2017 Global Health Day: Q&A on Ethics with Jim Lavery

Postgraduate Medical Education at the University of Toronto will host its fourth annual global health conference tomorrow, with the theme of humanizing global health and achieving equity. The day will include eight roundtable discussions and a keynote address by Professor Jim Lavery, the inaugural Hilton Chair in Global Health Ethics at Emory University in Georgia.

Lavory moved to Atlanta last fall after more than a decade as a scientist at St. Michael's Hospital and a professor at U of T, where he also completed his master's and doctorate. From 2005 to 2015, he was a co-principal investigator of the Ethical, Social and Cultural Program for the Bill & Melinda Gates Foundation.

Lavery is now developing a community engagement 'learning platform' for organizations that work in global health, in partnership with the Gates Foundation. He spoke with Faculty of Medicine writer Jim Oldfield about why he moved to Atlanta, what he hopes to achieve there and why a new way thinking about research and ethics is essential for more effective action on global health.

How was your first year at Emory?

I'm really enjoying it here. It's very different in terms of scale, moving from a large place like Toronto to one that is relatively small, but there is an intimacy here I like. That said, the move was fundamentally about fit. It's very unusual in our field to have a serious, endowed chair so on-target with the work we're doing. That in itself was a huge attraction, along with Emory's terrific reputation in public and global health. The other big issue is that my focus now is on building partnerships with global health funders and implementation partners, and Atlanta turns out to be an incredible epicentre for this work. Today I'm meeting with partners at the Carter Centre, for example. We're also right beside the Centers for Disease Control and Prevention with 9,000 employees. The Task Force for Global Health is here, along with headquarters for many Fortune 500 companies. There's an incredible concentration of exactly the people and organizations I want to work with.

How do you want to work with those organizations?

Our goal is better community engagement, so how you develop partnerships and bring new health technologies to where they're needed most, but in a way that is fair and respectful of the host country. We're mainly concerned with the human dimension of global health, which is too often taken for granted. Many failures in global health programs have been human-related. One of my favourite comments on this problem comes from Bill Gates, who was not initially keen on the social-cultural aspects of this work. After being in Nigeria, where a rumour that vaccination leads to female sterility helped encourage the spread of polio, he said science can simplify the job but the human piece is the ultimate test. I think he was acknowledging that a better understanding of the social dynamics that mediate the application of technology is key.

What would a better appreciation of those dynamics look like?

Technologies work through people, not in spite of them. The more we get that idea, the more our solutions will fit when we use them. One thing I like to say is that effective community engagement is on some level just what your mother taught you. Don't be an asshole. Be genuine, don't make people a means to an end. And if we do that, there are beautiful examples of how we can have tremendous impact. One study we published recently is about a group in Australia who figured out how to introduce technology that reduces transmission of dengue, with a naturally occurring bacteria called Wolbachia. This is a magic technology that does not involve genetic modification, but rather infects females and their offspring, shortens the adult lifespan and has anti-dengue properties. They took the human dimension very seriously and carefully managed the roll-out of this technology. As a result, they avoided the outcry and resistance we've seen in some communities, where new technologies were introduced without informing local residents. Other researchers are now considering a similar approach for dengue around the world, and for chikungunya and Zika.

Why has it been so challenging to bring the human dimension into global health?

We're learning as we go with a lot of global health programs. It's still a new field, and part of the problem is that for community engagement, we haven't even had basic agreement on what terms we should use to discuss it. There's no academic journal devoted to the subject, and people can be quite dismissive sometimes. 'We don't need to be told to be nice,' or 'We can't afford it and don't have time for it.' You actually hear this stuff. So we're trying to show that global health programs can be appropriate, or 'right-sized' in ways that don't add a burden and which facilitate success. But it's been quite a slog. Beyond the issue of common terminology, it's hard to figure out why some projects are successful. And when things go wrong, people often don't want to talk about it. So when I see good examples of community engagement I try to ask, 'Are the results publishable?' Because if we don't elevate this work to an important science in its own right, our investments won't produce the best returns.

Are you optimistic?

Well, global health is the wrong place to be if you're not optimistic. I'm a short-term horizon optimist. I think we can make focused, minor improvements that partnerships can amplify. If we can understand community engagement better, if we measure it more effectively and demonstrate its impact, it can be adopted in any context. It's a narrow area with huge implications and limitless scalability. I think that while many global health organizations have a sense it's important, they lack a coherent value proposition for it. But look what happened with Ebola in West Africa last year. When people finally saw the social and cultural importance of burial rituals and integrated that understanding into their efforts, it helped turn the tide in the epidemic.

How are we doing on the cultural aspects of global health in Toronto?

Toronto is an incredible place with a huge wealth of talent in global health. And many people there are incorporating community engagement into their work. Zulfiqar Bhutta, Prabhat Jha, Stanley Zlotkin, Peter Newman, Dan Allman. There's a long list of people doing tremendous work, large-scale trials, working with host communities. But many funders in Canada would like to see clearer value in the community engagement piece, and a lot of great work is still going unpublished.

Will you ever live in Canada again?

Canada is a hard country to leave, and I still have good connections with my team in Toronto. On the personal front, my daughters have ‘aged out,’ which means they can’t immediately qualify for U.S. visas. When my wife and I moved down here, leaving them was really hard, so we can't imagine not coming back at some point. And we’re ferociously Canadian.

Humanizing Global Health: Achieving Equity will be held on Thursday, June 8, at 11:30 a.m. in MacLeod Auditorium. Click here to register.