Tau Tavengwa (TT): You are both health experts, broadly. What is that?

Renzo Guinto (RG): I really hate the word expert.

TT: Okay, global health people. What does that term mean? And what is the history of that term?

RG:  Last week I gave my first intensive course—Intro to Global Health—with a focus on Asia. The first session was about “what’s global health?”. Many people still have this idea that global health is [something] away from home. So as someone from Southeast Asia, Africa is global health. But also, our own backyard is global health as well. Global health is also local health. [There] is this idea that it’s defined based on space… that health is created in certain spaces. 

But global health is also about the fact that a lot of the drivers of health now are moving from one country to another; some even don’t move because they’re planetary in nature. Climate change is not moving from one country to another. It exists, it affects the whole planet, it’s a global health issue, therefore. And we’re even using the new phrase “planetary health issue”, because it’s not just about the health of people, it’s also about the health of the planet. 

So it’s about health outside, but also health inside. I’m trying to laymen-ise things. [Global health] is a recognition that health and its drivers, and even the responses to the health issues, are coming from everywhere—whether vaccines produced from one nation, or digital technology and information that does not see any kinds of boundaries. I think that’s the health reality that we live in today.

Tolullah Oni (TO): I completely agree. It really drives me up the wall, that “other” health framing.
I think I may have scandalised some students at Cambridge when we started the global health course and in the student induction I said, “If you’re looking to learn about health inequalities in poor countries, then don’t come to my course. Because that’s not what we’re about.”

I would say that global health as a designation exists out of a failure of public health to evolve. Because what you’re describing is public health. We get to the social determinants of health, upstream factors, etcetera. What aspect of public health today isn’t global? 

Like you said Renzo, [the idea of global health] is created in certain spaces, by certain people, certain institutions. I dare anyone to think about a single aspect of public health today that isn’t global. Maybe what is different then, is the level at which one is acting. I might be acting very locally, and then I call that local public health, or I might be acting very globally in a multilateral space, and then I’m in global health. And I don’t really agree with that. 

We lack an understanding of public health that is fit for purpose, and I think that’s what global health stepped in to fill. It links health to the planetary and the transboundary because that is what the evolution of public health should have been more cognisant of. We know upstream determinants, but we didn’t evolve into transboundary determinants. There’s no sovereignty when it comes to planetary risks. Air quality in your neighbourhood is not only influenced by cars and whatever other pollution sources exist in your area. The controlled burning or raging uncontrolled fire that is happening 5,000 miles, four countries away is also influencing it. So, you have to govern it together. Therefore, those transboundary risks really characterise what global health is, because it needs transboundary action.

RG:  You started by saying that with global health there’s a recognition of the failures of the traditional public health response. Now I’m curious: where did public health fail? Did it fail in, for example, dismantling the structural barriers, because it has focused very much on addressing the symptoms and the pathogens? Has it failed in terms of really trying to fight for and achieve justice? Because its ambition was reduced or tamed. In public health, we’re happy that people are healthy, on the average, without necessarily being concerned about the gap. And I think that’s where global health [officially claims] a special concern for equity. Is that a result or a reaction to public health’s neutrality or lack of concern for equity?

TO: I wouldn’t agree that public health is neutral. I think it’s neutered in its response. Because in public health—and this is the opportunity for global health in public health—there is a disconnect between what we teach and what we do. The public health I learned is very much also about inequity and understanding the gaps, because that’s where understanding social determinants of health come from as well. Recognising that lower income versus higher income people in the same households don’t have the same access to healthcare. It’s recognising targeting of particular populations at-risk: hard-to-reach or poorly reached, however you want to phrase it.

But I think the problem with public health is best characterised by [the fact that] most factors that determine health lie outside of healthcare. But when it comes to what should we do about it, I think the conventional public health response [is] neutered and focused on healthcare. As a healthcare professional, because…there wasn’t a guiding framework to support the work that is almost beyond your [healthcare] lane, you stick to primary care. There’s a lot of work to do there. You stick to immunisations. You stick to those important but very, quite local things. 

You don’t tackle the upstream IP or whatever. You just tackle, well, “let’s strengthen the health care system”. Because there is stuff to do there as well. You focus on the hard-to-reach: let’s get to those mothers who don’t access antenatal services … The things that we can do. You don’t focus on the fact that part of the reason they’re hard to reach is the way that we’ve developed and built the city has pushed people further away, because there’s been foreign direct investment that funds infrastructure detrimental to health, or there’s been poor local regulation to say people need to have access to healthier homes and environments. [Public health] is not as ambitious in its interventions. And that’s where global health is.

