Power and allyship in the Global North and Global South

Where does power lie in global health? What are the historical and systemic barriers that perpetuate inequities, and what is the impact of political shifts towards nationalism? 

Catherine Kyobutungi and Madhukar Pai join Gavin to talk about their recent Comment published in The Lancet, "Shifting power in global health will require leadership by the Global South and allyship by the Global North". Join us to learn about the challenges and opportunities for Global South leadership and the importance of redefining knowledge, success, and problem identification in global health.

You can read Catherine and Madhu's Comment piece here:
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02323-7/fulltext?dgcid=buzzsprout_tlv_podcast_generic_lancet

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello and welcome to the Lancer Voice. It's January 2025, so Happy New Year, and I'm your host Gavin Cleaver. Today we're going to be talking about the Global North and the Global And for that, I'm joined by Catherine Chobotungi, the Executive Director of the African Population and Health Research Center, and Madhukar Pai, the Chair in Epidemiology and Global Health Research at McGill University, Montreal, Canada.

They recently published a comment in The Lancet on the topic, so we'll be talking about that, and we'll be exploring the intricate dynamics of global health leadership, looking at the collaborations between Global North and Global South. We'll look into the systemic barriers that sustain inequities, the impact of political shifts, and the critical need for genuine allyship.

What are some of the challenges and opportunities for the global South, and how can we reset knowledge sharing and relationships in global health? I hope you enjoy this conversation.

Madhu Pai and Catherine Kyubatungi, thanks so much for joining us on the podcast today to talk about your comment that was published recently. In the Lancet, talking about kind of leadership roles and collaboration between the Global North and the Global South. Now, Global North and Global South is a quite a common phrase in the kind of the worlds of global health that we work in.

But I thought for our listeners, it might be interesting to get a kind of overview of what we mean generally when we say Global North 

Madhukar: and Global South. We used a simplistic binary framing in this comment, and we also pointed out the limitations of that. But essentially, when we say global north in this context, we are primarily talking about Europe, North America, Australia, New Zealand, this rich block of countries that have much of the world's wealth, while only has about 15 percent of the world's population.

The global south, we primarily mean all of the parts of the world what we would call low and middle income countries. It's a, I think a nicer way of framing it rather than developed versus developing countries or first world versus third world countries that are very hierarchical and even racist in their framing.

So we preferred something like global north and global south to make a point. As, as simplistic as a binary is. 

Gavin: But it doesn't necessarily mean, to make it ultra simplistic that 

Madhukar: some countries are in the north 

Gavin: and 

Madhukar: some are in the south. No, we, we're less worried about the geographical north and south.

We're more worried about what those countries have and how they behave how did that framing first come about? We wrote a piece actually led by Tamriz Khan published in BMJ Global Health a few years ago, extremely widely read piece. On how various terms came about, including, first world, third world, developing, high income countries, low and middle income countries each has a different origin and sometimes it's not quite clear where they originated.

But what we did mention was which kind of binaries to avoid because of their hierarchical. Or they presumed supremacy of some and lack of of advancement of others. That's why I think that piece got a lot of traction because everybody's struggling with this way we speak and write especially in global wealth.

Global development is no different, actually, they're even worse in some ways, right? Rich versus poor, donor countries versus donor dependent countries, right? Beneficiaries. It's a very top down way of looking at the world. And we are gently trying to steer the conversation towards more lateral rather than hierarchical ways of looking at the world.

Gavin: It does feel like the language in this sphere has moved on relatively quickly. You know what I mean? I remember growing up, for me, it was always first world and third world before I was interacting with with the global health world. It's one of those things, isn't it? Where you can see how problematic it is to frame it like that when you when you look back on it.

Catherine: Sometimes it's hard to tell where this terminology comes from. You just read a document and there's some new terminology and say, okay, that, I think that sounds better than the previous one. And, but I don't think we're at a place where the terminology is perfect. It's just that it's easy and it's very complicated to try to maybe use different terminology when the community uses global north, global south.

But I think as Madhu has said, we are still evolving from maybe more discriminatory terminology to something different, but still not perfect. 

