Kotha S, Jadad A, Hu H. Creating a pandemic of health: opportunities and lessons for a university initiative. Harvard Public Health Review. Spring 2015;6.
The creation of entities to pursue scholarship that bridge disciplines is a common occurrence in a modern university. This trend has been particularly acute with respect to the field of global health, given its development, over the last 20 years, as a major field of research and training, the availability of large associated sources of funding, and the emergence of major worldwide partnerships for global health. [1. Merson MH. University engagement in global health. N Engl J Med. 2014 May 1;370(18):1676-8. doi: 10.1056/NEJMp1401124. PubMed PMID: 24785204. ]
What is the unique mission of a university-wide entity dedicated to global health in a large university that already has a diverse set of faculty working on global health dispersed in many of its academic units? This is a situation facing many universities today. Some argue that the obvious “added value” of such an entity, whether a Center, Institute, Program, or other construct, is to function as a hub for information and sponsor of global health seminars, workshops, and courses; a cross-campus synthesizer of research and training initiatives in global health; a source of pilot funding for new initiatives; and as a service center, i.e., providing the legal, financial, operational, technological, ethical, and compliance issues inherent in working internationally. [2. Koplan JP, Baggett RL. The Emory Global Health Institute: developing partnerships to improve health through research, training, and service. Acad Med. 2008 Feb;83(2):128-33. doi: 10.1097/ACM.0b013e318160b0a7. PubMed PMID: 18303356. ] [3. Macfarlane SB, Agabian N, Novotny TE, Rutherford GW, Stewart CC, Debas HT. Think globally, act locally, and collaborate internationally: global health sciences at the University of California, San Francisco. Acad Med. 2008 Feb;83(2):173-9. doi: 10.1097/ACM.0b013e31816096e3. PubMed PMID: 18303363. ] Another potential “added value” of such a hub is the identification and pursuit of new major research and knowledge translation initiatives that capitalize on the synergies potentially offered by an entity that connects scholars across many disciplines and that do not merely “cannibalize” existing efforts.
In this paper, we summarize the perspective, process, and outcomes associated with creating an “added value” institute of global health at the University of Toronto. We proposed from the outset that the most impactful “added value” of such an entity would be the creation of a new category, one guided by a fresh pedagogy that allows all of its stakeholders – students, faculty, staff and partners, particularly from the corporate, non-profit, public and community sectors – to look critically at how health equity is impacted by current institutional arrangements and prevailing power dynamics between the “haves” and the “have nots”, and across multiple levels of privilege [4. Farmer P. Pathologies of power: rethinking health and human rights. Am J Public Health. 1999 Oct;89(10):1486-96. PubMed PMID: 10511828; PubMed Central PMCID: PMC1508789. ] With this foundational understanding, this hub can enable its stakeholders (with students and communities as its top priorities) to work in multi-disciplinary, multi-sectoral social innovation teams towards social and economic convergence to improve health equity locally and globally.
The Institute for Global Health Equity & Innovation at the University of Toronto
In 2012, a new University of Toronto-wide Institute for Global Health Equity & Innovation (IGHEI) was established and housed in the Dalla Lana School of Public Health (DLSPH). Founded in 1927 by the Rockefeller Foundation (along with the Schools of Public Health at Johns Hopkins and Harvard) DLSPH is the largest of such Schools in Canada and highly ranked globally in terms of Social Sciences and Public Health (US News & World Report, 2014). The mission of IGHEI is to focus on “complex global health equity problem‐solving that could not otherwise be successfully addressed by a single discipline or research group.” The overall strategy is to harness the “brain trust” of faculty who were working individually or leading in any of the University’s affiliated Centres and units dedicated to global health but, as its own surveys have shown, are in efforts that have been historically isolated from each other. [5. Pinto AD, Cole DC, ter Kuile A, Forman L, Rouleau K, Philpott J, Pakes B, Jackson S, Muntaner C. A case study of global health at the university: implications for research and action. Glob Health Action. 2014 Aug 27;7:24526. doi: 10.3402/gha.v7.24526. eCollection 2014. PubMed PMID: 25172428; PubMed Central PMCID: PMC4149743. ]
Principles of Engagement
