Health and politics

How does health shape politics? How does politics shape health? Why do some diseases get international attention and funding when others don't? What role do institutions play? Richard Horton, Eduardo Gomez, and Jeremy Shiffman join Jessamy and Gavin to discuss the talking points from a new Lancet Series on Political Science and Health.

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Political Science and Health

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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.

Jessamy: Hello and welcome to the Lancet Voice. I'm Jessamy Bagonal. It's May 2022 and I'm here with my co host Gavin Cleaver. Today we're talking to Richard Horton, our Editor in Chief, and we're joined by authors of a new series on political science and health. Jeremy Schiffman, Bloomberg Distinguished Professor of Global Health Policy at John Hopkins University, and Eduardo Gomez, Associate Professor and Director of the Institute for Health Policy and Politics at Leigh University.

We talk about how health shapes politics. And politics shapes health. Most importantly, we discuss how using a political science lens can help us understand power. Who holds it, what they do with it, and how it influences global health policy. As always, you can find us on Twitter at jessamibagunal and at gavincleaver.

Let's kick off and I wonder whether you can tell us about how this series started and I thought Ed and Richard Maybe you could do a kind of combo answer for this question. 

Eduardo: So the series got started three years ago when I started to realize that political scientists had a lot to say about global health and global health politics and policy and the literature started to address this by political scientists in response to the HIV AIDS pandemic in addition to other social scientists And I thought it was time to really try and share this knowledge that's been accumulating in the field of political science with others in the policymaking realm and try to establish a dialogue between political scientists and policymakers.

I felt that at the time that political science, I still do that. There's a lot of theoretical and empirical approaches that political scientists have that. Policymakers around the world can learn from, and political scientists have a very sophisticated way of studying institutions, the bureaucracy, presidents, and their ideas.

Going back to the theoretical empirical approaches and lessons, there is a lot that political scientists can offer to the policymaking community. I thought that this was a great. Opportunity or this would be a great opportunity to share those, but also thought it was important that we start to develop a dialogue between political scientists and the policymaking community and what political scientists can learn from policymakers in an international sphere.

So I thought that's where the the ideas came from. And so for this series, and at that point, I then went to Richard and started engaging in discussion about the possibility of doing a special series on this topic. 

Richard: Yeah, and I think I was delighted when you approached me, Ed I've been very lucky to have worked with Jeremy in the past who really opened my eyes to, The power off political science thinking in the context of global health.

Jeremy has done some absolutely seminal work in the realm of maternal and child health on really got us to think carefully about what we could do better to elevate. Certain dimensions of maternal or child health into policy and political space, we're very good in the global health community at gathering quantitative data, publishing endless papers putting out calls to action more than we know what to do with.

But we're really bad at translating that evidence into action. Basically, we're just bad at implementation and part of that is that we just don't understand the processes by which a piece of science can be taken up or not by decision makers and Jeremy showed me how political science. can ask some really key questions and, more importantly, provide very practical answers.

So when Ed came to me, it was like instant yes, of course we'll do this, because in a sense I've been just waiting for somebody like Ed to come and say, let's try and develop this idea further. So I really do hope. That this series can open the floodgates a little bit to more papers that have a political science perspective, and really try and build bridges between a global health community that's rooted in the history of epidemiology and public health research with a very different scholarly discipline and to see what can come of that fertilization.

Gavin: Richard, I have a broad question for you that I think might be a good jumping off point. For, a very broad discussion across these papers. How political is health and medicine? 

Richard: It's very political, but it's a source of great controversy. If I look back over the last couple of decades and think about where the Lancet's got into trouble.

In the media, for example, it's usually been over issues that relate to politics, whether it's to do with civilian mortality in the Iraq war, conflicts between Israel and Palestine. We, this week, are publishing an editorial. that you led for us, Gavin, on the Roe v. Wade decision. Health is political, but many of our friends in health don't always believe it to be and get quite upset when A medical journal, a scientific journal puts its great big foot into politics, but, and certainly in the past where we have got engaged in these very difficult debates, editorials have appeared in other journals condemning us.

for bringing politics into medicine. Indeed, we have been boycotted by elements of the medical community for our stepping into the political medicine space. So it's a fraught area. And it's full of risks but that is the history of health, we can't escape it. Now if political science can illuminate those difficult relationships, which I believe it can, then all to the better.