Gavin: That's interesting, actually. Obviously we're talking in like brute terms, almost global north and the global south. It's very hard to.

make a kind of hard and fast distinction in that area. So what are some of the nuances that the current usage of global north and global south actually miss apart from geography? Obviously, 

Catherine: I think it's the fact that even within when you say the global north, it's easy to think of global south.

It's easy to think Asia, Africa, Latin America, but even within those regions, there are nuances there, like not every African country is the same as the other, and not, Africa is not the same as Asia, and Asia is not the same as Latin America, but we assume that it's this homogeneous blob that everything is the same, that they have the same problem, the same issues, the same challenges.

Maybe the same opportunities. It still misses the differences even within this very, I would say, problematic dichotomy of North and South. 

Gavin: And what your comment kind of touches on, and which a lot of the literature in global health is centered around nowadays, is the problematic relationship between the global North and the global South.

Perhaps you could tell our listeners a little bit about what forms that problematic relationship takes before we get on to talking about your comment. 

Catherine: This framing is within the context of global health. And at first value, global health seems like this good thing, like this thing that is maybe accepted and understood and practiced with some kind of common understanding about what it's about.

But now when you start digging deep about the actual practice of global health, you That's where maybe these problems start emerging about the manifestation between North and South and how it is accepted that there's a North and a South, even when geographically it doesn't make sense, economically it doesn't make sense, culturally it doesn't make sense.

But it's accepted. And the question is who accepts it? Who defines these terminologies? Who uses them? And then how do they get accepted globally? It still reflects those hierarchies in power that, of course have a long history. Colonialism. And all that. And as I say, that first value, global health looks like this innocuous good thing.

But then when you start peeling off the layers, then you actually recognize that global health has been accepted as that thing that people from the North do to people in the South. So it's like Northern scientists and practitioners practice global health on global South people. Okay. And some, I don't think we have a question that like how did we get here?

How is this normal? That this is something you accepted as a norm. And and as, again, as I said, it, these, there are no historical practices and reasons and how we got here. But I think we're at a point where we have to question this acceptance of people from one side of the world doing things for.

And on people from another side of the world, and and then frame this as something that is aimed at achieving equity. And maybe without questioning, do the people in the South find this equitable? Do they find it okay? But there's such a, the system is so entrenched that it's hard to even imagine a different system.

So again yeah, long historical reasons, but really I think it's the time is ripe to question. This acceptance of what global health is, for instance. 

Gavin: Yeah, it makes me think, actually, of all the kind of departments, institutions, that, for example, still have the words tropical medicine in the name.

Institutions in the Global North that are actually based around going to the Global South and doing research on people there and on on places there. It's it really shows, I think, you're right, how historically based the whole situation 

Madhukar: is. As much as we think global health is this very equitable, neutral field, it continues to be extremely imbalanced in terms of power.

At every level, actually. Doesn't matter whether it's money in terms of wealth, who holds the wealth in terms of who sets the agenda of what needs to get done. Who is funding who where is all the money flowing who gets to publish whether it's Lancet or whether it's our journal plus global public health who gets to go to conferences, even who has the right to present on behalf of who and it's to global health, simply put, It's neither global, nor diverse, nor inclusive.

And yes, we're talking about this in 2025, almost. It's shocking that, a field that is born out of colonialism continues to be this imbalanced even more I think, during the pandemic, where we saw rich nations, pretty much. Holding vaccines and allowing millions of people to suffer and die in under vaccinated countries without any access.

So it's a sad reality. It's very clear from the data. Actually, none of this is our opinion. It's all factually borne out. Question is what do we do about it, which is what the comment really was focused on. 

Gavin: Yes, I've been following you on social media for a long time now, Madhu on Blue Sky, of course, these days.

And the conferences point is one that's always incredible to me. I think obviously in my privilege growing up in the UK and having the sort of passport that is waved through a passport control, It had never really occurred to me until I started following you on social media and saw your your campaign against putting conferences in places that are difficult for people to access around the world.

But it is, it's still having, now, armed with that knowledge, it's incredible to me that conferences are still organized in places, that it can actually require people months of work and thousands of dollars. to access in the first place. And it did, it actually perpetuates inequality massively, doesn't it?

