In public health, we think a lot about doing good. More specifically, we aim to do what’s morally right, has the greatest impact, and is sustainable in the long-term. However, it can be difficult to arrive at a universal definition of what ‘doing good’ really means. The more I thought about it, the more questions I had. How should one measure good and bad? How might different cultures perceive morality (the extent to which an action is right or wrong) differently? How do we design interventions or policies that are morally just, both in the short and long term?

Thus, I decided to embark on a little project. Over the next few months, I will be reading two books: Justice: What's the Right Thing to Do? by Michael Sandel and Practical Ethics by Peter Singer in an attempt to answer all the questions I have about what it means to do good. I will then summarise my biggest takeaways in a series of blog posts, in consultation with external sources, such as the Stanford Encyclopedia of Philosophy and journal articles discussing ethics in public health, if necessary.

In the first article of this series, I will be summarising one approach to making moral decisions: the greatest happiness principle, or better known as utilitarianism. If you are someone who feels that the right thing to do is the action which brings the most benefit, you might be a utilitarian. Or if you’ve heard of cost-benefit or cost-effectiveness analyses, you may be familiar with utilitarian principles, which guide many decision-making processes used in companies and governments. [Disclaimer: that this article is not a critical philosophical evaluation of the utilitarian school of thought - though resources can be found at the end of the article for further reading.]

A classic tale¹

Theories are often best explained with a story. Where morality is concerned, we can turn to the classic tale of the four English sailors stranded at sea. In this story, there was a captain, a first mate, a sailor and a cabin boy. After their ship sank, they escaped to the lifeboat with two cans of preserved turnips and no freshwater.

They subsisted on small rations of turnips for the first three days, followed by a turtle that they caught and the remaining turnips over the next few days. However, for the next eight days, they ate nothing. Worse still, against the advice of the rest, the young cabin boy drank seawater and fell ill.

Eventually, on the 19th day, the captain suggested drawing lots to determine who would die so that others might live. The sailor refused - and thus, no lots were drawn. Things were looking bad. The next day, the Captain told the sailor (who had refused to draw lots the previous day) to look away while he and the first mate used a pen knife to kill the cabin boy. The three of them then fed on the body and blood of the cabin boy for the next four days. On the 24th day, help finally arrived.

Upon their return to England, they were tried and tested. The sailor became the state’s witness, while the captain and first mate went to trial and subsequently confessed that they killed and ate the cabin boy out of necessity.

Was it right to kill the cabin boy?¹  

There are many things we could discuss about this story. For now, let’s think of some possible reasons why killing the cabin boy might be justified, and reasons why it might not. I’ve outlined some possible reasons in the table below.

What are the two rival approaches to morality illuminated?¹

This story and little exercise help us reveal two rival approaches to morality, and both approaches are compelling in their own ways.

The two arguments justifying that it was right to kill the cabin boy are what we’d call utilitarian arguments. The utilitarian school of thought generally holds the following views:

• The morally right action is the action that produces the most good. The right thing to do is whatever will produce the best state of affairs all things considered.
• Utilitarian theories are consequentialist, in that the morality of any action or arrangement is determined solely on the outcomes they produce.

On the other hand, the two arguments justifying that it was wrong to kill the cabin boy are libertarian arguments.  The libertarian school of thought generally holds the following views:

• Consequences are not all we should care about. There are actions that are fundamentally morally right and justified no matter the social consequences.
• In libertarianism, the morally right action is that which respects each of our individual right to liberty - the right to do whatever we want with the things we own, whilst respecting others’ rights to do the same.

In this article, we will dive deeper into utilitarianism. Utilitarianism presents an intuitive way of thinking about how to do good, and currently guides many decision-making frameworks in governments and corporations. We will explore libertarianism in a separate piece.

Utilitarianism: the greatest happiness for the greatest number^1–3

If you are familiar with utilitarianism, you might have heard about Jeremy Bentham (1748-1832), an English moral philosopher, legal reformer and founder of the doctrine of utilitarianism.¹ Bentham argues that we are governed by pain and pleasure. We like pleasure and dislike pain, and this foundational principle should thus form the basis of our moral behaviour, and by extension, our political and legal decisions.^1,2

Therefore, the right thing to do, the good thing to do, is to maximise happiness, which is the overall balance of pleasure over pain. According to Bentham, the right thing to do is whatever will maximise utility: whatever produces happiness, and whatever prevents suffering.^1,2

But what exactly is utility - the exact thing we are trying to maximise in order to good? Since the conception of the utilitarian doctrine in the 19th century, many definitions of utility have been proposed. I found the four main conceptions of utility summarised by Bellafleur and Keeling (2016) was helpful:³

‘Utility’ can be understood as:

If the morally right thing to do is the action which maximises utility, doing good would involve calculating the utility of all possible actions, in order to choose the action that produces the most utility. From the political viewpoint, a utilitarian would argue that good governments should calculate the costs and benefits of all their policies, and proceed to do those that will maximise the happiness of the community concerned as a whole.

Utilitarian policies in action

Public health practice in essence aims to prevent disease, prolong life and promote health of populations through the collective efforts of society, and seeks to preserve the health of the maximum number of individuals possible - ideally the entire population.⁴ Coupled with the field’s attention towards the short- and long-term consequences of any policy, public health has therefore been argued to be guided by utilitarian principles.^4,5 Here are some examples of public health policies guided by utilitarian principles implemented in during the COVID-19 pandemic:

• Overriding individual preferences to attain population-level benefits: When Singapore’s renowned Circuit Breaker policy was implemented, mask wearing was mandatory, leaving home was strongly discouraged except to seek essential services, social gatherings with those outside your immediate household were disallowed.⁶ Overriding individual liberties during the pandemic was seen as necessary in order to limit disease spread throughout the population and prevent the overextension healthcare resources.
• Allocation of scarce resources: A limited global supply of masks at the start of the pandemic saw global recommendations to prioritise masks for healthcare workers on the frontlines, who will be in direct contact with infected patients.⁷ Protecting healthcare workers meant that more people could be treated, therefore maximise overall utility.⁵
• Questioning the concentration of resources and power: The pandemic saw high-income countries purchasing and hoarding a majority of the world’s global supply of COVID-19 vaccines. 58 countries, led by India and South Africa, rallied together to propose a temporary waiver of the Trade-Related Aspects of Intelletual Property Agreement (TRIPS), whose primary role was to protect intellectual property (IP) rights worldwide.^8,9 If passed, a temporary TRIPS waiver would scale up the manufacture of COVID-19 vaccines, medicines and medical technologies across the globe, thereby increasing equitable access to countries that were previously unable to afford them. We can argue that this proposal was partly guided by utilitarianism: the removal of IP protection (potentially stifling future innovation) to get big pharma companies to share their technology can help the world avoid a prolonged pandemic, countless lives lost and detrimental effects on the global economy.

How is the utilitarian principle helpful to us when deciding to do good?^1,3

From the above examples, it is evident that utilitarianism has many strengths.

• It offers us a framework to evaluate how good or bad something is. The greater the amount of utility it offers to a greater number of people, the more morally right the action is. The right thing to do, the good policy, is the one that produces the most utility for the greatest number.
• It is simple to understand. You can explain utilitarianism to someone by summarising it as a principle that aims to maximise good in the world. It is also intuitive to many of us, to weigh the costs and benefits of any actions, before choosing the one that provides the most overall benefit.
• It is particularly useful in collectivist societies. Utilitarianism’s emphasis on the greatest happiness for the greatest number can make it particularly intuitive to communities that emphasise collectivist values (i.e., Asian countries generally), where the interests of the ‘group’ take priority. In such societies, understanding utilitarian principles can help us understand which actions or policies are likely to be perceived as ‘good’ or ‘bad’, and guide us in acting accordingly.
• It provides an impartial framework for decision-making. Utilitarianism treats everyone’s preferences equally. In the utility calculations used to determine the action that best maximises utility, every individual’s preferences or interests, pleasure and suffering, are accounted for.
• It provides justification for redistributive policies. Some of us may feel that the rich should share their goods with the poor. Utilitarianism helps us understand why the redistribution of wealth and resources can be the right thing to do. The law of diminishing marginal utility holds that as we consume more of something, the amount of happiness derived from each additional unit consumed decreases. Utilitarianism can therefore justify a redistribution of resources (e.g. wealth) from those who have the most, to those who need them the most, to maximise utility.
• It provides justification for prioritising common interests over individual ones. During a pandemic, utilitarianism can be used to justify policies that encourage the entire population to get vaccinated; or enforced quarantine of individuals who refuse to get vaccinated. From the utilitarian perspective, the infringement of individual rights can potentially be justified, to derive significant benefits at the population level.

What are the limitations of utilitarianism?^1,3

However, the utilitarian principle fails to account for some critical things. Consider this question: is torturing a terrorist suspect ever morally right? Utilitarians may say that, yes, it is morally justified to inflict intense pain on one person if doing so will prevent death and suffering on a massive scale. To the utilitarian, numbers count. If enough lives are at stake, they would argue that we should be willing to override our principles about dignity and rights.

• It fails to respect individual rights. In pursuit of the maximum happiness for the greatest number, utilitarianism could enable actions/policies that violate what we perceive as fundamental norms of decency and respect. In the above example, the utilitarian argument assumes that the suspect is in some way responsible for an impending terror attack - and even if he is not, he is still deserving of the harsh treatment because of his suspected affiliation. However, these arguments fail to account for the problematic fact that torture is a violation of human rights and no individual, should ever be subject to such treatment.
• Surely, the end cannot justify all means? In utilitarianism, the morality of any action is determined solely by the outcomes produced. As long as the outcome increases overall utility, the means deployed to attain it, no matter how unethical they were (to lie, oppress, torture, etc.) does not matter.
• In reality, not all preferences are equal. Utilitarianism may be used to justify policies that discriminate against the minority to benefit the majority. Greatest happiness for the greatest number, right? In such cases, it may be that the preferences of the majority race, class, ethnicity, or political affiliation (whichever trait(s) that defines the majority group in question) are privileged over those of the minority, based on sheer numbers.
• Utility calculations are complex and difficult to execute. Individuals can have varying preferences, and may react differently to the same policy or action. In addition, to carry out these calculations, we would need to measure them on a single scale. One of these scales is money: a cost-benefit analysis is a type of decision-making tool widely used by governments and corporations, which translates all costs and benefits into monetary terms (e.g. weighing the immediate monetary cost of COVID-19 vaccines and lockdowns against the monetary benefits of increased productivity from a population with herd immunity) to compare them on the ‘same level.' Instinctively, the objection is clear. Surely, there are some things that cannot be simply measured by their monetary value (e.g. try to quantify the monetary value of being socially isolated from your loved ones during a lockdown). While the utilitarian principle may be intuitive to many, the complex nature of utility calculations make it inaccessible to put into practice.

Conclusion

That’s a wrap! Above is a summary of how utilitarianism can be a helpful (and not so helpful) tool in thinking about doing good. I had lots of fun diving into the greatest happiness principle, and I hope you did too. One of my biggest takeaways was learning that the utilitarian principle is fundamentally consequentialist in nature and how it was compatible with public health practice. Writing this up also helped me articulate the discomfort that the utilitarianism made me feel - that when taken to its extreme, it may not account for individual rights and can be used to privilege the preferences of the majority. Overall, it is a useful tool to evaluate how moral decisions can be made, and that can be seen by how it actively informs decision frameworks used by governments and corporations. In my next piece, I will explore libertarianism, and how it can guide moral decision-making.

References

1. Sandel MJ. Justice: What's the Right Thing to Do? New York: Farrar, Straus and Giroux; 2009.
2. Driver J. The History of Utilitarianism. The Stanford Encyclopedia of Philosophy 2022. [Internet]. Available here (Accessed Apr 2023).
3. Bellefleur O, Keeling M. Utilitarianism in Public Health. Montréal, Québec: National Collaborating Centre for Healthy Public Policy. 2016.
4. Royo-Bordonada M, Román-Maestre B. Towards Public Health Ethics. Public Health Rev. 2015;36:3.
5. Kirkwood K. In the Name of the Greater Good? Emerg Health Threats J. 2010 2:e12.
6. Ministry of Health. Circuit Breaker to Minimise Further Spread of COVID-19 [Internet]. Available here (Accessed in Apr 2023).
7. Nebehay S., Koltrowitz, S. Masks Should Be Prioritised For Health Workers to Avoid Shortage Against Coronavirus: WHO [Internet]. Available here (Accessed in Apr 2023).
8. United States Seeks Answers on COVID-19's Origin While Stepping Up “Vaccine Diplomacy”. Am J Int Law. 2021;115(4):732-739.
9. Mendis, S., Regional vaccine production is key to ensuring equity. BMJ. 2021;374.

Notes

• Special thanks to Jerald and Jean, friends in law and philosophy respectively, for recommending the two books that I will be devouring over the next few months!
• Huge thanks to Jet, Venny, Sean, Siew Ning and Maike for your comments on early drafts of this piece! <3
  
  
  

University lasted four years. Some dread their university days coming to an end, for its end would mean facing the inevitable need to usher in the intimidating demands of adulthood. Others welcome the transition into life after more than a decade of formal education, excited to truly live the way they want, free of the constraints and routines of university life.

I belong to the second group. Although I very much enjoyed the safety net that university has offered me to fully experiment and grow, I am ready to explore my next chapter in life, and to seek new adventures that life is willing to throw at me. But before I bid farewell to these four fruitful and eventful years, I would like to commemorate all that university has gifted me - all its highs and lows.

In this essay, which is an emotional snapshot into my four years at university, I attempt to:

• Distill every year of university into one paragraph each
• Chart the emotions (when I felt anxious, elated, content, fearful, etc.) that characterised my journey here
• List the most surprising things I learned about myself
• Identify all the things I wish I did differently
• Articulate the directives I want to take forward
• Note the things I want to accomplish next

In sum, university was all about learning how to navigate new friendships and old ones; navigating unhealthy and competitive comparisons with others and coping with stress; identifying concretely my strengths and weaknesses; and defining for myself the kind of life I want to aspire towards.

(If you’re new here, hello! My name is Shiying. I am currently an Analyst at Costello Medical, a healthcare consulting firm. I graduated from the National University of Singapore with a B.A in Global Studies and a minor in Public Health. You can say hi or read more about my profile here!)

Could you provide a quick glimpse into each year at university?

Year 1 (2018/19) was an excited, nervous and anxious beginning all rolled into one. It was all about testing the turbulent waters of transitioning into university, making friends, joining new interest groups and just really trying to find my own place. I recall feeling shy as I made new friends, nervous when I stepped out of my comfort zone to try a new sport, and anxious when I signed up for one too many events that I could not keep up with. It was also the year I spent a significant amount of my summer break in China: first at Zhejiang University for a short exchange programme, followed by Peking University for summer school. I ended the academic year with Orientation Week for the incoming freshmen at the University Scholars Programme (USP; also my residential college), which was incredibly fun and ended up being key to solidifying friendships made in a very uncertain first year.

Year 2 (2019/20) was spent really focusing on research, the public health interest group I started and building my leadership portfolio as Producer in a theatre production group at USP. All I knew was wanting to put myself in good stead for internship applications the following year, while also trying to prove to myself that I was capable of producing high quality work and leading big teams. I also tried for and received the Laidlaw Research Scholarship in 2020! Filled with anticipation in carrying out a region-focused research project on antimicrobial resistance during the summer, all plans were effectively disrupted due to the COVID-19 pandemic. With Singapore entering its Circuit Breaker (our version of a lockdown), the stress that came with managing an uncertain pandemic situation could not be overstated. In the midst of all the uncertainty, I decided to (and was lucky enough to be able to) draw a comic raising awareness about antimicrobial resistance and start writing about public health on my blog.

Year 3 (2020/21) was the year I diverted some attention away from school to focus on writing online. I had a secured an internship at a local hospital and was confident that I’d be able to manage my grades well. Where writing was concerned, I knew that I wanted to write a series of profile pieces on public health professionals who inspire me - which would provide me both the exposure to brilliant minds as well as the accountability of putting nothing less than good writing out there. This became one of the best decisions in my life. I went from becoming a nervous student fumbling with her interview notes while simultaneously trying to stay attentive to my subject, to ending my third year with a part-time science communications gig with two scientists I deeply admire.

To say that I was over the moon to be offered such an opportunity would be an understatement. The process also affirmed that I can write, and I do enjoy it so much. This was also the year I went through a break-up. And following a 3-month hospital administration internship that I did not enjoy,  coupled with the process of nursing my heartbreak and the daily fulfilment I got from writing part-time helped crystalised my priorities once more - I turned my attention away from public sector jobs towards those that greatly involved writing and research in the private sector instead.

Year 4 (2021/22) was the year I set my foot down and thought deeply about what I wanted- from my career, my romantic relationships, my friendships and most importantly- my relationship with myself. It was a period of great stress, and the year flew by in a whirl. Yet, the year was made special by many peak moments - reconnecting with old friends, making new ones, writing my honours thesis on vaccine equity (woohoo), giving romantic relationships another try and taking better care of myself. I chased after the job of my dreams and decided I will no longer settle for less.

What were the emotions that characterised my college journey?

With some semblance of a chronological order:

• Sheer joy and excitement at making friends who were kind, ambitious, funny and genuine to ride the rollercoaster that is college, together.
• Belonging and happiness with my suitemates and housemates at USP.
• Uncertainty and insecurity from (1) pursuing my own goals and interests that were distinctively different from that of my peers; (2) focusing so much on the process of doing and learning while neglecting the value of defining specific endpoints (i.e job, research publication) to work towards.
• Confidence from having my contributions and views valued by classmates and professors (whom I thought were brilliant).
• Feelings of inadequacy and insecurity from not being able to do it all: dress well, exercise regularly, do well in all my classes, nurture the relationships important to me, all at the same time.
• Contentment with putting my best foot forward for the endeavours I chose to strive for.
• Discomfort from going out of my comfort zone (WCT, USTrack and Field, USProductions, etc.) and the sheer happiness and feelings of accomplishment from having surmounted said challenges.
• Confidence at having my skills affirmed: writing, research, mentoring my juniors, being a good friend, being a good daughter.
• Relief at earning my own pocket money to fund my own self-care and invest in my own growth.
• Navigating a whole spectrum of emotions when my first romantic relationship came to an end.
• Moving between confidence and uncertainty in seeing new people and experiencing love again.
• Empowered and humbled from learning all over again about how to be my own best friend, and how to be a good, supportive partner.
• Excitement and wonder from the intimate, soulful connection that comes with being seen, and appreciated for all that I am, by another person.
• Deep joy when I'm writing and doing research; when I'm laughing with my friends and family; and when I achieved the goals I set out to attain.
• The rollercoaster that is distress, anxiety, determination and fear, which came with cycling through job listings and ultimately realising that there were only few job options that made my heart sing.
• Let’s not forget the ever-present dread that I may end up in a job I hate after I graduate.
• Relief and absolute joy when I received a job offer from my first-choice company.
• Excitement for what is to come after university (yes, we end on a high note)!
  

What are the most surprising things you learned about yourself?

• I really, really love taking walks. Walks are restorative and healing in a way like nothing else.
• I need time by myself- a lot of it.
• I am capable of both the arts and the sciences, but not so much in commerce, hahaha

What are the things you knew about yourself all along, and college days just confirmed them?

• I prefer being on my own and intimate one-to-ones to large groups.
• My preference for harmony tends me towards people-pleasing, a tendency I am practising to notice and put my own needs first when necessary.
• While I am adept at both quantitative and qualitative work, I have a stronger preference for qualitative work, especially those related to humans and human systems (e.g. I grasp topics like global governance and health systems more quickly and intuitively than epidemiology and biostatistics).
• I can write - for both public consumption (my blog and popular science) and an academic audience (school papers and research).
• I can conduct interviews - I've got an affinity for connecting with others, but never really used this skill with professionals whom I thought were out of my reach, until I did.
• I deserve the best (like anyone else, really), and that I should always shoot for the stars.