Jessamy: Thanks Richard, that's a great answer, and I just wonder whether we might pick up on some of the things that you were saying. saying about Jeremy's work in terms of framing and forming global health priorities. And I thought that was a great paper. And I just wondered, Jeremy, whether you might be able to walk us through the kind of framework that you put across about how these issues become a priority or why they don't become a priority.

Jeremy: First of all, really appreciate the fact that Ed and Richard had the wisdom to produce this series. The community of political scientists. I'm sure are really grateful and there are dozens of colleagues that Ed and I have, political scientists who are outstanding scholars who work in the global health space.

There are too numerous to mention here but we cite a lot of them in our papers. And this is a small but growing community of folk and their voices need to be heard. With respect to My paper that I wrote with Yusra Shawar, another member of this community, an outstanding rising scholar. Our paper isn't about why issues get attention or are neglected.

It's not a complete explanation for that. It's a focus on one dimension of that. The framing dimension. So I want to make that clear. And the idea here is that we reviewed lots of scholarships. From political sociology and within global health to examine the potential role that the way issues are publicly portrayed or position the way elites and grassroot actors frame issues, the ways in which these may shape why some issues come to attract attention and are neglected and we find considerable evidence that indeed these framing processes matter and in particular, we identify three framing processes, which we can use.

Thank you. Call securitization, moralization and technification and securitization effectively means the portrayal of an issue as a threat to humanity commonly existential and you can think here about pandemic influenza or Ebola as examples, moralization. refers to its portrayal as an ethical imperative.

So think about antiretroviral drugs for AIDS. The idea that everybody deserves access to treatment, not just those who can afford it. And then technification refers to the portrayal of an issue as. It's a wise investment that science can solve, and here you can think of perhaps about neglected tropical diseases as an example of an issue that's been technologized.

But a lot of political scientists and sociologists know these framings exist, and a lot of global health folk know these framings exist and try to use them. To me, really, the deeper point of the paper, the deeper finding is not that. It's the contingency of these descriptions. And by that, I mean there's nothing inevitable about any particular issue being framed in any one of these ways, even though it seems like it's inevitable.

And I'll just give you a quick example. Thankfully, antiretroviral treatment for HIV AIDS It's increasingly been seen as something that is what's called a merit good. It should be offered regardless of ability to pay. Everybody deserves that. That's great. Why is that not true for insulin for diabetes?

What's the difference? There probably isn't a morally relevant difference. But one is perceived that way, the other is not. Another example, pandemic influenza or Ebola to varying extents have been perceived as global security threats. They're both diseases that transmit across borders. They're both emergencies of international concern, right?

 Cholera is like that. It's never been designated as such. Yet it potentially could be. And cholera has killed Many more people in recent years than Ebola. So what's going on here? There's something odd in the way these processes unfold and it brings to bear the idea that politics matters.

There's something underlying these dynamics that are historically contingent, even as they appear to be inherent characteristics of the issue. So that's what we were trying to get at. I could also comment, but I'll, I don't want to take too much time. There's also something ethically, I don't know how to describe it.

We should be a little bit worried about the quality of democratic deliberation that infuses these processes and about a bit of zero sum competition that occurs as disease constituencies compete for attention in these spaces. 

Gavin: Yeah morally ambiguous, perhaps. It's it's a very opaque process in the way you describe it.

Jeremy: It is opaque. Some of it is not. And it's the job of scholars and others and political scientists to elucidate these processes. You were asking Richard, is health political? I think we political scientists would say, of course it is. It's like we don't even think about it, power infuses all these processes and therefore it's political.

They're, it's battle over control, over resources, over priority, over ideas. There's contestation, there's multiple forms of power, so of course it's political. And some of it's opaque and some of it's not. You hope that. Less and less of it will be. I 

Jessamy: wonder whether we could just pick up that point that you talk about HIV, antiretrovirals, and insulin in terms of The sort of framing of them because with all of these there are advocacy groups that try and frame them like, as you say, people are aware of these different, ways that things can become a priority.

What more than framing. works? Is there a bit of luck? Is it timing? Is it, what are the, there, there are so many other factors and influences. 