Because it's simply access to these conferences where knowledge is 

Madhukar: shared. Absolutely right. It's actually quite devastating these days. Canada where I am, it's extremely difficult. And UK is extraordinarily difficult and US. And of course, with all of this are the new governments which are like extremely right wing.

A rollback of democracy in many parts of the world. The anti immigrant, anti refugee sentiment is sky high and the visa issues are tied to this whole notion of we need to control our borders, that all these other people are coming and taking over our land, our jobs, and our whatever and it impacts global health more than many other fields.

Because how do you have a quote unquote tropical medicine conference in Canada or the U. S. And not have people from the so called tropics who are suffering the most and have the most knowledge to share on it, can't even get a chance to come. So it's like really lopsided and almost unquestioned, as Catherine said, right?

None of those conferences even think it's bizarre to have an AIDS meeting in Montreal where many Africans couldn't even make it. Nobody felt that was really absolutely bonkers bizarre, right? That the continent that is most impacted by AIDS somehow is not there to share their knowledge. It's just purely shameful, but it's happening every day in global health.

Catherine: And I think it speaks to what I said earlier about what is global health really? Because if it wasn't this practice where people from the North do things on and for people in the South, it wouldn't make sense at all. Why are you doing research? That you're sharing with people from the same geography that are not affected by this problem.

And you have all these amazing scientific papers and discoveries that you're sharing amongst yourselves. It doesn't seem like somebody doesn't even question. Why are you sitting in a conference where you collected data on an illness, on a problem, on a health issue, on a challenge that affects people that, and that none of them is in the room and you're talking amongst yourselves.

What is the point? Honestly, if you ask yourself, what's the point, what's the point of this conference? And so again, it goes back to we've never sat down to question. For who and for what is global health. And it's become, I think some would say that it's it's something like a career. So you can decide to be a comedian and now you decide to do global health and global health, you never even stop to think that a comedian's role is to do something in society, maybe to entertain the people happy, global health at the heart of it is equity in health in the world.

And you never stop to question that you're engaging in practices like these big conferences that cost thousands of dollars. in a space where you're not actually solving any problem other than sharing the latest information amongst yourselves as academics and practitioners. So for me, that's, that, I think that's at the heart of where we has a problem that global health practitioners, global health has is steeped into careerism.

It's a career just like any other. And I don't think global health should be a career like football or, commit comedy. It should be a career that is grounded in the need to see equity in the world. And these practices don't advance equity at all. 

Gavin: I think your mention of equity there goes to the heart of what you are talking about in your paper.

And it brings me very nicely onto my next question, which is I wanted to ask you both how academic institutions in the global North contribute to this sort of perpetuation of racism. of inequity through their sort of research and education priorities. 

Madhukar: I can see how we perpetuate many of the inequities that global health suffers from.

First of all, our academic institutions are merely a reflection or a mirror of our global north societies and governments. For example, let's say I'm an academic in Canada and I'm inviting Catherine. To come here to be my guest faculty from Kenya, Uganda. And if she can't get a visa then, I am part of the problem because it's my government in Canada that's denying her a visa.

So this is just the society that we are part of. And if our governments are holding vaccines or were holding vaccines, our academic institutions are silent and not able to really say much or do much about it. And then our own academic institutions are very hungry for money in terms of grant monies.

We don't like grant monies directly going to Catherine's institutions. We would rather have it go through our institutions because that is how we get big overheads out of these global health grants. And we would like to control the money as PIs. So we have a say on what gets done or not. We get to decide, because they hold the purse strings, who will get to be the first author or senior author and where research gets done and how.

So it's enormous power. In the hands of Global North institutions and many Global North academics, as well intentioned as they may be, we are all part of this system where we are rewarded on the basis of the wrong incentives, the incentives for our progression here in the Global North are things like how many first authored papers do we have?

How many grants do we hold as PI? How many million dollars did we bring in? How much overheads did we bring to our institution? It is not to do things like, have we really been a good ally to Katherine's institution? Have we actually helped solve the HIV problem and is it really led by Africans solving their HIV crisis and we are being good allies to them?

There's no there's no place in the CV to even talk about trust building and allyship work. It's all about me. How much did I get? How many awards did I win? And that's what I'm incentivized and at my institution. And that's how most Global North institutions are. That's partly why everything in global health is dominated by Global North academics.

