Lucy Gilson (Harare, Zimbabwe, 64 years old) has dedicated her career to researching health systems and how to make them more equitable. The South African academic, director of the Division of Health Policy and Systems at the University of Cape Town and professor of Health Policy and Systems at the London School of Hygiene and Tropical Medicine, believes that equality in access to health is not It can isolate from other global challenges, such as climate change or efforts for a more supportive economy.
Gilson has been awarded this summer with the 2024 Virchow Prize ―which recognizes exceptional contributions to the promotion of global health― due to the “holistic approach” of her work “to safeguard human and planetary health.” In this conversation, which he had with EL PAÍS by video call from Cape Town, Gilson talks about the social consequences of the covid-19 pandemic and how neoliberalism “dehumanizes” public health.
Ask: The Virchow Prize recognizes his contributions to both planetary health and human health. How does this dual approach align with your work on equity in healthcare systems?
Answer: These elements go together because in both the greatest weight is carried by the poorest. That’s true for both climate change and human health. Our biggest challenge is how to support, feed or empower these less privileged people for whom access to health represents a burden on a daily basis. We want health systems to take care of us all, but particularly those who need it most.
Q: So, when studying health systems it is important to understand them within a social and environmental context?
A: We need to think about how health systems respond to shock. How they adapt to climate change, changes in health and other conditions that have to do with both planetary and human health. A health system is an image of how we live on the planet, it is an image of our concept of well-being. That is why they must not only address diseases, but be more proactive to better address the human health consequences of planetary health and put those with the greatest needs first.
Q: But the latter does not always happen.
A: It happens very little, unfortunately, but it should be a constant goal. It is always important to reaffirm and promote it. Advocate not only for overall population health, but also ensure that health systems are advancing the goal of social justice.
Q: The Virchow Foundation recognizes that its work functions as “a bridge” between the global south and the north. How has your view of global health evolved while working in Cape Town and London?
A: I have had the privilege of working in Africa for over 30 years, as well as being born in Zimbabwe. This has taught me that it is essential to understand social contexts in order to understand global health challenges and how to address them. I think I have been able to bring those realities from the global south to the north to teach and research them. You also have to understand that there is a power dynamic. It is the north that has the power. That is why I wanted to bring those worlds closer and show in London those experiences that the global south can contribute and reconcile these two realities.
Q: A constant demand of the countries of the global south is to have an equal participation in global issues and not to be seen through the prism of charity.
A: No country wants to be seen from charity. In the geopolitical power dynamic, which extends to global health, southern countries claim to be part of the decision-making process. Don’t decide for them, but rather share knowledge and experiences as equals. They know that if you are not in the conversation someone will speak for you, and that is paternalistic and demeaning.
Q: Are we closer now to having equality in this global debate?
A: It depends on what place in the world we are talking about. For example, in the World Health Organization members make decisions equally. But in reality it is those with funds and geopolitical power who dominate the conversation.
Q: The covid-19 pandemic exposed the weakness of the health systems of many poor countries, which even today do not overcome the social consequences of those years. Was the pandemic evidence of geopolitical disparities?
A: We only have to think about access to vaccines, or what in Africa they called “apartheid of vaccines.” The division of power translated into inequality, in access to what everyone needed to protect their population. Covid-19 was an example of these power dynamics in the world.
But not everything was the same in all poor countries. There were experiences of all kinds in the south and north. There were many experiences in the global south of how communities responded to that challenge and not everything was shady. Furthermore, there were situations such as corruption in the distribution of masks and other health supplements that were an evenly distributed problem throughout the world. Also in the poorest communities in European countries there is a legacy of covid-19, which only aggravated poverty and the health situation.
Q: What were some of those positive experiences in countries of the global south?
A: Communities that came together to support each other when responding to the challenge, not only of the disease, but of the blockage of health materials. In Cape Town, where I live, there was a very important community support network, connecting communities across the city. There was an exchange of resources and experiences and support for neighbors that was extremely positive. This mutual support is part of the muscle that communities must have to respond to challenges, whatever they may be.
Q: The need for this union in civil society is a key point of his work.
A: Civil society has an incredibly important role to play, as does free media. And this is partly because they are mechanisms for holding the government to account. And in any country, we always need the government to be accountable for what it does. But let’s not forget that the government is also the one we want to work with to support the populations and take care of them.
The public sector in democratic societies has the responsibility to respond on a large scale to many different challenges. That is why I believe that governments have an important role to play as organizations in charge of the health of the population. They not only have to manage healthcare facilities, but also advocate for investment in the broader actions needed to tackle the causes of poor health.
Q: How can the approach to public health be improved?
A: Healthcare systems are often seen as machines. And they are not. A health system is a collection of people working in linked teams, framed by routines, practices, values, norms and broader sociopolitical factors. So if you work to strengthen that system, it is important not only to think about the resources you need. Policymakers often do not take seriously the need to create enabling environments for such systems.
That may mean issues related to decentralizing authority, so that people in the community can make decisions for themselves. Or also encouraging collaboration between government departments, because they need to work together to address the causes of poor health. Government bureaucracies often operate in a very isolated manner, are very rigid, and their authority flows from the top. That can undermine local initiative.
Q: What is the great global challenge for public health policies at this moment?
A: The global economic situation and the way we think about the economy is important when we talk about planetary health. I think we need to think about the nature of global economic forces and the influence of neoliberalism and its fiscal policies on what governments do. We must be concerned about how commercial forces influence health and health systems. The pharmaceutical industry influences who has access to vaccines and medicines, for example. Furthermore, commercialization and the growing acceptance of the profit motive in healthcare systems has a new force. I see healthcare systems as networks of care rather than machines that need to be incentivized to provide a service.
Q: So, To have more humane health systems we need more humane economic systems.
A: We have to think differently about our economies and how we care for the world, just as we care for our personal health and the health of our community. And we need to think differently about how we regulate access to what we call global public goods, like pharmaceuticals. There must be greater equity in the distribution of global public goods so that the needs of everyone are met and not just those with the most wealth and power.
Tendencies is a new project from EL PAÍS, with which the newspaper aspires to open a permanent conversation about the great future challenges facing our society. The initiative is sponsored by Abertis, Enagás, EY, Iberdrola, Iberia, OEI, Redeia, Santander, Telefónica and the strategic partner Oliver Wyman.
You can sign up here to receive the weekly newsletter from EL PAÍS Tendencias, every Tuesday, from the journalist Javier Sampedro.