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Geopolitics of global health - part 1
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In part 1 of our episode on the geopolitics of global health, host Garry Aslanyan speaks with Ricardo Baptista Leite, who maps his career journey from treating patients with HIV and tropical diseases to serving four terms as a Member of Parliament in Portugal. He is also the founder and president of the UNITE Parliamentarians Network for Global Health, which brings together current and former political leaders in more than 100 countries pushing for science-based health policies. Together, Garry and Ricardo reflect on the global forces and factors that shape the economic, social, and political landscape affecting health for all.
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Hello and welcome to the Global Health Matters podcast. I'm your host, Gary Aslanyan. At the start of the new year, we're doing something different. We're bringing you a two-part episode on geopolitics of global health. This will include a reflection on the forces and factors that shape the economic, social, and physical landscape affecting Health for All. Geopolitics is often an underestimated concept in global health, and its direct or immediate impact on research or programs can be hard to grasp. However, the global policy landscape is changing more rapidly than ever due to the influence of pandemics, regional conflicts, and technology. These are some of the topics I'll be discussing with my guest today. He is Ricardo Batista Leite. Ricardo is currently the CEO of Health AI in Geneva, but before this, he was a four-term member of parliament in Portugal. He is also the founder and president of the Unite Parliamentarians Network for Global Health, a network of current and former policymakers from more than 95 countries. Hi Ricardo, how are you tonight? Doing great and yourself? Good, good. Looking forward to discussing and learning more about your experience and also this topic. Maybe we can start by you telling our listeners how your career started as a medical doctor and how you got involved in issues at the intersection of politics and health.
SPEAKER_02Well, first of all, thanks for having me. It's a real pleasure to be here. And sadly, we should have more medical doctors doing uh that uh pathway, I would say, towards uh being more active in the political scene. I think everyone would benefit from that. In my case, I was very fortunate to know from a very young age as a child uh that my passion laid in public service, uh, whatever that meant. But uh I rem I grew up in Canada and uh I remember distinctively going on a school trip to visit a local regional parliament and understanding that the idea of a group of people chosen by the collective community to represent interests and defend the rights of the people was something that I found fascinating. And um, growing up, I was also fascinated by science and medicine. I knew that if I would go into political science or economics, I would never be a medical doctor. But the other way around, I thought it could happen. And so I decided to follow my first passion of becoming a medical doctor. I did that for my first life, so to say, then having followed through my residency in infectious diseases. And then when an opportunity came, I was I got involved in medical school and local politics. Actually, I was doing uh an internship at WHO in Copenhagen at the World Health Organization when the government of my country in Portugal uh collapsed and there was a snap election. And since I was involved in some local politics uh on the side of my medical career, um, I was called on to run for parliament and I and I seized that uh opportunity to serve my country at a very difficult time.
SPEAKER_01We do hear or know that P in public health stands for politics, Ricardo. You already mentioned the example of the government collapsing in Portugal and how that influenced your decision to run for the office for parliament. How do geopolitical events continue influencing your decisions and actions?