And many Global North academics are also very leading very precarious lives in the sense that they have to bring a huge chunk of their own salaries through grants. They're on what we call soft money. And that soft money existence makes them extremely precarious, but also extremely aggressive in terms of looking for the next grant.

Pushing their careers ahead of the work that needs to get done because they are really pushed to the back by their institution. So lack of security. And precariousness is a very deadly mix and it really pushes Global North Academics to be very self centered at the cost of equity, I would think.

Gavin: That's an interesting framing really, isn't it? Because it makes it such a kind of like structural issue for literally how all these institutions structure, how knowledge is is structured. researched and put out in the first place, which is a very deep 

Madhukar: rooted problem, isn't it? Extremely structural, which is why we call them institutional barriers, right?

A single good person in a global north university will struggle as well intentioned they are. We know lots of good intentioned really solid people in the global north, and I'm sure Catherine will fully endorse that. But we are often helpless when our own institutions have set different incentives and targets for us rather than doing the right thing.

So it takes, that's why I think it's even possible to decolonize quote unquote one's own practice in global health. But decolonizing our institutions is an absolute nightmare. It's virtually impossible the way the institutions are structured in the global North, our governments being the single biggest barrier I would think to genuine equity.

Gavin: Yeah, so I was gonna ask, short of kind of deconstructing modes of knowledge, In the Global North, what are some of the changes that might be necessary to better promote an equitable collaboration with Global South? 

Madhukar: I think as we framed in our paper, two things need to happen like almost simultaneously.

It isn't there is one right way to do it. I think the Global South genuinely needs to own the space of global health. If it's anything to do with them, they need to be in charge, which is exactly what Catherine has been talking about, right? So if it's malaria in Uganda, then Ugandans will have to lead that agenda.

They will be the ones to solve it. Not for me in Canada or anyone else in the US or UK to solve that problem. So they need to claim the space that is rightfully theirs. And we, people like me in the global north, need to rethink what we've been thinking of as ourselves as leaders in this space. We're not leaders.

We are not going to be the ones solving the problem. We are far away from the problem, to be honest. And we can make disastrous mistakes because the further you are from the problem, the less and less you have lived experience, the less and less you have contextual experience. The less and less we are likely to get it right.

So we need to be a lot more humble about our role. And as we said in the comment, our role changes from being a leader in global health to being a good ally or a good co liberator, if you wish to folks who are really, truly at the front lines struggling with the issues and solving the issues. Allyship is a very complex idea and it's a very rich, loaded term but I think we've given concrete examples of what allyship could look like in our article.

Gavin: Perhaps we could talk about some of those concrete examples how has this looked in practice so far, this, 

Madhukar: this notion of allyship? Let's take something concrete. We lived through this extraordinary pandemic where Global North nations hoarded vaccines refused to back their intellectual property waiver that was requested and endorsed by hundreds of countries.

Even today, rich nations combined together and colluded with big pharma to scuttle the pandemic accord, which was meant to avoid this kind of hoarding and lack of access and equity in future pandemics. So I think the right thing we could have done, should have done, is to not only share vaccines very quickly.

also helped other countries manufacture their own vaccines by sharing the vaccine technology. And certainly we should have all backed the pandemic accord or treaty to make sure this kind of egregious inequities don't occur in the future. So allyship for me is to genuinely show up when there is a need and center others rather than ourselves.

Look at the impacts crisis in Africa right now. Again, vaccines are being donated at a slow trickle when Africa needs way more than that. And Africa needs to manufacture their own vaccines so that they are not left high and dry every time there's a pandemic or there's a crisis. And I think Global North allyship means supporting Africa in their efforts to manufacture their own medicines, drugs, and vaccines.

So these would all be concrete examples by which Global North can be better allies than we have been all these years, I would think. And then in the, in a comment, we've also given examples of what Global North allyship among journals could look like. So journals like Lancet, journals like ours plus Global Public Health, what can we do to make our journals much more safer for colleagues from the Global South who rarely get an opportunity to publish with us?

How diverse are our editorial boards? All of them are examples by which I think global north based institutions, governments, academia, journals, we could all make a difference. Even global north based conferences. At a minimum, we should rotate the conference between the global north venue and the global south venue.