What are some things you wish you did differently?

• I wish I developed more empathy for my parents earlier. I wished I listened and honoured their views more.
• I wish I gave myself the gift of rest. Massages, tea and time spent simply being still with my thoughts. In a related vein, I wish I was softer on myself. Life would have been a lot less stressful if I cared less about what others thought about me.
• I wish I committed to regular rigorous exercise much earlier.
• I wish I picked my role models more wisely, and questioned the views of others more rigorously.
• I wish I read more books.
• I wish I thought more deeply about the things I wanted, and to go after them- sooner.
• I wished I made more public health cheatsheets and notes as handy reference materials that can be used over and over again. Public health is such a broad and diverse field (one of the reasons why I love it), and with topics so interconnected, it would have been so helpful to quickly pull up some notes.
• Talk to more seniors. I've already done a fair bit of this, but it would have been great to connect with others outside my interests.

What are some directives you want to take forward?

• I write best when I'm well-rested, and when I have a soft, flexible deadline. While I may still be able to produce high-quality work under time pressure, it’s helpful to keep in mind that it may not be the most creative or inspiring piece.
• I’m more motivated to work when I haven’t told others about my goals yet.
• I tend to overestimate how much I can do. I should thus always factor in buffer time for rest.
• Focus on just a few things and do them well.
• Vulnerability sets the foundation for intimacy. I should try my best to be vulnerable and cry on a trusted person's shoulder, all the while reminding myself that I don't need to go through hard times alone.
• All of us have the gift of intuition. So, listen to your gut and body, everytime.
• My emotions are windows into my wants and needs. Instead of ignoring them, I will allow myself to feel and honour them. After that, I can proceed to figure out what’s wrong and solve the problem.
• As I progress through life, what I want, and need, will change.
  

What do you want to accomplish in the next five years?

Keeping in mind that I’m more motivated to work when I haven’t shared my goals with others yet, here is tiny glimpse into what I’m excited about:

• I want to consistently produce high quality work in the healthcare and scientific writing industry
• I want to publish a series of articles on areas of interest outside my full-time job
• I want to write an article with Maria Popova

And that's it- four years of university summarised into one article :) Thank you for reading, and here's to a most fulfilling and invigorating next four years!

Note: Thank you Jet, Chinni, Jing Yi and Venny for providing your thoughts on this piece!

This blog post was developed for my friend Sumbal Shahbaz but also intended for anyone interested in getting started with scoping reviews. Thank you Prof Natasha Howard, Ms Charnele Nunes and Ms Kim Kee for teaching me all that I know about scoping reviews. Welcome to Singapore, Sumbal!

What is a scoping review?

I understand the scoping review as a systematic, rigourous literature review often used to synthesize research evidence. According to the pioneers of the scoping review method Arksey and O'Malley, a scoping review aims to map the existing literature in a field of interest in terms of the volume, nature, and characteristics of the primary research, particularly when it has not been extensively reviewed yet.

What is the best way to get started?

I got started through reading some of my professor's published scoping reviews. I recommend you to do the same. This was my favourite.

The next best way to get started is through this PRISMA website containing an introductory video and the scoping review checklist, which contains the 20 essential and 2 optional items to report when completing a scoping review. You can even download the fillable checklist, as well as their special 'tip sheets' which will guide you through how to conduct and report your scoping review to produce a high-quality paper.

What is a difference  between a scoping review and a systematic review?

A scoping review aims to map the body of literature on a (broad) topic area by providing an overview of a (potentially) large and diverse body of literature. Because of that, they consolidate studies from a larger range of study designs and methods. The mapping of individual studies is descriptive in nature, and does not usually include a critical appraisal of individual studies or a synthesis of evidence across different studies

A systematic review aims to summarise the best available empirical evidence/ research from a smaller number of studies to answer a focused, specific question. Hence, they generally consolidate evidence that assess the effectiveness of interventions, which often translates to a focus on RCTs.

Here's required reading for scoping reviews, which you will also need to craft your scoping review methodology:

• Arksey, Hilary, and Lisa O’Malley. ‘Scoping Studies: Towards a Methodological Framework’. International Journal of Social Research Methodology 8, no. 1 (February 2005): 19–32. https://doi.org/10.1080/1364557032000119616.
• Levac, Danielle, Heather Colquhoun, and Kelly K O’Brien. ‘Scoping Studies: Advancing the Methodology’. Implementation Science 5, no. 1 (December 2010): 69. https://doi.org/10.1186/1748-5908-5-69.
• Khalil, Hanan, Micah Peters, Christina M. Godfrey, Patricia McInerney, Cassia Baldini Soares, and Deborah Parker. ‘An Evidence-Based Approach to Scoping Reviews’. Worldviews on Evidence-Based Nursing 13, no. 2 (2016): 118–23. https://doi.org/10.1111/wvn.12144.
• Pham, Mai T, Andrijana Rajić, Judy D Greig, Jan M Sargeant, Andrew Papadopoulos, and Scott A McEwen. ‘A Scoping Review of Scoping Reviews: Advancing the Approach and Enhancing the Consistency’. Research Synthesis Methods 5, no. 4 (December 2014): 371–85. https://doi.org/10.1002/jrsm.1123.

In case you are wondering about the difference between a scoping review and a systematic review, here is a resource outlining the differences between 14 different types of reviews:

• Grant, M. J., & Booth, A. (2009). A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J, 26(2), 91-108. https://doi.org/10.1111/j.1471-1842.2009.00848.x

I've read up about scoping reviews. How can I start working on one?

• This is a free and fantastic NUS edX course on how to conduct systematic reviews. It is a short course that has multiple steps relevant to the scoping review process. I highly recommend it. It covers everything from how to conduct preliminary search, developing a focused research question, constructing a comprehensive search strategy and how to manage your references with a reference manger such as EndNote.
• If you are short on time and prefer reading text to watching videos, this NUS Libraries Systematic Review Guide is incredibly useful. However, I would still recommend watching this part of the course on how to construct comprehensive search strategies across different databases (e.g PubMed, Embase, CINAHL, Scopus, Web of Science etc.) and how to use EndNote to manage your references and construct your PRISMA chart.
• Browse through the bibliographic databases to search for medicine/ public health journal articles: Other databases include Global Health, which NUS does not subscribe to. I am using PubMed, Scopus, Embase, IBSS, and Web of Science for my scoping review. Interdisciplinary databases such as Scopus and IBSS were selected because my topic concerns global governance, which is interdisciplinary in nature.
• Search for NUS-subscribed databases (restricted to NUS staff and students only).
• Make use of softwares and tools to make your research life easier. I personally use Rayyan to conduct title and abstract screening. It is free and intuitive. This video is the best tutorial on Rayyan I've watched. I also referred to this article to export my references as a RIS file from EndNote and import them into Rayyan.
• Learn how to use EndNote.

How do I formulate my search strategy?

Many systematic and scoping review papers often develop their search terms in close consultation with a librarian. I encourage you to arrange an appointment with a librarian at your institution to develop the search terms together. I learned a lot from mine about how to craft my search terms around my research question's key concepts, my aim and objectives, and how to adapt searches to different databases.

You should document your search strategy during your preliminary searches and final searches. Feel free to download this document containing a rough template that my librarian Toh Kim Kee and I worked on for you to develop your search terms.

Getting to the final search terms you will use in your scoping review is an iterative process. There is often some trial and error involved, and can be tedious when trying to adapt search terms to different databases. To work around this, I  found that categorising versions of my searches by date and database searched on Excel helps a lot.

How can I combine my scoping review procedure with thematic analysis?

We want to thematically analyse our findings during and after the data extraction phase. You can use the following resources from Braun and Clarke:

• Braun, Virginia, and Victoria Clarke. ‘Thematic Analysis.’ In APA Handbook of Research Methods in Psychology, Vol 2: Research Designs: Quantitative, Qualitative, Neuropsychological, and Biological., edited by Harris Cooper, Paul M. Camic, Debra L. Long, A. T. Panter, David Rindskopf, and Kenneth J. Sher, 57–71. Washington: American Psychological Association, 2012. https://doi.org/10.1037/13620-004.
• Braun, Virginia, and Victoria Clarke. ‘Reflecting on Reflexive Thematic Analysis’. Qualitative Research in Sport, Exercise and Health 11, no. 4 (8 August 2019): 589–97. https://doi.org/10.1080/2159676X.2019.1628806.

You're ready!

By the time you've scoured the resources above, you should be ready to conduct your own scoping review!

Done by: He Shiying (September 2021)

Introduction

The COVID-19 pandemic has wrought devastating economic and social disruption worldwide, with tens of millions at risk of slipping into extreme poverty (Chriscaden, 2020). The pandemic has brought about severe crises across public health, employment and labour, food security sectors, and its impacts are worst felt by the poor (Chriscaden, 2020). Vaccination presents the most important opportunity for the world to overcome this ordeal. However, as of 23 September 2021, just 10% of people in LMICs are fully vaccinated (Maxmen, 2021). The numbers are more dismal in low-income countries, with less than 1% fully vaccinated (Maxmen, 2021). This gap between wealthy and poor countries will continue to widen as booster shots become increasingly in demand. It is crucial to address a global health issue such as ensuring vaccine equity- particularly how COVID-19 vaccine equity is governed on the global stage. The pandemic is a global health challenge that can only be overcome collectively- and vaccines offer the most potent tool to do so. As such, this literature review is an attempt to synthesize current literature discussing the global governance of vaccine equity, with a focus on pandemic vaccines.

This review will outline current international laws governing vaccine equity, the gaps in global governance of vaccine equity, the lessons gained from the 2009-H1N1 pandemic, COVID-19 Vaccines Global Access’s (COVAX) effectiveness and the possible next steps to improve current global governance efforts. This review has found that while substantial literature exists expounding on the ideal governmental structures required to attain vaccine equity, further work is required to evaluate the practicality and effectiveness of such lessons and recommendations in actual policies implemented.

International Law Governing Vaccine Equity

When it comes to ensuring vaccine equity, the literature frequently draws on international human right norms. There were repeated references to the World Health Organization (WHO) Constitution, the International Covenant on Economic, Social and Cultural Rights (ICESCR), International Health Regulations (IHR) as well as the Universal Declaration of Human Rights (UDHR) (Gostin et al., 2020; Labonté & Schrecker, 2007; A. Phelan, 2020; A. L. Phelan, Katz, et al., 2020). For example, the right to health is first expressed in the WHO Constitution, stating that “[t]he enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” (A. Phelan, 2020). The right to health was also subsequently enshrined in the Universal Declaration of Human Rights (UDHR), which has been argued to be part of customary international law (A. L. Phelan, Eccleston-Turner, et al., 2020).

There is also much discussion about the obligation all states have to collectively realise the right to health, with pandemics being a pertinent example. For instance, Phelan argues that the "full realisation of the right to health globally" is intrinsically contingent upon international cooperation, especially for infectious diseases that are easily transmissible across state borders (Phelan, 2020). Further, as per the IHR, "states have obligations to prevent, detect, respond, and control the spread of international public health threats, including obligations to provide international assistance and cooperation" (A. Phelan, 2020).

Yet, specific the international legal instruments currently in place to ensure vaccine equity appear to be weak. The Nagoya Protocol is one example. While it obliges developing countries to provide access to biological samples to developed countries to develop vaccines and drugs, there are no equal obligations imposed on developed countries to provide assistance, cooperation, or benefit sharing in the form of developed vaccines (A. Phelan, 2020).

Gaps in Global Governance

The other existing instrument is called the Pandemic Influenza Preparedness (PIP) Framework, which had been introduced by the WHO since the H1N1 pandemic (Turner, 2016). It is the only international legal instrument that oversees equal distribution of vaccines before the COVID-19 pandemic. In enabling the WHO to manage a stockpile of 150 million vaccines, this framework aims to enlarge access to pandemic influenza vaccines (McAdams et al., 2020; Turner, 2016). However, this instrument has seen limited effectiveness because only 2 out of 25 influenza vaccine manufacturers have come on board, and failed to make the full donation commitments (Turner, 2016). Critics have also argued that the framework would have limited impact firstly because similar measures have been tried and tested outside the framework with limited success at expanding access to vaccines. Secondly, it does not alter any of the existing market-based economy that drives vaccine production and procurement (Turner, 2016). Thirdly, since the PIP Framework’s distribution processes are determined based on countries' public health needs and risks, the framework is rendered unhelpful because an actual pandemic will see a limited vaccine supply with equally urgent needs across countries, making distribution based on need and risk difficult (A. L. Phelan, Eccleston-Turner, et al., 2020). Fourthly, the framework is specialised for influenza vaccines only. This means that for non-influenza pathogens like SARS-CoV-2, which is responsible for the COVID-19 pandemic, states are left without an international framework to look to for guidance.

The existing vaccine procurement mechanisms also structurally promote vaccine nationalism. There are two main ways by which countries can procure or receive their vaccines. Self-procurement, also known as bilateral agreements to directly purchase from manufacturers, is the fastest and most efficient way to procure vaccines (Turner, 2016). However, it is expensive – in terms of finances and technical knowledge. Hence, HICs are more likely to be able to self-procure vaccines. States that are unable to self-procure vaccines may receive them as donations from International Organisations (IOs) such as GAVI Alliance, WHO and UNICEF (Turner, 2016). These IOs may receive donations from manufacturers and states or act as a procurement agent by purchasing vaccines directly from manufacturers. During the H1N1 and COVID-19 pandemic, we see HICs self-procuring via Advanced Purchase Agreements (APAs), also known as sleeping contracts between a government and a vaccine manufacturer (Eccleston-Turner & Upton, 2021; McAdams et al., 2020). APAs allow governments to reserve doses of a vaccine for diseases that have not even arisen. In the previous 2009-H1N1 pandemic, there was already evidence of vaccine nationalism, for vaccines were the only means of preventing infection of a rapidly-transmissive virus (Fidler, 2010). This was evident in the 2009-H1n1 pandemic in two ways. First, developed countries had placed advanced orders for the 2009-H1N1 vaccine- reserving majority of the globe's manufacturing capacity for themselves (Fidler, 2010; Turner, 2016). The WHO and the UN had to appeal to countries and manufacturers for monetary donations to purchase vaccines to meet the needs in developing countries- which still left them with limited supplies (Fidler, 2010). As such, we learn that APAs are ineffective at securing sufficient levels of access to vaccines for developing states.

Learning from the 2009-H1N1 pandemic

During the H1N1 pandemic, a mere 12.3% of all influenza vaccines were donated, compared to 59.4% via self-procurement (Turner, 2016). To understand the extent of reliance on donations, the African region derived 94.5% of its vaccines from these donations, and for the South-East Asian region, the number was at 91.2% (Turner, 2016). It was evident that developing states were dependent on donations, which is dangerously prone to vaccine nationalism (Turner, 2016). To illustrate, the WHO had distributed 40% of the doses for developing states at least three months after developed states received theirs, when states were already entering a 'post-pandemic phase' (Turner, 2016). This delay resulted in 7000 deaths, primarily occurring in developing states- a number that will only inflate in a more severe pandemic (Turner, 2016).

There are however, redeeming points about the pandemic. Unlike other pieces of literature that had been heavy on the criticism, Abelin et al.'s piece had been generous in their praises for the vaccine industry's response during the H1N1 pandemic. The authors argue that the vaccine manufacturers, thanks to longstanding commitment to pandemic preparations the past decade, was able to churn out "significant quantities of safe and effective vaccines" a mere three months after the declaration of the pandemic (Abelin et al., 2011). The authors also praised the efficient collaboration that occurred between "between global health authorities, scientists and manufacturers" to facilitate what they described as "the most comprehensive pandemic response undertaken" (Abelin et al., 2011). The glowing response in contradiction to other pieces on the pandemic could be because of the authors’ positions in The International Federation of Pharmaceutical Manufacturers and Associations International Vaccine Supply taskforce, which requires good diplomatic skill to navigate interests of all parties (Abelin et al., 2011).

COVAX’s  Effectiveness

Eccleston-Turner and Upton's paper is the first thorough analysis of COVAX and whether it has met its aims of guaranteeing equitable access to COVID-19 vaccines in LMICs. Sure enough, it echoes previous literature in stating that while equitable access to the vaccines remains a priority, evidence from past pandemics predict that access will continue to be limited in developing countries (Eccleston-Turner & Upton, 2021; A. L. Phelan, Eccleston-Turner, et al., 2020; Turner, 2016). Fortunately, COVAX Facility's at-risk funding strategy has been successful specifically in accelerating COVID-19 vaccine development. It has managed to fast-track and scale at-risk investments in vaccine research and development as well as to expedite the production of doses even before clinical efficacy has been established (Eccleston-Turner & Upton, 2021). COVAX pillar–funded AstraZeneca/Oxford has also received regulatory approval- a successful portfolio candidate because it is viable for distribution in LMICs given its capacity to be manufactured rapidly globally, more easily stored compared to the mRNA vaccines and is significantly. This arm of COVAX has truly successfully resulted in the most rapid development of a vaccine for a new pathogen. (Eccleston-Turner and Upton, 2021).

However, the success has not transferred over into its role as a procurement tool for LMICs. COVAX's success is limited by widespread prevalence of vaccine nationalism, where wealthy nations' participation in bilateral advance purchase agreements put them in direct competition with the COVAX Facility for vaccine doses (Dyer, 2020; Eccleston-Turner & Upton, 2021; Eyawo & Viens, 2020). The COVAX Facility's efforts are undermined by bilateral advance purchase agreements because they increase global competition for a limited supply of vaccines.

Recommendations for steps forward

Several papers talk about leveraging on crisis as catalyst- that COVID-19 presents an opportunity to reinforce core principles and goals of global health governance, particularly the principle of equity to ensure equitable access to vaccines.

First, IOs can look to alternative funding arrangements rather than relying on the goodwill of donors. There is currently an abundance of untapped funding fund in sovereign wealth funds, insurance companies and more that can be used to address health crises- including the COVID-19 pandemic (Kickbusch et al., 2018). However, it is the mobilisation of these resources that is difficult. Vaccine equity falls under the broad umbrella of global health equity- a domain that requires long-term, sustainable financial investment. Annual funding for global health, including vaccine equity is pegged to increase to US$274-$371 billion by 2030 (Kickbusch et al., 2018). The scale of the vaccine equity problem, just like many other global health issues, is too large to be resolved through charitable capital alone. This financial need requires the critical participation of the private sector. However, current financial markets lack the necessary structures to facilitate the needed sustainable investment in global health to provide returns to investors. Hence, IOs can look to filling this gap in order to ensure long-term sustainable financial returns on goals such as vaccine equity (Kickbusch et al., 2018)

Second, IOs can reconfigure APAs to the international community’s advantage. McAdams et al. acknowledges that bilateral deals such as APAs are inevitable. What the international community needs to do is to "configure these deals to also benefit the new COVAX” and incentivise wealthy countries to make bilateral deals that have positive deals for everyone else (McAdams et al., 2020). Two ways this could be done is to increase the fungibility of investments in vaccine candidates and to ensure supply chain harmonisation (McAdams et al., 2020).

Conclusion

This literature review has outlined the current international laws governing vaccine equity, the gaps in global governance of vaccine equity, the lessons gained from the 2009-H1N1 pandemic, COVID-19 Vaccines Global Access’s (COVAX) effectiveness and the possible next steps to improve current global governance efforts.

This review has also found that there is a dearth of studies examining the effectiveness of COVAX since its inception. There is also a lack of studies examining how lessons from the 2009-H1N1 pandemic has been incorporated into later funding mechanisms and international regulations, including COVAX. There is also little literature investigating the incentives in place that fund pharmaceutical R&D during a global public health emergency, and the implications of such in future pandemics. This could be because the contractual agreements between governments, non-governmental organisations and the pharmaceutical industries are opaque to the public. Much of the literature also gloss over the roles that stakeholders such as states, IOs, non-profit organisations, manufacturers and health authorities play in the global governance of vaccine equity.  