SPEAKER_02Well, in terms of geopolitics, affected my life even before I was born, in the sense that my parents were uh born and raised in uh in Angola, actually from my father's side, three generations before him in Angola, which was a colony of the of Portugal at the time. Um, but in reality, uh, three generations born in a country, you feel as part of that country. And um in 1975 with the independence movement and civil wars, uh my parents basically became refugees and have to live leave everything behind at a very young age. Portugal was a mess, taking up a million refugees from the foreign former colonies following the Carnation Revolution of 1974. And so my parents decided, since they were young, they had nothing holding them back to start a new life in Canada, in Toronto, where they had some family. And um I ended up being born and raised there. And if it hadn't been for that circumstance, maybe I would have been born and raised in Angola. At least it would have been hotter. But I'm very grateful uh to have been raised in in Canada, but to have those roots and uh just actually recently, my father uh had not been back in nearly 50 years to Angola, and we went together about a month ago, and it was uh it was quite interesting, uh if you allow me to share this personal side of that story, uh, because I of course I knew it was going to be emotional. What I did not expect uh from for me personally was to feel that I was completed in a way that I didn't know I needed to be completed, that there was a part of my roots that was missing, and that it was kind of, you know, when you have a puzzle and you're missing a piece, and it it felt like it it it was it I found it. And uh me see I've heard the stories for decades since I was born, and all of a sudden being there with my father, that was uh a very, very relevant and personal moment. And uh and so this of course shapes uh the way one looks at the world, right? Because then as a teenager, we my parents decided to go to Portugal, and I of course went with them and to be closer to the extended family. And so if you look at it, I'm really the product of the Atlantic, uh, you know, this triangle between Africa, North America, and Europe. And inevitably that influences the way you look at the world and the decisions you make. And at the time I was I I became very passionate about public health throughout medical school. And that that, of course, I think is very much influenced with this this background, this global vision. And I have to say also that going into infectious diseases also had a very unforeseen consequence in my perspective of life because I ended up working a lot with HIV and AIDS, patients living with this condition, um, also tuberculosis, uh, viral hepatitis. We also dealt with a lot of tropical diseases coming from Angola, Mozambique, Cape Verde, uh, Guinea, Santumé, uh, the Portuguese colonies would end up sending the most complicated cases to my hospital in Lisbon. And all of this really brought to my attention something that medical school had not been able to do, which is the real determinants of health. Uh, understanding the social factors that actually ensure that someone is sick or not sick, understanding that there are parts of society that society prefers to ignore, what we call marginalized populations. And uh understanding the power of the patient movements, of the HIV movements at the time. I was very, very fortunate to have met amazing uh advocates and leaders, but also to see a lot of discrimination and stigma. And so we see this tremendous ripple effects that uh really made me rethink uh health. Um and uh when I it pushed me in a certain way towards politics and understanding the different phenomena from a cultural local perspective. So going to your question of geopolitics, it's all local, right? It's all conditioned by the cultural factors, but then within this global scale of phenomena that so uh nowadays anyone working in this space really has to have these different layers of understanding of the reality.
SPEAKER_01I understand that you led an establishment of a parliamentary network focused on health. Can you tell me more about it? Well, you're right.
SPEAKER_02And um actually when I was elected for the first time in parliament, I ended up staying for I was elected four or four terms. Um the first time around as a junior MP, um, it was funny because um as soon as I sat down in the committee, one of the first hearings I participated with in was with the leader of the HIV community in Portugal, who was actually a patient from my hospital. And uh he he said that the that we had a subcommittee or a special interest group on HIV and AIDS, and he said in the committee, without telling me beforehand, that he told all parties that they should nominate me as the coordinator of that group. And I was this just this junior MP that nobody knew that had just landed in the parliament and they all looked at me. And they, you know, when when a patient advocate of his magnitude asks for something, he gets it. And uh and they appointed me. And that was transformative uh for I think a lot of the work that then followed. We were able in the middle of the uh IMF European Bank, uh, central bank bailout of my country to actually come up of with a consensus of a resolution project that was voted unanimously following hearings with patient advocates, scientists, pharmaceutical companies. We brought everyone together at the table in a way that had never been done before and built a consensus between the extreme right and the extreme left, if you will. And that was really what led towards, despite the financial crisis, Portugal keeping on track with many of its commitments and many of the goals that it had set in the field of HIV, viral hepatitis and tuberculosis. And so that actually led to uh inspiring uh me and others that there is potential for change within the role of legislators. And so uh that actually adding to the fact that in most international conferences I would go to, I was normally the only member of parliament present. I felt that there was untapped potential there. And so I proposed in 2016 at the World Health Summit in Berlin that we should create a network at the time focused on infectious diseases and a network of um current and former members of parliament. Right. And UNAID stepped up. They gave us our first small grant that allowed us to create the Unite Parliamentarians Network to end infectious diseases. Today we've evolved with the support of WH Show to become the Unite Parliamentarians Network for Global Health, currently present in more than 100 countries. Uh, we have members of our secretariat throughout seven countries around the world really trying to push for science-based policymaking in health. And you can see that transformative power. Uh, and I've been very fortunate to work through the experiences I had. As soon as the Ukrainian war started with the Russian invasion, I stepped up and I went as a medical volunteer with the support of the United Parliamentarians Network and worked as a medical volunteer during the summer of 2021 in Lviv. Um, and you know, we don't we're not fearful of taking a stand, but we also believe that we need to continue the dialogue, especially when it comes to health, especially when it comes to saving civilians from the terrible tragedy of war.
