereignty, I think a lot of that language was used by, you know, USAID specifically sort of global health assistance providers generally. I mean, I think they would say this is exactly what we're trying to do. We're trying to build capabilities in our partner governments, we're trying to incorporate partner government priorities into our planning. We're trying to strengthen institutions and create the conditions for greater self sufficiency, et cetera, et cetera, et cetera. My question is, why didn't that happen? What were the barriers between global health assistance and stronger institutions or a stronger health system generally in the countries where it has operated?
- [39:25]
B
So one of the things that I think was why that sort of good in the rhetoric didn't translate to reality is to an extent it's historical. It's a consequence of colonialism and the belief that. And the infantilization of some of the. And I'll speak specifically about the African continent because that's the one I know the most. There was almost a paternalistic approach to sort of we have to do it for them because they can't do it. That's one. If we look at the sort of the golden years of global health as we refer to them, you know, the 25 years from of global fund, et cetera, et cetera. You know, when we invested a lot, we created all these multilateral institutions. The intention was good, the intention was right. There was a crisis, there was an emergency, it was a disaster, hiv, tb, malaria, et cetera. Then we built an emergency architecture to deal with that, but then allowed it to continue to function beyond an emergency. Now you can't have a hospital where the only department is the emergency department. You have to have the other systems. And then if you. But if all the money is being invested into the A and E type of department, so the emergency response, the crisis driven architecture, then the other parts of the system remained weak and underinvested in. And also there was a failure to accept that. The perception, the rhetoric I had and the language I had a lot of times was oh, African governments can't. African governments won't and therefore we will do it. Because there's no point, they're not going to do it anyway. So people created parallel structures, they did things outside government. And if you don't invest in government that you say can't do something and you don't allow them to do something, they're never going to be able to do said things. So it became almost self perpetrating. And that's as we said, they can't do it, therefore we'll do something. We'll recreate parallel systems, therefore they don't do it and therefore they don't learn how to do it. And so over time, you know, it's self perpetrating and therefore you continue to justify the existence of these parallel systems. So one of the conversations or challenges I always had with the leaders of a lot of these global health institutions is what's your exit strategy? How are you going to be sure that when you walk away, things don't collapse? And it's not just their responsibility, it's also responsibility. It's a joint responsibility of the governments of the countries that they're working in and the leadership of those institutions and the people funding those institutions to be sure that you can invest, you can, you know, stick your finger in the dike now, but actually fix the dike so that when you pull your finger out, there is a system that can work. And if anything, the sort of. In some of the countries where the USAID sudden crisis resulted in hospitals and clinics not opening the very next day was the exact description of that failure to think about how you exit PEPFAR changed in its latter years. It did actually move away from just parallel funding of HIV to actually starting to invest in the system. Recognizing that HIV long term outcomes are really dependent on having a broader health system that is affected, it started moving in that direction, but too often we just created vertical silos and didn't invest in the foundations. Again, understandable in the sense that if I'm donating money, I want you to be able to tell me what my money did. And it is far easier to say 100,000 people got to access antiretroviral therapy than to say the health system in that country can now measure the number of people actually going through health facility doors. The latter is actually critical if you're really to have data to inform planning and investment in your health system long term. But it's not as sexy for whoever is being able to say we led to this. So that's part of the problem why donor driven health systems always going to be they're not going to do what you need to do in the long term. So again I keep saying there is also responsibility on the countries and the governments in those countries to invest in the less sexy in the necessary infrastructural foundations and to insist on co creating and making the decisions about what donor funding actually is prioritizing for them. And that comes back to I'm not a politician and I don't think I would ever run for politics. But the importance of politics in terms of health cannot be underestimated. I bring that to one of the things I keep saying is that the most important thing we need to do in terms of improving the health political lens that health is seen in African countries is the citizens, the people who vote for these politicians need to understand what the politicians responsibility to them is for health. And you cannot win an election in the UK without having something in your manifesto about the National Health Service. Now whether it's right or wrong, things are different thing but if you don't, if you're silent on the nhs, you're not going anywhere. And a few years ago we did a literal battle of the envelope survey of a couple of years ago. Yeah, two years ago there was a lot of African elections and we looked at all the running parties, how many of them actually even had a paragraph on health? Very few. Now we need to activate our electorate to start asking and demanding of their governments and an ambition for health. President Muhammad has made it this, Zachary said, in its health implications a central part of what he's seeing as his legacy beyond his term in office. And I think that's great. But let's start with at least every incoming politician having a position on health and that will move us further towards health sovereignty than I think any other conversations we'll be having.
