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Gavin: Hello and welcome to the final Lancet Voice of 2023. I'm your host Gavin Cleaver and I'm joined today by my co host Jessamy Bagnall. Today we're going to be talking to Editor in Chief of the Lancet Richard Horton about his highlights and his lowlights from 2023 in health and looking forward to 2024.
Thanks so much for listening to our podcasts throughout 2023. And we'll see you in 2024 with a fresh line of guests and discussions about health from all over the world. But for now, it's just me and I talking with Richard Horton.
Jessamy: So 2023 year of high level meetings and declarations. And at the beginning of the year, there was a real hope that this was going to reinvigorate the multinational process to health. Lots of discussion about it. So in two sentences, Richard, has it worked?
Richard: One word, not two sentences. No, it hasn't.
It's been a year of the triumph of hope over expectation. Yes, we cram all these high level meetings into this week at the General Assembly and we had universal health coverage and that was a real expectation that there was going to kick start something big. And it fell utterly flat on its face.
Because unless you have two things, these grand statements mean nothing. The two things you have to have is, one, you have to have a political leader who is championing the process. And there is not one high level politician who has picked up universal health coverage to run with it. And by high level politician, I really do mean somebody who's in a G7 or G20 country.
And second you have to have new money and the problem with universal health coverage as much as I will nail my heart to the stake to advocate for universal health coverage. It is a bottomless pit at the bottom of which is another bottomless pit. And so you're not actually saying, give me this envelope of cash.
to invest in this vaccine or this drug or this diagnostic you're talking about a very broad range of issues that are absolutely fundamental for a health system. But if you are the donor, if you're the person writing the check, it's not entirely clear what the return on investment is you're going to get for your money.
And so it's hard. So no, I think that It's great for advocacy, these high level meetings they mobilize communities they get some media attention, they keep the conversation going, but any idea that they actually make real progress is for the birds, and I think we need to, that there's a lesson there, and the lesson is that if we really do want to make progress in some of these areas, then we need to reflect a little bit On the failure, the abject failure of these meetings.
No, I'm afraid D minus for me.
Jessamy: D minus. Okay. And just to pick up on that a bit, because in the past, we have talked about the need for kind of political buy in, we've referred to the NDG sort of agenda and some of the successes there by having people who, led that forward. From a practical point of view then, there's all this activity and energy that goes into these meetings and high level declarations.
How do they get someone to say I'm gonna take this forward?
Richard: It's a it's a great question. You have to go back and look at history to see how is it that certain people stepped up to the plate. And I'll give you one example that enraged The women's and children's health community at the time but was actually fantastically successful Stephen Harper, a really quite right wing politician, Prime Minister of Canada back in the era of the Millennium Development Goals picked up the subject of maternal health and children's health and wanted to make that a big priority for his government.
Now, for a conservative politician with all of the dangers around safe abortion and modern access to contraception real landmines for the more conservative minded community. It was extremely brave of him to pick that up. And because it was a conservative politician, he was able to get a lot of traction with other conservative politicians.
So I can remember trundling off to Ottawa for a meeting where he was. there with Banky Moon, leading on what was called the Muskoka Initiative. He brought billions of extra dollars to the table, thanks to his leadership. And it served a very important role for him domestically. He wanted to have a foreign policy that showed Canada in a very benevolent light.
And so choosing maternal and child health was something that had high appeal for the Canadian population. Public and gave him an opportunity to use that to embellish his otherwise quite sharp edges as a conservative prime minister. You can then look at, if you look on the more liberal left side, Jen Stoltenberg picked up exactly the same subject plus vaccination also around the same time and for similar reasons was able to mobilize a liberal community.
And again, get enormous traction. So where are the Stephen Harpers and the Jens Stoltenbergs of the 21st century? They're just not here. And that's telling you something very important and actually rather worrying, which is that in the 2000s, health was politically fashionable. The health community was taken seriously.
We had something to say to high level leaders. And now we don't. We're not fashionable, nobody particularly wants to have their photograph next to a health leader anymore, even in the era of post pandemic. So why is that? Why have we in the health community not been seen today as having value add to the political process?