SPEAKER_01In the time of pandemic, we also have seen an interplay between domestic and foreign policy when countries were trying to kind of balance that. What kind of lessons have we learned um during and after pandemic that could guide us forward?
SPEAKER_02Well, uh, I had promised myself that I would stay 10 years in parliament max. And when I was getting close to the 10-year mark, the world uh was confronted with a pandemic. And uh at the time uh within my party, I took up a very serious responsibility as basically representing the main opposition party positions in this field and being the only ID-trained doctor in parliament. So I ended up playing a very active role during that time. Very proud to have been next to a political leader of my party who said this is not a time for opposition, this is a time to unite efforts, something not very common around the world. And so, as a member of the opposition, we proactively tried to support the government as much as we could, and uh, despite many differences of opinions along the way. That being said, during the week I was in the parliament on the weekends, on every Saturday for 12 hours, I was in my local hospital emergency room, COVID room. I went back after eight, nine years without practicing to just support my colleagues. That was extremely important for me to see what the pandemic actually represented in the real world in terms of dealing with the patients, the burnout of the healthcare workers, the people crying at the end of 24 hours shifts, right? Not even being able to breathe with the masks, we kind of forget what was the pandemic, especially at the beginning, people sleeping away from their families because they had no idea what we were dealing with.
SPEAKER_01Right.
SPEAKER_02And we cannot forget that. Because right now I see a negotiation for a pandemic accord, and people are dealing with this as if it were a minor issue. Do we really want to be remembered as those that failed to prevent the next pandemic have failed to learn our lessons? Because that's what we're aiming for if we are unable to find an agreement to the pandemic. And I think the main lesson is that we need to be better prepared. We need to learn how to coordinate better. Some mechanisms that came out of the pandemic were very important at the time. I'm thinking of COVAX and the ACT Accelerator in terms of ensuring access to vaccines around the world. But it failed in many ways, right? In terms of equity, in terms of access, particularly in low and middle-income countries. But it was built on the fly in the middle of the storm. Now, in the moment of Tcaln, we should actually use this moment to learn the lessons and get the procedures better. But more than that, we have what is needed to prevent the next pandemic, to detect outbreaks early and stop them from becoming global phenomena. But for this, we need to agree on some basic concept. It's not a question of taking away rights or sovereign leadership from any country. It's working together. And we do need some strong surveillance mechanisms, possibly independent mechanisms, that will reinforce the role of organizations like WHO, which are instrumental as the main normative agency for health at the global level. But we need to find that common ground of agreement. The negotiations are still going on. We also have to learn to listen more, particularly to those that normally don't have a voice. Low and middle income countries have stated it clearly, and through the Unite Parliamentarians Network, we've heard it, that there's no more changes without us. We need to ensure buy-in from the start, which means the future needs to be co-created. I think the the international negotiating body, which is trying to bring together different stakeholders, is doing their best to ensure everybody's voice is heard, but they have to be more than heard. Their vision has to be incorporated in the process. People need to feel that they're being listened to. More than that, it also becomes clear that regional leadership, you know, even when it comes to logistics, to uh manufacturing of goods in the global health space, uh, is something that possibly has transformed global health forever. I honestly believe the pandemic has transformed global health from having these one-stop shops to build masks in China to an interdependent or interregional dependent globalization in which regions will want to have more and more autonomy and then be interdependent for global economic trade. And that is a major shift from where we were going until the pandemic. And that major shift needs to be incorporated into global health policies and understood, understanding that that will have tremendous impact on climate, on costs. It's more expensive, but it's a necessity because people will not accept it any other way. And so it's really, we need people who really understand these different phenomena and ensure that the voice of those that are sometimes not heard are actually incorporated uh actively in the processes.
SPEAKER_01Ricardo, you mentioned earlier that all of those experiences you had, how critical they were to help you understand and shape your career. Sometimes some of the global health professionals find uh what happens at the geopolitical level, it feels a bit detached or elitist for them, or uh things that happen behind closed doors, like G7 or G20, these discussions, um, they hear about them that they may not completely grasp it, or how these influence day-to-day global health programs or research, but we know they matter. What are the kind of critical skills and understandings that global health professionals should have to better understand and navigate the geopolitical environment impacting their programs or their research, Ricardo?