- [45:46]
A
Yeah, what do you make of that? Why hasn't it been as salient a political issue?
- [45:51]
B
People have been persuaded that health is their individual responsibility and the responsibility of their families. They don't see governments as doing it. And if you think about so in Nigeria, I know Nigeria best of all, I'm from there. Over 70% of healthcare delivery is in the private sector. We now have with this government continue to push for national health insurance. But the population that's covered by the national health insurance at the moment is infinitesimally small and most of that provision is to public sector hospitals. Most people never go to a public health, public sector hospital until they're in dire straits. Their local pharmacies provision is private, their local doctor is private. Everyday maternity is private. So they don't see government in their health system on an every day. And I've had the privilege of just becoming a trustee for the Health Registration of Nigeria, which is the body for private sector health providers in the country. And we've just challenged them to say, you need to stop seeing yourselves as just service providers, but actually as the architects of the system, since most of the service provision sits in your sector, you should be having conversations with governments about priority setting, about investment, about health insurance works, how the data you generate can help governments to inform investment. So it's almost like the status quo is if you go to your local health center and what you see is a USAID badge and you don't see the banner of the Nigerian government or your state government, you don't associate your needs and your services with the government having a responsibility. So we need to, and this is, I think our responsibility as advocates to actually start bringing that conversation back to people to say, you do know that health is a right, that your government has a duty to provide you access to. And whatever your problems are, you need to start asking your elected representatives or anybody who aspires to be your elected representative, what are you going to do to ensure that my children can get vaccinated now? My children can get access to this new malaria vaccine that is available, but not everybody is getting at the moment so that my wife can have a safe delivery, my mother can get access to whatever intervention she needs. I can get access to mental health care. We need to move it away from something that is done in families and everybody gets together and we donate money and find the local provider into starting to expect hold governments accountable to that.
- [48:34]
A
So the Trump administration has answered your critique of the former global health assistance model with these bilateral health agreements that are being negotiated under its America first global health strategy. I know this is something that you've been paying close attention to. There are ways in which that process does seem to be in direct conversation with some of the criticisms that you outlined of the way that global health assistance has been provided in the past. It talks a lot about mutual accountability. It brings bilateral government relationships into the equation in a very direct way. You know, I think in some countries it's probably politicized the conversation around health and global health assistance in ways that maybe wasn't the case to such a degree before. It's very controversial in some places but it does seem to be in direct conversation with the previous model in an attempt to, to deliver health assistance differently and with different expectations. Are they taking the right approach?