That's a really concerning change, and again, it requires a little bit of introspection on our part. I think the answer is that we don't have a story to tell that we're giving to political leaders and the pivot that we've made away from these, I hate the vertical horizontal dichotomy because it's a false dichotomy, but just for the sake of this discussion, I hate the pivot away from the more vertical initiatives where you were talking about the life of a child or the life of a mother, Or the life of somebody with cancer or another non communicable disease.
And we've moved to these sort of big general areas. We talk about health promotion and universal health coverage. And it's meaningless. You can't connect. You can't. You can't connect to it. How do you put a face on universal health coverage? Really, at the very basic level, it's, you're not offering that politician something that he or she can then use domestically.
For their own purposes. I think that we have to, recalibrate actually looking ahead and learn some lessons from these failures. How do you think we get back to that more human story about health? I can remember years and years ago when Grutal and Brundtland was Director General of the World Health Organization.
The big concern back at the very beginning of MDGs around 2000 was poverty. I remember her standing up and she did this absolutely brilliantly, but that's what happens when you've been a prime minister or president, you know how to do this game. And she said, poverty has a woman's face.
immediately you can it's, it gives you your answer. You don't just look at poverty as, some threshold less than a dollar a day or some economic argument. You can picture a woman in a community, in a village, in a slum, in an inner city, and immediately empathize with that individual.
And that's what we have to do now. So how do we humanize If it's back to UHC, how do we humanize that? I don't have a simple answer to that. I'm not even sure there is an answer to that. I think that maybe we do need to go back to some of those messages that we had, now, two decades ago and rethink about how we present communities.
Migration. Why aren't we having a picture of a woman and a child in a migrant camp or as a refugee? The whole discourse around migration, which has become so racist, we've lost, all we do is talk about numbers now hundreds of thousands of people coming into the country legally or illegally or whatever.
But we need to put a face on it. This person is just like you, are you all right? I think 2023 has had. Lots of things that have been encouraging, but also a lot of important lessons that we need to learn if we're if we're going to make progress towards 2030, which is coming up very soon.
Jessamy: It also might not be the fault of totally the health community, because, what I'm getting from what you're saying is that we're having all of these discussions, but we're actually removing, the humanity is being removed from discussions about health. And, you look at all of a lot of the health leaders around the world, and they're on social media, they're, they're really out there, they are trying to tell a story, but is there also an element that politicians don't want to hear it now?
Or is it, does it go beyond politicians? Does it go to people, to populations that we're not being able to connect to?
Richard: I think you're right. I think you're right. I think that politicians don't want to hear it, and that's partly because The whole economic political context today is different from 10, 20 years ago, and it's really weird to think about it.
But, you go back to 2005, Tony Blair, Prime Minister, remember him, G8, Glen Eagle Summit 2005, his commission for Africa was published. And note G8, that is G7 plus Russia. The world was a different place then, Russia was playing ball with international organizations. There was a lot of money kicking around for development aid.
The UK government could literally make global health and development a major priority in a country like ours, where people might, as they are now, be very skeptical of those kinds of issues. Exactly the same in the United States. Remember, it was a Republican president who initiated PEPFAR, not a liberal Democrat president.
So it yes, that was a time which was extremely propitious for investing in the issues that we care about, and today that is not the case. Some, then some people took out some dodgy mortgages, right? Exactly, they did, indeed, and you had the financial crisis, and then you had Trump and Brexit, and the whole thing fell apart, and now nobody's interested in multilateralism, and it's all bilateral relations, it's all what's in it for me.
and not what's in it for somebody else. So we've got more isolationists, more selfish, less money kicking around. So it's not a good environment. You're right. Combined with the fact that we've got these Bay asks that we're really not in a great place.
Jessamy: So there are some positives to take from that, because there are definite tangible points that we could, a forward on.
Richard: Yeah, no. And there have been some, for example. COP28 isn't perfect. It wasn't ideal to have a fossil fuel advocate leading the COP28. We had the first Health Day. So health for the first time broke through in discussions about climate. That is a massive success for the health sector. I would say that it's a massive success for the climate and health science community because it's that community.
that put together the evidence that gave the politicians the confidence to make health a visible priority. That, and that's a superb success story, gives enormous hope for COP 29 and subsequent multilateral discussions about where we are with climate. We have, we, as in the health community, now have a seat at the table, whereas we didn't before.