Jeremy: Yes, of course. And that I wanted to emphasize that it's not, framing is one piece of this. It's the meaning work. It's the politics of public signification of issues.

And there are many, so many other pieces and I don't think anybody has. fully figured out what all these pieces are, but we certainly need to look at, among other things, who are the actors involved? How much power do they have? What forms of power do they have? And there are multiple forms of power.

Some are obviously financial power. Some are the power to compel others to act. States can compel individuals to act. Some Forms of power considered epistemic power, the control over knowledge, or authority by virtue of being an expert. Some is moral power, reproductive health activists, the Catholic Church have moral authority, people like Nelson Mandela, who are listened to by virtue of their ethical standing.

Also the forms of collective action that, that, that unfold can they inspire social mobilization? civil society activism? Do they have reach into states, networks, ties? You have to piece together all of these. The political context, for instance did an issue get its particular, did it get a target in the SDGs?

If so, why? How? So all these things come together, political context, actors, forms of power, forms of collective action, framing processes, and all these, and then there are obvious factors, is this, in terms of securitization, a lot of the, I'm not a securitization scholar, but a lot of my colleagues are outstanding securitization scholars.

And they, one of their key insights is that whether an issue gets securitized, whether it gets designated a public health emergency of international concern, has as much to do with whether elites and publics in rich countries are afraid of it. As it does, whether it is a true threat to the world, so these kind of high income, low income power dynamics shape these processes as well.

So I've been studying this stuff for a long time. But I don't think I've figured it out. And I don't think anybody has, there's still so much more work to do. As soon as someone tells me they think it's obvious why some issues get attention and others do not, I immediately know that they don't know.

What's happening? 

Jessamy: Just move on a different conversation. Richard, do you have any reflection on those points? 

Richard: I do a couple of thoughts actually in response to Jeremy. First of all, I think, it is a political issue as to why some people. don't think health is political. When somebody writes an editorial in the American Journal of Medicine to say, condemning us for doing something, which is what happened a few years ago, and arguing that medicine is not political.

There's a political question as to why that person felt that a particular issue was not political and not relevant to health. There's a sort of reflexivity here, questioning the question. Also, I haven't seen Jeremy for a while. It's a chance for me to also say to him about another paper he published.

I've been out of the office for two years and I've just been going back to the office and throwing away all the junk that had accumulated over years and decades. And I threw everything away. Apart from one or two really important papers, and one of them was one of yours, Jeremy, and it was a paper.

I 

Jeremy: think I know what 

Richard: you're going to ask me about. Exactly, yeah, it was a paper that was about the lancet. Or partly about the lancet. And you asked some very important questions about why is the lancet doing what it's doing? How has it got to do what it does? Who authorized it to do what it does? Who is it accountable to?

Two one Earth is going on with the Lancet . And it was a really, I remember reading it at first and I thought, Hey, this guy's meant to be a friend. , 

Eduardo: and he's asking 

Richard: all these difficult questions. That's what I thought first. And then the second thing I thought was we didn't really set out to do any of this.

Its kind of just grown over the years. All this work in Global Health series and commissions, and. But then you get to a point where these questions become really important. And and then my third thought after, calming down a bit, was to then think, actually, you know what, this is a really interesting question, because some of our series work, and some of them don't work.

I'm not going to name the series that, that don't work, because it wouldn't be fair on the authors. But I had an email recently from an author who said, we've published three series on this particular subject in the Lancet over the years, and all three series have failed. totally failed to make any difference at all.

We, literally a dozen papers. And so he said, so we want to do a fourth series, which we really think is going to make a difference. And I said to him, I said, look, before we do any more, don't we need to stop and think, why have these three series completely been ignored? The problem is that We're not equipped to answer those questions.

I'm not really sure I know where to start to answer those questions. And that's where we need political scientists to come in and say, Okay, you did all this work. It's been totally invisible. Why is that? So I think these questions are absolutely central to our mission. And we don't spend really any serious time asking them in a structured, scholarly, sensible way.

Anyway, I've got your paper, and I'm very grateful for it. 

Jeremy: The first thing I want to say, and this genuinely I'm not I mean it. I'm really grateful for the role that Lancet has played in the world of global health. It's played a, thank God it's really played a central role in elevating global health in the world.