That would, I think, be the lowest bar for any meeting that considers itself global health in the year 2025. Thank you. If we continuously hold these meetings in hostile visa, hostile countries. I'm afraid we have completely lost the plot on what global health is or should mean. So lots of work to do. It's not like I have a thousand great examples of allyship by Global North.

Power does not like to shift power or share power. So there is nothing in the way Global North institutions or governments behave that gives me any reason for hope. Yes, there are a few institutions that are trying to do the right thing, but Global North has accumulated power over centuries by taking power from others, taking wealth from others through colonialism, settler colonialism.

So we have a horrible track record behind us. That is why it's extremely hard for us to even understand. what shifting power or sharing power even means, let alone enacted, right? It even doesn't even occur to us. We can have assumed that we were born rich and wealthy. We're not born rich and wealthy.

We've accumulated wealth by extraction and ongoing extraction. And neocolonialistic, capitalistic practices that harms the global south immensely. So it will take a huge amount of self reflexivity to even come close to knowing what the problem is, let alone doing the right thing. A spectacular example is climate crisis, right?

So the Global North is the reason why we are in this catastrophic climate crisis. And yet, how many Global North countries are willing to even admit that, let alone compensate and do reparations for the Global South through the last loss and damage fund that has been created, right? Reparations is something we don't even talk about anymore, right?

How do we address the colonial damages that have caused immense harm even to just African continent, right? How do you even account for the damages done to them and the ongoing damages done to them? So that's why somebody rightfully critiqued of a comment by saying, you have given terrific examples of why nothing will change in global health.

And I'm like, yeah, I know, I'm sorry, but I was just, we were just being honest. In the state of affairs, right? The first half of the commentary is very depressing because it really lays out down to its bone why global health is so messed up, right? It's the second half where I think our editor, Jana.

wanted us to bring some hope by sharing some positive examples of what's possible, or what others are actually doing in a meaningful way to shift power. 

Gavin: Yeah, I was gonna say, a lot to do doesn't even begin to cover it, does it? Oh, so Catherine, perhaps we can come to you and talk a little bit about what the challenges are for Global South leadership in this situation, while we wait for the Global North to address these points, which could take a while.

What is it that the Global South. can be doing and is doing with the kind of opportunities and challenges for the Global South countries. 

Catherine: I think maybe I'll start from what would Global South leadership look like. And I think leadership could come at different levels. The beginning point is how are problems identified?

What is a problem? For instance, in Uganda, what is a health problem in Kenya? What is the biggest challenge that the Kenya faces? The beginning point of how we identify problems, I think would need to change. And the lead, the leadership would come in from the global South scholars, academics, researchers communities to define their own problems.

And that would mean dismantling like the current practice of relying on this knowledge system, which depends on literature. So you did a systematic review and it tells you, yeah, there's a big problem, but there are biases that have been built into that, into the papers, which gives the systematic review and what is known as lived experiences and passes knowledge is shunted aside.

It's a scientist somewhere in the global North. We'll sit down, do a systematic review and decide that malaria is a very big problem in one district in Uganda. And then they'll fly in to come and do more research about this big problem. If you asked anybody in that district and say, what's your biggest problem?

They've never said malaria is a problem. Not to minimize the impact of malaria, but if you are to, if you ask them to prioritize the biggest problems, maybe malaria wouldn't feature. And so the fact that we have this knowledge system, which has, Which has been accepted as the best way to define problems means that in many instances we're addressing the wrong problems.

So leadership would come from how do we define problems? Who defines problems? And a different way of acknowledging that perhaps the people that we're trying to help may be know better what their problems are than us using a system to define what their problems and what, of course, what solutions are.

Gavin: Which is such a basic level, isn't it? But it shows how deep rooted the issues are that we're still talking about allowing the Global South to define what a problem is. 

Catherine: And it may not be malaria. It doesn't matter how much we think malaria is a problem as a global health community. If your community says it's not our problem, then you should listen to that community and say, Okay, so what's your problem?

And let's deal with that. And you might find that by dealing with a community problem, over time, you actually deal with malaria indirectly. So that's the beginning point of who defines the problem, how we define problems. And then of course at the end of the day, what gets done and who gets to do that.

