Q: What are the challenges in global health that leadership can help solve?
I think the major challenge that we see in the world related to global health is the disparities. We spend 10% of global GDP on healthcare. In theory, if we could spend it more evenly, everybody in the globe would have a healthcare system as good as in the United Kingdom.
Unfortunately, we spend a huge amount in the West and very little in the global South. As a result, we have impoverishment and disparities across the globe. But I believe those are things good leadership can fix, or at least address.
When I think about leadership I don't think of it as a specific person who has certain traits, but rather as a property of the system. It's more about relationship building, engagement, negotiation, and understanding. We have to look at how people who are in the leadership roles engage with other people to try to achieve a global objective. Of course one has to see this as an extremely long-term project.
Q: What do you mean by long term?
It's generations for sure. When we look at the United States, it took us 100 years to really develop stronger health outcomes, where our life expectancies went from the 50s to the 70s and 80s. That came, obviously, with improvements in the public health sector and in health generally—medicine, hygiene, clean water, sanitation, etc.—but economic development was also a key factor. A similar time frame was required in England: that 100-year period.
We're working very hard with Ethiopia now. It's a low-income country with the goal of becoming a lower-middle-income country over the next 35 years. We keep saying it's going to be a tough road, but if you look at other countries that have invested in health at the same time that economic development was happening, they made the transition quickly—but quickly being 50 to 100 years.
Q: Is there a positive feedback loop between economic development and public health?
Completely. The evidence on this is unequivocal. The health of your population is a fundamental asset for development, and development will bring about health. You get into a virtuous loop if you can start it running.
Politicians recognize it, but ministers of finance, who are fundamentally important to development and to health, often seem to want to stay away from public health. The evidence is very good that employment and health are related. But it's hard to make the sacrifice in the current budget for the future benefit.
Q: What are some of the paths to fixing the disparity?
Some of the keys to the approach are engagement and understanding and awareness, which are leadership functions.
Even within the United States, where there are huge disparities, many people who are on the higher end of the income realm have no idea what the experience of the lower end really looks like. For instance, in the United States, 40% of people born to the lowest quintile will stay in that lowest quintile in the generation to come. Yet we think, "This is the place where anyone can rise up."
Those kinds of misperceptions also happen between countries across the globe. So first we need to have understanding and awareness of the issues. I have great hopes because of the internet and the many communication efforts that happen. But beyond that we need the political and social will to do something about this. We need people to see it as in our enlightened self-interest to mitigate disparities.
Q: I imagine mitigating disparities is not as simple as spreading money in some different way, that there are many other steps. If you look at the U.S. system, there's a lot of spending and results may not be as good as other places.
The disparities come from things that are much deeper than just the money; they come from culture, power, and hierarchy, all of which, I think, are a piece of leadership. Outstanding, effective leadership and governance attenuates the potentially ill effects of that concentration of power.
One thing we're doing in global health at Yale is a Yale Global Health Leadership Institute Conference, where we bring representatives from countries who are in top leadership positions in their countries and that have a real problem they want to solve, usually ultimately around disparities, and we engage with them to provide tools that equip them to work on the issue.
Q: How much are the challenges the same across countries? How much do various cultures create differences in how you approach them?
We're wildly similar in the sense that inequality is just part of the human existence, in every country. We see that inequality in education and income track with inequality in health. Each impacts the other. And that is true everywhere, from the United States to Indonesia.
However, the context—the political will and the cultural norms—vary quite a bit. We've used the World Values Survey to understand how societies differ. Each culture has norms about how much they tolerate inequality or what they think the role of government should be. Those norms are vastly different country to country. Even among countries we think of as having similar values, like in Western Europe, they're vastly different.
The root problem of inequality is in every country, but the tools to address it have to be tailored to the context of each specific country.
Q: Could you give some specific examples of how you're working on these issues in China?
In China, we work very closely with Tsinghua University on developing leadership and management capacity among women health managers. As part of that, we did a study looking at a huge cohort in rural China right after they passed new comprehensive insurance policies that were supposed to insure everybody in the country. It turned out, unfortunately, this policy was quite regressive in that the middle class really benefited, but the poorest of the poor didn't see much benefit.
Each county ended up offering a different kind of package. The insurance that the poorest counties offered was so poor and the hospitals were so far away, it wasn't worth sacrificing a whole day of labor to seek the healthcare. So even if they were given the insurance, people really couldn't use it very well unless it was a much more generous benefit.
It's a classic example of how policy that seems to be aimed at mitigating inequalities ends up helping the middle class, which is the group that keeps the existing leadership in power. We do this in the United States all the time.
Q: What are some of the dynamics in the Chinese healthcare system? How involved is the government? How big are the inequalities?
The inequalities are just enormous, as are other inequalities in China. In Beijing or Shanghai, you're going to get the very best healthcare possible. Outside of those cities, you're going to get really much worse healthcare.
The healthcare dynamics in China are fascinating because of their age-old traditional medicine. Not only do they have the issue of how to finance Western medicine, but also how, culturally, to introduce Western medicine so that people will use it appropriately.
One of their biggest problems is the way the government reimburses for medical care. Physicians and hospitals get paid the best for prescribing medicines. In fact, they can sell the medicines themselves directly to patients. So there's overuse of ineffective antibiotics; it's probably as bad as anywhere in the world. One additional noteworthy issue in China is, because they are stoking their healthcare system with new insurance plans, a lot of private entities, good and bad, are coming into the market. They are there to consult on how to spend this money, to develop new technologies, or to bring Western technologies—MRIs, CT scans, etc.— to China. The impact is to a medicalization of China.
From a public health perspective, that's not always the wisest road for a country to go down because medicine is expensive; public health is a lot cheaper and can help your whole population. I fear that China is going to do what the U.S. did—spend huge amounts of money on medical technology even though outcomes aren't going to be that much better.
Q: Are there opportunities for entrepreneurs and for private-sector growth in the healthcare sector in China?
Definitely. In healthcare, it's always tricky because unlike a regular marketplace, the patients don't have full information, and there are huge barriers to entry. I think, over time and properly regulated, private-sector growth will be good for China. It's just a matter of doing it wisely.