RG: That’s the business of global health. But maybe we should not be using the word “business” because of its negative connotation. In global health, we’re concerned with issues that range from Intellectual Property, urbanisation and the economy, and now, planetary health. We want to decarbonise the entire vaccine production chain—from the manufacturing to dissemination system. We want to address the planetary system so there will be no, or less, climate-sensitive infections in the first place that require the vaccines. The scope of our healing mission keeps on expanding. The challenge now is, are we equipped? Do we have the bandwidth? How do we not get burnt out?

TO: Yes, how do we not end up making the same mistakes as we did in public health where we talk big, but only do small things?

TT: Can you talk a little more about the failures of the current system? I know you already broadly intimated what those failures are. Could you expand with more specifics here?

TO: I would say three things: One is failures in terms of truly integrating actors, and by actors I mean people, sectors and the institutions that govern and actually shape health. 

The second is the failure in evolving our understanding of the risks around the transboundary nature of health, and failure in evolving our conceptualisation of social and upstream determinants which were always at the core of public health thinking. Those are what drew me to public health after my medical training. We talk about “upstream”, but failed to evolve quickly enough to talk about the climate reality as part of that. Public health should have been leading on this ages ago. 

The third was a failure to disrupt the knowledge around it. I liked the point that you made, Renzo, about justice. Public health as a profession failed to interrogate and disrupt what we accept as the dogma, as universal. What is true about health in the Netherlands doesn’t necessarily hold in the Philippines, but in some aspects might hold in Ghana, but not in Nigeria. 

It failed to challenge the power imbalances that shape knowledge and the institutions that determine health. I think it wasn’t ambitious enough in shaping that.

RG: I 100% agree. Particularly the imagination failure. It can be hard to imagine how actors that live or exist thousands of miles away from your home—in different sectors, in a different country—influence the more proximal determinants of health that you experience, that you encounter, whether in the hospital, on the street or the foodscape. In addition, the other failure we need to acknowledge within the public/global/planetary health community is our moral and ethical failure. The failure to bridge what we claim to be espousing versus what we’re actually doing in terms of issues around equity and justice, for example. 

Planetary health creates an opportunity for us to register our concerns not just about people living today, but those who will be living 100 years from now. There is an intergenerational equity dimension that we can really embrace and manifest. If our decisions today fail to take into account the survival and thriving and flourishing of future generations, that’s a moral and ethical failure on our part. We cannot keep claiming to espouse these positive values without living and breathing them every day, and fighting to deliver on them. 

In public and global health, it’s only recently that we have started recognising that the social determinants
of health that are at the core of our work are actually governed, controlled and influenced by the corporate sector and commercial actors. The decisions around our roads, food, etcetera, are made by very few elite forces. They’re making the decisions in corporate boardrooms that we do not have access to. It’s only recently that we have also realised how, unwittingly, we’ve been conniving accomplices to what amounts to crimes against the wellbeing of society. Maybe this is because we were not very consistent with our values. If we are really standing for equity and justice, we should not be naive when it comes to dealing with these forces: we should build our armour against [them] so that our values remain intact, our voices are not drowned, and our space not contaminated.

TT: You have both mentioned evolving the knowledge systems around which public health is built. Where would you say the opportunity for tinkering with this lies, and what would that look like? What is it meant to achieve?

RG: People like Tolu and I have been trying to fight these oppressive knowledge systems every single day. The two of us come from the global South—from Africa and Asia respectively. We have been working hard to centre sources of knowledge that have been peripheralized for a very long time—knowledge from communities, from indigenous populations and from non-Western communities. I always wonder why in the primary global health textbooks, there’s no chapter on the contributions of Asian and African knowledge systems, ethics and philosophies to global health thinking. This is something I’m hoping to address in the coming years.

If you look at the global health ethics chapter, it’s primarily based on Western philosophy and the Judeo-Christian tradition. Of course, there’s nothing wrong with those sources of knowledge, but we’re only seeing half or even less than half of the entire story of global health. As a result, we’re missing out on potential solutions that may be informed, for example, by Islamic, Buddhist, Confucian and other ways of thinking. We’re working hard to bring more of these perspectives into the mainstream global or planetary health discourse. 

