8 February 2021
Ultimately, the only way to change anything is through people. Training is not just about transferring knowledge; it’s about building confidence and a sense of purpose, about creating international networks of friendship and collegiality, and about advocating for better healthcare. Access is a horribly complex issue and is about every part of the surgical system, from governments who need to see the value of surgery and fund it, through to the patients who have to be aware of the services they need and feel empowered and able to use them. In the middle of these two extremes are the health care workers, who need every ounce of knowledge, confidence, and friendship they can find. Training is one means to give them these.
COVID-19 has highlighted the effects of inequity on health, both within and between countries. It has also been an exemplar of the fact that healthcare acts as a heavily interdependent system in which public health and acute care are inextricably linked, where societal health and individual health are co-dependent. More than that, it has demonstrated that global health is really just that – the management of a pandemic in Brazil or the United Kingdom can have a material effect on countries across the world. There seems little doubt to me that the immediate effects of COVID-19 will be a worsening of inequality, but I have optimism that it might also point us to a better way of doing things, with projects like COVAX reflecting what multinational efforts can achieve, and the problems of vaccine nationalism and viral variants illustrating that isolationism breeds worse outcomes. It is an opportunity to reset our approach to health, and has also highlighted the absolute need for oft-overlooked specialities such as public health and intensive care medicine. The only way we can ensure that progress is not lost is by learning these lessons and ensuring that governments are not allowed to forget them.
I think the global explosion in social media means that more voices are heard than ever before. However, in the chaotic world of the Twittersphere impassioned voices can be easily lost in the noise, and ignored by those with influence. Worse still, fringe opinions can be inflated and influence the debate to an extent which they do not deserve. More than ever health and care workers need to find consensus, and speak together. A common approach to evidence and rationality is needed so that the published views of health and care workers are broadly consistent with each, and don’t seek to undermine the common good. There is a role here for journals, professional bodies, and academies to get the best of their contributors and members, and present their views in a way which is impossible to ignore. There is always a place for free speech and challenging opinions, but to influence policy we need clear, cogent arguments with the weight of the majority behind them.
Targeted programmes like this encourage partnerships to address challenges that often fall outside of more traditional funding streams. Surgery and anaesthesia is a case in point: 5 billion of the world’s population lacked access to safe, affordable surgery and anaesthetics care when needed in 2017 – with surgery as cost-effective as some of the most basic public health interventions – but for years has been difficult to work into vertical programmes which focus on particular diseases. Surgery and anaesthesia are the ultimate cross-cutting element of a healthcare system, supporting a vast range of other services as well as providing curative care for wide range of debilitating or fatal conditions. I think the example of the AGP to other donors is that by widening the scope of programmes to look at system-strengthening efforts you can achieve a huge amount more than by focussing on a single disease. In addition, programmes like this bring in a range of interested actors who might otherwise have felt excluded from the global health or health development community, and more hands to the pump can only be a good thing.
This brings me back to the first question: people are the most effective agents of change, and this change is most likely to be sustained within a long-term relationship. Health Partnerships are enormously powerful in breaking down the toxic legacy of colonialism, and disabusing well-meaning HIC participants of some of their naivety around what international programmes really mean. Partnership are two-way, long-term, and require an equal commitment to change from both parties. They allow projects to go beyond a short-term focus on outcomes, outputs, activities or whatever other nonsense jargon is expected to be reported and instead allow workers across different healthcare systems to understand different perspectives, learn from each other, be inspired, and find new motivation. In my experience of health partnerships, the problem of improving care in LMICs is as knotty and complex as they come. There are no easy answers, no quick fixes, and any real change must come at the level of the individuals involved. This takes trust, and time, and these come best through a long-term partnership of friends.