- [49:56]
B
It's not a, yeah, it's not a right or wrong. It's not a they're right, we're wrong or you know, USAID wasn't perfect and the bilateral negotiations are definitely not perfect. There are definitely. We've already touched on some of the things that African leadership had already identified was a challenge. There are too many decision making is way, way, way removed from where the need is. There are too many intermediaries often of whom the vast majority of whom are Global north entities, not organizations in the countries where the so called investment is happening that absorbed, took bits off the investment before it actually got to the location of need. There was very little room for genuine consultative, collaborative co creation of programs and systems that were being developed under that system because decision making was out there. So yes, there were definitely flaws but there were also some very, very good things. Let's not dismiss some of the very good things that happened. The speed and the clarity of the response. I keep using the HIV crisis because it' easiest one to tell. It probably would not have happened if we didn't have that kind of globally driven coordinated system. But there were also problems. The bilateral MOUs don't necessarily solve those problems because first and foremost this is not a. We touched on power earlier. This is not an equitable negotiation. Here we have a world power with a lot of resources holding most of the cards negotiating with countries who are not just that they don't. They may not have the expertise and skills in negotiating in those ways traditionally but also have the immediate crisis of I have a clinic that won't open tomorrow if I don't get some money to put back into the system. So it's an inequitable negotiation and the speed and the urgency with which they were trying to drive it through would cause one to query whether they actually wanted a fair negotiation to happen or whether there was an agenda to just push it through. Claim yeah, we've done this together and you chose what you want. A lot of these MOUs were of course had never been fully published so we don't know the detail of what went on. But some of the stories are coming out were of a disproportionate handover of the risk to host governments for a significantly, I would say smaller amount of investment which almost all the ones I had the privilege of reading had A and if we change our mind, we can pull out that money anyway. Now, those countries who had the expertise, knowledge, who had already started doing the thinking cross government about how they restructure their health priorities and investment would have been in a better position to negotiate cross government because like I said, the key issues to negotiate cross government, you can't just have the health minister negotiating this because health decisions affect other parts of government and vice versa. But the speed, I think creates a significant risk that these actually might not necessarily be the best outcomes for either party, for either side. And also there's of course, the big gap in the fact that health requires collaboration at a multilateral level that cannot be addressed through bilateral MOUs. You cannot deal with the Ebola situation that we're dealing with in DRC and Uganda at the moment. If the only mechanisms for engagement are through bilateral FMOU's, there needs to be to be things that happen that need to be decided collectively as a globe, at the very, very minimum, at least at a regional footprint, but in my view, at a global footprint that a bilateral MOU cannot resolve and actually potentially could make slightly more difficult. And so while some of the rhetoric that's been given as the reason for dismantling the USAID and moving to bilaterals is recognized and acknowledged as based on some degree of reality, the response itself may not, may actually create a whole new set of challenges of their own. But again, this is where there is an opportunity for African leadership to exercise agency by negotiating properly, not just turning up unprepared, not turning up without considering what do we have, what are our own priorities, how do we push back on some of these asks and these demands. So there is really an opportunity and a necessity for the governments at the receiving end of these bilateral MOUs to come ready.
- [55:10]
A
I think that's so well said. I really want to highlight a couple of things. I mean, just the speed with which these MOUs have been pushed. There are big questions about civil society engagement and the transparency there and the ability for sort of citizens to participate in this process. I guess I'm mentioning these things because I'm just struck by how much of this, at the end of the day, as you have consistently stated, it just comes back to power. And you could imagine a sort of alternative process where African governments were given sort of broad scope of opportunity to get the right ministers in the room to engage civil society in a sort of deliberative process and then to come to the table on a more equal footing. It sounds like that's sort of not what you're seeing here. My interest in making this point is what's the alternative? If the two sort of large scale phenomena that we're witnessing are a transition away from the sort of older global health assistance sort of emergency model coupled with or sort of intersected with a push for health sovereignty on the African continent and in other parts of the world, how might those two things meet in a more productive, collaborative, empowering way? Is there sort of an alternative image of this that you can imagine? Yeah, yeah.
- [56:51]
B
Politics always talks about a third way and nobody's really quite articulated what that third way is. It's supposed to be the best of everything, which of course never really comes out that way. But I think there is why neither
- [57:03]
A
of us work in politics, I suppose.