I think that's the bottom line. If you ask me, do I wish the Lancet had never entered the world of global health? I would say, no, absolutely not. I think the Lancet has done much good for the world and you, and your decisions as editor have been, this has been a great boon. So I, that's my first point.

Richard: That's kind, but there, there, there is, exactly, there's a good but there. 

Jeremy: Yeah, here's the but. It's time, and you and I have talked about this The Lancet deserves to be studied as an actor in global health and with critical scrutiny. The sources of its authority, its power to convene, its what voices are included, what voices are excluded, what forms of knowledge are privileged, what forms of knowledge are not privileged it deserves critical scrutiny just as much as Gates, the Nigerian government.

Medecins Sans Frontieres, the WHO, because you are, you have become not, and I know Richard, you would acknowledge this. You're not a neutral actor, a neutral forum for medical knowledge. You are an actor with a stance and your editors are, and the journal is, and that's. Fine and and good, and because you and your journal have become powerful actors, you and your journal deserve critical scrutiny, as do we all.

And the, on the, by what do all of you speak? And I think you can very much justify having a voice, but that's the point. 

Richard: Absolutely. No, absolutely. I completely agree with you. I think it wasn't until I read that paper though, of yours, that I had thought about how we need to step outside of ourselves and look at what we do with that critical eye, very much no I fully 

Jeremy: agree. And not just, others need to step out and watch because both internally and externally, actors and scholars of multiple disciplines from multiple parts of the world. Should do that. So there are multiple voices offering this analysis. 

Richard: There's another issue that we've published on, and again we don't have the skills in the EPI and public health community to answer this question.

And this is work that's been done by Tom Bollocky and colleagues looking at some of the determining factors in which countries performed well and didn't perform well in the pandemic. And his one of his conclusions was that the issue of trust in governments and interpersonal trust was central to those countries which performed well now, trust is a very, we know what trust means at a sort of, in our ordinary conversation, but from a scholarly point of view, we don't Really, I don't fully understand the meaning of trust and how to study it and how to break it down and what it actually means mechanistically and what we can learn from a statement that trust is essential to understand the pandemic response that I think.

is where political science can step in and help us to understand that. And so when we're thinking about pandemic preparedness and we're all, WHO and governments are all rushing ahead now, trying to implement pandemic treaters and strengthening health systems and thinking about vaccine platforms and how do you redesign COVAX and all of this technical stuff, which is all important.

But if trust is a central determinant of success, who's looking at that? I can tell you WHO isn't looking at that. The World Bank isn't looking at that. Our government isn't looking at that. I think that's where the political science community plays an absolutely key role or should. 

Eduardo: I think that's a great point.

Richard, I think that political scientists do, although this is not my field of expertise, there's a lot of discussion about trust and how does, what are the origins of trust. And I think a lot of political theorists that talk about democratization and going from those who look at the role of Alexis de Tocqueville that came to early America and looking at communities of trust.

And the early colonies and there's been a lot of literature over time looking at the conditions for trust in government. I think that these are central critical issues in political science that that I think that I agree that we can provide some insights in. And why hasn't that happened in, in global health or or any kinds of health?

I think in American politics, there's been some. Discussion about trust and helping in the global level. I guess a lot of it has to do with research methods as well. It's a very difficult issue to address. It requires a lot of qualitative methods and interviews and interviewing people about their beliefs in government and beliefs and in vaccines.

And so this is a research agenda that I haven't really seen much done at the global level, but certainly There are political scientists that could provide a lot of insights into this theoretically and empirically. So I completely agree. It's something that, that we should encourage political scientists to get more involved in especially at the global level.

Jeremy: And just to add that there's some scholars like Robert Putnam who was at Harvard, who did a great deal of excellent research on trust, social capital, and how this, affects political performance. So there's a whole tradition in political science that examines trust. Trust isn't the sole purview of political science by any means.

Sociologists, anthropologists, psychologists, economists study it. But there is a tradition in political science and Bollocki's article gets at this very nicely. 

Jessamy: That's such an interesting conversation. And I guess it answers one of my questions, which was COVID 19 and the sort of. political determinants of health, lots of people have talked about and political sciences role in that.

Do you have anything else to say on that sort of pandemic, political science, political determinants of health point above and beyond the trust aspect? 