That's been a big success. Thank you But it's a bit difficult to think of many others this year I would say.
Gavin: And Cup 28, as we said in our editorial last week, is a qualified success given the background that it came again.
Richard: Again, a lot of chatter on the sidelines and people very unhappy about the pandemic treaty.
But there will be, fingers crossed, a pandemic treaty. And we don't have many treaties. The only other treaty we've had is the WHO has led is the Framework Convention on Tobacco Control. If WHO is able to successfully navigate this very difficult draft through to success, that will be a great victory.
Obviously, the proof will be in the pudding of its implementation. But still, that will be a landmark for WHO, a landmark for the health community. And it means that politicians will not be able to run away from their responsibilities for pandemic preparedness and response. We in the health community will be able to hold governments accountable because of the pandemic treaty.
It's not going to be perfect on intellectual property, for example, but it gives us an instrument to monitor the progress of governments for preparedness and that's important.
Gavin: I love the phrase, the pudding of implementation. I think when we talk about the pandemic treaty for, something to look forward to for next year, it does have to come against a background, doesn't it, of the many elections that are so crucial across the world next year and how they might feed back into that because there's some there's a potentially concerning developments isn't there for climate change for a pandemic treaty.
Richard: Yes, obviously, the big one is in November, the in the United States, and I don't even want to contemplate the outcome of that election. It could go very badly wrong. And the worry is that if the previous incumbent gets elected a second time, I'm talking about the 2016 incumbent, then He will have learned all of from his mistakes during his first term.
And if he pursues his agenda, he is really likely to be much more effective at isolating the United States. And again, eroding, if not destroying multilateral progress. So it is very worrying. But there are some other big elections happening, which are also of of great import. And I'm not thinking of the United Kingdom here.
India has its election next year April, May. Now that's a really important moment. It's likely, you never say for certain, but likely that the present leader, Narendra Modi, is going to. win that election. The opposition isn't very strong, but there's an opportunity with a new government to, to have a different conversation and, in fact I don't want to bring too many of the Lancet's pieces into this, but, we've got a piece of work a Lancet commission on India's health system that, is on a glide path to publication for a few months, hopefully after the election.
And we're talking now about how do we build a bridge between the group who's produced that commission which is who are some of the leading lights in Indian health policy. and the government so that they can take up those commissions recommendations and absorb them into the new government program.
Russia and Ukraine have got elections next year, which is interesting. Russia will have a presidential election. Now, I think we again, we can all be fairly sure about who's going to win that. But nevertheless, There will be a moment where even within the narrow confines of freedom of expression in Russia, the Russian public will have a moment to speak.
There's also going to be an election in Ukraine. And again, we've seen President Zelensky be unbelievably effective as a defender and advocate of Ukraine's right to exist as a nation, but he will be held accountable by the Ukrainian electorate too. How long will that conflict go on? Should there be a compromise or not?
These are all issues that are going to come into the discussion next year.
Jessamy: Can I just take us back to what we were talking about before about the health community saying things and politicians not wanting to hear it. We've got these massive elections next year. India, US, Russia, Ukraine. Do you think that health will be a topic in the campaign?
That are going on
Richard: not in any substantive way, and it's always amazes me in a country, for example, like India, where just by virtue of its size. It has some of the highest absolute numbers of maternal deaths and under five deaths. We know how to save the lives of those children, and yet health is not a priority.
If you look at the amount of money that the Indian government invests in health, it is tiny. There is no serious commitment to building a true universal health coverage there. No, it's a bit more complicated than that because Health budgets are devolved to states, so it's, the political process isn't so easy, it's not just, it's not just about persuading federal government and then you flick a switch, and everything happens across the country, which is how China works, and how China's been so effective, so democracy brings compromises and trade offs, but nevertheless, no, not in India, and absolutely it won't be, In the United States, I'm sure in the uk.
Yes. I think that, the NHS, which has become such a sort of emblematic of who we are as a nation I'm sure that will be a major subject, but it is, it, it is not surprising because there are many competing claims on government, but if you look at across many countries, ministries of Health are some of the weakest ministries across governments.