- [57:05]
B
Exactly. Yeah. So I think there is. What African countries should be aiming for and what would like to see from the conversations I've had is locally owned. We decide what our priorities are. Regionally anchored. We work across our continents to develop and leverage economies of scale to help address those priorities. But we remain part of a global architecture because there will always be a need for the entire world to have a common goal and a common vision contributing based on what assets you have. That's what the pandemic agreement, and I know it's only focusing on health security and health emergencies, but those are the principles that drove the creation of a pandemic agreement, that there should be certain things that we all do together, contributing as we can and as we need so that we all benefit. Now, with the polarization of politics, I think there's even more, a stronger need for the regional equivalent of that, where the political extremes may be narrower for more common consideration and collaboration and engagement, and for regional institutions to almost act as an in between, between the global institutions that may be a little bit too removed from the front line and the frontline itself, where not all the capacity, expertise or resources may exist. What I would have. So somebody asked me so would I have preferred that USAID was never dismantled? Then I say, I've always said to every donor country agency in multilateral, they say, what is your exit strategy? I would have light a clock an exit strategy, a timeline that is designed based on the vulnerability of the other partner with a very clear mission that we will exit xyz, we may continue to do abc, but you need to pick up the baton. A little bit of time and planning, I think would have been a win win on all sides. Nobody would have argued. Now nobody is arguing with the fact that the previous system was not ideal, but the way it's been dismantled has actually, in my view, narrowed the space for conversation about what should replace it. So what we're doing is. So some of the response is let's look for other people to plug that gap, to still do the same thing, the same way, rather than what we should really be discussing is what is the right way to do this going forward.
- [59:57]
A
You mentioned earlier the Accra reset and the leadership that President Muhammad has brought to bear through that process. What are the other key institutions or who are the other key leaders that you're looking to to begin to sort of shift that balance of power and establish a more equal footing in the global health landscape?
- [60:28]
B
Right. So there is, I think at wha, there was a presentation that actually suggested that there were at least a dozen movements looking at global health architecture reform. So there's the dialogues that Wellcome has led. There's of course, what predates a lot of this Lusaka agenda, which has, you know, the recommendations from the agenda still haven't been implemented. WHO has now stepped in to also be part of leading this discussion around global health system reform. Africa CDC as the newest global, regional global health body, in itself, part of its creation and its role is part of this reset restructure dialogue. How do what should happen at a continental level? What decisions The Africa Union and the members of the Africa Union said we need our own public health agency on the back of the West Africa Ebola outbreak. That will be its priorities and its mandate will be defined by us. So I think the Africa CDC has not quite yet delivered on that magnet. It is doing a lot. And the response, the coordinated response to Covid across the continent was significantly down to the Africa CDC leadership. We need to recognize that. But part of the challenge of Africa CDC is still. The member states have not put their money where their mouths is. You said this is our regional public health body, but you're not funding it adequately. It has, you know, there is almost mission creep and year on year there's a new priority, there's new mandates and everything. There needs to be a what do we need Africa CDC to prioritize on our behalf and then we make sure that they're equipped to deliver on it. The African Union in itself is part of this change because like I said, health is politics. The Africa Union has had Agenda 2063. Most African citizens don't even know what Agenda 2063 is. Now there is a responsibility to stop. And I'm not saying it's an either or, but if you have a strategy around health for your own continent that you've all signed up to and endorsed, then you should invest in it, prioritize. It isn't a contradiction to the SDGs. It isn't. It's actually very well aligned with it, but put into a contextual continental development lens. So I think the African Union needs to step up in its conversation around the new the global health architecture reform. In addition to Africa cdc, we have ama, the African Medicines Agency. That's the newest kid on the block. Absolutely wonderful. Necessary. And Mimi Dacko is an excellent leader for creating an important part of the global health architecture from an African lens, the regional architecture. Another Again, I keep going back to the AU because we talk about Africa demographic dividend, we talk about how many billion people under the age of 25, we talk about the size of the market, the population is continuing to grow, etc. But it is 55 different markets. So the AU's free continental trade Area Agreement is a really important part of this discussion about the global health architecture and the regionalization of that, the global funds of the world. So first of all, I want to qualify. I'm a huge believer in who. The fact that it exists makes a whole difference to so much that we do globally. And there are challenges about how it's funded, about how it's run, how it's governed, how it's represented, which are reflective of any other global ecosystem where there's a power imbalance. But we need a who. We need it not just as a normative body, but to step in where countries are not able to do things on themselves and to step in where collaboration at a good, either regional or global level is needed. Global fund, tb, hiv, malaria. They were supposed, in my view, address the crisis and then push the solutions into the health system. That hasn't happened at the pace that we would like to see. So in the conversations about, besides our crisis, about what do we do to change the global health architecture? I think too often the conversation is just turned to focusing on these global health institutions