Offline: Why science should matter more to global health

Abstract

A brief experiment in global health comes to an end this week. On Sept 26, the iERG (the thankfully short acronym given to the independent Expert Review Group on Information and Accountability for Women's and Children's Health) hands its fourth and final report to WHO's Director-General, Margaret Chan. The iERG is a creation of the Commission on Information and Accountability for Women's and Children's Health (CoIA). CoIA was, in turn, the product of Ban Ki-moon's signature global health initiative, Every Woman Every Child. CoIA was chaired by the Prime Minister of Canada (Stephen Harper) and the President of Tanzania (Jakaya Kikwete). Such high-level political leadership ensured that CoIA's recommendations were taken seriously, especially since Canada was promising billions of dollars for maternal, newborn, and child health programmes (its highly successful Muskoka Initiative). The purpose of the iERG (declaration: its two co-chairs are Joy Phumaphi and myself) was to strengthen accountability for women's and children's health, which meant making sure the promises of all stakeholders were actually delivered. The philosophy behind the iERG was animated by Paul Hunt, a former UN Special Rapporteur on the right to the highest attainable standard of health. He envisaged accountability as a three-part process—monitoring, review, and remedy or action. The integration of human rights into health proved to be a powerful idea, one that has helped to accelerate progress for women and children worldwide. But there was one further lesson from this embryonic architecture of accountability—the neglected value of science as a political instrument to catalyse advances in health. Governments and multilateral organisations are essential partners in determining the direction of global health. Civil society is increasingly recognised as a forceful additional actor in shaping global health policy. The burgeoning engagement of non-governmental organisations at the World Health Assembly has exemplified not only the emergent diversity of global health, but also its gradual democratisation. And the private sector is now recognised as an indispensable voice too, and not only for its money. But science and scientists also have a role, and my experience in working with the iERG has been that science deserves far greater attention as a tool for global health decision making. Surprisingly, many global health leaders turn away from science and feel uncomfortable among scientists. Partly, this aversion is because leaders of health-related agencies often have little-or-no scientific background themselves. Alienation from the language and practice of science may, understandably, lead to anxiety, scepticism, and rejection of science itself. Good global health leadership demands a suite of political skills whose acquisition may be entirely antipathetic to science. But global health needs to learn to love science—and scientists. Here's why. Science performs at least five vital functions for global health, and especially for global health accountability. First, science can deliver the most reliable data to inform decision makers (think of the contribution made by the Global Burden of Disease study). Second, science can support the impartial evaluation of global health programmes. Third, science can offer divergent visions of the world's future through its predictive models, varying conditions and outcomes which offer choices to political leaders. Fourth, science creates new ideas that can help to accelerate action. Examples might include Dean Jamison's Commission on Investing in Health or Ana Langer's Commission on Women and Health. Finally, scientists can be advocates for policies based on the best available evidence. But there is a danger. Although one might lament the fact that science is a persistently marginalised cultural force, a technocracy can never substitute for democracy. The control or influence of society by a technical elite will only produce a new tyranny. Experts are unaccountable to society. Technical solutions may not be humane solutions. The technocratic becomes the inverse of the democratic. But even a justified fear of science is no excuse for ignoring the contribution science can make either to the alleviation of human suffering or to the delivery of social justice. Scientists are surely sometimes guilty of private diffidence and public arrogance. But those who could use science to advance the health of their societies and who choose not to do so are guilty of far greater atrocities.