And the health community as such, it is very politically weak and I think that's the role, that's the role of a journal like the Lancet or journals here at the Lancet and the academic community that surrounds them to try and use the work that they do to be the foundation for trying to make health as strong the political issue, but it's always a struggle.
Jessamy: Maybe we've done lots of external talking, we just briefly look internally, and have your reflections on, two or three really big projects or things that you feel especially happy about at The Lancet.
Richard: 2023 has been a really big year for us, obviously, because of our 200th anniversary and I can't let the year pass without mentioning, at least mentioning it.
I do feel at the end of the year that we've spent enough time talking about our 200th birthday and I'm done with talking about ourselves. But it was a moment to reflect. I always have to preface anything I say about the anniversary by saying that the reflection comes from a position of humility.
Because we do have to acknowledge right up front that the journal, we're based around the world, but our hub, so to speak, our center of gravity is here in London and that comes with a history and in the very opening editorial of the Lancet on October the fifth, 1823. we talk about one group of our audience being colonial practitioners.
So we are born, we are a journal born out of colonialism and slavery and occupation and extractive capitalism. And that's not the best start in life. And it means that we are often and understandably if not justifiably, I would defend us today, but understandably attacked or viewed with skepticism because of that origin.
So it's very important for us to own it and embrace it. But I would then go on the step and say, and then learn from it and then say okay, we accept all that, but how can we then use this Lancet for some good? And that's where I think we can be. a platform, a convening place to bring scientists and health workers from around the world together to talk about their perspectives on health and give them a voice.
And I'm sure we get it wrong and I'm sure there's more we could do and what we do, we could do better. We do try to do that. And I think over the last, certainly over the last 20 years. We have given a voice to people and about issues that many other journals haven't and don't. And so while I'm willing to accept all of our imperfections, I will defend our our efforts to reshape the global agenda around health and medicine.
And so that's, I think that's the starting point, a sort of humble apology, and a bit of a punchy defense. And then so that's the 200th anniversary was it was great. We focused on some major themes. And I think we created a lot of attention to those themes around climate and health and maternal child health.
And research generally, and UHC, and mental health, this was all very good. But also for me, some of the commissions that we published were really were really seminal, and for me, the most moving commission that we launched, which was in the air only a matter of weeks ago, was the one on medicine and the Holocaust.
That I think was the, not just emotional, but Important because it goes to the heart of who we are in the world of health. My profession. I'm so proud to be a doctor. I love my profession. I love everything about medicine. I couldn't love it more than I do love it. And yet, I had to acknowledge that it was my profession, let, not just took part, let the path to and the implementation of the Holocaust, and to understand that it was people like me Who did medical degrees not very different from the one that I did, who led that who made the argument that there was life unworthy of life and that you could brand certain people and certain groups of people As being unworthy of life and then design the killing tools to not just exterminate them, but to exterminate them in the most animalistic way.
Face yourself in the mirror with that story every morning and it's very hard to put another foot forward without really questioning all your values. The bottom line of this commission was to tell that story and to make the case that it's such a big story for medicine that it needs to be taught to every single medical student across every country of the world, and I fully endorse that 100%.
But what also came out of that commission Equally important was the idea that every human being has universal dignity, autonomy, respect, and the protection of individual, not collective, but individual human rights is absolutely paramount as a lesson of the Holocaust. Now, this is very interesting because we published this commission two weeks in The, what is a war, conflict between Hamas and Israel, and I think everybody who I know was utterly horrified by the bestial terrorist attack.
that Hamas perpetrated on Israelis on October the 7th and it is absolutely right that attack should not be seen as a legitimate act of resistance to occupation, it should be seen as something outside the bounds of legitimacy and we are still learning today the horror of that attack. At the same time, we are now seeing tens of thousands of civilians in Gaza being murdered, especially children and women, which is unacceptable.
The lesson of the commission on the Holocaust that we published was the importance of the health professions defending the dignity, autonomy, and respect for individuals and protecting individual human rights, which means that we have a duty to vocally. condemn Hamas for the atrocity that they committed on October the 7th, but at the same time, condemn the killing of Gazan civilians that is taking place still to this day.