In planning the new institute of global health, we started with the argument that it is particularly critical that such an entity is guided by a mission, vision and set of guiding principles that transcend archaic assumptions and ways of working in global health. In this context we mean principles that are often grounded in a benevolent, but misguided worldview based on colonial medicine and international health, in which consciously or subconsciously, global interventions from “First World”, “Developed” or “Rich” countries are exported to “Third World”, “Developing” or “Poor” countries, and labeled as “development relief”, “humanitarian aid”, or “capacity-building” initiatives. This antiquated narrative, although filled with utopian ideals, is, in fact, rife with a colonial mentality of superiority, and has the effect of placing the blame of poverty (and ensuing ill health) on those in marginalized or disadvantaged communities. The implication is that if “these” groups truly want to transcend their deplorable situations, ‘they” would be more like “us” and pursue market and other interventions that will lift them out of poverty [6. Esteva G. Development. In: The Development Dictionary: A guide to knowledge as power (Sachs W, 2nd Edition). New York: Zed Books, 2010. ] Too often, the narrative in high-income organizations centers around selfless and magnanimous aid and technical assistance to “needy” populations with very little insight by those in the former as to the avoidability of the situation and an understanding that most disease on the planet is a product of the political and socio-economic conditions in which people work and live. [7. CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization. ][8. Goldberg D. Global health care is not global health: Populations, inequities, and law as a social determinant of health. In I. Glenn Cohen (Ed.), The Globalization of Health Care. New York, NY: Oxford University Press, 2012. ][9. Stonington, S., Holmes, S.M.,& PLoS Medicine Editors. (2006).Social medicine in the twenty-first century. PLoS Medicine,3, e445. ] We need to transcend a worldview or paradigm of “wise/rich/generous” entities in high income countries (HICs) “supporting/helping /aiding” partners in low/middle income countries (LMICs) as a means of justifying the use of resources spent outside of their respective countries. In Canada, for example, monies spent on global health in low/middle income countries (LMICs) often fall under the rubric of “social responsibility.” In the US (at institutions that some of these authors have been affiliated with in the present and/or past), particularly in institutions that receive state funds, the rationale for these global health activities is often put forward as part of “capacity building” to ensure global security, further diplomacy and the pursuit of new emerging markets and opportunities for American economic growth. [10. Institute of Medicine Board on International Health. America’s Vital Interest in Global Health: Protecting Our People, Enhancing Our Economy, and Advancing Our International Interests (Washington, DC: National Academy Press). 1997. ][11. Centers for Disease Control and Prevention, ‘Protecting the Nation’s Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy’ (Atlanta, GA: US Department of Health & Human Services, Public Health Service, CDC). 2001. Available at: http://www.cdc.gov/globalidplan.] This narrative has often led to deep mistrust on the part of the formerly colonized partners. [12. Arnold D. ed., Imperial Medicine and indigenous Societies. Manchester: Manchester University Press. 1988.][13. Fanon F. A Dying Colonialism, translated by Haakon Chevalier (New York: Grove, 1965). ][14. Keller RC. Geographies of Power, Legacies of Mistrust: Colonial Medicine in the Global Present. Historical Geography. Volume 34 (2006): 26-48. ][15. King N. Security, disease and commerce: Ideologies of post-colonial global health. Social Studies of Science. 32:5-6 (2002): 763-89. ][16. Vaughan M. Curing Their Ills: Colonial Power and African Illness (Stanford: Stanford University Press, 1990). ]
In training the next generation(s) of critical thinking global citizens, it is important to avoid pedagogy and programming that reflect these ways of looking at the world and which do not adequately take into account how health and disease risk are shaped by law, economics, politics and practices ranging from trade policies, to discrimination, lack of access to financial capital and social justice, and the myriad ways in which those who hold power and privilege perpetuate these inequities. It is also essential for everyone involved to recognize that dire health inequities exist in societies that pride themselves about their level of financial wealth and technological advancement, particularly amongst women, immigrants from non-dominant ethnocultural groups, and indigenous populations. Research, innovation and education initiatives in global health, therefore, must recognize the need for multi-directional collaboration, fuelled by the conviction that every participant has much to learn from others, regardless of their location or wealth level, as is underscored by a series of “reverse innovation” examples in relation to global health systems. [17. Binagwaho A, Nutt CT, Mutabazi V, Karema C, Nsanzimana S, Gasana M, Drobac PC, Rich ML, Uwaliraye P, Nyemazi JP, Murphy MR, Wagner CM, Makaka A, Ruton H, Mody GN, Zurovcik DR, Niconchuk JA, Mugeni C, Ngabo F, Ngirabega Jde D, Asiimwe A, Farmer PE. Shared learning in an interconnected world: innovations to advance global health equity. Global Health. 