In sum, while there is much existing literature examining the ideal governmental structures required to attain vaccine equity, further work is required to evaluate the practicality and effectiveness of such lessons and recommendations in actual policies implemented.

Word count: 2000 (Excluding citations).

References

Abelin, A., Colegate, T., Gardner, S., Hehme, N., & Palache, A. (2011). Lessons from pandemic influenza A(H1N1): The research-based vaccine industry’s perspective. Vaccine, 29(6), 1135–1138. https://doi.org/10.1016/j.vaccine.2010.11.042

Chriscaden, K. (2020, October). Impact of COVID-19 on people’s livelihoods, their health and our food systems. http://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people's-livelihoods-their-health-and-our-food-systems

Dyer, O. (2020). Covid-19: Many poor countries will see almost no vaccine next year, aid groups warn. BMJ, m4809. https://doi.org/10.1136/bmj.m4809

Eccleston-Turner, M., & Upton, H. (2021). International Collaboration to Ensure Equitable Access to Vaccines for COVID-19: The ACT-Accelerator and the COVAX Facility. The Milbank Quarterly, 99(2), 426–449. https://doi.org/10.1111/1468-0009.12503

Eyawo, O., & Viens, A. M. (2020). Rethinking the Central Role of Equity in the Global Governance of Pandemic Response. Journal of Bioethical Inquiry, 17(4), 549–553. https://doi.org/10.1007/s11673-020-10001-2

Fidler, D. P. (2010). Negotiating Equitable Access to Influenza Vaccines: Global Health Diplomacy and the Controversies Surrounding Avian Influenza H5N1 and Pandemic Influenza H1N1. PLOS Medicine, 7(5), e1000247. https://doi.org/10.1371/journal.pmed.1000247

Gostin, L. O., Karim, S. A., & Meier, B. M. (2020). Facilitating Access to a COVID-19 Vaccine through Global Health Law. Journal of Law, Medicine & Ethics, 48(3), 622–626. https://doi.org/10.1177/1073110520958892

Kickbusch, I., Krech, R., Franz, C., & Wells, N. (2018). Banking for health: Opportunities in cooperation between banking and health applying innovation from other sectors. BMJ Global Health, 3(Suppl 1), e000598. https://doi.org/10.1136/bmjgh-2017-000598

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Maxmen, A. (2021). The fight to manufacture COVID vaccines in lower-income countries. Nature, 597(7877), 455–457. https://doi.org/10.1038/d41586-021-02383-z

McAdams, D., McDade, K. K., Ogbuoji, O., Johnson, M., Dixit, S., & Yamey, G. (2020). Incentivising wealthy nations to participate in the COVID-19 Vaccine Global Access Facility (COVAX): A game theory perspective. BMJ Global Health, 5(11), e003627. https://doi.org/10.1136/bmjgh-2020-003627

Phelan, A. (2020). Human Rights Implications of Pathogen Sharing and Technology Transfer. In S. F. Halabi & R. Katz (Eds.), Viral Sovereignty and Technology Transfer (1st ed., pp. 120–134). Cambridge University Press. https://doi.org/10.1017/9781108676076.009

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Turner, M. (2016). Vaccine procurement during an influenza pandemic and the role of Advance Purchase Agreements: Lessons from 2009-H1N1. Global Public Health, 11(3), 322–335. https://doi.org/10.1080/17441692.2015.1043743

Done By: He Shiying (November 2019)

In 1980, the World Health Assembly declared the successful eradication of smallpox, bringing an end to a fatal disease that caused an annual 500 million infections and 2 million deaths worldwide (World Health Assembly 1980). Such an incredible feat depended upon 21 years of collaboration between key international organisations, all countries, international non-governmental organisations and health professionals, and had elevated vaccination as key to enhancing global health (Fenner et al. 1988). Vaccination has prevented at least 10 million deaths between 2010 and 2015, with millions protected from severely debilitating diseases such as polio, measles, pertussis, and pneumonia (Strategic Advisory Group of Experts on Immunization 2018). Not only do vaccines directly improve population health outcomes, nations also reap massive gains in productivity and economic growth (World Economic Forum 2018). Yet, despite global efforts to ensure universal access to immunization since 1974, it remains a faraway goal. As the end of the most recent Global Vaccine Action Plan (GVAP) approaches in 2020, more than 19 million children still lack access to basic immunization, overall progress on vaccination coverage across the globe has stagnated, with any progress made thus severely threatened by backsliding in the wake of emerging global challenges that current global governance efforts seem ill-equipped to handle (Strategic Advisory Group of Experts on Immunization 2018). This paper highlights two of such challenges, namely poor governance of the global vaccine supply and the rise of vaccine hesitancy. In order to ensure universal access to immunization, there is an urgent need for global governance to address both gaps.

The first gap in the global governance of vaccination is poor global management of vaccine supply. The GVAP aimed the number of countries experiencing stockouts at 25 countries or less by 2020, but the current number laid far behind at 65 in 2015, revealing little improvement since pre-GVAP levels in 2010 (Lydon et al. 2017). A study found that one-third of WHO Member States had experienced at least one vaccine stockout for at least one month”, with Sub-Saharan African countries and middle-income countries experiencing the worst of stockouts (Lydon et al. 2017). The primary reasons for stockouts were delayed government funding, delayed procurement and poor forecasting and stock management. Such dismal results persist despite procurement aid and knowledge exchange from the WHO, UNICEF, Global Alliance for Vaccines and Immunization (Gavi), the World Bank and initiatives such as the WHO Vaccine Product, Price and Procurement (V3P) project and Vaccine Procurement Practitioners Network (World Health Organization 2019; n.d.).  Apart from stockouts, more vaccines globally are wasted every year because of poor logistics and cold chain management (World Economic Forum 2018). When vaccine supply is compromised, trust in immunization programmes become undermined and the health of the most vulnerable becomes threatened (Lydon et al. 2017).

The second gap in the global governance of vaccination is insufficient attention on the rise of vaccine hesitancy. Vaccine hesitancy is defined as the “delay in acceptance or refusal of vaccines despite availability of vaccination services” (Eskola et al. 2015). The GVAP aimed to eliminate measles in at least five out of six WHO regions by 2020. However, 2019 saw the highest number of measles reported since 2006 (Lobley 2019). Significant measles outbreaks had occurred in four out of six WHO regions in the past three years, including countries such as the US, Japan and Germany with histories of good vaccination coverage and had previously been declared measles-free (Nature Medicine 2019; Wamsley 2019). Vaccine hesitancy is driven by government complacency, inconvenience of vaccination and declining confidence in vaccines, with the last being perpetuated by vaccine misinformation. Vaccine hesitancy is a threat to global health because vaccine-preventable disease are highly contagious. Several cases in Japan were linked to citizens returning from the Philippines while outbreaks in the US were linked to returning citizens from France, Israel and Ukraine (Wamsley 2019). Apart from the launch of a Strategic Advisory Group of Experts (SAGE) on Immunization Working Group on vaccine hesitancy (Larson et al, 2014), little interventions were introduced despite calls for global collective action on measuring and quelling vaccine hesitancy from as early as 2011 (Larson et al. 2011). It was only this year when vaccine hesitancy had been recognised one of WHO’s top ten threats to global health, and when the first Global Vaccination Summit was organised, which had merely called for global action against the spread of misinformation (World Health Organization and European Commission 2019).  

In order to address poor global management of vaccine supply, more can be done at the regional level. MICs can develop cross-border group purchasing organisations (GPOs) akin to that of the Pan American Health Organization (PAHO) Revolving Fund, which has  substantially reduced cost of vaccine products for its 41 member states (Tirso 2014). Doing so can greatly reduce costs of key vaccines to overcome problems of insufficient government funding as MICs transition away from reliance on donor aid. Further, the 19 million children that lack access to vaccines are often located in resource-poor regions, where innovations in logistics and cold chain management are desperately needed to overcome local energy shortages to reduce wastage (World Economic Forum 2018; Strategic Advisory Group of Experts on Immunization 2018). Investments in innovations that reduce vaccine wastage should be channeled to regional vaccine manufacturers, which in turn ultimately increases local capacity, cost savings and health outcomes in the long run.

Next, in order to address vaccine hesitancy, there is an urgent need to reinforce vaccination’s role in development and target the spread of misinformation at the global, regional and national levels. While hard laws such as treaties usually have little to no improvement on health outcomes, studies have shown that including institutional mechanisms such as automatic penalties and sanctions, mandated regular reporting and compliance assessments can increase their effectiveness (Hoffman and Røttingen 2015). Hence, the next GVAP from 2020 onwards should be a legally binding treaty that frames vaccination as a basic human right with the aforementioned institutional mechanisms incorporated (Gostin et al. 2013; Hoffman and Røttingen 2015). A formalised treaty exerts institutional power that can empower NGOs and all stakeholders in health systems to hold political leaders accountable, similar to the mechanism by which studies on The WHO Framework Convention on Tobacco Control’s found that the treaty and its negotiation process were associated with stronger adoption of tobacco control measures in ratifying countries (Craig et al. 2019). Not forgetting the crucial role the web plays in disseminating vaccination-related information, public-private partnerships must be established with social networking sites to curb the spread of misinformation. The president of the American Academy of Paediatrics, Kyle Yasuda, had successfully engaged with Facebook to remove anti-vaccine misinformation from selected algorithms (The Lancet Child & Adolescent Health 2019). However, since more remains to be done on Facebook and other social media sites, the treaty can leverage on its enforcement mechanisms to mandate Member States to form similar public-private partnerships adapted to regional and national needs. At the regional level, organisations such as the Regional Immunisation Technical Advisory Groups (NITAGS) play a crucial role in exerting pressure on international organisations to hold relevant conferences such as the Global Vaccination Summit in LMICs to allow equal opportunity to key stakeholders in LMICs to easily engage in the decision-making process. Alongside NITAGS, NGOs like the Bill and Melinda Gates Foundation are also in the prime position to engage the expertise of social scientists, experts in social marketing and communication and diseases to address the multi-disciplinary nature of vaccine hesitancy at the grassroots level.

Lauded as the most cost-effective intervention to dramatically improve health outcomes, vaccination lies at the heart of healthcare. Despite having made great strides in vaccine coverage in the developed world, much of the developing world still lack access to the most fundamental vaccines. At the same time, vaccine hesitancy has finally reared its ugly head, bringing about widespread measles outbreaks across both the developed and developing world, threatening to reverse decades of progress. The path to universal vaccination coverage demands for improved governance of the global vaccine supply though the formation of cross border GPOs and investments in innovations that increase the capacity of local health systems. Further, vaccine hesitancy signals the need for the reemphasis of vaccination’s importance through a legally-binding treaty and engagement with private actors as well as actors beyond those in science and technology. It is only with governance at the global, regional and national levels can the world effectively prevent cross-border spread of vaccine-preventable diseases, ensure universal access to vaccination services and ultimately promote better health outcomes across the globe.

No. of words (excluding citations): 1337.

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Hoffman, Steven J., and John-Arne Røttingen. 2015. “Assessing the Expected Impact of Global Health Treaties: Evidence From 90 Quantitative Evaluations.” American Journal of Public Health 105 (1): 26–40. https://doi.org/10.2105/AJPH.2014.302085.

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This article is part of the Public Health People series where I meet with different public health professionals from all around the globe. Join me in exploring the greatest insights from their fields, their passion projects and their principles for both work and life.

Doctor. Writer. Activist. Professor. Businessman.

Dr Jeremy Lim has one of healthcare's most intriguing stories.

He is the co-founder and CEO of AMiLi, Southeast Asia's first dedicated precision gut microbiome company. He is also an Associate Professor and Director of Leadership Institute for Global Health Transformation (LIGHT) at the Saw Swee Hock School of Public Health. Jeremy also serves on the boards of Dover Park Hospice, HealthServe, and Special Needs Trust Company (SNTC). He is an inaugural Equity Initiative Fellow for Southeast Asia and China and speaks regularly on health-related issues both locally and internationally. And if this list is not formidable enough, he is the author of the book Myth or Magic: The Singapore Healthcare System, has spent years serving in both the public and private sectors, and is involved in advising several health tech companies across the globe.

Not only does he believe that healthcare is incredibly complex, but he also relished in all its complexity by immersing himself in all facets of the system: the public, the private, its political domains and in the global arena. Why? He is not looking to treat just its symptoms. He wants to cure healthcare’s biggest problems at their roots.

However, my conversation with Jeremy was unlike any other. At the start of our chat, I found myself tilting my head in puzzlement. So inexplicable is this man's character. All his accomplishments point towards confidence. My initial impression of him was everything but. With his shoulders hunched, and a perpetual need to fiddle with his fingers in an almost nervous gesture, he seemed to shrink into himself. Occasionally, his hands would play absentmindedly with his collar, or shift down to turn his coffee cup between his fingers. At moments, he spoke so quietly that in the din of the cafe, I feared whether my phone's audio recorder would be able to pick him up.

But as we spoke, Jeremy’s self-assuredness became evident-- not in his body language, but in the sharp edge of his words. He was eloquent, charismatic and witty, his words judiciously selected and subconsciously pruned from years of writing and speaking.

Indeed, Jeremy possesses an uncommon, paradoxical bend of character in the public health scene. One that is able to hold the nurturing, graceful patience of an educator with the steadfast, pragmatic edge of a businessman. Nothing reveals this more than his winding journey through public health. That will form Part 1 of this article. Part 2 of this article then consolidates Jeremy's biggest takeaways from his years in the field. His words, although delivered lightly and interjected with playful banter, were laced with steely determination. There was an undercurrent of urgency throughout our conversation, not because he was short for time, but because these were lessons that he felt the world needed to hear.

And consistent with many of the subjects featured in the Public Health People series, Jeremy describes his career moves as part of a "series of happy accidents." Grab a cup of coffee, and let’s dive right in.

Moving From Medicine To Health Systems

"Of all forms of inequality, injustice in healthcare is the most shocking and inhumane." - Martin Luther King Jr. quoted in Jeremy's book: Myth or Magic: The Singapore Healthcare System

Jeremy's appetite to learn, coupled with his perpetual quest towards mastery is symbiotic with his lifelong goal to undo deep-seated inequality in global access to care. He wants to ultimately enable anyone, regardless of where they are in the world, to have access to affordable and quality healthcare.

"When I was in medical school, and throughout the early years of specialist training as a surgeon," Jeremy says, "I was volunteering for medical missions in countries such as Indonesia and Cambodia within the region." He had been on track to become a surgeon. But during his time abroad, he grappled with difficult issues of balancing having the good intentions of helping others and not doing more harm than good. "It was a privilege and a responsibility to be providing humanitarian assistance.” When serving in communities with social and political contexts vastly different from home, “The last thing you want to do is go down to communities in need and mess things up."

There was still much to learn. In 2002, Jeremy's interest in global health eventually led him to pursue a Masters in Public Health at Johns Hopkins Bloomberg School of Public Health.

The year he spent pursuing his MPH was a "bloody busy year." He was also undergoing specialist training as a surgeon and serving as president of the school's International Health Society. "I had the opportunity to straddle two worlds: the world of surgery and the world of public health," a challenge he initially welcomed. If you're a student, you might be familiar with the art of timetabling to manage your classes and workloads. Jeremy took it to a slight extreme. He had strategically grouped his in-person and online classes to just Monday's and Tuesday's, freeing up larger blocks of time for everything else.

What happens when you juggle multiple fiercely demanding commitments all at once? "That year," Jeremy chuckles, shaking his head, "was a total disaster." During the early stages of your career, "achieving a professional level of mastery requires an almost fanatical devotion. He inclines his head, "I can't decide to be a surgeon until five o'clock and then go off to run a committee elsewhere." Eventually, he had to make a choice. "I knew that I was just being bad at both. It didn't make sense to be mediocre in both areas."

So, Jeremy asked himself two questions. Between surgery and public health, which option meant a faster road to creating impact on a large scale? And where would his skills and interests be more readily needed? "Surgery was and is still incredibly popular. There is no shortage of people far more talented to take my place," he says. On the other hand, "There were so few doctors who were interested in health as a system and wanted to make a difference." His then boss advised him to focus on becoming a really good surgeon. And that in 25 years, he could think about making changes. Jeremy raised his brows. "I don't really want to wait 25 years." There were too many broken things that needed mending, immediately. And it was with this conviction that marked the beginning of his transition out of clinical medicine into what he called, "the policy and management side of the house."

Step by step, he was building a repertoire of tools to cure, rather than treat systemic problems in healthcare. He spent a little more than five years at SingHealth, the largest of Singapore's three healthcare groups today. There, he oversaw research and education programmes, which included developing the group's strategy in basic health services research and driving programmes in healthcare management and leadership to enhance human capital.

Next up was policy work. Jeremy spent some time as a senior consultant at the Singapore Ministry of Health. There, he was focused on the planning of clinical services using 'Integrated Care Pathways' for major diseases such as stroke, COPD and hip fractures as part of the nation's clinical strategy. He was also overseeing policies around physician remuneration.

Advocating For Universal Health Coverage

Who would have thought that Singapore's landmark 2011 General Elections would mark another key career transition in Jeremy's portfolio? For years, there have been failed attempts to introduce healthcare policies with a welfare bent in Singapore. Healthcare costs were rising in the last decade and many feared that all it took was severe illness to ravage a family's life savings. Public calls to shift more of the burden of healthcare costs from the individual and the family to the state had been dismissed. The state feared that increased subsidies would encourage moral hazard.

When election season arrived, the opposition had organised themselves around making healthcare more affordable. And when the opposition won 6 out of 87 seats, its best performance since the country's independence in 1965, this 'landslide elections' sparked a newfound optimism and desire for innovation in the nation's healthcare policies.

The people had spoken, and riding this wave of hope was a golden opportunity for Jeremy: he was going to champion for healthcare reform. "I wanted to push for universal health coverage and a national health insurance scheme that would safeguard protection for our older generation."

"The calculus was, how do I be an effective social activist?" Jeremy would quit his then position as CEO of Fortis Colorectal Hospital, Singapore to become a full-time activist. "I became a jobless, penniless social activist with nothing but an internet connection." He quirked a sheepish grin. This noble undertaking would have been impossible without his family's support. "Luckily, my wife is also a doctor and in a stable role. She's very supportive, even though she chides me by saying 'You're always doing this to stress me!' To which I'd reply, 'Thank you very much, dear.'" He chuckles.

And so began his journey into the politics of public health. "I met ministers and politicians from all political parties to advocate for my views and raise awareness on what I thought was wrong with the health system." He was deliberately vocal, churning out article after article. "I just write, write, write!" He would not realise the implications of this foray until much later.

Taking An Ambitious Stab At Writing

In 2013, Jeremy would publish what became a momentous piece of literature in Singapore, and arguably, the world. Backed by a bold and rigorous attempt at explaining the why's and how's of the Singapore healthcare model, Myth or Magic: The Singapore Healthcare System was the culmination of Jeremy's ferocious push for change in Singapore. "Whenever it comes to discussions about healthcare, only the Minister for Health, the doctors and the prime minister will participate in a very vigorous debate. Everyone else will keep their mouth shut," he huffs, exasperated. "This is because healthcare is complex and nobody wants to look stupid." Healthcare policy is ever-evolving, and while selected policies outlined in this book might be dated, the lessons in Singapore's political philosophies are timeless.

In the book, and throughout his public commentary till today, Jeremy is unashamed of reaching for big, bold questions that would make politicians squirm in their seats. "If you don't understand how the health system works,” he says, “then you cannot have a proper debate or a discussion!"