and say, you didn't do what you should have done, or you're doing things that you shouldn't be doing. I think we need to turn it back and say, so what is who is missing from this architecture, this conversation? And it is predominantly governments at national level across the African continent and not stepping up and determining and defining their own priorities. Where's your national health plan? Are you funding your national health plan? Where are the bilateral conversations? We have loads of regional entities that have a potential to be Part of the solution. Ecowas, the Economic Committee of West African States, is a big player. It's had the West African Health Organization for more than three decades. How much genuine change and movement through sub regional collaboration is happening through the existing entities that we have before we start looking further afield, either to create new ones or to dismantle what exists. And so long as the conversations about reform start from the global entities, we will get it wrong. We have to start from the bottom. And that's why I'm particularly exercising and interested in ACCRA resetting that. They said we start here with us at national level as communities and countries of shared interest to work together to solve the bottom up end so that we have a system that then plugs into an effective global. It then becomes easier to justify not having some functions at global level because they should be and are being resolved at national level. So besides, I don't think it's necessarily which reform movement is getting it right and which isn't. It's actually much more about what is the result that each of these conversations are aiming to get. And if all you're looking at is should there be a global fund or should they not, should there be a who, should they not? We're missing the point. The point is really what should be resolved at what level and therefore what system do you need to do that most effectively and efficiently? And you can't answer that for regional or global if you haven't addressed DACA local.
- [67:12]
A
It seems like so much of that comes back to the point that you made earlier about citizen pressure, citizen engagement, demanding more from your elected officials when it comes to health and the provision of health equity. I'm really struck by that observation. We're speaking in the middle. Well, maybe not the middle, maybe the beginning, maybe the end. It's hard to say of a major outbreak on the African continent, Ebola outbreak. Are you seeing the response to that outbreak as a sort of reflective of some of the transition that's underway in terms of leadership, responsibility, regional cooperation or regional power? Or is that outbreak response still following sort of well worn paths that are more reflective of kind of the. The historical approach to outbreak response?
- [68:11]
B
Okay, I said that the Ebola outbreak was actually a stress test of today, of the global health system today and whether all the rhetoric and the post Covid commitments are real. But what I'm seeing is the same thing. Crisis appeal for support, donors, varying speed, varying amount. And we start the game by saying we're going to train people to do surveillance, we're going to train people to do community engagement. We're going to train people and government still almost unfortunately still at the fringes of the response in their own countries. So I don't think the test is will we move money better? Will we respond better? Will we work with and through governments to ensure that the investment actually leaves something behind so that we're not starting from scratch every time. Because this is not going to be the last Ebola outbreak in drc. There will be others because not just about the ecology, the conflicts that are pushing people, the one health challenges that are actually exposing humanity to more and more pathogens that are currently not known or to which we don't. We're not traditionally exposed. Those there will be. But if every time we respond as if this is the first time this has happened, we're not building the system. And so I am concerned at every level in the sense from at national level, what didn't we learn? There's those saying, oh yeah, it would have been better if USAID hadn't pulled their staff. But the question is, when the USAID pulled the staff, what did you do with those staff? What happened? What did you make of the. What was the best response that you put in place? Nothing is not acceptable or it should be better because we have a regional institution. Africa CDC is still underfunded. It's even to deploy and respond. Who Afro Africa CDC are needing to ask donors to help us to deploy to respond. And then the donors themselves are, you know, the presses have shrunk, the willingness to donate is shrunk. Access to medical countermeasures remains inequitable. We're now just about, I think this week or so they're now beginning to do the field trials around potential therapeutic interventions and potential vaccines to try for these things to suggest that again, the drivers or prioritization of investment in countermeasures are not local. They're not driven by what the risks are locally. Do I think things are better? I don't think they're that different, sadly. They're not necessarily worse. They're definitely not better, but they are not that different. Some things are better. WHO and Africa CDC are working really closely together. That is good to see. I think they have complementary responsibilities and are more than the sum of their parts when they work together. The GRC government is actually building on its experience. It has manageable outbreaks a lot of times. So it's built of inexperience. But of course one of the biggest factors that is affecting this, and we've heard about the attacks on the healthcare responders is that there is a deep level of poverty and inequity in those affected regions that causes the. We're dying from malaria, we're dying from malnutrition. We're being attacked by, you know, cut through by the conflict we're having to force migration because of moving from our homes. And you don't respond. And it's just this one disease that you care about. That. That we. We heard those similar sorts of conversations during COVID We heard those conversations in the last pockets where polio hasn't yet been eradicated, that crises and emergency responses are always going to be hampered by what you did before the crisis. And that hasn't really changed that much. So I feel slightly pessimistic about how much we've actually learned and what's changing.