Every human life is of equal value, whether it's an Israeli life or a Gazan life. And what I find so perplexing, distressing, upsetting, is that people on both sides of this conflict do not recognize the humanity of those on the other side of the conflict. I have written one or two things in The Lancet about this, and I have been criticized by my Israeli friends.
for praising the Director General of the World Health Organization for what he said, for talking about the attacks on Gazan children. I've been condemned by them for putting the responsibility for that on Israel, and then I've been condemned by Palestinian friends for condemning Hamas. It seems to me that this is where we have a completely complete misunderstanding about the issue.
We're talking about the common humanity of Palestinians and Israelis. And until we get to a point where we recognize and respect the common humanity of both populations we're never, it's not about peace even we're never going to stop this conflict. I think that the Holocaust Commission was so fundamentally important for medicine.
But also has so many implications for other aspects of our world and conflict today.
Jessamy: Yeah, I love that. I went to go see Prime Minister Mia Motley at LSE on Tuesday. And she's a bit like you, Richard, in that she just, the way she speaks, you could just listen.
Richard: Talks too much. Sorry.
Jessamy: I'll teach you an eloquent way.
You just want to listen to them forever. Anyway, she was saying something very similar about, what is it? that allows us to see the humanity in each other? How do we get to that place?
Richard: If we had an answer to that question, wouldn't that be I think that's I always start from the position of children, actually, because I think, if you've been lucky enough to have a child, the love you have for that child, it surpasses the bounds of any other love that you could have in life.
And once you realize how precious that child is to you, and then you think about somebody else who also has a child, and how precious the life of that child is to them, equally to yours, I think as soon as you start to think about that a little bit that's what brings humanity to the conversation. I do think there's something about children which it's impossible, yeah, I can have an argument with an adult.
And I can disagree and strongly and come close to not actually but come close to hating somebody for their views. But you can never do that about a child. And, you look at the, in any conflict, actually, I don't want to just foreground Israel Gaza, there are many conflicts in the world today.
That have been going on for a long time in Sudan and Myanmar in Yemen in many parts of the world, in Ethiopia and it's the, and it's the destruction of that, of the next generation, and and when you think about that, that, I think, does, it stops you, because when you put it in the context of your own child or children, And you think that actions will affect them, then actually, it doesn't matter what your political views are and how strongly you feel about them.
Actually, you know what? You need to get real. But I
Gavin: think what you're touching on there is empathy, isn't it? Yeah, just exactly. It's such a vital ingredient, and it's such a striking aspect of the Holocaust Commission that humans have this capacity so easily other different groups. I
Richard: think, there's a writer He's not terribly easy to read, but it's very interesting.
Somebody called Emmanuel Levinas, who is, was a French philosopher, who wrote about the face of the other. And it's very interesting that when you think about the other, you use the word the other. When you put a face on the other, that face, and it, what he writes about is how, when you look at that face of the other person It commands you, it orders you to have a responsibility for that other person.
It's a very interesting, if you think about it in your own ordinary daily interaction there's some truth in that, it's very hard if I look at you, Gavin, it's very hard for me to say something unpleasant directly to your face, and you were looking at me. And you are, in a sense, commanding me to have a responsibility towards you, just because of our interaction together.
Magnify that, take that at a population level, so to speak. And this is, maybe this comes back to the very beginning of our conversation, about how do you put a human face on universal health coverage, or poverty, or climate, or whatever. Because as soon as you put a human face on the other And there's that command to have responsibility.
There's a, there's something there that you can't deny. You can't run away from that responsibility. You can't push it to one side. You're a human being and so am I. And there's something about our face to face interaction that demands something of you and me together in a reciprocal relationship.
So there's something in that, I think that we need to I think there's some essential truth there that if one could find a way to amplify it might be a way forward to maintain the humanity of health. So
Gavin: Richard, the UK formally rejoined the Horizon Europe project and this month in December 2023.
How relieved do you think the scientific and health community will be and are you personally relieved about the situation?
Richard: This was massive news that we were able to come back into the rise, and there was a huge, almost audible sigh of relief from this, from the academic community but we need to do more we do need to rebuild our networks across Europe and that does mean having a seat at the table of many European institutions, which we have relinquished.
Alright. We have an election next year, and at least based on current trajectories we'll have a very different government and I think it's a government that isn't going to, on day one, rejoin the European Union, but perhaps on day two, is going to start overtures of closer collaboration, and I think we already know from the polls.