Three years after that fateful general election, In 2014, Singaporean Prime Minister Lee Hsien Loong had announced the introduction of the Pioneer Generation Package for Singapore's Pioneers- those born on or before 31 December 1949​. This package had guaranteed additional subsidies and cash transfers for healthcare. Jeremy says, "The government had clearly listened, not to me but to the voice of the people." He was planning to re-enter the workforce, for with the new scheme, he felt that "it's no longer fun to be a 'rebel without a cause."

Swivelling Into Consulting And Business

But Jeremy couldn't return to the public sector. "At the time, very candidly, I was unemployable here in Singapore." At my astonished expression, Jeremy felt compelled to school me in a much-needed lesson in the politics of public health. "Of course! My dear," he emphasized, folding his arms and leaning forward across the table, "Would you hire someone if you had the impression that this guy had offended the government?" Shaking his head, he leaned backwards. "Healthcare is a big, tightly regulated space here."

And that marked the beginning of a deeply challenging journey into healthcare’s private sphere. At leading management consulting firm Oliver Wyman, he served as partner and quickly rose to helm the firm's Asia Pacific arm in Health and Life Sciences. "I was very, very fortunate that we caught the wave of healthcare consulting going this way." The firm was one of the early movers into the space. "We rode that wave and built the largest healthcare practice in the region. Now, it's a lot more competitive." Seven years later, Jeremy would attempt to catch and surf what might be the next biggest wave in healthcare.

Venturing Into The Gut Microbiota

Today, Jeremy is the founder and CEO of Asian Microbiome Library (AMiLi), Southeast Asia’s first and only precision gut microbiome firm. Human microbiome research is expected to break revolutionary ground on introducing new therapeutics, diagnostics in treating all forms of infectious diseases and metabolic conditions. Together with his co-founders, "We decided we wanted to start a microbiome startup. Aimed to advance gut microbiome research, AMiLi is set to serve as a hub for gut microbiome innovation and therapy. “We knew that if we weren't going to do it, nobody else would," he says. When asked to describe his role, he chuckles, "My co-founders are the gastroenterologist and clinician-scientists. As for me, I'm the resource mobiliser- the guy who goes around begging for money."

According to some estimates, the human microbiome market is projected to grow from 894 million in 2025 to 1.6 billion in 2028. Jeremy is banking on making the right bet once more. "It's definitely a huge wave- spanning from the commercial, the clinical, the scientific domains- it is really going this way.” Beyond industrial trends, the field has great potential to meet the healthcare needs of millions across Asia. “And because this is the right space to be in, with problems worth solving," he closes in a matter-of-fact manner. “AMiLi's success is a function of how well we execute it."

Embarking On Lifelong Advocacy

Despite his diversity of experiences within and across the field, one belief remains unchanging: that speaking up remains an indispensable driver of change. Close to a decade after his social activist days, Jeremy's voice remains a resounding force for change in both the country and the region's healthcare landscape. Activists are watchdogs- they keep our governmental leaders on their toes. And Jeremy's words demand both transparency from our leaders and increased engagement from our citizens. In a recent piece, Jeremy urgently calls for Singaporeans to join the conversation that will decide how much they will spend on care:

"MediShield Life is a lynchpin of the Singapore healthcare financing system. It’s also inherently political as all of us Singaporeans and Permanent Residents are mandated to enrol and pay premiums. Data and transparency in decision making can strengthen the sense of ownership and support for MediShield Life, and also allow the council and MOH to tap the diverse experiences and expertise of all of us."

Doctor. Writer. Activist. Professor. Businessman.

That is Jeremy Lim, and he is on a mission to cure healthcare’s biggest problems at their roots. How does he take on this daunting endeavour, and how might you do the same? In this next section, we take a peek into Jeremy's mind. Here are eight of Jeremy's biggest takeaways from his years in the field.

If You Don't Ask, You Don't Get.

"If you ask, the worst thing that can happen is people say no. There is no harm- all you need is a thick skin." Although Jeremy was awarded the Fulbright scholarship to pursue his MPH in the US, it wasn't enough. In a bold move, he decided to write to the Shaw Foundation to request for some assistance. In his letter, Jeremy first described his situation, followed by a breakdown of the fees and the estimated sum he needed to fully pay for his studies. "Lo and behold, I received a check for the shortfall in amount- in US dollars!" Jeremy says, his eyes still racing with bewilderment all these years later.  "The foundation very kindly decided that it was a deserving case and they will send over some money." The moral of the story? Jeremy laughs, "To find your prince you must kiss a lot of frogs. So, just keep on kissing!"

No Margin, No Mission.

Many who want to do good scorn the idea of profit-making, preferring to focus their efforts on growing the good that they are doing. Jeremy calls this out as simply foolish. But there is nothing quite as taxing as to be constantly strapped for funds. To him, passion alone cannot drive impact, much less any long-term, sustainable difference. Jeremy shared the story of Sister Irene Kraus, the same person who coined the phrase, "'No margin, no mission.' She was a nun who successfully directed six hospitals. She believed charity alone was not enough to sustain a mission and that institutions had to be financially solid." He adds, "You can be as noble as you want to be, but if you have no resources, if your institution or organisation doesn't have a surplus, then nothing will work."

However, Jeremy qualifies that there is a second part of the quote that people do not know about. The second part is, "No mission, no need for margin." To the individuals who are deeply driven by a cause that rings deep in their bones, be heartened to know that purpose remains equally crucial. "If you don't have a noble mission, then you don't deserve to make money," Jeremy finishes. "You need two legs to walk, and they must walk in unison."

Learn How To Manage Money.

When asked to describe his time at Oliver Wyman and AMiLi, Jeremy's jaw sets and his eyes turn determined. "Things were certainly tough, but very good learning," he says. "People never fully understand the pressures of running a business until you are thrust into confronting the profits and losses." So, learn how to manage tight budgets. Learn how to sell and persuade others. These skills, he says, are transferable no matter which sector you enter.

"If the business fails," he pauses, "people lose their jobs." Any entrepreneur or founder takes on great risk and responsibility." The reason why Jeremy holds great admiration for founders? "Running a business is the most masochistic thing you can do to yourself! You are essentially punishing yourself by finding the difficult problems that nobody is solving, and telling everyone, “I will try to solve it." He says with a half-smile on his face. "It's much more comfortable to be a follower."

Don't Be Scared To Try.

Transitioning between major career shifts can be daunting. Jeremy's advice? "Don't be scared to try," he implores. "I say this after having transitioned and reinvented myself a number of times." He offers a personal example. "When I became the Founding Partner & Head of Asia Pacific Region, Health & Life Sciences at Oliver Wyman, I knew nothing about consulting," he says. "But you learn, and you must have the confidence that you are reasonably bright, you're prepared to work hard, and if you're a nice enough guy, people would want to help you." He finished softly, his gaze as-a-matter of fact. "With all that in place, have faith that you will figure out the rest along the way.

Get Comfortable With Systems Thinking.

"I would urge people to understand more systems thinking," Jeremy says. "It is very valuable to look at root causes and the underlying mental models that drive any problem." Healthcare is not just about a patient's visit to the doctor. Managing disease at the biological level is but one dimension. To name a few, healthcare is also about sustainable financing, preventing provider burnout, building a robust pandemic response and more. A whole multitude of factors influences the outcome- making long-term predictions difficult and planning absolutely essential.

Systems thinking is also a superpower to help you solve problems more efficiently. "If you can see the signal out of the noise, or more critically, 'join the dots’, then you can achieve that deeper understanding. This skill, he qualifies, takes years of experience and lots of practice. Once sufficiently skilled, apply systems thinking to any phenomenon and you'd see a pattern emerge, "almost Sherlock Holmes-like."

Ask, "What Is The Problem That We're Trying To Solve?"

A standard consulting question, Jeremy explains, "Oftentimes, people don't know what they're trying to solve. They just know that they're not happy." But ask this question enough times, "You will then understand what is that people really want."

"Don't boil the ocean," is another maxim in the world of consulting. Consultants, he reminds me, are not academics. "Clients pay a lot of money to solve their problems as soon as possible. We simply cannot spend time trying to solve everything," Jeremy says. "We have to be very pragmatic. If one hypothesis does not work, then let's test the next one."

Ask, "How Can I Help You Do Your Job Better?

Jeremy premised this piece of advice with a quote from Peter Drucker: "The purpose of an organization is to enable ordinary human beings to do extraordinary things."

If you are a leader of your team, Jeremy says that it is critical to understand that, "Your job is not to do other people's jobs. Instead, your job is to help people do their jobs better." To Jeremy, most businesses are about the people. "If you can bring out the best in your people, the problems tend to solve themselves." Part of building an organisation that builds extraordinary people is to inculcate psychological safety. "Don't you want to feel supported by your bosses?" He raises his brows. "Everyone wants to have a sense that someone is watching out for you and wanting you to succeed."

Be Fair And Always Strive For A Win-Win.

Life is full of difficult choices. Hire people. Fire people. Steal a deal from someone else.  "I tell my team in AMiLi that yardstick is two-pronged," Jeremy says. "We make sure we return a decent profit to our investors while ensuring that we are proud to tell our grandchildren what we did."

Even in the cutthroat corporate world, there is honour amongst thieves. "You can be tough, but you must remain fair," he says. "Maybe I'm a bit biased, but there are so many things broken. To some extent, we can all win because there are many unmet needs.

Conclusion

"Health care is the most difficult, chaotic and complex industry to manage today.” — Peter Drucker in Managing in the Next Society

Rare is the clinician that views healthcare as more than the sum of its parts. Rarer still is one that dedicates his entire career to understanding its complex wiring and intricacies- if only to make a difference. Jeremy has traversed the vast lengths of healthcare. But while his portfolio may impress many, to him his work is far from done. His work will set the groundwork for not just the generations before us, but the generations that come after. His attention to what influences care at every level is what makes his voice so striking.

It has been an honour to be able to share Jeremy’s teachings with the world. I hope you enjoyed this conversation as much as I did.

Book recommendations

Jeremy is an avid reader. Here are just three of his recommended books to get you started.

• How Will You Measure Your Life? by Clayton Christensen, James Allworth, and Karen Dillon. (Jeremy recommends Christensen's books because they are not only relevant and helpful, he is also "such a deep, insightful thinker." Jeremy says, "I do encourage talented young people to read this book for it is a book well worth reading to get your head screwed on right.")
• From Condoms to Cabbages: An Authorized Biography of Mechai Viravaidya  by Thomas D'Agnes
• Mountains Beyond Mountains by Tracy Kidder, or anything on Paul Farmer.
  

Thank you Meeta, Jared, Emmanuel and Jet for reading earlier drafts of this piece!

This article is part of the Public Health People series where I meet with different public health professionals from all around the globe. Join me in exploring the greatest insights from their fields, their passion projects and their principles for both work and life.

Why Did I Want To Speak With Dr Raj?

We've met educators who have changed the trajectory of our lives.

I once dreamed of becoming a humanitarian worker with Doctors without Borders for the longest time. I had it all planned out: Since I had no interest in becoming a doctor, I'd either become a pharmacist or an epidemiologist, then join the MSF team and do lots of good.

It was a 2-hour guest lecture by Dr Natarajan Rajaraman (Raj) back in early 2019 that made me seriously reevaluate my conviction to join a humanitarian organisation as a healthcare worker.

Even back then, he’d struck me as eloquent-- a powerful communicator who easily outshone other professors. In his lecture on 'Capacity Building', he shared his experience in health systems strengthening projects in Sierra Leone, saying:

"We don't just need Doctors Without Borders. We need Secretaries Without Borders and Engineers Without Borders."

This quote has been  permanently seared in my head ever since. It readily resurfaces in my later seminars on human rights, humanitarian aid, and international law. Time and time again, my classes reinforce the pertinence of this one quote. Thanks to Dr Raj, I realised that overcoming the nuanced challenge of inequitable access to care isn't the noble task of healthcare workers alone.

It was not until Nicola suggested that I  speak with Dr Raj that I recalled this specific lecture.  Recalling his powerful insights, I did not hesitate to drop him an email.

Raj is currently the executive director of Maluk Timor, an Australian and Timorese NGO focused on enhancing primary healthcare in Timor-Leste. Prior to joining Maluk Timor, Raj was head of medical services at HealthServe, an NGO that provides medical care, counselling and social assistance services to disadvantaged migrant workers in Singapore.

Raj has a background in medicine, global public health and education. Evident from his current appointments, he feels deeply for the health of vulnerable populations and post-conflict health systems strengthening. And he does that best by training healthcare workers and improving the quality of healthcare facilities.

One of my favourite things from our conversation was how readily—almost instinctively—he contextualises his responses to distinct circumstances in his life. Facts, to him, are nothing without context, an understanding indicative of his years spent in cross-cultural settings, where a prize is often placed on understanding the other side.

Raj also has a quiet way of making people around him feel comfortable. He exudes a calm presence, speaking with an incisiveness which he punctuates with good-natured humour. A bio he offered at one of his speaking events wrote: "Raj enjoys reading and movies. Raj loves cats. And motorcycles. But not cats on motorcycles."

As someone who had once been interested in joining the field, I wanted to find out: what are some key insights I should know before deciding whether global health is for me? What should I know if I want to thrive in this field?

In this piece, I am honoured and excited to share Dr Raj’s circuitous journey into global health, his biggest takeaways from years in the field, and his personal tips for making your global health career a more fruitful one. Peppered throughout are some of Raj's pictures from the field and his witty commentary.

How Did Raj Find His Way Into Global Health?

Rudolph Virchow, a man described as "the principal architect of the foundations of scientific medicine," once said:

"Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community. The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them."

At the time when Raj was about to choose his college career, he would have agreed with Virchow. The only difference was that his motivations were grounded in his faith. "When I was 18, I decided that the most faithful way that I could follow Jesus was to be involved in medical missions—someone who does health related work among poor people."

Helping those with less became the guiding principle for many of his career decisions, including that to become a medical doctor. However, soon after earning his degree and embarking on his first few mission trips, Raj tasted medicine's bitter reality.

"When I started working as a volunteer doctor in a village in East Timor for about six months in 2007, I discovered that there were a lot of needs that I just had no ability to meet, he says. "Things like managing water and sanitation within a village, and how to do preventive healthcare."

Raj knew how to vaccinate a patient, or prescribe antibiotics to treat an infection. But he did not know how to set up a childhood immunisation programme or establish clean water supplies and enforce sanitation practices. "You realise that goodness, there's just very little impact that we doctors can make without the right systems around you," he says.

"And so that's what led me from clinical service to capacity building and health systems strengthening." He proceeded to pursue his Masters in Public Health and never looked back. Raj went from doing direct clinical work to indirectly enabling others to do clinical work.

While the map of Raj's career might look like it all panned out according to a well-written script, it was anything but. "You know," he says, "Like many things, this is probably one of those things that is going to sound a lot more coherent in hindsight than it really was going forward."

And when I asked him about the things he wished he had known earlier, Raj gazed upwards and paused. "There were lots of periods in my life where I was not sure if this is the type of work that I wanted to do. I was potentially giving up a default but lucrative career trajectory, to do something less conventional, less prestigious and less financially rewarding.”

In a society that places a premium on prestige, it takes a certain amount of courage to pursue the less glamorous thing. But Raj had long intuited that life's worth and purpose cannot be found in remuneration figures.

"This," he says, gesturing to his office in Timor-Leste, "is just the best thing I could be doing with my life right now." He wishes for his younger self to give himself fully to helping the marginalised. That would have relieved himself of the internal tug-of-war that constantly plagued him. Raj presses his lips together, his gaze thoughtful. "I would tell my younger self to just chill, and carry on. It will be totally worth it."

How Did He Know That Global Health Was A Good Fit For Him?

In paying attention to our heart's true longings and ferociously nurturing our innate talents, we can produce outcomes that would surpass even our best work in fields that are ‘trendy’ or in vogue. The sweet spot is finding a role where our internal values and our strengths and skills intersect. Discovering all of that, Raj says, "is just a function of experience and trying different things."

He saw his own career switches not only as opportunities to do good, but also opportunities to "gather some data on the things I enjoy and the things I feel I'm relatively good at."

Raj started out as a medical doctor and spent some years as a nonspecialist doctor in Singapore’s government hospitals. However, he spent significant time toggling between clinical work at home and various global health projects. Soon, the first of three factors that made him realise he was a good fit for global health emerged.

The first, was the illuminating joy he found in teaching. "I enjoyed the experience of working with somebody from one level of understanding to another." Not only did he enjoy it, he had a natural strength for it. I can attest to his use of analogies throughout our conversation.

He eventually spent close to a decade working on short-term health development and health system strengthening projects in low-resource countries. Some of these projects included empowering Timorese doctors as educators, as well as programmes to train health service providers in skills such as interpersonal communication and basic management of community health centres. Raj was also involved in developing and teaching the global health curriculum at Saw Swee Hock School of Public Health.

Next, Raj realised that he does his best work outside the clinic. "I work with ideas and data better than I do with, you know, directly with human beings.”, “I work better in systems, planning and management. In many ways, I work with humanity better than I do with real people."

And much of his work for the past few years has been exactly that. "Within an organization, either as the medical director or executive director, a lot of the work that I do is through other people,” he explains. “And so a lot of time spent is spent understanding what others are doing, and then providing direction and leadership to get the right things done."

Raj likens working in health systems management as akin to moving pieces across a chessboard. "A larger part of my work would be then finding out what my people need in order to do their jobs better,” he explains. “My job may then be to move some things in order to remove certain barriers, procure technical support or provide political cover.”

Finally, global health was the ideal setting for him to leverage his inherent skills. These are, surprisingly, the skills we often take for granted. Some of them could be as simple as the ability to type, create Excel sheets, automate workflows using scripts or create a website.

"I grew up mostly in Malaysia, Brunei and Singapore. These are high-resource settings. Anybody born and raised in such settings has almost automatically developed a lot of these skills that are very needful in global health settings." He also grew up amidst relatively efficient institutions, which he says equipped many of us with a vision of how workflows ought to be like.

"When you're in some places, you realize, good God, why on earth am I filling in 10 forms just to get a visa approval? Why am I filling in the same data in 10 different places?'” As Raj suggests, many of his invisible, culturally-ingrained skills had become more valuable in low-resource settings.

What Raj Has Learned From Years In The Field?

On medical education’s much-needed reform

"Teaching is the one profession that teaches other professions."

Good education is not just transformative. It is also life-saving. In weakened health systems that are chronically underfunded, understaffed and overworked, there is no greater imperative for education to do more with less. Raj offers two key reforms in medical education he'd like to see.

First, cut the fat from medical education. "Right now, a lot of legacy medical education systems are based on some smart people’s ideas of what the subject of medicine is about," Raj says. "Whereas what we really need is outcome-based education: we need to figure out the exact tasks a typical graduate doctor is supposed to perform, and work backwards from there."

Such reforms mandate that all curricula must prepare trainee doctors for practice. That requires shifting the current bloated focus on knowledge over to skills and attitudes, and to have students assessed as such. Raj says that while basic medical sciences such as biochemistry and molecular biology are still necessary, they are needed at a much less detailed level than is currently taught.

Second, preserve compassion at all costs. "People who enter the health professions tend to either be driven by a desire to serve and heal people, or a desire to put right something that's broken." However, somewhere along the course of one's medical education, “We take that raw material and turn it into something cynical, self-serving, and sometimes quite jaded." There might be many wrongs that call to be righted. Whether it is the profession’s cut-throat competition, sleepless work nights or otherwise. Health systems fundamental goal is to support our frontliners. Fail them and we fail our patients. Raj believes in an emerging field known as 'Healthcare and the Humanities,’ a domain that recaptures compassion and humanity with literature and poetry.