- [72:20]
A
A lot of this conversation has been about power. You told me at the outset that when you were thinking about a career in medicine, your father, a physician, warned you away from it because of how difficult he worried it might be for a woman in this field. I mean, power flows at institutional levels or international levels. It also flows down to the interpersonal level. I'm wondering, you know, now that you're at this point in your career, you're a prominent voice in this conversation about reimagining the global health architecture. How does your father's warning those years ago resonate with you now?
- [73:16]
B
Actually, I took it as a challenge rather than a warning in my graduating year of medical school.
- [73:22]
A
I am not surprised.
- [73:24]
B
My graduating year of medical school, 120 students, 20 of us were women then. And I think about my class and most of Those women, only 20 of us are in very influential positions now. To change that narrative, I think that's our responsibilities, to keep pushing against the status quo. My daughter is not in the health, she's not a doctor, anything like that. She was very, very, very clear, was not a career she had any interest in whatsoever. But her generation shouldn't have the same challenges that we had. We should be able to start to dismantle some of that. So I have always been. I mean, it's Maya Angelou's words. She said, of course, I'm a feminist. A feminist is about supporting women. And I've been a woman all my life, so why shouldn't I? So I paraphrase, she put it much more eloquently than that. But I have always believed that some of the challenges that we face in the health system is because of the lack of representation across the board. But Particularly of women. I mean, we all know the statistics. You know, 80% of the healthcare deliveries is led by is women. Leadership is mostly men. I think that is a problem. The current sort of regression globally we're seeing around the equity and equality argument is a serious concern. On the African continent we have some countries who have done brilliantly around gender representation in politics in general and in the health sector in particular. But we've seen some countries like my own in Nigeria that have gone regressed somewhat. So the fight continues and we need to continue to push for the representation, equal representation and in my view, in certain circumstances, maybe even switching the balance a bit to bring in new voices into the conversation about power and decision making and what gets prioritized in the health sector. What my role is. I see my role in twofold and I want to qualify this. I say something I actually mentioned on the talk I was doing earlier today is that being in the room or being visible doesn't necessarily always equate to having power. A lot of, you know, again, post was the Floyd George Floyd situation. I was working in the UK at the time and there was a whole flurry of organizations starting to write DEI policies to appoint leaders for dei. And that all fizzled away very quickly because it was performative. There wasn't a deep rooted commitment to changing the narrative because people in decision making didn't see the problem, because it doesn't disproportionately affect them, it doesn't adversely affect them. So part of, so just being seen as an African because there was a role I was once offered where I said all I needed to do was go out, fall down the stairs, break a leg and then you can tick every box of representation. Because it felt very much that I was just being invited. So we can, you know, one person, she'll be the woman, she'll be the black person, she'll be the local and the minority ethnic should be all those things. And then we don't have to bother about it. We can take that box. But so oftentimes there is a risk that you're given a platform, you're given space and that in itself becomes the end for me. Those of us have the privilege to be given the opportunity like you're giving me to actually talk about what we think is important, have to wedge that door open so the floods can come in and more importantly translate and transfer the knowledge of what we learned through our journeys so that the next generation can leapfrog that learning, they can adopt it and run. So I Believe very much. In addition to speaking when I have the opportunity and challenging status quo, because I'm at an age now where, you know, it's not as goes, I can now I've got pension. I can. I can retire. I intend to be one of those cranky retired people who sit down and just criticize everybody and say, I wouldn't have done it that way, but never perfect podcast guest. Yeah, but. But I think I have a responsibility to point out who else you should be interviewing, and I will send you notes that I have a list of people you should be bringing into your podcast so that we have more voices and the more diversity in the dialogue, the better the solutions we create. I also feel quite strongly that we have a responsibility to mentor people, to support them. On the same journey I had, I actually intentionally went to work with someone who I thought is navigating the hurdles I saw, and I wanted to work with her so that I could learn. And she was amazing support to me. So I hope and I try to offer the same sort of support to