SPEAKER_02This is a very important question because most healthcare professionals, if you work in an emergency room, you get used to the adrenaline of having to make decisions with very little small amounts of data and having direct impact and saving a life. That is an adrenaline rush that you will not find anywhere else. I've been through that life for many years. We look at global health policy or the G7 or G20 or the UN at large. It's you know, it's going from this high, fast-paced, direct impact environment to exactly the opposite. Very slow, almost uh non-consequential actions, a lot of uh lunches, dinners, and snacks in between and really nothing happening. That's a feeling you get. My experience has shown in the political scene that many times you do get frustrated through those processes. But if you keep the dialogue going, if you keep the, you know, if you have a clear vision where you want to go, you continue pushing. And if you have science and evidence to back you up, even better, right? And so be clear on what you're stating and make sure you're pushing it. And it may take months, it may take years. And all of those non-consequential encounters and diplomatic conversations and so forth, there is one day, one day that something happens and it makes it all worth it. And that moment has a transformation not just for one patient, but for millions. And so that is something that I think is extraordinary when it comes to politics, when it comes to global health. So I think that many healthcare professionals need to have more and more of this idea of the importance of the role of these fora of people who work in this space, play an active role within it also on as advisors, uh, bringing the real world experience. But more than that, if you are a healthcare professional working in a clinic, a hospital, anywhere in the world, you're so focused on your patients. What I've seen many times is uh you you you may end up losing the big picture of the system because you're you're doing your job and sometimes in very dire situations with and you're completely burned out. But the problem is the system. In most places around the world, not to say everywhere, we do not have health systems, we have disease systems, we have models that are broken and that are driving more and more cost and more and more disease. And so all of these healthcare workers that are burning out, they're in a rat race, you know, they're like a hamster on that wheel, just running and running, but not going anywhere, are actually taking steps backwards because the system is rigged in a way that it actually gets more and more people sick. And so understanding that is critical so that we can change the system. And when we talk about universal health coverage, which is so important and an important goal of this sustainable development goals, right now what we're seeing many times is rich countries exporting these broken disease models to low-income countries. Instead of using this opportunity with the support of technology to help low and middle-income countries to leapfrog, to avoid those mistakes, and to design actual health systems that are focused on well-being. Ecosystems for quality of life and well-being is what we should be aiming for. And so I do think that more and more, even in pre-grad training, we have to incorporate these concepts of global health and global systems. And it is not acceptable anymore, I believe, for anyone working in this space not to have a systemic view because at the end of the day it affects the the life of each patient, each doctor or nurse is treating every day.
SPEAKER_01Well, that's well said and needs to be better promoted and clearly. Every aspect of this really is um it's a part that needs to be really um included in different stages of careers for people to understand this. Yeah, thank you for that. Ricardo, you now lead Health AI, a global agency that works with governments, with WHO, with others, with a goal of ensuring responsible and equitable AI for health. I'm sure you have to navigate the geopolitics all of it just because of the topic and the times we live in. Any early insights on how things are going?
SPEAKER_02Yeah, I'm happy to share some insights. It's been six months on the job, more or less now.
SPEAKER_01Right.