Gavin: It's interesting, isn't it? Because as well, Jeremy, you were talking about prioritization, and we've actually seen across so many different countries, so many different methods of prioritizing how the response to COVID 19 played out.

Eduardo: I think that COVID 19 has really revealed to the world the importance of politics. In fact, when I arrived at Lehigh University, and I arrived in the middle of the pandemic, and this motivated me to create this Institute of Health Policy and Politics. Because we saw that politics had a direct impact on COVID 19 in the U.

S. My colleague Sandra Galea at Boston University and I wrote an article about this, how political interference really blocked a lot of key policies in the U. S. that were needed to, to address the issue. I, just a couple points on how politics and political determinants in COVID 19. I think that we've seen that the role of presidents and how powerful they are.

In terms of their conflicting views shared through social media this was very evident with Trump and Bolsonaro in Brazil, and how their views about science conflicted with scientists, especially in Brazil, leading to the the the sort of the resignation of key science officials in the government.

And so I think that, that Political scientists have a lot to say about presidents and their personalities and their views. And I think that we saw that with COVID 19, we also saw. Secondly, the importance of federalism and institutions and states in both the U. S. and Brazil and other countries. We saw governors that had completely different political views and scientific views.

In the U. S., some aligned perfectly with Trump and others, like in New York, they didn't. And so we had dramatically different policy responses. And so I think that those are politically, at least two major lessons that I saw, and I'm sure others saw as well, and issues that political scientists have been dealing with for a long time.

And as we saw in our series Iona Kickbush talks a lot about the new kind of international politics surrounding COVID 19, the decline of multilateralism, and the need for the emergence of a new international politics where the global south takes leadership position, given the inequalities in vaccines and access to vaccines and the need for their voice in ensuring equity, equitable distribution.

Jeremy: Yeah, I think those are very Insightful comments added. I'll just add one more and I think this point is engaged in the second article in the series led by Carmen Ho and let's say Joe Wong and Kimberly Speed and Hina Khalida are authors on that on universal health coverage. I think one thing that the response to global and national responses to COVID raised for me is a central concern in political science, which is the relative power of interests, self interested behavior on the part of states vis a vis principled ideas and cosmopolitan norms.

and how these two interact in shaping the actions and responses of government. And, we global health folk, issue calls for global solidarity and cosmopolitanism and hope that the world will behave ethically. But then we notice the self interested behavior, vaccine hoarding of nation states, especially, powerful countries that control resources.

Political scientists have been thinking about these issues for decades. It's a central concern in all sub fields of political science. To what extent is politics driven by interest? To what extent do ideas, do principled ideas, do normative Values matter. It's not a happy story as we observe responses to COVID.

You can see how self interested behavior came to the fore when push came to shove. That being said, I'm not as pessimistic as many colleagues in political science are because I think you also see some evidence of solidarity, of cosmopolitan norms, of concern for disadvantaged populations, of rights.

based concerns, not nearly enough, but they weren't completely absent. And there is a legacy, there is a historical legacy, especially emergent with the creation of the World Health Organization and the push for the right to health. And this still does shape state behavior, but it's just been so disappointing, the dominance of self interested behavior on the part of pharmaceutical companies and states.

So how, how do we set up global health governance structures that cultivate global solidarity? Respect for principled ideas, even as we know the political reality is that powerful states will protect their interests. This is where political science comes into play, right? We, one can't be naive.

You have to negotiate through the existing political terrain and the reality of that terrain. You can't wish away interest. You can't presume cosmopolitan norms will dominate. You can't, evidence is absolutely necessary, but it's never sufficient. I always tell when I'm talking with biomedical audiences, I say that the presumption that evidence is enough is not supported by the evidence.

So why would, empirically minded audiences accept empirically inaccurate? That didn't happen in COVID. You have to deal with the reality. And political scientists deal with the reality. We don't wish power away. We acknowledge that it's perpetually present. And we deal with it. And that in COVID.

Richard: My concern is the The community of political science. And is it big enough to answer the questions? If we look at pandemics, climate, migration, sustainable development goals universal health coverage. There are so many issues here that are just massive. And we need political scientists crawling all over them.