On the grounding force of purpose

Global Health has no shortage of talent, ambition, and compassion. But even among the brightest of the bunch, Raj warns that "this type of work can just be extremely discouraging." He paints a candid picture for us. "The field is often marked by a lot of failure and at times, a sense of desolation from not knowing who to go to for help,” he pauses. “ A lot of times, you're faced with problems that just cannot be solved.”

There are no words to describe the helplessness of seeing drug-resistant TB invading both the lungs of a patient-turned-friend, nor the heartache of examining a child’s sharp bones in a body ravaged by malnutrition, or the suffocating fear for mothers seeking maternal care in communities with high rates of gender-based violence and sexual assault.

Purpose, he says, helps tide him over the individual tragedies that he comes across. For Raj, his faith has become his surest defense against desolation. "If you don't figure out how to find meaning in your work, I just don't know how people will survive this kind of thing," he says, his voice steady and fingers wrung together.

Further, in an environment where pragmatism often trumps social justice, his values often war with the practical thing to do. His moral compass might say one thing, but the social, political, and cultural fabric of his working environment might force his hand towards another. But global health is also a test of grit and long-term foresight. Raj reminds himself that his work is not about him: it's about the community he is serving and ultimately aims to uplift.

On the challenges of complexity

I asked Raj if there were any secrets to strengthening health systems. His short answer was no. For all our brains and ambition, humankind has no step-by-step manual for how to help health systems go from zero to one. The problem? Health systems are just too complex.

"Singapore's health system does far better than most other places in the world. But if I take that system and try to impose it in another country that’s trying to rebuild one, there's just no way that it would fit." Trying to do that, Raj says, is like doing a heart transplant. "All health systems have got their many contingencies and paths of dependencies—from its history, its culture, to its political architecture," he says. "It is just not possible to transpose things."

People are complex. And at the community setting, they are the ones who determine which way the pendulum swings. Let us take malnutrition as an example. Early treatment in malnutrition among children is one of the most impactful interventions in global health. "When healthcare workers provide kids with immediate nutrition and medical attention, they can transform these kids' long-term outcomes,” Raj says.

Proper nutrition is gold disguised as treatment. By enabling proper brain and body development, nourishing a child is equivalent to securing a lifetime of earning capacity. The fight against malnutrition is equal parts a fight to break the poverty cycle.

But while the 'what' to do is glaringly obvious, the 'how' to do it is daunting. "How do we actually go to a community health center, go to the team that is providing that malnutrition care and help the team perform their role better? That's something that we don't know very well."

Raj and his team have tried countless tricks in the book. Educating the health teams does not seem to work, even if they retain what they learned. Material support, such as providing more accurate weighing scales, only slightly increased the centre's productivity. Monetary incentives have worked in some health centres but not others. They even tried recognising outstanding health centres to trigger a sense of pride and intrinsic motivation. While these measures have been tried and tested in different places, the results have always been mixed.

The take-home message is, "there is no silver bullet. There is no single 'package of interventions' that I can introduce to any health center and make it perform better."

On decision-making in global health

So, how does Raj decide what might work? He relies on several key frameworks. For one, "an intervention has to make sense from a first-principles point of view,” he says. "A lot of the work here is really about having some kind of educated intuition about what things work and don't work and trying as best as possible to support that with evidence." This requires asking:

• Is the evidence strong?'
• What has worked in the past and why?
• How will this intervention pan out, behaviourally and economically?'

This 'educated intuition' is not about guesswork. Almost akin to how artists can intuit the 'right' colour or brushstrokes for a painting, Raj is talking about a mental calculation of what might neatly fit into an existing blueprint. This is an intuition honed from years of tinkering melded with a deep attunement to cultural and societal needs. This often means taking an intervention from one country, making the necessary tweaks, and then testing it in a new context.

Other times, some decisions are best made because they are simply the right thing to do. Raj constantly returns to the concept of social justice and equity. "During those times, I'm just going to embrace it and say that this particular way should be done, because this is the equitable way to do it."

But if the bigger goal is to ensure that global health's moral arc continually bends towards social justice until it is completely achieved for all, decisions demand a sobering dose of pragmatism. "We sometimes come across a health policy that may be unjust because it excludes certain parts of the population. And that's simply morally wrong," he says. At times like this, he needs to remind himself that, "Those policies are what's politically feasible at this point. It's going to create the greatest good for the greatest number, so we're gonna go with it."

How Can One Begin To Thrive In Global Health?

In Global Health, the chances of burnout are high. But yet, the chances of great internal fulfillment are also high. Building on his most important takeaways, Raj offers some final tips on how to make your personal journey in Global Health more fulfilling- and enjoyable.

First, get comfortable with uncertainty.

Anyone who works in Global Health must get comfortable with uncertainty. For example, "Sometimes people just don't have email, refuse to check theirs, or simply don't own computers." When that happens, Raj says, "you actually need to go to their offices, sit down outside, and just wait for them to let you in." Sometimes, the waiting does not end with a house visit. "After you leave, you don't know the outcome until you get a call a couple of days—or weeks—later about whether or not your proposal has been accepted." Sitting through the unknown, especially when it concerns a health programme that can save thousands of lives, is an exercise that is equal parts practice and sheer will.

It is perhaps then fortunate for Raj that this uncertainty extends beyond his professional life. In Timor Leste, sweet bouts of serendipity spruce up the mundaneness of everyday life. "Without Yelp or a reliable Google Maps here in Timor," Raj says, "visiting a new restaurant can mean tasting the most awful salty noodles or the most satisfying three-course meal." Life in Timor never fails to remind him that life’s sweetest moments come from things that are least expected.

Next, learn a little bit about everything.

"In just this last one week, I had to change a showerhead, repair a motorcycle, and repair a car engine that wouldn't start." Plumbing and handy work aside, Raj also needed to create a website to host FAQs for volunteers who want to help at Maluk Timor. He even needed to do some basic JavaScript programming to automate some forms. "In Singapore, I could have depended on somebody else within the organization to do all these things,” he says. “But here, because a lot of that institutional capability is not present, I have to learn how to do them."

Raj is not talking about becoming an expert at everything. "As a rough rule of thumb, if picking up a new skill takes about 20 hours to go from knowing nothing to grasping the very basics, you should probably learn it." Quickly gaining a fundamental understanding of very many things is the key here.

A related point would be learning how to learn. Raj recalls his own experience picking up Mandarin to speak to his patients in Singapore. When he was in Sierra Leone, he had to pick up Krio, an English-based creole language spoken locally. Now, having worked in Timor Leste and finally settling there for a couple of years, he can focus on mastering Tetum. "Each time I learn a new language, I learn how to pick it up a bit more efficiently. Reaching the same level of competency for the next language I learned took a lot less time."

Finally, find joy where you work.

And when I asked Raj to share some unexpected differences between Singapore and Timor-Leste, Raj placed both his hands behind his head and grinned. According to him, the differences can't be more apparent and delightful.

"It's just the serendipitous stuff that happens all the time here." he says, shaking his head with mirth. He gives me an example, a scene that is virtually unheard of in Singapore. "You'll walk down the street and see somebody who's carrying a bunch of chickens upside down. My favorites," he says, "are the people who carry the chickens on their motorcycles." Raj tries to draw the scene with his hands. "They've got these horizontal sticks perched behind them on the pillion seat, and hanging on both sides of the stick are the chickens that they're bringing to the market." He grins cheekily, "I like to call them the biker chicks."

Conlusion: To Safeguard Health, Look Beyond The Physician

Virchow might have said that physicians should be the natural attorneys of the poor. Two decades after becoming a doctor, Raj would disagree. Safeguarding the health of any community is a possibility that can only be made real when you look beyond the physician and into the structures and institutions, both cultural and social, within which a doctor's role is embedded.

One's health represents the locus of life. It is from which all else springs: hope, joy, love, awe, spirit. While the fruits of his, as well his team’s labour may be slow to harvest, he finds no pursuit as quenching as providing others with the gift of health.

It has been my honour to be able to share Raj’s teachings with the rest of the world. If his experiences and ambition resonate with you, Global Health might just be the path for you.  

I spent my first year transitioning into university life and stretching myself to my academic limits. My second year saw me double down on building niche research skills and experimenting with my leadership capabilities. It has become quite obvious that a university degree alone isn’t sufficient for a fruitful career. Hence, like many others, I spent lots of time loading up my CV with extracurriculars which I thought were interesting, fulfilling and had promised teaching a skill or two.

And then, the pandemic hit. I saw the plans I spent a year preparing for (a summer spent abroad doing research; followed by an exchange semester abroad at a dream university) crumble to nothing. The pandemic has caused huge suffering. Health systems collapsed. People lost their loved ones. And among those who were safe, unemployment rates soared.

Being located in extremely COVID-cautious Singapore and fortunate enough to have a comfortable roof over my head, I had the ease of mind to ponder the road that lay ahead.

I came to two conclusions.

First, I do not want to be dependent on my future employer. I am going to do whatever it takes to make my career antifragile. Second, to do so means I must become a student elsewhere- anywhere but the archaic university system I was installed in. Save for a handful of life-changing modules, my university experience has not taught me how to make an impact on the world.

And so, my third year was a lot about making myself uncomfortable. This decision was of course, one fraught with uncertainty. One year later, I am elated to say that I have never felt more content, energetic or at peace with myself in a long time. I started writing online. I met amazing doctors, nurses, academics and public health experts who I deeply respect. I enrolled in ODW’s inaugural writing fellowship. I got my first role as a science communicator- a role that has thrilled me to no end.

It hasn’t been easy. I battled periods of crippling self-doubt and negative self-talk. I fell on my head and became hospitalised. I confronted my problematic relationship with food and health. But along the way, I also picked up habits I want to keep for a long time. I have been running for close to 4 months, and have run more than 260 kilometres this year. I made friends from different parts of the world that I want to keep close to my heart. And because I am more honest in my relationships than I have ever been, my relationships with my loved ones have grown stronger.

I am still filled with uncertainty about the way forward. I’m nowhere close to building an antifragile career (I’m still figuring out what that exactly means). But I have no regrets.

Here are some lessons from the past year that I want to keep close to my heart.

True self-care is unglamorous.

“Self care is essentially just ‘procrastination’ repackaged to make it more palatable” - My good friend Sean Heng.

It is foolish to take breaks when your body is not asking for it. Just because others tout the importance of self-care, doesn’t mean it’s always time for one. No, you don’t need to treat yourself with a break, or indulge in a sugary snack.

Forget what the internet has prescribed. While ‘self-care’ as a concept might have been recently popularised, the most effective measures have been known for ages.

True self-care is less glamorous. And you have learned that your body is the best judge. If you do any of the following,

Go outdoors. Exercise. Eat nourishing food. Write. Meditate. Spend time with your loved ones. Do the work you’re procrastinating. Get enough sleep.

The inner lethargy or bodily fatigue you’re feeling will go away. All of that isn’t just self-care. It’s life-care. Do all of that, life will take care of itself.

Running is meditation.

You’ve harboured a love-hate relationship with running for the longest time. So, you’d be surprised to learn that you’ve been running almost daily, for four months straight.

You used to hate it because you found your gorilla-like huffing and puffing distracting. The park nearby was also too crowded for your liking. Noise from the roads irked you. And the biggest barrier? You expected your performance to consistently surpass your last. Talk about putting unnecessary pressure on yourself.

So, how did you end up running on average, six times a week? The following tricks worked for you:

Leave your expectations at the door. Pop your earpieces in. Queue your favourite songs and podcast episodes. Run at your own pace. Run where there are little people and where it’s quiet.

Feeling stressed? Run. Feeling tired? Run. Feeling happy? Run.

You’re not the fastest runner. But you’re consistent. Someone wise once said that the best exercise is one you can’t stop doing. You started running in February with two goals: to become healthier and cope with the low moods you were experiencing. Now, you crave your daily run because it makes you so happy.

Running is meditative. It’s also free and convenient. You get to be outdoors. You get to be around trees and birds and run along a canal. You give your eyes a break. Running is quite possibly the best thing ever. The next challenge for you now is to figure out how to incorporate the strength exercises you used to do but have completely neglected since this new love affair started.

Important relationships reveal themselves naturally during your lowest times.

February to March 2021 would be one of your lowest and most emotionally turbulent periods of your life. Without going into too much detail in this public setting, you and your partner took a period of time off to re-evaluate whether you would still like to continue investing time and effort into what was a loving, six-year relationship.

As conflict-averse individuals, you had both subconsciously swept many problems under the rug, only for them to re-emerge later with a vengeance. Taking a break had been a difficult but necessary decision. It was also a great opportunity for the both of you to work through your personal issues.

You have always prided yourself on your independence. But it was different this time round. Overwhelmed with uncertainty, heartbreak and a crippled self-esteem, you cried for help. The moment you scanned your social circles for a lifeline, the people you knew you could count on instantly became crystal clear. They would be your listening ears, your voice of reason, and the comforting presence that grounded you as you tried your best to keep from unravelling. Your closest friends and your parents would become your bulwarks against desolation during this trying period.

These are the people you want to keep closest to your heart, and never, ever let go.

Life expands in proportion to one’s courage

This is a quote taken from the writer Anaïs Nin.

You used to be extremely terrified of taking risks. But ever since you started stretching yourself beyond the boundaries of school, life has truly expanded.

When it came to your professional life, you took the uncomfortable plunge to publish your first words online. As someone who could only write about things close to your heart, sharing your work was akin to putting your writing, your opinions, your entire being- up to public scrutiny.

But you realise that it wasn’t so bad after all. Before long, you start sending cold emails to professionals and experts you deeply admire. You sat them down at cafes and asked probing questions you’ve only ever dreamed of. You did all of that while keenly aware that a meeting gone wrong or an article poorly written could jeopardise your entire career. The stakes were on the table and I am so proud of you for embracing them.

You also discover that courage is a reserve that grows the more you tap on it. And being courageous has an amazing side effect: you start living. You went from a blubbering, awkward student interviewer to a (comparably more) confident conversation partner. You went from an aspiring amateur to a somewhat competent writer- a feat you never thought was possible.

Investing in your relationships takes great courage too. There is nothing quite so terrifying as laying bare your fears and insecurities in front of people you love and care for. Their rejection could possibly crush you.

But I want to emphasize that there is nothing more freeing than being able to be your complete self around those that matter the most. As for the people that can’t accept you the way you are, who cares? Life is way too short to have to pretend or hide.

So muster the courage to do the difficult thing. Want to improve your relationships? Have the courage to be vulnerable. Want to become healthier? Have the courage to sustain a healthy eating habit. Want to pick up a new skill? Have the courage to make time to practice, consistently.

“Kepler knew what we habitually forget: that the locus of possibility expands when the unimaginable is imagined, then made real through systematic effort.” - Maria Popova in Figuring

Have the courage to imagine the impossible. Then, as Kepler advocated, take systematic steps to make the impossible, possible.

Work isn’t work when you love what you do.

You would not know how much you were missing out on until this happened to you. Heck, you did not even feel this happy or fulfilled when you were doing research.

When it comes to writing for your site or for others, you could totally lose yourself in the work because it was fun and made your heart sing. You are learning things you care deeply about. You are creating work that will be helpful to others. And unlike school, where the quality of your work is oftentimes determined by some arbitrary metric (i.e grades), you know whether your work is good or not by simply evaluating the impact it has had on others.

And one glorious side effect of doing work you love is that instant gratification falls to the side. You constantly berate yourself for procrastinating. If there’s anything that will threaten your career, it’s the time you spend reading webtoons, scrolling through social media, and doing everything but the things you need to. Now, you wake up thrilled to get to work. You can’t wait to improve your craft. Sure, you still love to indulge in a good webtoon, but the temptation to seek immediate gratification has largely fallen away.

Being able to experience work as play is a blessing. Now that I’ve tasted freedom, my bar for my future options have risen, for better or for worse.

Lean into what makes your heart sing. Then, do the work.

“Expect anything worthwhile to take a long time.” -- Debbie Millman

It took me many articles, many more unpublished drafts and infinite rounds of re-writing before you’d stumble upon the kind of style that seems to work for you (for now). And when you finally do, you’ll notice it intuitively. You’ll experience a joy higher than Mihaly Csikszentmihalyi’s flow. You’ll be prouder of this work compared to any other you’ve produced. You can’t wait to create something like this again. And when you share your work with your audience, you’ll feel fearful- for you’re sharing a piece of art that you’ve poured your realest self into.

You’ll discover that you want to write deep, nuanced, reflective pieces. Most importantly, you want to write to uplift. Writing such pieces takes time. For some writers, publishing consistently (by consistently, I mean ‘weekly’) works best for them. But you’re part of the camp that prefers quality over quantity. Your work improves the more time they are given to ‘sit’. Discard the idea that readers will only pay attention to short, pithy listicles. If your work requires substantial length to illuminate its unique nuances, then write as long as you want.

Like all the advice that comes your way, test them and see what works for you. And then, put the necessary hours in and chart your own way forward.

Conclusion: Live life as adventure.

Sure, I am still uncertain about what the future holds. But at least now, I wake up excited for what the day holds for me. And really, life should be lived as though it were pure adventure. I’ve taken enough safe routes to knit me a cushion if I fall. Now, it’s time to take risks and do what truly makes my heart sing.

Why give up the opportunity to feel alive? Life is short. Do things that uplift your own spirit and expand your personal understanding of what’s possible.

A public note on gratitude.

“Nothing delights the mind so much as fond and loyal friendship. What a blessing it is to have hearts that are ready and willing to receive all your secrets in safety, with whom you are less afraid to share knowledge of something than keep it to yourself, whose conversation soothes your distress, whose advice helps you make up your mind, whose cheerfulness dissolves your sorrow, whose very appearance cheers you up!”  - On the Shortness of Life by Seneca

Here is a shout out to the group of people who have been some of my key pillars of support. I am really nothing compared to the accomplished writers and artists and scientists out there. But this academic year has really been a crucial one in my personal journey of becoming. Thanks to you guys, I now have the courage to re-imagine what I'm capable of.

So thank you-

For being there for me, be it about matters of the heart or the mind.

• Rachel, Sean, Kaisen, Jerald, and Jet for being a constant source of joy, encouragement, and for showing me that the true light in life comes from friendship.
• Jean and Cass for being akin to the big sisters I never had.
• Amelia and Alicia for helping me rediscover what a gift kinship can be.
• Matthew, having walked part of life’s journey with me as a partner, confidant, and companion. I wish you all the best in your next chapters of life.
• Chinni and Mingyang for always being an unrelenting presence with me through the mundane, as well as the toughest of times.
• My parents for the gift of unconditional love.

For sticking through my worst first-drafts and for inspiring better pieces.

• Meeta, my new bff thousands of miles away in Bangalore. You are an inspiration, a comfort, a true gem.
• My writing group Jared, Alysia, Rohen, Emmanuel and Natalie for always offering their time and generous perspectives on my work. A special shoutout to Alysia and Natalie who live and breathe many of the values I aspire to embody. Thank you for believing in the sanctity of craft and for inspiring me to create pieces that uplift others.
• On Deck Writing Fellowship, the best launchpad I could ever ask for.
• Jess and Andrea for being willing to take a bet on me, some unknown student who is entire time zones away.  

And of course, a shout-out to my favourite webtoons that were not only great companions during life's mundane moments, but also a comfort during rough times.

This was my final paper written for one of my favourite modules offered by the University Scholars Programme at NUS: Multidisciplinary Inquiries Into the Mystery of “Minds”.

I wrote my paper on Alzheimer's Disease because it had always been such a heartbreakingly debilitating disease. Not only do you progressively lose bodily functions, you forget your loved ones- and most importantly, the person you thought you were.  What if we could rely on the tools around us to delay the loss of our sense of self, even if it were just for a short while?