I recently read somewhere that there should be a Pluriversality of knowledge instead of a universality of just a single source of knowledge. Tolu, you and I are affiliated with the usual suspects in global knowledge creation and production. I’m currently at the National University of Singapore, number one university in Asia, one of the top 10 in the world, and you are at University of Cambridge. One of our colleagues, Madhukar Pai, uses the term “double agent”. So, we are in some sense double agents in these universities. On one hand, we’re part of the elite knowledge production system, but on the other, we’re also trying to fight this system and bring these new perspectives and ideas into it. 

Initially, in these circumstances, it can feel like you are a lone voice in the wilderness, but as more of us come in, you start seeing the change. It’s not just about us invading these powerful spaces of knowledge creation, though. It’s also about carving out new spaces or finding those existing spaces that we don’t usually listen to or learn from. So, I encourage my students to read materials, books, articles, written by people that they’ve never heard from, not the usual suspects.

TO: The thing you mentioned before, Renzo, that struck me is the moral imperative. I think that is more important than we allow for. I had a conversation with a colleague recently and asked the question: “Could you be a global or planetary health practitioner, and be (politically) right wing?” Thinking of that as incompatible made me question whether I was defining my moral imperative around my politics and if there’s any other way? It highlights how complex it is and how easy it is to default into one’s own perspective because you see yourself as one of “the good guys”, which can lead to excluding other points. I think it’s important to embrace that complexity. I don’t have the solution, but I think that’s okay. Bringing that level of lack of resolution into training is important too, because sometimes we shy away from things that we don’t quite know, so that’s not part of the curriculum. 

Sometimes we forget that we’re not just training future professors. We’re not just training future doctors or nurses. We’re training some of the future corporate people that we talked about earlier. We’re training future politicians and urban planners who will end up having roles in all these systems that are important for health. So, we shouldn’t be designing and delivering a purist curriculum that jams students up the minute they graduate and go out into a complex world where everything they have been taught just seems divorced from reality and irrelevant to the complexity they might face working in the pharmaceutical industry or big food manufacturing sector, for example. We need to develop curricula that signposts and prepares them to hold certain values while being able to navigate complexity, and that includes valuing inclusion. 

I agree that planetary health is doing better than global health in starting much earlier to centre indigenous knowledge systems. Planetary health brings into frame not just the environments that we shape, but the [shared] resources we have on this planet, and looking at how what we do interacts with what we’ve shaped, and how what we’ve shaped interacts with the natural environment. We are talking here about environments that have existed for a long time. Sometimes we think about how we live today and how society is structured as if we’ve always done this. And we hold certain things constant that actually have only been constant for the last couple of hundred years, which is just yesterday in terms of our species. Whereas there are other knowledge sources that have held a stronger golden thread of ways of living in better balance with the natural environment, shaping the environment and our needs in ways that are not exploitative or depletive or destructive to health. And they’ve stayed constant, but somehow we have chosen to dismiss that knowledge and way of being in the world as primitive. 

It’s clear that whatever we’ve been doing is not working and we need to make a concerted effort to access other ways that work better with the environment. We need to pull in other philosophies and the ethics of other contexts as a way of addressing some of the huge disparities and inequalities we have.

RG: Many indigenous cultures across Africa, Asia and in Latin America have been in existence for centuries, if not millennia, and have been espousing these ideas that our health as a species is connected to the planet’s health, that they’re inseparable. We need a holistic approach. It’s something widely shared across these cultures until the eras of colonialism and industrialisation began. Then capitalism became the main economic vehicle and we started measuring human progress in terms of GDP, not in terms of whether people are happy and healthy and natural ecosystems are preserved.
As we have been erasing these other systems, we have been measuring and documenting the wrong things. 

Another issue we need to have in full view is Power. We need to do a better job interrogating how the tentacles of power affect all things—the social and environmental determinants of health. I feel we are not fully equipped to do the necessary analysis and interrogation of power, and as a result we’re powerless to tackle and address powerful actors and regimes in the system. In my imagination, future public, planetary, global health education should be about power. The introductory lecture would be about the state of power in all its forms globally, and why each student should graduate from the programme empowered to address the powerful.

TO: Yes! We should be training people to understand why power is so important. Also ensuring that should they be in a position to wield it, they’re not just equipped, but motivated and driven to be part of the change they might have embraced as students.

TT: Let’s bring it down to the urban. More people are living in cities across the world now than ever before, and those numbers will keep going up for the next while. How and where does this evolution of health systems you are talking about locate in that reality? What kind of policies do we need in place in terms of how we think about health in our urban systems?