To help us understand what we're doing and what we should be doing. At least pointing us to options and possibilities of what we might be doing better. And I worry that the political science community isn't in global interested in global health, just might not be big enough to address this. So How can we incentivize more people to go into political science and feel that journals like the Lancet are a decent home for them?

And because one of the difficulties we've had with social sciences in the past has been that People say the Lancet isn't interested in that work, and even when it is, we're used to writing papers of 10 to 12, 000 words, and the Lancet doesn't publish those. I think it's just the, my question is, how could we build a better relationship with the political science community and incentivize that community to work with us?

Jeremy: That's a great question, Richard. I'll just reiterate that Ed and I have We have dozens of outstanding colleagues who are political scientists, sociologists, anthropologists, who do superb work analyzing all the issues you just mentioned and others, bringing to bear fascinating and thoughtful ideas that deepen our understanding of all of this.

And it would be wonderful to see more of them published in the Lancet. Because I think if you were reading a lot of their work, and I'm sure you do and I think the community acknowledges and appreciates the fact that you're someone who does appreciate the social scientific work.

And in other medical journals, it's very hard for us to find a voice. You appreciate the kind of work that our colleagues do. I guess part of it's our fault because, when we communicate using our, jargon, we understand that people don't want to read that stuff. If I start talking about, debates between neorealism and neoliberal institutionalism and constructivism and critical theory and blah, blah, blah, who's gonna, I know your readers don't want to have a whole on treatise on that.

So part of it is on us to take these concepts that are very, actually, honestly, all those terms I just used, they're very useful approaches, but we just need to explain why they are. So part of it is on us. Part of it is I don't know. I actually, maybe, Ed, you have further thoughts. How can our community better connect with journals like the Lancet, given that there's so many of our colleagues who are outstanding scholars?

Can I just throw in one further point? Political scientists, sociologists, anthropologists, many of them have academic incentive structures whereby they, advancing their careers if they publish in their disciplinary journals, right? American Political Science Review World Politics, International Organization, these are journals that are essential for political science.

Yes, they'll be happy if they publish in the Lancet, but then they won't necessarily be promoted. And this is unfortunate so that's one of the difficulties. 

Eduardo: Yeah, I think this is a very important question. First of all, thank you, Richard. I echo Jeremy's thankfulness to you for being so receptive and welcoming to political scientists.

And this is so important and critical. Let me just back up or just say that I agree in terms of what can we do in political science. What Jeremy raises a very important point that traditional political science departments like economics and sociology have a ranking of journals that they prioritize.

And of course the APSR, the American Political Science Review is the crown, the highest. That you can get. It's the journal for the discipline. And of course, there are many other journals that come underneath that are similar. Medical journals public health journals have never made that list.

And I think that needs to change and will change. And the reason I'm optimistic is because I've noticed, and I'm sure Jeremy has agreed, that more and more political scientists are coming into global health. And I think political science departments are realizing the importance of of these journals.

I think with COVID 19 showed that political scientists that have never written on health are now writing in on the health topic. And I think that will lead to recognition of of Lancet and other journals that are trying to establish, have more political scientists. I think that this Lancet series will have a tremendous impact in getting more interest by political scientists to write for the Lancet.

I think that we also can do our part in terms of, I'm involved. I think Jeremy, you're also a member of the health politics section for the American Political Science Association. And I'm a council, I'm a council member right now, and I'm sure that by sharing the, this Lancet series with all of our members in the health politics section that will further increase interest and in writing for the Lancet.

I think that I'm very optimistic. I feel that more than ever we're seeing, and I think COVID had a tremendous impact on this, on the interest of political scientists to work on health politics. I've seen several of my colleagues that have never worked on health that worked in compared to politics start to have an interest in health now.

So I think that the timing is right. I think that this will, will change. I think that the discipline needs to become more aware of. Of diversity and research and and I think that does take time and and and to realize, and I think this point needs to come across that the rigors of peer review for the Lancet are just as, if not much greater than our political science journals and and the quality of scholarship so recognition of that will be also be very important.

Jessamy: Maybe we could just, I'd just be interested in your thoughts on, how you see health shaping, but also being used for global diplomacy in what might be a post COVID world, although we might see some more waves, what are we looking at, do you think, for the next 10 years or so?