SPEAKER_02Um I decided to step down from my seat in parliament last May uh during the World Health Assembly Week to initiate these functions following a very extensive uh global recruitment process. HealthAI is actually a nonprofit foundation based in Geneva. And our goal is precisely to help build a global regulatory network that in an equitable manner ensures that we are able to mitigate the risks associated with artificial intelligence for systems and citizens alike, at the same time that we are capable of fostering investment and innovation towards the adoption of a responsible artificial intelligence for the benefit of health outcomes across the globe. How we aim to do that is being this bridge maker and implementing partner, if you will, for WHO and other international organizations. We believe that WHO and others have the role of defining the standards, that's not us. And we believe that countries, building up on what I was saying about the lessons learned with the pandemic, the countries are the ones that have to lead the validation process. And so what we're aiming to do is being the bridge where we build the capacity in the countries if the governments are willing to have our support, so that then each country has actually within their regulatory bodies the knowledge and the capabilities to understand artificial intelligence and to apply responsible AI standards. If you think about low and middle-income countries, most of them don't have these capabilities today. So as a nonprofit, that really is a driver of our mission of not working just with high-income countries, but with all countries, raising the tide for everyone to hopefully help narrow the digital divide that is currently ongoing. But more than that, I'm sharing my insights from my experience already. We are living a time of algorithmic colonization, or some call it digital colonization, in the sense that many global north organizations are basically deploying their AI-driven or AI-generated technologies into low and middle-income countries. They're extracting data with no oversight. In some countries, governments are paying these companies to do this, and they're basically taking away this gold mine from the country. So it is a new form of colonization that I think will end up leading to a social uh unrest if we do not address it quickly, particularly in the field, the sensitive field of health and health data. We are one of the few that I feel, and I'm proud to be leading this organization because we're actually proposing a solution that we believe is realistic and doable. And so we're getting a lot of support uh from the country levels, uh, regional bodies, and also a lot of philanthropic and other organizations beyond the fact that we're working very closely with WHO, YTU, uh, the World Intellectual Property Organization, uh, OECD, and many others, uh so that together we we can actually build this global uh network of regulatory bodies. Just one last thing to say is one of our goals through that network is to s is to have what we call an early warning system. So we were talking about pandemics, how we want an early warning system if there's an outbreak, so we can contain it. The same thing with AI. If we have these different regulatory bodies that Health AI helps certify so that they are capable of validating AI tools and make and keeping surveillance of their impact in their own communities. If something goes wrong, if there's an adverse effect, if there's an unintended impact of artificial intelligence in one country, we want everyone to get a red flag immediately. The first thing we learn in medical school is first do no harm. And to do that with AI is having surveillance mechanisms because it can go rogue. If it does, we have to have mechanisms to detect it early before it has further impact in societies at large, so we can keep citizens safe. At the same time, we build trust so that it leads to the adoption of these technologies that can lead to tremendous results. And the studies are showing if we have a symbiotic relationship between machines and humans, we can leverage uh the health outcomes to ways that we've never done before, towards that vision of health and well-being for communities, including those that today live in low resources settings. And so we're very motivated to help do our small part to use these technologies towards transforming global health for all.
SPEAKER_01Ricardo, I think you're the first person who actually gave this comparisons that made it very clear. That was very helpful. I think that if this understanding was better known, uh we would have less confusion about AI and all of that. Um this was really, uh really well articulated. Thanks for that. As we come to the end, looking forward, what do you think are the most important determinants, forces, geopolitical situations, uncertainty in the world that are going to influence the future of global health?
SPEAKER_02I heard someone recently quote Donald Rumsfeld, the old Secretary of Defense from the US, saying that the world is full of unknown unknowns. That was after 9-11. I think we are full of unknown unknowns, and that is the greatest risk we are facing. The fact that we have several raging wars that are violating human rights, that are leading to massacres at a scale and beyond that fueled by hatred and uh divisiveness, and much of it is actually through social engineering using social media uh with a very clear intent is something that I believe can have extremely negative consequences in ways that I certainly can't foresee, and I don't think anyone can. Beyond that, we do have these broken health systems that I don't see us fixing. So looking at it from a global health lens, uh not addressing the underlying causes of disease, of what is affecting the health of our citizens, understanding that 60% of the health of each citizen is affected by external factors that are not addressed in the hospital or in the clinic, which are where people live, what kind of social economic conditions do they have? What kind of workplace do they encounter every day? What kind of education background do they have, or access to education do they have? What kind of food do they eat? What kind of climate do they live in? The tremendous impact of urbanization and air pollution. And I could go on and on. And the commercial determinants. I mean, we're always talking about taxation and getting more and more