Introduction

Alzheimer's Disease (AD) is a neurological condition that results in dementia, which refers to a group of various cognitive impairments. Some of such impairments include disruptions in memory, information processing and linguistic ability (Sabat and Harré 448). As AD progresses to its severe stages, it results in impairments in carrying out activities of daily living. However, beyond mere reduction in quality of life, AD patients also experience something potentially even more debilitating: a loss of sense of self.

In Surviving Manifestations Of Selfhood In Alzheimer’s Disease: A Case Study (2002), neuropsychologist and social constructionist Steven Sabat puts forth that AD patients lose their sense of self not because of the neuropathology of the disease, but rather because of "dysfunctional social interactions" (6). Sabat supports this view by building on an earlier work co-authored with philosopher and psychologist Rom Harré (1992), which explored how AD patients are often unintentionally, perceived and treated as "helpless and confused,” (Sabat and Harré 454), or "defective" and "burdensome" (Sabat 28). As a result of such perceptions by their loved ones, patients experience depersonalisation or invalidation, resulting in a feeling of loss (Sabat 28). Given that this loss of sense of self is associated with anxiety and a reduced quality of life for AD patients (35), might there be a way to help them alleviate it?

Philosopher and cognitive scientist Andy Clark thinks there might be an answer. In Natural-Born Cyborgs: Minds, Technologies, and the Future of Human Intelligence (2004), Clark points to groups of AD patients who, despite experiencing progressive cognitive decline, continue to function at high levels (4). Clark attributes their high functionality to the utilisation of what he calls ‘wideware’ (3). In their own homes, these patients are found to extensively exploit the use of wideware such as labels, memory books, photos of loved ones, reminders and diaries, which serve as external memory aids that supplement impaired memory functions (4). Clark proposes that humans are able to integrate aspects of the external world (wideware) as part of their minds to supplement cognitive functions. The human mind, he argues, arises out of "looping interactions between material brains, material bodies, and the cognitive wideware of our cultural and technological environments" (9). Simply put, human minds are created and continually co-created by the joint interactions of the brain, body and its external environment. For these AD patients, their wideware has become so intrinsic to their cognitive functioning that their very removal is arguably tantamount to causing "harm to the person[s]" (5).

With Clark’s argument in mind, I seek to answer the question: how might AD patients be able to outsource certain memory functions to wideware in order to re-establish their sense of self? I will use Clark’s definition of wideware to examine qualitative interviews with AD patients in a five-minute film by the UK Alzheimer’s Society, as well as the results from a study evaluating the use of technological device SenseCam among AD patients. Ultimately, I argue that AD patients in the early stages of their disease can indeed utilise wideware to enhance autobiographical memory in order to re-establish their sense of self. However, as patients progress into the later stages of AD, it becomes harder for them to rely on tools as wideware to do so. What patients become increasingly reliant on becomes their loved ones in order to sustain their sense of self. The minds of AD patients hence increasingly rely on the minds of others as wideware in the later stages of their disease.

Why AD Patients Lose their Sense of Self

Before understanding the loss of the self, we must first ask, where does the self arise from? Neurophilosopher Patricia Churchland argues in her book Brain-wise: Studies in Neurophilosophy (2002), that the self is a non-physical thing, a concept that the brain constructs to help process one’s experiences as a “unit[ed] and coheren[t]” whole (61). She puts forth that since the act of ‘thinking’ is a function of the brain, the brain must be responsible for conjuring the construct of the self (61).

After establishing that the self arises from the brain, we examine the social constructionist view of the self. According to social constructionists, the ‘self’ can be broken down into two types.  The first, called Self 1, is the "self of personal identity", where the individual can refer to himself in first person using “I”, “me” or “mine”  (Sabat and Harré 447). Self 2 then refers to the collection of selves that arise not just from the individual’s brain, but also from other individuals’ brains (446). In order for Self 2 to come into being, it requires the cooperation and affirmation of and by others within the same social setting  (446). For example, an individual can identify as teacher only when he perceives himself as such and when his colleagues and students recognise and treat him accordingly in the school setting. Without cooperation between the individual and others, Self 2 will be impaired and fail to come into being, thereby profoundly influencing the way the individual's actions are perceived and subsequently treated (446). This paper focuses on Self 2 and will henceforth refer to Self 2 as the ‘self’.

AD patients often find themselves positioned as being helpless, confused or burdensome by the people around them (Sabat 26). To provide an example, in an interview with early-onset AD patient Richard Bozanich, he was asked to describe his experience living with the disease. When he read that the first Alzheimer’s patient said to her doctor, ‘I have lost myself,’ he “felt chills up and down my spine because that is what it feels like” (Strobel, online). He attributes this loss not just to how “other people perceive me, as if they don’t quite trust me on my own” (Strobel, online). He says, “I have been very independent all my life, and the thought of not being able to ‘do it all myself’ is hard” (Strobel, online). From Bozanich, we see how AD patients can experience a loss in their sense of self. Once such negative perceptions have been established by others, it becomes difficult for AD patients’ subsequent behaviour to be perceived otherwise (Sabat and Harré 445).

Utilising Tools As Wideware To Enhance Episodic Memory

“Wideware” is a term coined by Clark that refers “to states, structures, or processes” that meet two requirements. First, “the item in question must be in some intuitive sense environmental; it must not, at any rate, be realized within the biological brain or the central nervous system per se.” Second, “the item or procedure must play a functional role as part of an extended cognitive process: a process geared to the promotion of adaptive success via the gathering and use of knowledge and information, and one that loops out into the external environment some nontrivial way, so as to include and exploit aspects of the local bodily and environmental setting” (3). Clark provided the calculator and the notebook as examples of wideware (3). Examples of cognitive processes include those that “manipulate, store, or modify the knowledge and information that the organism uses to reach its goals” (3).

Much of the self depends on the brain’s ability to store autobiographical memory, which refers to information about one’s personal experiences and facts about the person (El Haj et al. 1). A key component of autobiographical memory is episodic memory, which aids the recall of  contextual details such as “locations, time, perceptions and thoughts” (El Haj et al. 4). An example would be “that day I got lost by the street because my phone ran out of power”. Episodic memories are key to daily functioning because they establish coherence between one’s past memories and present goals. However, the neuropathology of AD results in the formation of senile plaques and neurofibrillary tangles in medial temporal lobes in the brain, the very region responsible for retrieving episodic memory (Pennanen et al. 307).

Clark only briefly described how AD patients relied on labels and memory books to supplement their memories. I will explain how certain tools had been used as wideware to supplement episodic memory, and how they can help re-establish the sense of self. The Alzheimer’s Society’s five-minute film The Many Voices of Dementia Advocacy (2019) is a short film of seven AD patients sharing their tips and motivations for taking on dementia advocacy work. One uses her phone to send her reminders (01:11), another individual mentioned the use of the calendar to track dates and times (01:05), while another relies on pen and paper to “make notes on things” he wants to raise during his meetings (01:18). One individual had created a specific document specifying her unique needs, such as her need for rest days in between conference proceedings or for unique travel arrangements (01:44). This is a document she keeps close and shares with those she will engage with during a meeting or event (01:44). While the tools shared are quite obviously the same tools that people without AD also depend on, these tools are arguably those that healthy individuals take for granted and intuitively leave out in preference for more sophisticated tools, such as indie phone applications or computer software that has been optimised for efficiency.

In line with Clark’s criteria, the calendar, the notebook, the set of documents, are indeed structures or processes that “play a functional role as part of an extended cognitive process” (Clark 3). These tools constitute forms of wideware that are able to externally store information such as addresses, telephone numbers, reminders of specific dates, locations and times, as well as “specific needs”. The use of wideware in this case reflects an outsourcing of episodic memory, a function that the brain of an AD patient is no longer able to fully realise. Through outsourcing of their episodic memory, these tools have become an extension of these AD patients’ cognitive machinery. Further, since the mind arises out of brain-body-wideware interactions, the newly-reinforced mind has enabled patients to break free of conventional expectations of AD patients to take on the role of dementia advocates. One patient says that, “self-advocacy has given me my voice, it’s given me back my life…I’m so much more productive than I was told to expect after dementia” (Alzheimer’s Society, 03:46) while another shared that “I’ve gained my autonomy, my independence, my voice” (04:13). In being enabled to assume a new role as dementia advocates, the AD patients managed to re-establish their previous sense of self, from one that is helpless and defective to one that is independent and capable.

Episodic memory is also key to providing visual details that serve as important cues to trigger recall by the mediotemporal brain regions, which is necessary to update one’s conceptions of one’s own capabilities (Morris and Mograbi 1557). AD patients are only able to retrieve fragmented memories lacking the contextual detail necessary to update self-knowledge (Morris and Mograbi 1558). As a result, AD patients may turn to Reminiscence Therapy (RT) to stimulate recall of significant life events that were crucial to their conception of self (El Haj et al. 6).

RT uses music, items from the past, photos or videos to provide a reminiscence “bump” and stimulate the retrieval of the past (El Haj et al. 6). SenseCam, a wearable camera (typically worn around the neck) that takes photos automatically every thirty seconds, is one technology that can be used in RT. In a study conducted by Woodberry et al in 2015, SenseCam has been found to elicit vivid remembering of original events that individuals have experienced (340). During the study, six patients with mild to moderate AD had used SenseCam to record their daily lives. Throughout the two weeks of experimentation, participants were to retrieve their most recent memories every two days (342). Following the patients’ acts of retrieval was a review of the images taken by SenseCam together with their spouses or experimenters (342). During the review, the pictures are played in rapidly in a continuous manner, as though watching a movie of one’s day (343). After three months, patients were tested on longer-term recall ability of those same events without reference to any SenseCam images (343). The study found that SenseCam was better at helping five out of six patients remember events over a three-month period compared to reviewing a written diary (345).

Similar studies on SenseCam argue that it enables recall so effectively because it captures short time slices in a visual manner- thereby mimicking the qualities of autobiographical memory (Conway 1382). Further, these pictures are taken from the first person’s point of view, which triggers contextual cues necessary for recollection, making up for the deficit in the brain (Conway 1382). AD patients are hence utilising SenseCam to capture and store contextual cues to supplement neurological deficits in the brain regions responsible for episodic memory retrieval. SenseCam and the pictures captured are akin to extensions of patients’ recall machineries and hence, constitute as wideware. In the brain’s coupling with these two pieces of wideware, patients’ autobiographical memories are boosted, enabling them to remember self-defining memories that they would “normally…just forget” (Woodberry et al. 346). The use of SenseCam and its pictures as wideware has hence resulted helped patients re-establish their sense of self and in so doing, increased self-confidence and well-being (Browne et al. 713; Woodberry et al. 348).

In addition to SenseCam, much research is ongoing to develop more seamless use of advanced technologies such as other assistive technologies (AT) and virtual reality to construct highly realistic and immersive experiences for use in RT (Chapoulie et al. 6; Lindqvist et al. 393). Hence, technologies like SenseCam, once made more ubiquitous, have the potential to become a mainstay of RT to help AD patients re-establish their sense of self. This field is promising because conventional methods of recall such as a written dairy had been described by the study’s participants as “boring” and “unhelpful”, even decreasing confidence because doing so often drew attention to patients’ own failure to recall the event (Woodberry et al. 346).

Utilising Other Minds As Wideware

However, as AD patients approach the severe stages of their disease, the progressive beta-amyloid deposition and neurodegeneration in the brain reduces the functional connectivity within the default mode network responsible for autobiographical memory (El Haj et al. 9). Hence, as brain capacity declines, it becomes increasingly difficult for patients to outsource memory to tools as wideware in order to re-establish their sense of self. In the film, a patient says that “there is so much I want to do and share…I want to do as much as I can, because the day will come when I can’t” (Alzheimer’s Society 00:42). Another patient echoes his sentiments, stating that, “after being diagnosed, you're left with virtually no supports, go home, get your affairs in order, basically, get ready to die” (00:36), reflecting the acceptance of an eventual cognitive decline so severe that mere reliance on tools as wideware will not suffice in sustaining their sense of self. In Woodberry et al.’s study, it was found that three months after the experiment, some patients’ disease condition had progressed such that some forgot that the use of SenseCam was the reason for their improved memories, with some failing to remember even being involved in the research to begin with (346).

I argue that AD patients hence increasingly rely on the minds of others as wideware in the later stages of their disease. We start to see this from how patients still in the mild-moderate disease stages are best supported by loved ones without the disease. Agnes Houston, the patient who had prepared an A4 document outlining her needs in the film, had indicated that her personal assistant would be the main point of contact. The person responsible for coordinating the events Houston attends and making her travel plans is not her but her personal assistant (Alzheimer’s Society 01:44). Houston has outsourced larger volumes of episodic memory to someone more mentally capable in order to continue performing her role as an advocate. Similarly, the spouses of four out of six patients in the Woodberry et al. study were responsible for operating SenseCam, uploading the images onto a computer and reviewing them with the patient (346). Beyond adopting SenseCam and its pictures as wideware, the patients had outsourced to the minds of their spouses the memory functions required to operate SenseCam and review the photos taken with them.

Studies have also found that receiving support from loved ones greatly enhances the acceptability and adoption of AT such as SenseCam (Lindqvist et al. 394; Nygård and Johansson 90). For example, in a study that evaluated how AD patients remembered event times, most participants relied on significant others to “book train tickets” and “write down appointments in their dairies”, with one saying that “If I have to be punctual, my wife is present on nine out of ten occasions” (Nygård and Johansson 90). Outsourcing memory to loved ones is most obvious in advanced AD where patients may develop anosognosia (where patients become ignorant of their disease condition) and hence do not wish to seek external aid, particularly from technological sources (Morris and Mograbi 1554). Even then, regardless of extreme reliance on loved ones, patients cannot outrun the neuropathology of the disease (El Haj et al. 7). Since the mind arises from brain-body-wideware interactions, the inadvertent decline of the brain will eventually result in a mind so impaired that wideware can no longer support. When that occurs, the sense of self will eventually cease to exist.

In conclusion, AD patients in the early stages of their disease can indeed utilise tools such as notebooks, calendars and technologies such as SenseCam as wideware to enhance autobiographical memory in order to re-establish their sense of self. However, following disease progression, it becomes harder for patients to rely on tools as wideware to do so. As a result, AD patients increasingly rely on the minds of others as wideware in the later stages of their disease, who in turn help patients sustain their sense of self-- until the patient can no longer outrun the neuropathology of AD.  

Word Count: 2984 (without headers)

Works Cited:

Alzheimer’s Society. “The Many Voices of Dementia Advocacy.” Youtube, 16 Ju. 2019, At: https://www.youtube.com/watch?v=CE9TVGS-Jww

Churchland, Patricia. Brain-Wise: Studies in Neurophilosophy. Cambridge: MIT Press, 2002.

Clark, Andy. Natural-Born Cyborgs: Minds, Technologies, and the Future of Human Intelligence. Oxford: Oxford University Press, 2004.

Conway, M. A. ‘Sensory-Perceptual Episodic Memory and Its Context: Autobiographical Memory.’ Philosophical Transactions of the Royal Society of London. Series B 356 (2001): pp. 1375–84.

El Haj, Mohamad, et al. ‘Autobiographical Memory Decline in Alzheimer’s Disease, a Theoretical and Clinical Overview’. Ageing Research Reviews 23 (2015): pp. 183–92.

Lindqvist, Eva, et al. ‘Significant Junctures on the Way towards Becoming a User of Assistive Technology in Alzheimer’s Disease’. Scandinavian Journal of Occupational Therapy 20 (2013): pp. 386–96.

Morris, Robin G., and Daniel C. Mograbi. ‘Anosognosia, Autobiographical Memory and Self Knowledge in Alzheimer’s Disease’. Cortex 49 (2013): pp. 1553–65.

Nygård, Louise, and Marianne Johansson. ‘The Experience and Management of Temporality in Five Cases of Dementia’. Scandinavian Journal of Occupational Therapy 8 (2001): pp. 85–95.

Pennanen, Corina, et al. ‘Hippocampus and Entorhinal Cortex in Mild Cognitive Impairment and Early AD’. Neurobiology of Aging 25 (2004): pp. 303–10.

Sabat, Steven, and Rom Harré. ‘The Construction and Deconstruction of Self in Alzheimer’s Disease’. Ageing and Society 12 (1992): pp. 443–61.

Sabat, Steven R. ‘Surviving Manifestationsof Selfhood in Alzheimer’s Disease: A Case Study’. Dementia 1 (2002): pp. 25–36.

Strobel, Gabrielle. “Early onset familial AD: Q&A with Richard Bozanich.” Alzforum, n.d., At: https://www.alzforum.org/early-onset-familial-ad/profiles/qa-richard-bozanich

This article is part of the Public Health People series where I meet with different public health professionals from all around the globe. Join me in exploring the greatest insights from their fields, their passion projects and their principles for both work and life.

Love at First Listen

I listened to my first episode of the Unbiased Science Podcast during a regular walk from my university campus to the train station. On my first listen, I was hooked. I found myself nodding along, enthralled as the hosts broke down complex topics on how the human body's immune system worked and why we experience side effects after getting a vaccine. The episode lasted less than an hour- even shorter if I had listened at 1.2 x or 1.5x speed. I often paused midway through my walks to excitedly jot down notes on my phone. For example, I learned that what we might typically understand as "side effects" to a vaccine, such as a fever and pain at the site of injection, can simply be understood as our body’s immune response to the virus protein contained inside the vaccine.

Every episode thus far has been a delight. The best teachers ignite interest, re-package the complex into digestible chunks and by the end of class, leave you thinking, “Oh my gosh, I can’t wait to share what I learned today!" That is exactly what the hosts, Jessica (Jess) and Andrea, do for me.

The podcast’s tagline is, “Your trusted source for no nonsense— just science.” Indeed, the Unbiased Science Podcast’s social media pages have become a one-stop site for COVID-19 information. Ever since their first post in August 2020, the initiative has secured itself as a bastion of evidence-based-only information. The wildfire that is COVID-19 misinformation might have found its firefighters amidst a pair of zealous and charismatic scientists aiming to “bring scientific method to the madness.”

What is more impressive is their dedication to engaging with both timely and timeless information.

Vaccines prevent diseases. It is so much easier to measure the presence, not absence of disease. This is why we say that vaccines are victims of their own success. - A quote from Is This The Real Life Or Is This Just Fallacy: Vaccine Myths Part 2

For those feeling overwhelmed by COVID-19 information, the podcast provides a generous offering of equally, if not more, enticing listens for the knowledge-hungry. Some of their episodes include whether genetically-modified organisms (GMOs) are good for you, another on whether organic foods are truly more nutritious, and one on whether detox diets and cleanses really work.

The hallmark of their work?

Everything that they share is grounded in scientific evidence.

I had reached out to them for some advice because I loved their work so much. What I did not expect was such a thorough response from them. I am including their response here should you be interested in the same questions I was.

I could not be more excited when they so kindly agreed to an interview for this article. During our Zoom call, Jess and Andrea received me with exceeding warmth. While they spoke with their characteristic sharpness and acuity that defined their evidence-first approach to science, their responses were cushioned by their inviting laughter and sincere reflection.

Neither of them were afraid to be vulnerable either--something I found deeply humbling because that set an intimate stage for the heartfelt conversation we shared, albeit a short 50 minute one. Talking to them was like being in the classroom with your favourite teachers, those that would stop at nothing to ensure you get the help you need, making sure to throw some of their life experiences into the mix.

Please, grab a cup of coffee and join me in learning about the impact Jess and Andrea are making, the story behind the podcast, the secrets of their success, their struggles with self-care and the work-life juggle, as well as their vision for science communication. From here, the Unbiased Science Podcast (US) will be referred to as Jess and Andrea’s science communication initiatives on social media and the podcast.

The Podcast That Is Transforming COVID-19 Vaccine Sentiment

If US has a distinctive style, it would be their easily digestible explanations that remain faithful to scientific evidence. In an era where science has become heavily politicised, US has served as a lifeline for those who are seeking scientists with whom they can trust and form a profound connection.