others. I am unapologetic about being intentionally discriminatory in that sense, in that I preferentially support women, particularly women of African origin, because we're the least represented in the leadership architecture across the board. But the thing that I don't think we're doing well, and which is something that exercises. And I'm going to throw a question back at you. I'd like to hear your views about. This is the pipeline. Every time there is a leadership role in the big institutions, the big spots, the influential spots where power is leveraged, there's always that there are no women ready, there are no women at all, or nobody even considers women. So how do we intentionally create the pipeline so that it's not a, oh, there are no women. Okay, next time we'll try. I think that we have a responsibility to actually address that, and I really like to hear your thoughts on that. But how do we then make sure that those women are equipped for the system as they find it while they change it? And that's a double whammy. And not to be sexist, but a man appointed to the role can just, you know, the status quo suits him. That's the status quo. He doesn't necessarily have to change it to be successful. But for a woman in those positions, there's an expectation that you have to function within that system and also change it. So how do we prepare ourselves to be better at that? I like, I'd really like to hear what you think about that.
- [80:16]
A
Well, here we go. No, I'm gonna disappoint. I don't have an answer to that question, but I'll answer it with adding to the, the level of concern. I mean, I think the, the UN Secretary General race is about as much proof as you need that the narrative around not having a leadership pipeline is incorrect. I mean, there are numerous female candidates for that role and have been in previous races as well. The thing that worries me is that we're talking about flawed, in some cases, sort of politically fraught international institutions. I mean, the UN is one very prominent, prominent example. But I think you could go across the global health space as well. Exactly to your point. I worry about the woman leader who makes it through that, you know, supercharged political competition to find herself at the top of one of those institutions and as you say, is then held accountable or somehow blamed for its failures that were pre existing. You know, and I think that's, that's something that has to change in the conversation around what it means to lead an institution through a really difficult period. And it can't be a means of foreclosing that leadership opportunity to women. You know what I mean? So I don't have a good answer for you. I don't, I don't, I don't know how to simultaneously position women for more of those jobs while also not setting them up for blame or failure in the process.
- [82:09]
B
It's a glass cliff analogy, isn't it? About they don't, women don't get the opportunity until the situation is in a crisis. And then when they don't manage to fix everything, then they're blamed for it. And then it says, oh well, we've done the women, they didn't succeed. And they go, so again. And that's the sort of the patriarchy and the inequity in the system where more often men are allowed to fail and recover, women are not. And so part of that conversation we need to have is enabling, providing the same support to women and the same opportunities to women in leadership. It might be even more, because oftentimes they're the first of their kind that we do when men are in those positions so that you actually optimize their potential for success. Because we do need to see more women in those positions succeeding for more women to put themselves in the pipeline so that we start to see that rich diversity in the people running for these senior offices and who have the opportunity to lead these global defining institutions and bringing in new ways of thinking and new problem solving approaches to It. So it's not just always the same, the same narrative. Oh, I mean, there are all those, you know, 80% of the health workforce that are women. Within that exists a large number of women who have the potential to. Not just to lead, but to lead transformationally given the opportunity to either to be seen or to have a goal when the opportunity presents itself. So yeah, I mean, some places have taken, you know, there's a quarter, quarter approaches to it and you know, everybody's very critical about quot quarters. I don't have a problem with quotas because I know that the women who will get onto those quarters are already competent or in some cases far more competent than the men who have held those positions in the past. So whatever mechanisms, we need to think about mechanisms to ensure that women can be considered seen, given the space to lead those institutions at every level, from local government to global institutions like the UN so that we can actually start to see things differently. But we're not there yet. The little that people like me can do is talk about it like I do today, support those I think in the pipeline and the next generation, mentor, give platforms open doors, wedge them open and challenge. Continue to challenge the status quo because we have the. We've been given the agency and the platform to do so.