2013 Aug 30; 9:37. doi: 10.1186/1744-8603-9-37. PubMed PMID: 24119388; PubMed Central PMCID: PMC3765795. ][18. Campion E, Morrissey S. A Different Model – Medical Care in Cuba. N Engl J Med. 2013; 368:297-299. January 24, 2013DOI: 10. 1056NEJMp1215226. ][19. Depasse JW, Lee PT. A model for ‘reverse innovation’ in health care. Global Health. 2013 Aug 30; 9:40. doi: 10.1186/1744-8603-9-40. PubMed PMID: 24001367; PubMed Central PMCID: PMC3844499. ] It is also vital to move away from a traditional approach to global health of focusing on access to and barriers to healthcare towards an approach of focusing on how the histories of oppression and structural violence, as well as racism, classism, individualism, and discrimination drive the devastating inequities between populations, within and across national boundaries. [20. Goldberg D. Global health care is not global health: Populations, inequities, and law as a social determinant of health. In I. Glenn Cohen (Ed.), The Globalization of Health Care. New York, NY: Oxford University Press, 2012. ]
The November 2014 Global Health Summit
An 18 month consultative planning process involving hundreds of interviews with faculty/ students and external thought leaders led to a half dozen thematic areas for IGHEI. An internal organizing committee of over 60 faculty members and students was formed to oversee the planning for the thematic discussions for a 3-day Summit that focused on the overarching theme, “Creating a Pandemic of Health”. The Summit was held in Toronto from November 3-5, 2014, outside the University, was free to the public, and involved over 750 attendees, including local and global representatives stemming from academia (faculty/ students), government, non-governmental organizations, funding agencies and the private sector. In addition, 22 global health thought leaders, including Dean Julio Frenk from the Harvard T.H. Chan School of Public Health and leaders from Argentina, Bangladesh, Brazil, China, Columbia, Ethiopia, Guatemala, India, Mexico, Pakistan, South Africa, Tanzania, attended, and catalyzed sessions with brief presentations that directly led into intensive discussion workshops, in an effort to further develop the foci areas for the IGHEI.
The foundational theme of the Summit – “Creating and Spreading Health” – reflected the critical importance of appreciating health as a concept far broader than simply being free of disease. [21. Huber M, Knottnerus JA, Green L, van der Horst H, Jadad AR, Kromhout D, Leonard B, Lorig K, Loureiro MI, van der Meer JW, Schnabel P, Smith R, van Weel C, Smid H. How should we define health? BMJ. 2011 Jul 26;343:d4163. doi: 10.1136/bmj.d4163. PubMed PMID: 21791490. ] Two aspects were emphasized: (1) health is also the ability of individuals or communities to adapt, self-manage and thrive in the face of physical, mental and social challenges, including ageing and the presence of incurable chronic disease(s) and multi-morbidity; to heal when damaged; and to expect death peacefully; and (2) the notion that some aspects of health are amenable to social contagion. Studies have shown that obesity, smoking, alcohol consumption, depression and happiness can “spread.” Health may be amenable to this phenomenon.
Subthemes for the Summit were developed that addressed the idea that humans worldwide are becoming an urban species plagued by non-communicable diseases (incurable by definition),, financial crises, social disparities, global warming and ineffectual polarized political structures that are threatening the sustainability of the species. The subthemes that emerged include “Preventing the preventable, treating the treatable, transcending the inevitable,” which focuses on closer integration of primary care and public health; “Urbanism, health, and the growth of megacities” focuses on health challenges that arise as more of the world’s population flock to urban areas; “Politics, privilege and power” highlights the underlying, sometimes invisible issues that drive health inequalities; “Achieving convergence” questions the ability for countries to reach convergence in health in a world that is rife with conflict, gender inequities, lack of access to universal health coverage, education, and human rights, and “Global big data” highlights the promise of utilizing the enormous data at our fingertips to create health policies that improve access to and quality of appropriate health systems. More information on the Summit can be found at www.pandemicofhealth.ca.