"Thanks for all the help you've given and continue to give! I seriously come here when I want facts." - Zoe Hill on the Unbiased Science Podcast Facebook Page

"Love your podcast. As a doctor, your busting of several vaccine myths and your COVID vaccine explanations have been particularly useful in my addressing patients concerns about COVID vaccine. Also, particularly enjoyed your telling of the story of gentleman Wakefield. If you do another old wives tale episode, please address echinacea, zicam, and if you haven’t already, if letting your fever ride out when sick actually gives you a significantly boosted immune response and allows you to heal from cold/flu faster making the added discomfort worthwhile. - been arguing this one with my mom for years.” - Dan Levinsohn on the Unbiased Science Podcast Facebook Page

“Can’t thank you both enough for all the wonderful work that you do via this page to spread good information, augment hope through actual science, and eliminate the anxiety that comes with having to ask “wait is this article true or is this just bad info being circulated?” ✊😌❤️” - @uncleabe on the Unbiased Science Podcast Instagram Page

Their efforts have not gone unnoticed. They have recently been awarded as the winner of the Data Hero Awards under their most prestigious category: The Provocateurs. As the winners, they are recognised for “advocating for data access and transparency even when it was difficult and even dangerous.” Their win reflects another breakthrough achievement: in a culture that tends to sensationalise the individual, their nomination as the sole team amidst other candidates highlights the often overlooked fact that individual success often arises from the joint effort of a group of people.

Who makes the formidable pair behind the podcast?

US is co-hosted by Dr. Jessica Steier and Dr. Andrea Love.

Jess has a doctorate  in public health (DrPH) with a specialisation in health policy evaluation. She's also the co-founder and CEO of a public health data analytics firm called Vital Statistics Consulting (VSC). VSC’s bread and butter lies in designing and executing health policy and health program evaluations.

The firm currently collaborates with the largest federally-qualified health system in New York State as its research and evaluation team. Prior to starting VSC, Jess worked as a professor teaching biostatistics, epidemiology and evidence-based medicine to physician assistant students at Hofstra University in New York. She continues to do so at Marist College today.

Where Jess works with statisticians, health economists, epidemiologists and the like, Andrea works with researchers across the fields of immunology, infectious diseases, vaccine research, cancer immunotherapy and gene therapy. With a PhD in immunology and microbiology, Andrea previously worked in academic research, with a focus on infectious disease immunology: in particular, how pathogens that cause disease in humans interact with the immune system and lead to illness. .

Andrea currently works at Nexcelom Bioscience, a biotechnology company that develops instrumentation and assay technologies for biomedical research. She also serves as an Immunology Consultant for VSC. Recently, she wrapped up an immunotherapy research project on using CAR T-Cells for HIV immunotherapy, a project she has been involved in for the past couple of years.

The diversity of their backgrounds enliven their discussions, adding a multidisciplinary richness that gives the podcast its unique edge over the rest.

From getting kicked out of an anti-vax group to starting an evidence-based revolution

Jess and Andrea were certainly busy enough with their full-time jobs, so why did they start US? For one, scientific misinformation had long provoked a righteous wrath in both of them. “We frequently commiserate over our frustration with the anti-vax movement,” Jess said on an interview on The Vaccination Station. “Social media has given people a platform to spread unsubstantiated information, and it's just always mind-blowing to us how pseudoscience is so readily gobbled up by the public.”

She recounts the story of being kicked out of a mothers-only Facebook group for being too "militantly pro-vaccine" and "for weaponizing [her] credentials as a public health scientist." Her removal from the group was evidence for the distrust in science the pair had so accurately diagnosed.

When the pandemic hit, the duo felt that they could wait no longer. Remaining silent was as good as being complicit in exacerbating the public health crisis that fake news was wrecking. "Andrea and I strongly feel that we have a responsibility as scientists to debunk myths and communicate them to the general public,” Jess says. “And with that, US was born to translate science and research for the layperson.” Here’s a quote they said underpins what US stands for:

Science is not finished until it is communicated. The communication to wider audiences is part of the job of being a scientist, and so how you communicate is absolutely vital.- Sir Mark Walport, UK Government Chief Scientific Adviser

What you will not find on their page are misleading and clickbait-y titles. What you will get instead are the straight up, stone-cold facts.

Why did they decide to start a podcast, since they were already circulating infographics on other social media? Well, given the rapidly declining attention spans on social media, words and captions can only do so much in conveying the complexities behind scientific research. Turning to podcasting gave them the platform for communicating effective yet nuanced scientific discussion.

For more than just practical reasons, “On the podcast, we can really be ourselves. It lets our personalities shine through and play off each other. We're less constrained and have more freedom,” the pair shares during an interview with The Entrepreneur Doctor. Still, they remain active across Instagram, Facebook, LinkedIn, and Twitter to deliver accessible and accurate science to as wide an audience as possible.

Growing the podcast and community

Like many great teachers that came before them, Jess and Andrea make sure to place their students at the centre of their work. As part of their 'Heard from the Herd' initiative, their Instagram followers are encouraged to submit questions every Monday. They then compile many of these questions into a list before addressing them via Instagram posts, stories or a future podcast episode.

They also consistently chronicle the astonishing impact science has had on human history. Just recently, they have crowned COVID-19 vaccines as science's gifts to humanity.

The quality of their work also appears to be on an ever-upward trajectory. Instagram, where most of their followers are, is not made for sharing dense chunks of information.

But they have made it work. Over time, the pair seemed to have honed in on a format that works for them: condense the science and locate it within a single infographic. That way, readers can easily screenshot the post for future reference. More recently, they have been using more eye-catching colours, with deliberate bolding of keywords and including at least one picture so that their posts avoid getting too heavy on the eyes. Using only one infographic also ensures that their audience misses nothing should they forget to swipe on Instagram carousel posts (posts that contain multiple pictures).

The secrets of their success: a flaming chemistry built on 15 years of friendship and more

One of the things that struck me when I was listening to the podcast for the first time was the effortless chemistry between both hosts. And if I thought their camaraderie was great on audio, it was jumping off the screen during our Zoom call.

One might describe Jess’s conversational style as that of a storyteller, painting the arcs of the plot of the day. Andrea then comes in to fill out the details of the story. Between them was a natural and seamless turn-taking. They often finish each other’s sentences, one filling in for the other without hesitation. Listening to them teach is akin to having two parents patiently walk you through a complex topic, with the promise of understanding on the other side.

Jess communicates with her entire body. Being a visual thinker, as Jess speaks she constantly points at things in the air and draws circles and boxes in an effort to materialise her thoughts. Her speech follows the same illustrious patterns--giving rise to the characteristic way she engages the audience so well.

After Jess draws you in with her vibrant energy, Andrea proceeds to ground you with her trademark steadiness. Often responding with little hesitation, her sentences cut a straight and concise path to her arguments. Andrea’s no-nonsense approach subtracts from the noise to give you nothing but the facts, throwing in the perfect analogy here and there to concretise your understanding. Unlike Jess and ultimately reflective of her own teaching style, Andrea is judicious with her gestures, using them only when necessary to illustrate a point.

Their advantage in being a team lies in that they each attract different audiences. Some gravitate towards Jess's more exuberant, open-ended style. Others perk their ears to listen when Andrea hunkers down on the details of whatever evidence she's dishing out. If you’re like me, I enjoy the synergy of both styles. I often have pen and paper at the ready whenever it’s Andrea’s turn to speak, and rely on Jess’s summaries to tie my notes together.

Alongside their shared love for teaching and passion for science communication, they attribute their natural chemistry to their decade-long friendship. Fifteen years ago, the universe conspired for them to meet at Stonybrook University. Fast forward to today, they would reflect on the gift that is an unyielding, supportive partnership, built on the backs of joint ambition and purpose.

One of their secrets to building a great rapport with each other is simply openness and honesty. In the early days of the podcast, tensions were high as they were still figuring out the frequency of posting. "We had an incident of miscommunication early on,” Andrea says. They did not provide the details, but in an effort to resolve the issue, “Jess had stepped forward to say, ‘Listen, I need to clear the air- what you said had hurt my feelings.' I was like, oh my gosh, I'm an idiot-- I did not mean that at all.” And Andrea stepped up to clarify, “This was what I actually meant."

That incident set the basis for the transparency and honesty that marked their interactions-- the same principles that catapulted the entire US endeavour into success. "Andrea and I are obviously different people, with different political views and different opinions on things. So we've learned to read each other's triggers and moods," Jess says.

Beyond their friendship lies yet another critical factor: an intrinsic respect and genuine admiration for the other. As a team, they are each other’s biggest supporters. For example, when I asked how they personally thought their strengths and weaknesses complement each other, they wasted no time running a list of the other’s best traits.

"During meetings, when there's a lot of heated discussion and disagreement, Jess just comes in and just, like smoothes the waters," Andreas spreads her palms outwards, as though smoothing out the surface of an imaginary lake. "She just has this very calming presence and this mediating type personality." As Andrea spoke, I couldn’t help but notice how Jess had her chin propped beneath her wrist, wearing a shy but growing grin on her face as Andrea sung her praises.

"As for me, I'm very stubborn. I'm very data-driven,” Andrea continues, “Sometimes we'll get a message from someone, and I'm like, ‘Oh my goodness, I am going to rip this person a new one!’ And Jess will go, "Alright, calm down. Let's be a little more diplomatic about it." At this point, Andrea shoots Jess a knowing look.

Once Andrea is done, Jess starts by saying, “It’s just everything!” Her eyebrows crinkling as she contemplates the interactions between them that came to them as naturally as breathing. "Andrea is very outdoorsy and athletic. She's a marathon runner and she does Judo. She's just-" Jess pauses, bringing out both her hands to gesture at Andrea, going speechless for a while. “I look at her as just this, stunningly beautiful, athletic, amazing- I don't know- Amazonian woman!" As Jess nods in satisfaction at having found the right words, a small smile graces Andrea’s lips as she basks in Jess’s compliments. "I'm like a couch potato, a homebody, you know. I'm not outdoorsy or athletic,” Jess finishes with a sheepish grin. Andrea, as Jess testifies, “is the total package. She knows her stuff and just delivers it all in such a beautiful way."

How do they feel about their partnership, one year on?

"It's been really gratifying and really great. I feel very fortunate. You know, I think Jess is probably one of the most important people in my life these days," Andrea says while Jess nods in agreement.

The work-life juggle

At the start of our Zoom call, Jess’s three year old daughter had climbed onto her mother’s lap, asking to be carried. Andrea had waved her usual "Hi, Sophia!" before Jess muted her microphone and excused herself to get her daughter settled in. As I saw Jess' article on jobs.mom come to life in front of me, I wondered how the two spectacular ladies managed to wrestle with the demands of both their personal and professional lives.

The answer seems to be: “We’re still learning.”

Unsurprisingly, their full-time jobs take first priority. On a typical day at work, Jess manages her teams at her firm and finds herself in and out of meetings with clients. Andrea alternates between running assays at the lab and doing data analysis from home. Given the multitude of responsibilities both women juggle, "It's often very chaotic and every day is slightly different," Andrea says. "It becomes an exercise in really being very self-disciplined and organized."

When does the pair find time to work on US?

While the answer can easily be, “all the time,” US typically consumes all of their attention in the evening, after the flurry of the workday is over. They typically delegate the work between themselves before the week starts, taking turns researching, designing and posting the infographics you see on their social media channels. If Andrea is caught in the lab the entire day, Jess fills in for her and vice versa.

In preparation for their episode releases, both of them drop notes and references in a shared Google Doc throughout the week. When Friday arrives, they have an outline and all the references ready for recording. The audio is then sent for editing over the weekend and ready for release by Monday.

When the sanctity of their personal time is weighed against the responsibility they have chosen to shoulder, the latter almost always wins out. "We are, probably to our own detriment, always on our phones and on Facebook and Instagram,” Jess says. “Honestly, we get a lot of nasty and accusatory messages, but we also get a lot of genuine inquiries from people who want more information," Jess says.

That is why, Andrea adds, “We make a point to respond to every message because we feel this obligation and we're very passionate about it.” Andrea might slip in time during her lunch break to respond to messages, or in between lab sessions when test samples are incubating. They know that their decision to publish a social media graphic that night might make a critical difference for someone choosing to take the COVID-19 vaccine, or masking up before leaving the house.

"Yeah, it's just chaos all the time," Jess gestures at her own top, tugging at her collar before raising her hands in mock surrender. "I haven't showered and I'm wearing the same clothes as yesterday!" Andrea shakes her head, laughing in agreement. "But we just work all the time. And we love it."

The self-care struggle

The pair is unabashed about sharing their struggles online--an act of vulnerability I deeply respect. Knowing each other’s workaholic tendencies, "we try and send reminders to each other, you know, don't forget to take this evening off, or go relax,” Andrea says, raising her brows at Jess through the screen. “Or even eat! Have a sip of water!” Jess jokes.

Previously, they were churning out two posts on social media a day. That expectation, on top of their own professional and personal lives, "was completely untenable," Andrea says. "Before long, we decided that we needed to preserve our own mental health and sanity.” Now, they produce at least one social media post every weekday and release a podcast episode every Monday.

They were both frank about still being on the early end of the learning curve when it comes to self-care. "I was worried you're gonna ask me what I do to relieve stress," Jess admits. "My answer is usually just to sit on the couch and let my brain relax. But that doesn't ever really happen. I'm always kind of still going. So I have to figure that out. I haven't mastered that yet."

Andrea shares that she struggles with self-care too. During the pandemic, “We're working more. We're taking on extra projects. We're stressed and anxious because people are not listening to science," Andrea says. "So you know, let's be realistic, right? Some days, you're just surviving-- and that’s okay. I think people need to be honest about that, too."

Would they ever do science communication full time?

“I can't tell you how many people have said, 'Oh, I was on the fence about the vaccine. But because of your podcast, I signed up and I convinced my whole family to get it.'" Jess says. US has her feeling like a doctor, but for a wider population. For Jess, science communication has been nothing but incredibly rewarding.

Being able to see their work have an immediate impact on people's lives, has similarly been life-changing for Andrea too. "As a bench scientist, unless you're working on translational research projects, you don't always get to see your work make a tangible difference." Being in constant back-and-forth with their audience, Andrea says that "it is nice to see that we are making a difference to people."

Pursuing science communication full time might mean giving up their current jobs--a decision they are currently reluctant to make. The both of them believe that their careers as full-time scientists lends credibility to their work at the podcast.

That aside, both of them simply love research. Andrea finds deep satisfaction in the rituals of working in the laboratory, conducting her experiments on the bench and being at the cutting-edge of the latest research. As for Jess, diving into troves of raw data, extracting key insights from them and weaving them all into a story that can later be translated into policy underpins her passion at her consulting firm. Furthermore, being an expert in your field cuts through all the time spent needed for "expert clearance" to get your message out to the public.

So what is the verdict? "We're really enjoying the podcast. So I guess we'll see how things play out eventually," Andrea says.

If you’re passionate about science, communicate science to the masses.

At US, their mission goes beyond simply dispelling misinformation. "For us, it's really about growing a community of like-minded people who care about scientific evidence,” Jess says. We are arming them to spot pseudoscience and to say, 'Okay this is clearly not credible.' For them, success would mean growing the community to spread the commitment to science and evidence-based medicine.

Through US, the duo hopes to reach other scientists, the media and governments to emphasise the critical nature of science communication. "We have some of the most brilliant scientists in the world but they're unable to communicate effectively with the general public either because they’ve never received formal training or because it’s outside their comfort zones,” Andrea says.

They do have some tips for aspiring science communicators.

First and most importantly, practice teaching others. “While we don't have actual formal training in science communication per se, both of us have expertise in educating people on how to understand complicated topics," Andrea says.

Second, pretend that you are communicating to your most difficult audience. “I am aware of certain triggers that will automatically turn people off to the post,” Jess says. “So I’ll avoid certain types of language, really try to simplify the way that I'm presenting the information and avoid technical jargon.”

Third, take some science communications courses. In an age where scientists have to wear lots of hats, “I would encourage young scientists and students to take a public speaking course, or some sort of media communications course,” Andrea says. Both of them had to pick up graphic design skills “on the fly,” fervently agreeing that they would have signed up for such courses back in their university days if they could.

Lastly, try your best to remain apolitical and unbiased. "Obviously, we have our own personal political views, but we really keep those at the door,” Jess says. “And we do have some followers who hold very different political views. And that's a huge win for us.”

Their gift to the world

As I wrote this piece, I realised that Jess and Andrea have provided me with a gift no words can fully capture.

I learned that you can feel stretched beyond belief, with life's obligations pulling you apart at the seams, but still love every moment of your work because you believe and see its potential for good. I learned that you can protect and uplift others with gifts and love for one of humanity's greatest endeavours: science.

Perhaps most importantly, I realised that you don't need to have it all together to do something good for the world, as long as you remain steadfast to your principles and dedicated to your cause.

For me, they have enlarged the very realm of possibilities for what scientists can achieve.

PS: The Unbiased Science Podcast relies on its listeners for support. If you wish to support Jess and Andrea’s commitment to democratising access to accurate and reliable science, do consider supporting them by either sharing their work on social media, purchasing some of their merch, or even better- becoming a communicator of unbiased science yourself.

This article is part of the Public Health People series where I meet with different public health professionals from all around the globe. Join me in exploring the greatest insights from their fields, their passion projects and their principles for both work and life.

Chun Peng is in his second-last year of neurosurgery residency at the National University Health System and is currently working in Ng Teng Fong General Hospital. I met Chun Peng through a mutual friend, and he was so kind  to meet with me over an afternoon coffee even after completing a 36-hour shift. He enjoys a good cup of mocha and switches easily between lighthearted jokes and deep, insightful explorations of his career. What struck me the most was his commitment both to individual mastery of his own craft as a physician, and the collective nurturing of healthcare workers in his team.

Armed with the dream of one day working with Médecins Sans Frontières as a trauma surgeon, Chun Peng decided to pursue one of the toughest and most competitive residency programmes in medicine. It has been a most arduous journey, but Chun Peng would not have it any other way. After all, his job brings him great fulfilment: his hours take him closer to mastery, he forges important connections with his patients and he gets to create an impact doing what he loves.

Read on for best practices you can try, insider insights from his field and a glimpse into his own personal journey into medicine.

BEST PRACTICES TO TRY.

Don’t become a doctor for the money. If you’re considering becoming a doctor for the money and prestige, think again. On top of his regular working hours, Chun Peng says, “I have ten on-call shifts (24-hour shifts) every month, and the remuneration is certainly not lavish.” While the pay drastically improves after your traineeship, you need more than that to tide you through the years of toil. “You’ll see your peers advancing in their careers especially as a medical specialist,” he says. “What keeps you going really is the meaning you find in your work. This is why passion is so important.”

Pay it forward. What could be more important than saving patients’ lives? If it’s one thing that comes close, it would be nurturing the doctors of the next generation. It can be easy to brush teaching and mentoring aside in favour of personal advancement, or just to get much-needed rest. But not for Chun Peng. As busy Chun Peng is with ward rounds, clinics and operative procedures, he places the utmost importance on nurturing his team. “As doctors, our other role is really to be educators.” As with any profession, the deeper he dives into his own specialisation, the more he realises the importance of sharing the knowledge he has accumulated. Chun Peng is currently a registrar, with several house officers and medical officers under his wing. “You want them to care too, and the best way is to teach, share, and hopefully inspire them.”

Find a mentor. Mentors can guide, teach and inspire. Chun Peng had fallen in love with surgery many years ago because his supervising attendant extended a rare opportunity for him to enter the operating theatre. “As medical students, we don’t even get to enter the operating theatre at all,” he says. “I was lucky to have a supervisor who let me enter theatre and that’s where it happened.”