RG: Recently I moved to Singapore out of a very chaotic Manila—my home city that I love dearly, but hate as much, because living there you get used to wasting four hours each day stuck in traffic. In Singapore I’ve never been more efficient. It takes me 20 minutes to get across the city, where in Manila, the same distance would take two hours. That’s a very personal experience [that] illustrates the real-world education I’m getting here. As someone who teaches urban health—stuff like best practice, how best certain things should be done, etcetera—I’m getting to see how it can be done in real life, in terms of mobility, infrastructure and public space, and the foodscape, [how these] are key to promoting good health.

Singapore is filled with places to get delicious food, but they also have put in place policies regarding [things like] the salt and oil content of food. For example, I love Milo Ice. It’s a chocolate drink, [with] lots of ice. I’ve not been doing it yet, but apparently, there’s an option to say [you only want] 50% sugar. Some people might say it’s superficial or cosmetic, but I think things like this are important baby steps towards promoting good nutrition in a city that loves to eat so much. And there are many others. Road safety, for example. I think this city is very proud that your toddler can be walking around the streets without the worry that the kid might be kidnapped. If it happens in the Philippines, unfortunately, that might be the end of it.

TO: What [you said about] mobility, I was thinking, starting from a personal level, about running.
That’s how I judge a city. That’s what’s personal to me. Running is everything from… can I step out my door and go for a run, or do I need to get in a car and drive for an hour to go somewhere I can? Can I do it in ways that connect me to a natural environment or doesn’t put me at risk of road traffic injury or physical injury because of the infrastructure? Can I do it on my own? Or if I want to do it with others, can they also access this relatively easily? That’s my entrypoint in thinking about designing the city. 

I think we need to define the basics around wellbeing. And so what we’re talking about is mobility, about physical activity, about food, about connection to nature, about connection to others. That’s the first thing: a city that defines the basics around that wellbeing. 

Secondly, it provides those basics and incentivises the provision of those basics. It provides it when it’s in the public sector, incentivises when it’s the private sector, across the life course. It provides it for everyone, provides it for children, as you mentioned, provides it all the way to older persons. 

And then the third is that it connects today’s basics to tomorrow. What the needs of today may be and how we define the basics today may not entirely be in balance with tomorrow, with the future. 

Having defined those present basics, provided those basics, and then doing it in a way that is sustainable and connecting that to what would be available for future generations. You can apply those three questions with any entry point—from running to healthy foods, mobility, connection and social, mental wellbeing.

TT: Any last final thing either of you would like to add?

TO: The one thing I didn’t mention, and this links to what we were talking about regarding indigenous knowledges and pulling all these different ways together—years ago when on sabbatical, I got obsessed with thinking about a museum of public health. You know how you have the American Museum of Natural History? But it’s very basic science and it’s incredible. 

What if we had a museum on the history of public health, that brought in different histories of how public health, or planetary health, have been conceptualised in different civilisations. Because like you, when you talk about the history of public health, you think it starts with John Snow and the water tap in Soho. That is it. But what happened in different parts of Asia? All these things were there, but they need to be dug out. Those knowledges don’t need to just exist within the university system, because things like museums are publicly accessible sources of knowledge that cut across time and space. And if we could think about health in that way, I think public health can evolve more suitably to take on the global and planetary health mandate that it really needs to.

 RG: Wow, exciting! Sure, it can be a physical museum, but because we now live in a digital world and to ensure greater access to different audiences, we can also imagine a virtual museum. It’s interesting also, and this is a very short story… 

There’s a white Australian professor of history who when I was at Harvard in 2019, gave a lecture. He announced he was writing a history of planetary health, and that was the topic of his presentation. After the slides, during the open forum, I was excited to raise my hand. By the way, the moderator was the late Paul Farmer, who let me ask the first question. And I said, amazing presentation, blah, blah, blah. But there’s one thing that I observed. None of the photos that you showed on those slides look like me because they’re all white men. He’s writing the history of planetary health and actually he’s just writing the white man’s history of planetary health. And I ask, where are the indigenous roots of planetary health? Are there contributions from Chinese civilisation or the Inca civilisation? 

And the excuse? 

He’s only looking at English-written sources. A very lame excuse for a supposedly well-known historian.
The interesting thing is he also wrote the history of American public health in the Philippines, that was his doctoral dissertation. That is the problem.