- [84:51]
A
Well, this door is open. I am eagerly looking forward to your list of future guests, so don't hesitate to send that over. Hey, Barry, there's one question I ask everybody on this podcast at the end, and that is, is there anyone or anything that you would like to thank?
- [85:11]
B
Oh, where do I start? That. That's a really one person. That's a really difficult one. Let me see. Okay. I'm going to give more than one for different reasons.
- [85:29]
A
Most people do.
- [85:30]
B
Yes. So my mother would never define herself as a feminist. Neither will her mother. But they were feminists in the way I see I define feminism today. And so I would thank them for giving me the opportunity to see women differently from what was the cultural predominant narrative when I was growing up. I would thank them for letting me. I can run my mouth and my mother didn't shut me up too much. I was very fortunate not to be raised by a mother who believes in children being seen and not heard. We were heard. And I think that belief in that I had an opinion and it was valid and worth sharing had I had that ingrained in me from the get go. So I would like thank my mum for that. My mom and her grandmother and her mother, my grandmother as well. The first woman I saw In a biosciences. I had a direct interaction in a biosciences space with who was in a leadership position was a professor Amazigo. She is a Nigerian professor of parasitology who led the West African orchoserchiasis elimination program which predates, you know, it was the very first on call elimination program from the 70s and 80s or the 80s actually Samazigo was the first, like I said, woman in a senior leadership space in science. I met in my pre med year and she was no nonsense. I'm still in touch with her today because I, she, she, she occupied a space that there were very few women in and she made no apologies for that. She had control of her brief. She was super, is super brilliant and she did not take prisoners. I've told you in my medical graduating year there were 120 of us and 20 women in our pre med year the ratio was like three times three to one in terms of female to male. And she was our only female professor. But she's also the professor that everybody remembers. So she and I talk about her a lot because she imprinted on me how important it is to be seen and to be effectively seen when you're representing, whether you like it or not, a whole gender. Who else would I are there so many women who have allowed me space and men who have given me room, who have held the door open or who have told me here's where you need to be open. And then people I don't know who have mentioned my name in rooms where it ought to be heard, some of them, I've heard somebody mention it and I don't know who they are. So I'd like to thank them for that too and I owe them that. But I'd say the person who made me actually be bold in latter parts of my career in recent years is my daughter in the sense that she, like I said, she has nothing to do with health. She's an actor. But when she was in her sixth form, she challenged me. She said, go and do global health travel. Go and leave that place. I'm only swatting anywhere. I don't really need you to be here every day. She gave me permission to take my advocacy onto a global platform. I wouldn't have done it without that. And I don't think she necessarily thinks it was such a big deal. It was to me. So all the people I thank are women. There are a few men, but most of them are women.
- [89:18]
A
Well, it sounds like I owe your daughter a thank you as well for putting you out there to join me today. Iberia, thank you so much for being here and has been great.
- [89:27]
B
Thank you for having me. It's been a pleasure.
- [89:30]
A
And I want to thank my production team, Tom Cherup and Mai Ilagan, Tanya Karas, my editor, and Malik Tilman for that beautiful free kick in the U.S. win over Bosnia and Herzegovina. Thanks. See you next week.