So that is, that's where for me, leadership comes in and in the way to do some required, dismantling our own. Worldview, because we are trained in the global system. So our worldview, what problems are defined is shaped by this this system. So it would need to change our own worldview as African scientists and African, researchers.

So I think for me, that's fundamentally where the leadership would need to come from. Now, having said that, I think Madhu made the point that these two things go together. The Global South leadership may not be practical in the short term. And that's because the, this leadership has not been nurtured.

It has not been grown. It has actually been stifled and has been suppressed with time because of the system in which we exist. So that's where the allyship and the leadership need to go together. That somehow in the Global North, practitioners need to cede ground while Global South practitioners step up to take, and now to take up the space that has been vacated, that has been ceded by the Global North.

So that and I'm not, I'm quite. pessimistic generally about the world. But I also think that there are levers and there are nudges that can be pushed to make some progress. It may not be progress that transforms the world, because I think global health exists within a context. There are bigger issues, political issues, economic issues, and global health exists in that.

So I don't think it's my place, maybe it is, to dismantle the global capitalistic system and all that stuff. But I think as a, I think as a field, there are things that we can do better and there are things we can do differently. And that's why I believe that the allyship, if I was to add on to what Madhu said, the allyship from the global north is to recognize first what the problem is.

Again, why do we do what we do? I think if every single person in the north was to ask themselves, why am I here? Why am I a professor of global health at this university? Why do I have a class of 50 students doing global health? Why? Let's, if we redefined the incentives of why we do what we do, take it away from tenure and promotion and more grants and I don't know, like very huge CVs.

And the, all these metrics that measure the wrong things, to be honest, and we shifted why we exist to, can we actually change something in the world in which we live? Let's start from there. And as academics, of course, the system exists. We exist in that system, but with time, I think we have a responsibility and we have an opportunity to change that system where we can take the aesthetic structures.

But if we can't change it ourselves, I think the other players in this ecosystem, like Who can start shifting the incentive structure because the reason why academics do what they do is because funders accept it. And it's because the academic institutions accept it. If funders started asking for different metrics of success, academics would comply and follow those new metrics of success.

So I think academics. There are those I don't know, catalysts that could go and start influencing how funders change, how funders see the world, what is success, what is greatness, what is excellence. I think we have an opportunity to do that. And once that shifts, then I think the academic institutions will follow suit because if you want the money.

You have to show results. It's not just papers and I don't impact factors and I don't know whatever it is. It is to say, yes, we've been working in this country for 15 years and yeah, we've saved 10, 000 lives and we have proof that we actually saved 10, 000 lives. Not we've published 2000 papers after 15 years and we are great.

No, I think if we change the metrics of what success is and if we change the reason why we exist as a community. And I think it's not outside our power as global health practitioners, wherever we are to shift that. Then, of course, I think the rest can follow suit. And beyond changing the measures of success, changing the measures of how we define problems.

Because, again, the reason why we do systematic reviews is because that's what funders want. Need, they will say, yeah, you can't say this is a problem unless you've done 10 systematic reviews and you've published all these papers. So if the funders say, yeah, we want to see problems defined differently.

We want to see input of the communities you want to help. You want to see the inputs of decision makers in the countries where you want to solve problems. You want to see the input of, the communities that you want to serve as a way of problem identification. And it's not something that is it's, is possible.

There are ways of doing this. So I think as. The allyship from the Global North is those allies that are going to be the catalyst to shift how funders see the world, how funders measure success, how funders see greatness. And then I think the academic issues will follow suit. And then with time, I think we can actually shift global health practice.

And for me as as I don't know, a research leader in the Global South, my role is to. Yeah, open the eyes of my fellow Global South practitioners about the system that exists in the world and that we can aspire for a different system and that we should also be ready to confront our own biases and orientations to think of a different world where communities drive change.

Gavin: Is there a way that Global South countries could work better together in a kind of form of solidarity? 

Catherine: Yes and no. I think solidarity is easier said than done. Again I come from the African continent and we have all these structures, you have the AU but I can tell you that when push comes to shove every country is still one of 54.

