How empowering young people can make global health systems stronger and fairer

Afifah Rahman-Shepherd remembers first becoming aware of the consequences of inequity in global health when she visit her mother's homeland of Bangladesh. She carried that idea with her, she says, through her studies in biomedical science, her Masters in infectious disease at the London School of Hygiene and Tropical Medicine, and her work on global health and health security, first at the Pasteur Institute in Paris, then at the Chatham House Centre on Global Health Security (now the Centre for Universal Health) in London.

By the time she started her PhD on regionalizing pandemic preparedness and response at Singapore's Saw See Hock School of Public Health, the COVID-19 pandemic and the Black Lives Matter movement had brought into sharp focus how many communities around the world were being failed by the global health sector.

Since then, her research and writing have focused on finding ways to decentralize global and public health, shifting power and resources to regional and local levels to ensure everyone gets the care they need. She was the lead author of a study in the BMJ looking at progress on antiracism policies in the world's top global health institutions, and for PLOS Global Public Health she covered how conflict of interest in healthcare, in the form of incentives for prescriptions, impacts the quality of care doctors give their patients in Pakistan. She was also among a group of young global health scholars and professionals who published an open letter in Nature Medicine calling on G7 and G20 leaders to act on their commitments to address global health crises.

"Working in the global health sphere and living in the times that we are, it has felt very natural to me to converge health security with equity," says Rahman-Shepherd, now 32.

In many cases, making public health systems more equitable means completely overhauling their structures and systems. And Rahman-Shepherd believes today's young people – with their unprecedented access to information and their openness to connection and collaboration – are uniquely placed to lead that change.

Ahead of International Youth Day, Exemplars News spoke with Rahman-Shepherd about the role young people can play in rethinking and reshaping global public health to make it work for everyone.

How does inequality and lack of diversity in the leadership of global health institutions make it harder to achieve health for all? And what are the solutions?

Rahman-Shepherd: It's paradoxical. We can't have health for all if we have systems and structures that are deeply entrenched in discriminatory practices based on how individuals and communities are racialized. How can we talk about health for all if the policies and practices were not designed to include all?

We don't know the optimum governance structures to achieve more equity. There's lots of effort being put towards describing what these strategies or new global and public health systems and structures should look like – for example, the work of the O'Neill-Lancet Commission on Racism, Structural Discrimination, and Global Health.

In our study, we saw that organizations with more diversity in decision-making spaces ended up not only making more commitments to equity, but also had more mechanisms of accountability to monitor their progress against those commitments. Having stronger data collection and analysis, building that evidence base, is one fundamental way of diagnosing the problem, describing its impact, and then knowing what to monitor and tackle. You have to walk the talk. That means systematic tracking of organizations' statements and commitments, and also routine public reporting, transparent mechanisms for whistleblowing and independent investigation, and creating an independent expert body to monitor progress across organizations.

What can young people bring to efforts to reform global and public health systems? How can the sector better engage with young people?

Rahman-Shepherd: There need to be more decision-making spaces at the table for young people. There are seats for civil society, seats for industry, but we don't have seats for youth. It goes back to social diversity and idea diversity, to borrow a phrase from the Global Health 50/50 initiative. If we want bold, new, and transformative ideas, we need to be empowered to say not only that we want to be at the table, but maybe we want to change the shape of the table, or we don't want this table at all.

One of the strengths of my generation of researchers and health leaders is our drive and ability to form coalitions. We have so many WhatsApp groups, collectives, and networks and so much energy to find like-minded folk and collaborate. With social media, we have more potential to connect than ever before, to break down geographic borders and disciplinary borders, even ideologies. People aren't seeing silos anymore. That's maybe unique to the youth of today and it can create real change.

You're a proponent of the One Health approach to health systems. Can you explain how it works and can you think of examples of countries or communities that have set up successful One Health networks?

Rahman-Shepherd: One Health aims to optimize the health of humans, animals, and the environment all at the same time. We now recognize how interconnected and interdependent we are as a people and a planet. Many health threats that have epidemic and pandemic potential arise at this interface and crises like COVID have brought a lot more attention to the One Health movement because politicians and funders are seeing its relevance.

Across many parts of Africa and Asia, they have fantastic One Health Networks. And they are increasingly community-led, because in those regions, public health has always been intertwined with community health. Much of public health is run through community volunteers and community healthcare workers, so they know what's going on in their areas, what's going on with their chickens, their crops, their water supplies. They've already been doing One Health without calling it One Health.

Kenya's Zoonotic Disease Unit is a successful example of the One Health approach. Over the past 15 years, it's led to faster detection and better control of zoonotic disease outbreaks, which strengthens Kenya's health security and also global health security. And there are many other good models.

But even those often face one of the biggest challenges to maintaining effective One Health networks, which is financial sustainability. For example, funding for more than 90% of One Health initiatives in sub-Saharan Africa relies on donors from outside the continent. National governments should prioritize public health more in their domestic spending – that balance isn't quite right yet.

What is the biggest health issue facing young people today and what can they do about it?

Rahman-Shepherd: I could go with the obvious and talk about issues like pandemic preparedness and response, antimicrobial resistance, and climate change – there is so much to choose from in terms of global health crises. But I think more important is whether myself and my peers can figure out how to make an equitable impact on all of those issues.

We need to ask ourselves what our role is. What space do we want to occupy? What position and privilege do we have, and how do we spend it responsibly? And how do we cede space to others who have just as much to contribute, but not the platform or the visibility?

To make sure we don't replicate the same problems that we already have in global health, we need to forge relationships with our peers and our mentors where we empower one another, relationships that are more equal than they have been in the past when established academics and health leaders were more territorial.

And we need to ask uncomfortable questions about why we have inequities in our global and public health systems. It's about shifting our values and that's not just a global health conversation, that's a humanity conversation. And it's an important conversation to have, to get to a better place.

This interview was edited for length and clarity.