Be human. How do you connect with your patient and their families in times of crisis? Establishing a much-needed connection when confronted with issues of life and death simply asks for one thing: empathy. But accomplishing this is no easy feat. “You must put yourself in their shoes and truly try to understand their points of view,” Chun Peng says. The job of a neurosurgery doctor is really, in such times of stress, be a stabling and comforting presence. “The stress on the family is huge. Our job is to work with them to come up with a decision we both think is best for the patient. And that also involves eliminating the sense of guilt from family for whichever decision that was made,” he says.

Lead with respect. It takes an entire village to raise a child. In healthcare, it takes an entire health system to ensure a patient’s recovery. And multidisciplinary teams are at the core of this. At a hospital, a team can comprise of doctors, nurses and allied health members. In the operating theatre, the team comprises the surgeon, the anaesthesiologist, the nurses and technicians. Everyone brings a different set of skills to the table. “You need a team to make things work,” Chun Peng says, and the keyword here is respect. ”As the doctor, you’re ultimately responsible for the patient. It then boils down to how you lead and engage everyone in the team to form a cohesive plan that ensures the best outcomes for the patient.”

AN INSIDER’S LOOK.

On the beauty of surgery. Two things drew Chun Peng to surgery. First, it was the calm it extended amidst the flurry of the hospital. “In the operating theatre, everything is quiet and under control. Everybody- the anaesthesiologists, nurses, and technicians have their role to play,” he says. “You just focus on what you’re doing.” Second, it’s being able to see the immediate impact you have on your patients. Chun Peng still recalls his life-changing surgery posting when he was still a medical officer. “This man came in with a hole in the stomach- it was absolutely ruptured. It was amazing how, the day after surgery, he was like a normal person again, ready to go home.”

On mastery and sacrifice. The privilege and prestige that comes with being a physician come at what some may perceive as too great a price. The hours, academic and technical rigour as well as the weight of expectations can be overwhelming. “I’m currently working at least 80-90 hours a week,” Chun Peng says. “That’s the standard for my neurosurgery training. “ In order to bear the noble responsibility of saving lives, sacrifices must be made, sometimes at the expense of welfare. “We can hire more trainees and cut down our working hours. But there’s a trade-off: we wouldn’t have the skills to be good enough,” he says. Training is crucial and the hours are necessary to attain the level of professional proficiency required by the job. When you put your life in the hands of a doctor, you want nothing but the best. “It is what it is. We chose the profession for a reason, and we have to accept it and do our best.”

On having a support system. We often overlook the role of family, culture, social support and mentors in an individual’s success. For Chun Peng, he credits it all to his wife, children and parents-in-law. “I’m thankful that I have an understanding wife. Not only is she looking after the kids, but she’s also working as well,” he says. “Without her support, there’d be no way I could’ve survived.” He is also grateful to his neurosurgery team. “At the hospital, we are one another’s main source of support,” he says with a laugh. “You know that you won’t die alone because you’re dying together.”

On death and palliative care. If your family member has a life-threatening stroke and is comatose, do you decide to let them go, or to agree to an operation that could leave them unable to feed themselves for the rest of their lives? Families may have to confront such difficult decisions in the most unexpected times. In his line of work, Chun Peng has cried together with families as they make such difficult choices. Unlike other chronic conditions such as COPD or cancer, the patients that he sees often have to make decisions on matters of life or death in a matter of minutes. After all, who can predict a stroke or an accident? “One way prevent the crippling guilt and burden that family members have to bear,” Chun Peng says, “is to start talking about advanced care planning and dispel the taboo that surrounds issues of death.”

On the sacredness of trust. Doctor-patient relationships are perhaps one of the most precious, delicate things in the world. When you relinquish some control of your own body over to a doctor, you are entrusting him or her with a great deal of faith. This trust is something Chun Peng deeply cherishes. In no other profession, he says, does someone willingly share their deepest secrets with you. “This privilege and trust is something that we cannot take lightly,” he says. “As a doctor, if you maintain that as your core and always put patients first, you won’t go wrong.”

READ.

Here are some of Chun Peng’s recent favourite reads:

• Admissions by Henry Marsh

• Do No Harm by Henry Marsh

• When Breath Becomes Air by Paul Kalanithi

This article is part of the Public Health People series where I meet with different public health professionals from all around the globe. Join me in exploring the greatest insights from their fields, their passion projects and their principles for both work and life.

Who is Nicola Pocock, and why did I want to meet with her?

I first got to know Nicola through Twitter. She was the first person to respond to the article I wrote about Nikki K. Here was her response:

Her comment on my first article ever had spread warmth down to my toes. I immediately looked her up and what I found just floored me.

Currently an Assistant Professor at the London School of Hygiene and Tropical Medicine (LSHTM), Nicola has worked with Aidha, The Asia Foundation, China Medical Board and the International Labour Organization (ILO).

And her research interests? They lie at the intriguing intersection between migration, labour exploitation and health. This intersection is a strategic one: Nicola believes that adopting a global health-based approach is an effective way to get issues like child labour and human trafficking on the policy agenda. But her task is far from easy. Working closely with some of the most vulnerable groups in the world puts her in touch with a great deal of suffering.

Right now, Nicola is at the most exciting point in her career. She and a small team have been tasked to revise one of the most important tools used to measure child labour estimates around the world: the Statistical Information and Monitoring Programme on Child Labour (SIMPOC).

I had an entire list of questions for her. When I reached out to her, she received me with the same warmth and empathy that distinguished her academic pursuits. In this article, we cover the following:

• How did she end up working in the fields of migration and labour exploitation?
• What is it like doing research fieldwork with trafficked persons?
• What is the role of academics in fighting for social justice in global health?
• How might we do impactful research that uplift the communities we study?
• What are her philosophies for work and life?

This article took me a long time to write because I wanted to do her justice. I hope you'll enjoy this conversation as much as I did. If you're interested in pursuing a meaningful graduate career, this article ends with Nicola’s curated list of helpful resources to point you in the right direction.

How did she end up working in the fields of migration and labour exploitation?

Nicola’s PhD was in human trafficking in Southeast Asia- a topic that brings to mind heavy themes such as violence, exploitation and trauma. It’s already difficult enough to discuss, let alone study for it for years. How did Nicola decide to pursue her PhD in this area?

Like many wide-eyed fresh graduates before her, Nicola aspired to change the world.

After completing her undergraduate education at the University of Warwick, she had jumped on a plane to Eritrea to become a volunteer English teacher. But she would be in for a rude awakening. "It was a repressive military dictatorship,” she says. “When I got there, it was just so much more difficult than I imagined." Realising that she might be better suited for a role elsewhere, she left Eritrea and joined her mother in Malaysia, where she could still experience life outside the UK. Then, she found a volunteering opportunity that would later inspire her to study one of the most complex issues in the world.

Aidha is a non-profit in Singapore that teaches financial literacy and confidence skills to foreign domestic workers and lower-income Singaporean women. It had been less than an hour's bus ride away across the Malaysian border in Singapore- which had been perfect for Nicola.

There, she met Dr Sarah Mavrinac, the founder of Aidha. In Dr. Mavrinac, Nicola saw the kind of person she could become. “Sarah had a PhD in accounting from Harvard Business School and had been a professor in Singapore,” Nicola says. “But when she noticed a gap in financial literacy among marginalised groups of women, she decided to quit her professorship to start Aidha."

Nicola loved Aidha. "The hope and optimism there was just infectious. It was a community built on lifting one another up," she says, wearing a smile so wide I couldn't help but grin in return. Since she was working closely with female domestic workers in Singapore, it was at Aidha where she first learned about migration in ASEAN- in particular, just how many low-wage migrants there were in the region. “I even came back to Singapore to work, just to continue volunteering at Aidha,” she says. From 2009 to 2012, Nicola upgraded her intellectual prowess during her time as a researcher at the National University of Singapore and honed her craft while knee-deep evaluating real-life programmes doing her soul’s work at the non-profit.

Thoroughly inspired by Dr. Mavrinac’s impact, Nicola aspired to start a non-profit that will inspire the same hope and optimism Aidha did. Since Aidha was the culmination of Dr Mavrinac’s profound intellect and passion, the path ahead was clear: she was going to get a PhD too.

When the time came for Nicola to apply for her PhD, she was keen to do her thesis on financial literacy among migrant workers- informed by her time at Aidha. However, she came across a project that immediately piqued her interest. “It was a project investigating the experiences of human trafficking survivors in Cambodia, Thailand and Vietnam,” she says. "It looked so interesting,” Her desire to do work related to migration and exploitation made the project a perfect fit. And this initial interest soon blossomed into years of generating evidence for advocacy for some of the world’s most vulnerable persons.

What does fieldwork in human trafficking research look like?

Research in this field is very much about uncovering the reality of people’s lived experiences. And for an issue shrouded in crime and danger like human trafficking, social realities the truth need to be triangulated with as many stakeholders as possible.

Nicola had been ready to fly to Thailand to conduct her PhD fieldwork in Thailand’s fishing sector in 2014 when the US Trafficking in Persons (TIP) report had just been released. According to the report, Thailand’s efforts to combat human trafficking had just been downgraded. It was now categorised as a ‘Tier 3’ nation, the lowest ranking tier, joining 22 other countries including Iran, North Korea and Saudi Arabia.

“I was anxious throughout my plane ride,” she says. “I was scheduled for interviews with government stakeholders in the fishing sector. And they were getting slammed for severe human rights violations.” As global backlash against Thailand unfolded, Nicola had anticipated great resistance during her interviews, “I was so sure that it’d be hard to get them to share.”

But the situation had been the complete opposite. “Everyone wanted to talk to me about it.” She counted off her fingers the people whose stories she collected: social workers, frontline NGO staff, policymakers and policemen. The global reports had missed one important thing: the stakeholders in Thailand already knew there was a trafficking problem. And they were actively trying to address the problem. “They needed someone to tell their side of the story- the stories that don’t make it out there because no one wants to listen,” Nicola says.

Whose stories needed telling? For one, those of the policemen. “I love interviewing the police because people in law enforcement reveal the most fascinating insights,” she says. As a trafficked person, your fate lies not only in the hands of your employer but also in those from law enforcement. Further, the police are often painted as the bad guys. They’re either seen to collude with exploitative employers or slammed for not doing enough to help trafficked persons.

But the reality isn’t so simple. Nicola recalls one of her interviews with a labour inspector, “in a province of hundreds of thousands, there were only two labour inspectors who could inspect fishing boats.” Her interviewees had cried out at the impossibility of their tasks: “How are two people going to root out all the trafficking the government has demanded?” In that situation, there were no corrupt nor lazy officials. Rather, the problem was having insufficient resources and suboptimal government policies.

And here’s a surprising insight: manpower shortage in government agencies turned out to be a persistent issue in Thailand. According to one labour official, “out of 85 staff members, only 5 are permanent staff members who own the legal permit to conduct legal inspections on the fishing boats.” This means that those 5 members are constantly overworked. That’s not all. The police are just not incentivised to find trafficked cases. “If you find any forced labour cases, your workload increases for a week,” Nicola says. “And you’ve already got enough to do.”

Like Nicola, I find myself empathising with them. And perhaps the most important discovery was that human trafficking persists in Thailand not simply because of corruption, or outright ill intent. Rather, the problem had been rooted in systemic failures and government policy restrictions.

What is the role of academics in fighting for social justice in global health?

Startup founders build and distribute.

Artists create and share.

What about academics?

What makes global health research distinct from other domains of research? Unlike several fields where research can remain purely theoretical, global health deals with immediate matters of life and death. Hence, global health research should transcend the mere publishing of papers and attending conferences- into creating tangible impact.

Should academics then publish and advocate? According to Nicola, an academic should shoulder the dual responsibility of both inquiry and advocacy. Unfortunately, many stop at inquiry.

Even Nicola, whose work is fundamentally impact-driven, confesses that she herself is slow to disseminate her work on a larger scale. "You get no brownie points for engaging with policymakers and going out of your way to share your work more widely,” Nicola says. And because academics are not incentivised to translate their hard work into tangible impact, “the equally, if not, more important work of getting the right people to pay attention gets neglected.”

"The very least you could do is to share your work with others, and set closed-door government and partner meetings." All of this she learned from Cathy Zimmerman, her PhD supervisor and colleague- also the second woman (after Dr. Marvinac) to have a profound impact on her life.

Given workload constraints, Nicola believes that academics should, at the minimum, publish and get their material into the hands of folks who can advocate.

How might academics fulfil this role more fully?

Put yourself in Nicola’s shoes.

After months of interviews and analysis, you find out that trafficked fishermen in Thailand suffer from violent abuse and mental health trauma. What would you do?

After learning that due to language and cultural differences, migrant workers in Malaysia have their mental health issues dismissed and cannot receive proper diagnosis and treatment when they are ill- what actions might you take?

Would you publish your papers and be done with them? If you were to imagine yourself as part of the communities there were studied, what would you want academics to do?

This is where intentional dissemination and advocacy of work comes in. “We make sure we arrange a meeting with the relevant stakeholders to discuss the results of our work,” Nicola says. Emails don't cut it. Share your work with government agencies in person.

She recounts one of her meetings with the social welfare department in Thailand overseeing shelters for trafficked persons. “We found problematic levels of PTSD among our study population,” she says. “During this meeting, we were able to have a productive discussion on how the department can address the trauma the migrants were facing.”

The results were straightforward: the community needed counselling services- immediately. Without that meeting, it might have taken months, even years for the social welfare department to even chance upon the results of the study. How many more months might the community need to wait for the department to then provide the psychosocial care that they need?

In short, intentionally disseminate and advocate for the work you’ve spent months to years crafting.

How might we do impactful research that uplift the communities we study?

First, maintain academic neutrality. Much of Nicola’s research involves fieldwork: sitting down with stakeholders and conducting in-depth, often highly personal interviews. When studying the populations she does, it can be easy for the academic to want to be seen as the righteous advocate- and forget that the interviewee simply wants to be seen. Since research is all about uncovering lived experiences and social realities, how can we then honour their worldviews and experiences?

It boils down to the kind of questions you ask. Questions should be (1) neutral and (2) open-ended. That way, the persons you are speaking to are encouraged to express their opinions freely. Ultimately, you want to create a reassuring space where the other party feels safe. “You want to make people feel comfortable to share,” Nicola says. And to do that, “you need to be careful. Ask neutral questions and avoid making any value judgments.”

Second, embrace complexity. “Being in this space, you realise that there is just no straightforward, black-and-white answer to any social problem,” Nicola says. Problems are instead, highly complex and multi-faceted. What does she mean by that? Let’s take an example: since the COVID-19 pandemic, the world has seen skyrocketing numbers of child labour. “Schools are closed. Parents are losing their jobs,” she says. “To put food on the table, kids are being sent out to work.”

Protecting children isn’t as easy as outlawing child labour, or re-opening schools to get them back in. “Once kids are out of school,” Nicola closes her eyes, “it’s very difficult to get them back in.” Given the current economic and public health crisis, we need to realise that sending their children to work is a necessary reality for many families.

The important question here is no longer: How are we going to get children out of their dangerous jobs and into school? Rather, the question we should ask is: How might we protect kids from getting injured or permanently disabled when they’re working, so that they can continue finding better jobs in the future?

To Nicola, embracing complexities means adopting a systems perspective. This means acknowledging that processes overlap, systems feed into each other and solutions often require structural change that can take decades to undo.

It helps that Nicola is fascinated with her subject matter. To her, complex social issues such as human trafficking or child labour are “the juicy stuff”. But she also acknowledges that, to someone else, they could be really difficult. Take her field for example. Working in human trafficking often means navigating difficult government structures, not to mention getting up close and personal with criminal activities. Impacting change can too, be slow and discouraging.

But she stays rooted in her stance. The difficulty is not a suitable excuse. Imploring academics not to be afraid, Nicola urges academics to ask, “What’s needed? What are the complex issues hiding in plain sight that are waiting to be addressed? What is it that the world needs academics to do?”

Her philosophies for work and life

Be honest to both yourself and to others. “It’s so important to put your cards on the table,” she says. “Don’t hold back on what it is that you’re really interested in or curious to find out about.” Her advice? Admit what you know and what you don’t know. And be respectful.

To create meaningful impact, show up for your partners. Actively nurture your relationships with your partners, regardless of whether they are your students, non-profits or policy-makers. This is because relationships need to be tended to with care. “Add value. Connect them with people that can fill their needs. Offer resources and expertise,” she says. At the end of the day, strong partnerships open doors to real, sustainable change. “These valuable relationships don’t come by often. You’ve got to leverage on them the best you can.”

Grow alongside your students. If there’s one thing Nicola loves, it’s learning from her students. “Our students do amazing things,” she says, throwing me a winning smile. “Their enthusiasm is infectious and just so inspiring.” Unfortunately, academics aren’t always encouraged to spend time with their students. Still, Nicola urges fellow colleagues to actively lift students up, either through active mentoring or connecting them to relevant resources. The result is usually a win-win-win: the professor gets to learn, the student gets to contribute, and partners benefit.

Concluding with hope and optimism

Nicola hadn’t mentioned the one defining trait that led her to do great work: her ability to inspire hope and optimism. It had radiated off her throughout our Zoom conversation and subsequently over our email correspondence. After writing this piece, I realised that it must have been the same spirit she carried with her to Eritrea and the same spirit that nurtured her loyalty to Aidha.

When it comes to combating tough problems in migration and labour exploitation, the world needs someone who is patient enough, curious enough, has a strong sense of justice and willing to go the extra mile.

And Nicola checks all boxes.

Her favourite books in recent years (Nicola’s notes are italicised)

1. Hope in the Dark by Rebecca Solnit - restorative if you are trying to do anything related to social justice.
2. Mountains beyond Mountains by Tracy Kidder - an inspiring story of Dr Paul Farmer setting up Partners in Health.
3. Love Warrior by Glennon Doyle - for lessons in vulnerability and remaining true to yourself.

Nicola’s published works

Here are some of Nicola’s published works, all of which are great references if you would like further reading on migration, labour exploitation and health.

• Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study
• Labour Trafficking among Men and Boys in the Greater Mekong Subregion: Exploitation, Violence, Occupational Health Risks and Injuries
• Universal health coverage in 'One ASEAN': Are migrants included?
• Moving towards culturally competent health systems for migrants? Applying systems thinking in a qualitative study in Malaysia and Thailand

Nicola’s list of recommended resources

If you’re interested in finding out more about using research skills for impact, or career resources for those with advanced degrees,  here are some of Nicola’s recommended material:

• Roostervane - career resources mainly aimed at PhDs transitioning out of academia, but useful advice for masters graduates too. Their youtube interviews on transitioning PhDs are also great.
• Heterodox Academy - a group of academics and educators promoting viewpoint diversity and critical thinking as part of research and teaching. They have a podcast too.
• Effective Altruism - a movement promoting the use of reason and evidence to do the most good in the world, including evidence-backed philanthropic giving.
• The Michelle Obama’s Podcast - I’ve really enjoyed her insights on building your career, managing family life and work.
• Conversations with Tyler - To learn about development economics in a friendly conversational way from Tyler Cowen himself. He has a fun and  piercing interview style.

A note from Nicola on 6th Jan 2021, who will be taking on a new position at the Lumos Foundation. while remaining an honorary academic at LSHTM.

“Since this conversation (12th Oct 2020), I’ll be moving into a new role as Head of Data & Research at the Lumos Foundation. Believing that “Children belong in families, not orphanages,” The Lumos Foundation is a non-profit aiming to end the institutionalization of children and promote shifts towards family and community-based care globally.

I am excited to join Lumos and look forward to leading efforts in documenting their systems change model. That aside, I can’t wait to learn from partners and colleagues about the important issues around family-based care and early childhood development among others. Looking back on my journey, I’m now coming back full circle to the NGO world- which is heartening and will no doubt be enlightening.”

Thank you so much for reading.