It's rare to find that one thing that the 54 countries will agree upon. They will sign all these commitments, but when it comes to action, every country first say, okay, what is. What is that thing that is going to win me the next election, not what did we sign up for as the African Union or the African community or whatever it is.

I think solidarity is easier said than done. We don't have solidarity at the political level, at the economic level. I don't think we're going to have solidarity at the global health level. practice level. So yes, there are all these mechanisms. Africa CDC is a great institution. It's trying to do all these things.

But I think we are very far from that point where you can think that it's the solidarity that is going to save us because politically we're not set up for solidarity. We're not. The colonial boundaries We are made in such a way that they are not just geographic boundaries, they are cultural, they are social.

And so we are wired to be Ugandans and not Africans. We are wired to be Kenyans and not Africans. So we are Ugandans first, and then perhaps we can be South Africans, and then perhaps we can be Africans. Maybe never. 

Gavin: I wanted to talk about political, the political aspects of it, actually, because obviously there's been especially in the global north, some pronounced political shifts recently towards a sort of nationalism and further to the right and more of a kind of isolationist turn.

I'm going to ask you the question, what are the implications for equitable global health partnerships? I can't imagine the answer is particularly positive, but I'm still going to ask you the questions anyway, what the implications are for this rightward turn in the global north at the moment.

Madhukar: I think is it Lancet that recently did a whole series on the U. S. elections and its implications. So I think the U. S. election results and the upcoming Canadian election results are all taking us in a very dark place, in my honest opinion. It wasn't easy earlier. It's going to get spectacularly harder now to justify why we need to have global health, why collaboration matters, why equity matters, why partnership matters, because it's now retracting to me, myself, make America great again, make Canada great again.

It's all about us and all of our obsession now is to find somebody to other. These people are Haitians. These people are Mexicans. These people are coming from somewhere else. We need to deport them. We need to solidify our boundaries, our water walls and whatnot. All of this does not add up to any kind of equity, let alone genuine equity and partnerships, right?

So I expect everything to be even harder in the coming years. And in concrete example terms. I think I can already see the U. S. government, the new U. S. government trying to dismantle something like PEPFAR, for example. And I was in, in in Johannesburg last week attending an entire week's long TB, TB meeting.

And I can, I could tell the anxiety growing among my African colleagues. On how they're going to sustain millions of people in antiretroviral treatment in the Africa region if something were to bad to happen to PEPFAR. And I would think that this is exactly illustrative of our article, right? So while some of us should fight for PEPFAR to, to continue and not suddenly abandon millions of people.

I think global South based African leaders should be asking right now. What is their strategy for keeping their own Africans on HIV medicines? How are they going to manufacture it? How are they going to access it? If PEPFAR funding were to collapse, does that mean people are just going to die due to lack of treatment to HIV AIDS?

So they need to show leadership at this point. They need to have a contingency plan in place already on how they're going to keep millions of people on HIV treatment. I think that would be an example of genuine leadership. That Africa decides that they're going to manufacture their HIV medicines, their vaccines, their mpox vaccines, so that they become less and less reliant on Global North.

And all the hegemony and power differential that comes with. So I think this is a beautiful real world illustration of where leadership should come from and in the meantime, what Global North, well intentioned individuals and and organizations should fight hard to continue to do what is right until the time when Africa is self reliant and no longer needs any support for HIV or anything else for that matter.

Catherine: I think it's hard to be optimistic, it's hard to be honest looking at where the world is going. But actually my bigger concern is that what we observe politically I think is a result of other things. And and those other things to me are things like the growth of misinformation and disinformation as an industry that peddles not just in, scientific what can I, untruth or falsehoods, but now goes into political falsehoods and creates narratives.

and really drives narratives in society. And so there's like a as scientists, I think there's something we are not fully prepared for around the information. I think the attention economy, it's called in some ways, the attention economy and how that has grown by leaps and bounds. And we are fully unprepared on how to deal with it.

So it's driving political shifts for, so that's one thing, like these changes are happening within a bigger context and whether it's one president today. I think for me, those are a bigger concern because one president is, four years, five years, but the next president actually might be, shaped by these things that we're not dealing with adequately.

So for me, the bigger context is a problem and the bigger context has the misinformation, the disinformation, but also an underlying anti science movement. So for me the anti science movement actually is a greater concern maybe than PEPFAR. PEPFAR, can be four years and then, a new president comes and PEPFAR is re established.