Eduardo: Just very briefly, I think that two things come to mind in terms of using health for future global diplomacy after COVID. The first is certainly inequalities and access to medicine. Now, of course, this is a very old topic, but This has been further, problematic with COVID 19. And and I think Iona's article in the series really highlights this.

The decline of multilateralism, the rise of vaccine nationalism, and the need for the global south to have a voice in establishing international norms and commitments to vaccine distribution. I think that's, Going to be a critical going forward. We cannot have the situation again when a vaccine nationalism emerges and we have to focus on that as a source of global diplomacy.

And as a Yona and Austin point out, amplifying the voice of the Global South leaders and international organizations to achieve this. The second, in my own research, looking at the commercial determinants of health and nutrition, I think that we've seen COVID have a tremendously negative impact on nutrition and lockdowns and quarantines impacting nutrition and access to nutrition, especially in urban food deserts.

In our increasingly urbanized cities around the world and how we ensure that in the future pandemics that we are equally as committed to addressing These nutritional deficiencies in urban areas in rural areas I think that needs to be at the center of global health diplomacy discussions in the future so that's what I wanted to say.

Jeremy. Do you want to go ahead? 

Jeremy: Yeah, i'll just add one point which I think comes through in the third article in the series on diplomacy I think one thing that may well happen and we already see it in the context of COVID is that powerful states are going to compete to look good in vaccine diplomacy.

That already between China and the United States, for self interested reasons, they're going to engage in health promotion and supporting other countries with health. Now, some people may object to that because it's not pure. The motives aren't pure, but, this gets back to what we were saying before about how the essential political science concern is the role of interest vis a vis.

Principled ideas and norms in shaping state behavior. Bet we'll see more of this. And some people may interpret that negatively. Others might say that you know what? As long as they're doing it, who cares why they're doing it? But there's just one, one prediction. More of that stuff.

Richard: I'm not very optimistic. Actually for several reasons. Firstly. I think that our governments are deliberately obfuscating and failing to learn the lessons of the pandemic because some of the lessons are difficult and raise very complicated political challenges for certain governments.

Just to give a couple of examples and I've, sorry, I've mentioned this. On many occasions that this pandemic is actually not simply a pandemic. It is a synthesis of epidemics where you have a virus interacting with a previously unhealthy population, an epidemic of non communicable diseases all on the background of inequality and issues of inequality in general health.

are difficult for governments to address and it's much easier to think of the pandemic as just being about a strange virus that comes out of China and and you have a magic bullet of a vaccine or an antiviral to deal with it. And the much more complex political questions they don't want to address and they're definitely not addressing them.

I think all of that then also you have to look at then the context. Of the pandemic within the environmental plant climate crisis that we're facing. Because there we talk about health is different. Diplomatic tool. I wish it could be, but the power of the fossil fuel industries are not going away anytime soon.

And if you want to put the World Health Organization against Saudi Aramco, who's going to win? A bunch of well meaning health diplomats are just not going to win against the most powerful company. You saw that it's now displaced Apple is the richest company in the world. It's the most. Powerful company that's shaping the future of the planet.

I think we, again, this is where political science becomes important because I think those of us in health can sometimes be extremely naive and think that we can use what we do to somehow shape the global political dialogue. The forces of geopolitics are so powerful. that actually this is where we need to analyze those power structures much better than we currently do and integrate them into our thinking in health.

And we don't do that at all at the moment. I'm optimistic in the sense that, life is a struggle. And as long as we continue to struggle, then there's always hope, but my God, the forces are tough that we're aligned against, so let's not be naive about it. 

Jessamy: I love the way you try to turn it around to an optimistic note.

Yeah, very grateful for that. 

Gavin: But the note that we're still ending on is that life is a struggle. 

Jessamy: Yeah, that's the optimistic part. Life is a struggle. 

Richard: But the point there is that we have to engage with the struggle. So it comes back to what Jeremy was saying earlier, for a journal like The Lancet or for the scientific community, this isn't just about getting grant, getting tenure, publishing a bunch of papers.

This is about using science as a political instrument to accelerate social action and being very open about it and being very deliberate about it and not being afraid of that.

Jessamy: Thanks so much for listening to this episode of The Lancet Voice. Please subscribe share and engage. You can find us on all your usual podcast platforms. See you next time.