That more people now would be in favor of having a closer relationship than would not be by a considerable margin.
Gavin: I think the gravity of polling in that situation is undeniable. And I think it's something that not in the next parliaments, potentially, but parliaments further on will have to be revisited simply due to the weight of feeling.
And I was going to say about the Horizon Project is it's important to celebrate rejoining, but it's also important to not make it too much of a celebration. But no. We saw those kind of government graphics trumpeting re entering the Horizon Europe program, but you have to remember who and what took us out in the first place.
Absolutely. Absolutely. So rebuilding these things that we had for decades anyway is important, but it's also frustrating that so much political capital was spent at the time in undoing this, and we're now having to spend so much political capital remaking the things that we already had.
Richard: That's right.
We're watching the governing party tear itself apart at the moment. And we hopefully will have a new government that is pretty unified in terms of its political program. One strand of which will be they have said to build a more trusting relationship with the rest of Europe. But I think it even goes beyond Europe.
There was a time. Where I was immensely proud of my country as being a leader in global health. Even under certainly under Tony Blair, as I've mentioned with the 2005 Glen Eagle Summit, but even under David Cameron, he used his convening power to bring together international actors on highway planning, on nutrition on vaccines.
And this was us using our real respect that we have in the, in, in the international community. based partly on our research base, but based on the National Health Service, based on a genuine commitment to development aid. And now what we've got is a country that not only practices overtly racist policies towards refugees and migrants, but a country that has stepped back on 0.
7%, a country that has folded the Department for International Development into a very dark corner within the Foreign and Commonwealth Office. And so we have relinquished our leadership role. And I want to see us get back on the global stage and be a leader because we've got things to say, we've got people who have expertise to bring to these to these matters.
And we have a voice that deserves to be heard, not just out of national interest, but because I think we have a genuinely altruistic interest in trying to persuade. a very rapaciously neoliberal world to think more about how it can distribute its vast wealth in a more equitable way. So I want to see us, yes, absolutely, Europe, But actually the world.
And how can we get back to that leadership position and use our I mean, that was what was so good about Blair and Cameron, they use the strength of our health community and our medical research community. They use those as instruments to make a difference. We want to be partners in that again.
And so that's a big imperative for a new government. I do worry about the labor opposition that they have got themselves into a position where they've rebuilt trust and competency, but now they need to have a story. That is a story of optimism for people, and they haven't got that yet.
And they need it. And and I think again, this is where the health community can actually be positive and tell a good story because the health community ultimately is all about, especially if you think about health in a much broader sense than just, for being free of disease. The health community is a story about life, basically, as about.
about the possibilities of life. How do we, again, how do we infuse ourselves into that discussion? And I worry at the moment that we are fighting amongst each other in this country. We've got more doctor strikes planned now. And I understand the arguments about pay restoration.
And they're absolutely right. And I do believe that doctors, whether they be doctors in training or consultants, they do deserve to be paid more. I would just say yes, but, we have a, an unwritten contract with the public an unwritten contract of trust with the public. And we have to be very careful about how we hold that in our hands.
And if we damage that, it's going to be very hard for us to win it back. Yes let's be advocates for the welfare of the health professions, 100%. But at the same time, let's also remember who we're there for. We're not there for ourselves. We're there for the public. We're there to be advocates for the public, to decision makers, those with political power.
Just be we just need to be cautious about how we navigate the next year. But as a group of people in society, we have an enormously important voice. To tell that positive story about what we can achieve
Gavin: politically. There was it really stuck out to me in Lulu's campaign in Brazil where one of his one of his main messages of his campaign was that he wanted politics to be able to carve out a time for Brazilians to take a Bacan, which is the Brazilian cut of.
to dip in a little bit of flour, to put it on the barbecue, and to stand around the barbecue having beers with the family while the pecanian cooks. And that's what he wanted politics to be. And sometimes I feel that positive message, as you said, of life and of living gets really lost. But it's so important to have this kind of, not only be governed, but to have this kind of light touch that allows people to embrace the conditions for living.
Richard: Exactly. And this is where I think that sometimes We get it wrong about what's the meaning of health. And without rehearsing all the WHO definitions of what health is. Health, health is about being able to thrive and flourish in the environment in which you live. You don't have to be able bodied and 100 percent disease free to do that.