Of course, there are big issues which are going to happen in the four years, but the anti science movement may even have greater ramifications, whether it's PEPFAR or not. So the context in which these changes are happening for me is a huge concern. And then beyond, of course, the changes in funding if PEPFAR was pulled, it would be catastrophic.

I don't think there's any African government prepared for instance, to step up and do what PEPFAR was doing. But the other issue, which is again, part of the context, I think is the narratives. I think we had made some progress around, humanity, there's humanity, solidarity, we're human beings, equity.

And now all this is Oh no, DEI is nonsense. Let's like forget DEI, like all this. Why do we have to talk about this? Racism is now the norm. It's okay to be racist. It's okay to be anti Semitic. It's okay to be things which we are, society could not tolerate. Now we are tolerated at the highest level of political power.

So it, it changes the narrative completely. So you even don't know where do we start talking about localization? Like localization maybe is the last thing on anybody's mind because even the narratives within the people would be in power. It's what are you talking about? Why do we need to dismantle this power?

There's no need to dismantle it. It should be as it is. So it's the narratives that are going to set us back many centuries. And then of course the funding is now a much bigger short term problem. But the narratives I think are going to be much more enduring. And then they'll make it even harder with time to recoup the ground that maybe the momentum that we started making when it comes to decolonization and all these other things.

So then now, of course, now it comes to us, the Global South people and the leaders. I had hoped that COVID would be a wake up call to our political class. It wasn't. We're still stuck in this fantasy about how the world works. And maybe this is going to be another wake up call, maybe the real one.

But ultimately, African, South African governments. Have to step up, whether it is today, whether it's in five years from now, whether it's 10 years from now, they have to step up because you can't keep like. in this state where you're dependent on the goodwill and the mercy of others, and you're dependent on an election cycle.

Every four years there's anxiety. If this happens, then, I don't think that's sustainable. So African governments need to step up. How they step up. It's, of course it's a long term thing. And it goes back to those things about allyship and how things can work differently.

But I think the political class needs to recognize that we live in very dangerous times. And It is dangerous to be from a poor country or from a region of the world that is deemed to be of a certain kind and is put in this big black box. of of inferiority. So I don't think our political class has woken up to that fact.

Things are quick about to get worse before they get better. 

Gavin: I think you're so right. And what's struck me recently about the political situation in the U. S. is that even if, as I say, in four years time, We get a quite left wing government in that wants to put in programs all over the world, for example.

You still, as you mentioned, got that danger of four further years down the line, and even further right wing government coming in the U. S. So it actually Hopefully, we could pull away the veil, wouldn't it? If that makes sense, that actually the U. S. is not a reliable long term partner for these programs by this point.

The polarization there has got so bad that it can no longer be relied on as a stable because, global health needs to work in decades. If a program can get removed every four years and then brought back every four years, but we've lost the four years there, we're just trying to rebuild.

It makes it an unsustainable situation, 

Madhukar: doesn't it? And hopefully people will read and listen and engage and think harder. As Catherine said the coming years are going to be even more harder, I think, for equity in global health. We're already seeing signs of it very clearly. So everything we said in our comment is even more relevant, I think, in the coming year, coming years in terms of the, Changing political context and the worsening of even basic human rights these days are not guaranteed for anyone, right?

I think the conflicts around the world, including Gaza tells us. There are people who are still not deemed worthy of humans and human rights. And that's the sad reality we are faced with. So lots of work to do. And it's a pleasure to go to collaborate with Catherine on this. She inspires me and I hope we can platform more such people in both in the journal and in the podcast as well, Kevin.

Because that's what we need to be hearing, I think. 

Gavin: Madhu bhai, Catherine Shobhatangi, thank you both so much for joining me on the podcast. It's been a real pleasure to talk with you and I wish you all the best for 2025 and beyond. Thanks, Kevin. 

Catherine: Thank you.

Gavin: Thanks so much for listening to this episode of The Lancet Voice. If you're interested in other podcasts offered by The Lancet, as well as all of our videos and infographics, you can head to thelancet. com slash multimedia. Thanks again, and we'll see you next time.