The above thematic areas were created to be broad and inclusive to ensure that faculty, students and members of other sectors could easily see a place for themselves within IGHEI or as partners with IGHEI, regardless of their location. The mission of IGHEI has been further refined to generate meaningful solutions to the complex health inequities we as a society face today. Through its activities, the Institute aims to promote health equity through novel “glocal” innovation that seeks to eradicate differences in population health that can be traced to unequal economic and social conditions and are systemic and avoidable to redress health inequities from the individual through the community to the planetary [22. Kotha SR, Jadad A, Daar A, Upshur R, Bhattacharya O, Bhutta Z, Forman L, Gibson J, Henry D, Jha P, Kohler J, Nixon S, O’Campo P, Hu H, on behalf of the Institute for Global Health Equity & Innovation Global Health Summit planning Committee and other affiliated faculty and partners. Creating a Pandemic of Health: A New Initiative on Global Health Equity and Innovation. Plenary Abstract accepted for the 14th World Congress on Public Health, February 11-15, Kolkata, India. ] IGHEI’s engagements are based on the principle of valuing the wisdom and expertise of members and partners to produce new knowledge that serves society and builds collective capacity at the intersection of health, equity and innovation (also known as “the sweet spot”).
We now move into the next phase, clarifying our values, rules of engagement, guiding principles and responsibilities, all of which are premised on the concept of “radical inclusion” and diversity that is necessary to create optimal levels of synergy throughout our work. We will focus on catalyzing collaborations to create healthier, more equitable communities, making deep links between our health and the health of our planet. We will offer Toronto, one of the world’s most vibrant, multiethnic, multicultural cities, which enjoys a health system of universal coverage for medically necessary health care services provided on the basis of need, as an incubator for health interventions that promote equity and social innovation. Community-led practical experiential opportunities will be seeded with emphasis on “real life health equity challenges”, ideally with contributions from members of marginalized communities working in partnership with members of academia, the government, the private and the not-for-profit sector, promoting the idea of “learning by doing.” Additionally, the Institute will enable the creation of university-wide pedagogy embedded in courses throughout the student life course, from the undergraduate through the doctoral programs, focused on demonstrating that the current state of global inequity is not a natural occurrence. A pool of resources (financial, methodological, technological, administrative) will be at the disposal of students to support their social innovation projects, with participation from peers, faculty and community members, and members of other sectors.
Above all, the Institute will serve as a safe space for open and constructive dialogue focused on legitimizing “unasked” questions [23. Nixon SA. Critical public health ethics and Canada’s role in global health. Can J Public Health. 2006 Jan-Feb;97(1):32-4. PubMed PMID: 16512324. ] and “taboo” subjects as a means to promote the collaboration and creativity that are required to tackle some of the most pressing challenges of our time, as members of a species that must engage in large-scale co-creation efforts to promote optimal levels of health for all humans as members of a sustainable planet.
In summary, in planning a new University-wide Institute for Global Health that was “value-added” to the University’s current global health footprint, we found that it was critical to examine the values, principles of engagement, and other aspects of the new entity’s ethos while also committing to a wide process of stakeholder engagement. We hope this description of the process and associated insights may assist other universities in similar endeavours.
Many of the ideas and concepts in this manuscript stemmed from discussions among a large number of students and faculty members who contributed to the design, planning and realization of the 2014 Global Health Summit. The authors, who were Co-Chairs of the Summit (SRK, AJ, HH), are particularly indebted to the two other Summit Co-Chairs, Abdallah Daar and Ross Upshur, as well as the Summit’s lead coordinator, Ellena Andonio, for designing, guiding and executing the Summit’s overall plan. We are also grateful for the ideas and discussions generated by the Summit’s Executive Committee, including Onil Bhattacharya, Zulfiqar Bhutta, Lisa Forman, Jennifer Gibson, David Henry, Prabhat Jha, Jillian Kohler, Stephanie Nixon, Patricia O’Campo, Shafi Bhuyian, Adalsteinn Brown, Freida Chavez, Arun Chockalingam, Andrea Cortinois, Ophira Ginsburg, Anita McGahan, Katia de Pinho Campos, Laura Rosella, Katherine Rouleau, Arjumand Siddiqi, Daniel Sellen, Steven Verderber. Additionally, we are indebted to Liya Bibla Eben-Ezra, Trillium Chang, Jenny Gatov, Svjetlana Kovacevik, Ashita Mohapatra, Navita Singh, Rossini Yue, who generously provided input in imagining a suite of innovative “student-centric” global health programs within the DLSPH.