money for a broken health system that needs more and more money because people are more and more sick in this vicious cycle. Why don't we just start using money from those that are causing disease and tax those instead of taxing every single citizen that are actually victims of these determinants? You know, when we talk about fast food chains, and at the same time we're seeing those fast food chains actually sponsoring sports events, right? And so that these kind of uh inconsistencies, I think, need to be reflected upon as a society, because by not doing so, by allowing, for example, the tobacco industry to use the wording of harm reduction, which has been a critical policy, for example, to address drug policy, to try to sell people, young people, with vaping and heaty tobacco, which we has tremendous long-term effects, many of which we are unaware of today, knowing that the tobacco industry is the main causer of deaths around the world when it comes to health-related deaths, we understand that we are living in a world of contrasts, of misinformation. Uh, and so those are those unknown unknowns, along with many of these clearly intentionally fueled acts of disinformation that see now in social media have steroids to go really global fast, I think are some of the biggest challenges that we face, along with extremely powerful technologies such as artificial intelligence, uh, along with synthetic biology, along with the rise of quantum computing and many other innovations that are rising up fast at a pace that we do not imagine. If we do not prepare the world to embrace those technologies and these transformations and adapt the institutions to that, well, we can find ourselves in uh between a rock and a hard place. And it's in the it's the responsibility of all of us, of course, the politicians, the multilateral organizations. But I would focus here to the listeners in the sense that it we need a strong civil society. We need people to stand up, we need people uh to actually come together, people who believe in science, people who understand the data, who understand the evidence, to not be afraid to speak up, not be afraid of the insults on social media. As Martin Luther King put it, uh there's nothing worse than the silence of the good ones. And that is really what is happening today, because the only people we hear are the people who are screaming. And I honestly am getting fed up of it. I was fed up of it in politics, I'm fed up of it as a global citizen. And I think we need the good people of the world, because they are clearly the majority, to not be afraid and understand that it is that we are fighting for civilization, we are fighting for a human, for a human species, we are fighting for future generations. And so that at the same time as it can be scary, maybe, at the same time, it should be a strong motivation that we can once again provoke change in a positive sense and use all of these unknown unknowns and also the rise of all of these fascinating technologies for the benefit of humankind. And I'll certainly continue doing my small part now through Health AI and Unite Parliamentarians Network.
SPEAKER_01Great. What I took from this is that we need to be ready for known unknowns and unknown unknowns. And that they're both in front of us if we want to achieve our goals in global health. Thank you so much, Ricardo, for uh this conversation. Best of luck with all of your endeavors and uh have a great day.
SPEAKER_02Thank you so much. It was a real pleasure.
SPEAKER_01Ricardo provides a realistic and personal perspective on the role of geopolitics in his own life and his work in global health. He has shown that it is possible to be successful in influencing political change on a global level while keeping one's feet firmly rooted in the local and cultural realities. Ricardo emphasized the impact of the technology on the future of global health. He shared his vision for achieving universal health coverage where health systems are fit for purpose and are supported by, but most importantly safeguarded from powerful new technologies. Tune in next week as I continue part two of this discussion on geopolitics. Before I finish today, let's hear from another one of our listeners.
SPEAKER_03Hi, my name is Mariy Masigalwembeck. I am a center scientist with the African Society of Laboratory Medicine. I first discovered the Global Health Matter podcast during the COVID-19 lockdowns. Since then, I've regularly come back to the podcast as a trusted resource to be kept abreast of topics that matters and recent developments in global health. I particularly appreciate the fact that the podcast gives a special place to a diversity of voices and perspectives, especially those from the global south. I'm much looking forward to the new season of the Global Health Matter podcast in 2024, and what would be the emerging topics that we should be paying attention to during the upcoming year. I do hope that some attention will be provided to the World Health Resolution on capacity strengthening for diagnostics and how this can contribute to expanding access for all in the global south and in Africa in particular.
SPEAKER_01Thank you. Thank you, Marguerite. We value your comment, particularly that we consistently include voices from the global south. I really appreciate that, and we strive for that uh in the podcast. And thank you for your suggestion to include access to diagnostics which we will take on. To learn more about topics discussed in this episode, visit the episode webpage where you will find additional readings, show notes, and translations. Don't forget to be in touch via social media, email, or by sharing a voice message.
SPEAKER_00Global Health Matters is produced by TDR, a research program based at the World Health Organization. Gary Slanyan is the host and the executive producer. Lindley van Nieker and Obadiah George are content and technical producers. The podcast editing, communication, dissemination, web and social media designs are made possible through the work of Maki Kitamura, Chris Kos, Elisabetta Desi, Isabella Suder Dayao, and Chembe Collaborative. The goal of Global Health Matters is to produce a forum for sharing perspectives on key issues affecting global health. Send us your comments and suggestions by email or voice message to tdrpod at who.it and be sure to download and subscribe wherever you get your podcasts. Thank you for listening.