It's a, it's something much deeper about. The way your physical and mental capabilities at a particular point in time can adapt to the place that you find yourself in. And so we you don't have to have perfect health in a way and you don't have to have a perfect environment. But what you do have to have is to be able to match your well.
bodily and mental being in whatever environment that you're in, and then you can thrive. And I think if we could pay attention to those two elements, the environment that you're in, and making the best that you can of your health, then we go a long way. The point I always come back to is, it is not surprising, I've probably said this before on a podcast.
It is not surprising that if people live in a degraded environment with a not very good school and no good GP services and the buses don't work. Is it, and there are no jobs. It's not very surprising if people drink a bottle of vodka and smoke 60 cigarettes a day. a day, it's really not surprising.
That is a perfectly rational response to the environment in which you live.
Gavin: And it's also not surprising for that if they lose faith in institution.
Richard: Exactly. And they lose faith in medicine. If we just go around telling people to stop smoking and stop drinking. Which are great abstract messages, but totally meaningless if you are living in that particular environment.
So I think, we have to have a much more, I hate the word holistic, but a much more, but let's say capacious view for you of health than we currently do. And and that really, actually, that was the idea behind planetary health. The definition of health. is more than just the human being.
It is about the natural systems around you. And we should have a say in that we should have a voice in that we should talk about that. And we don't do that enough. Even public health has such a narrow focus on risk factors. And these issues that we know are important.
And my God, we've failed so much to, to make progress in many aspects of health for particular segments of the community, because we haven't had this more capacious view of what health is.
Jessamy: Or even a common sense view. For me, I'm just actually taking the bus and realizing the route that it goes and then go to the hospital.
And we always have a danger of where the health community is wonderful community, but it's also a very specialized privileged community. And we have that distance that we have to keep reminding ourselves to overcome because otherwise I think we do get bogged down in the knowledge, bogged down in the methodology and we miss some of these sort of common sense aspects that allow us to have that capacious you at the moment.
Richard: Yeah. With we're not taught it. We're not, it's never been part of our mindset, I think, and from the, from day one at medical school, or even doing science at school. The environment, we abstract the human being from the environment and just think of the human being as a body.
And that focus on just the body in a way it's You go back to the beginning of the Enlightenments or even before and the sort of the SIUs anatomy, the sort of famous drawings of the SIUs. That, that became, and then in this country. Hunter, that became the definition of what medicine was.
It was about the architecture of the human body and we stopped there. And in other countries, they've had a they've had a different view. In Germany, there really is a stranded discourse because of Virchow. Which is much more political and seeing public health with a much more political lens than we do.
So I think we, every country becomes trapped in its history to a degree, and we have to break out of that. One of the, one of the books that I read in the last year or so, which had a big effect on me was because it was written in English, and I don't speak Spanish or Portuguese.
was Jaime Braille's book about what he what was the meaning of public health to him. He's an Ecuadorian public health doctor, academic, who spent his entire life in Latin America writing in non English languages, and then outcomes this little summary of his life story. And, it's the different conceptions that have come out of his experience, particularly with indigenous communities.
Not the social determinants of health, but the social determination of health, not talking about public health, but talking about collective health, the emphasis on solidarity amongst groups of people being more important than top down recommendations to stop smoking and drinking or get a vaccine or whatever it is, there's as important as those things are.
It is what we, as a community, do for ourselves. Do we do that in this country? We don't do that. In America? No, they don't do that. In most European countries? No, they don't do that. We live in these little atomized, homes. In our flats and our houses. And Because that's how we've organized ourselves.
But in other parts of the world, where we don't hear their stories, because sometimes we're caught in our own atmosphere, they There's a different perspective, and we have a lot to learn from that, actually. And again, I think that's one of the roles of an organization like The Lancet to give the opportunity for other voices to look at the world through their perspectives in ways that we, we don't, and then to think about how we can learn.
I, instead of a Faculty of Public Health, we should be having a Faculty of Collective Health.
Gavin: Thanks again for listening to The Lancet Voice in 2023. Great. We'll see you again in 2024 and we hope you have a restorative time over the rest of the year.