Lucy Gilson, researcher: ‘The health system is a picture of how we live on the planet’

Lucy Gilson has dedicated her career to researching health systems and how to make them more equitable. The academic, 64, director of the Division of Health Policy and Systems at the University of Cape Town and professor of Health Policy and Systems at the London School of Hygiene & Tropical Medicine, believes that equality in access to health cannot be isolated from other global challenges, such as climate change, or efforts to create a more supportive economy.

Gilson, who was born in Harare, Zimbabwe, was awarded the 2024 Virchow Prize this summer — which recognizes exceptional contributions to promoting global health — alongside Johan Rockström for the “holistic and systems-based approach” of their work “to safeguarding human and planetary health.” In this interview, which she held with EL PAÍS via video call from Cape Town, Gilson talks about the social consequences of the Covid-19 pandemic and how neoliberalism “dehumanizes” public health.

Question: The Virchow Prize recognizes your contributions to both planetary health and human health. How does this dual focus align with your work on equity in health systems?

Answer: These elements go hand-in-hand because in both cases the greatest burden is borne by the poorest. This is true for both climate change and human health. Our greatest challenge is how to support, feed, or empower these less privileged people, for whom access to healthcare represents a burden on a daily basis. We want health systems to take care of all of us, but particularly those who need it most.

Q: So when studying health systems it is important to understand them within a social and environmental context?

A: We need to think about how health systems respond to shock. How they adapt to climate change, to changes in health, and to other conditions that have to do with both planetary and human health. A health system is a picture of how we live on the planet, it's a picture of our concept of well-being. So they need to not just address disease, but be more proactive in better addressing the human health consequences of planetary health and putting those with the greatest needs first.

Q: But the latter does not always happen.

A: It happens very rarely, unfortunately, but it should be a constant goal. It is always important to reaffirm it and promote it. To defend not only the health of the general population, but also to ensure that health systems are promoting the goal of social justice.

Q: The Virchow Foundation recognizes that its work acts as a “bridge” between the Global South and the North. How has your vision of global health evolved through working in Cape Town and London?

Q: I have had the privilege of working in Africa for over 30 years, and I was born in Zimbabwe. That has taught me that it is essential to understand social contexts in order to understand global health challenges and how to address them. I think I have been able to bring these realities from the Global South to the North to teach and research them. You also have to understand that there is a power dynamic. It is the north that has the power. That is why I wanted to bring these worlds together and show in London these experiences that the Global South can bring, and reconcile these two realities.

Q: A constant demand from countries in the Global South is to have equal participation in global issues and not to be seen through the prism of charity.

A: No country wants to be seen as a charity. In the geopolitical power dynamics, which extend to global health, countries in the south demand to be part of the decision-making process. Not to have decisions made for them, but to share knowledge and experience as equals. They know that if you are not in the conversation, someone will speak for you, and that is paternalistic and demeaning.

Q: Are we closer now to achieving equality in this global debate?

A: It depends on where in the world we're talking about. For example, in the World Health Organization, members make decisions equally. But in reality, it's those with funds and geopolitical power who dominate the conversation.

Q: The Covid-19 pandemic exposed the weakness of the health systems of many poor countries, which even today have not overcome the social consequences of those years. Was the pandemic evidence of geopolitical disparities?

A: We only have to think about access to vaccines, or what they called “vaccine apartheid” in Africa. The division of power resulted in inequality, in access to what everyone needed to protect their population. Covid-19 was an example of these power dynamics in the world. But not everything was the same in all poor countries. There were experiences of all kinds in the south and north. There were many experiences in the Global South of how communities responded to that challenge and not everything was opaque. In addition, there were situations such as corruption in the distribution of masks and other health supplies that were a problem evenly distributed throughout the world. Even in the poorest communities in European countries there is a legacy of Covid-19, which only aggravated poverty and the health situation.

Q: What were some of those positive experiences in countries in the Global South?

A: Communities that came together to support each other in responding to the challenge, not only of the disease, but of the blockage of medical supplies. In Cape Town, where I live, there was a very important community support network, which connected communities across the city. There was an exchange of resources and experiences and support for neighbors that was extremely positive. This mutual support is part of the muscle that communities must have to respond to challenges, whatever they may be.

Q: The need for such unity in civil society is a key point of your work.

A: Civil society has an incredibly important role to play, as does free media. And this is partly because they are mechanisms for holding the government accountable. And in any country, we always need the government to be accountable for what it does. But let’s not forget that the government is also who we want to work with to support populations and take care of them. The public sector in democratic societies has a responsibility to respond on a large scale to many different challenges. That is why I believe that governments have an important role to play as agencies responsible for the health of the population. They have to not only manage health facilities, but also advocate for investment in the broader actions needed to tackle the causes of ill health.

I see healthcare systems as networks of care rather than machines that need to be incentivized to deliver a service”

Q: How can the approach to public health be improved?

A: Health systems are often seen as machines. And they are not. A health system is a collection of people working in interconnected teams, framed by routines, practices, values, norms, and broader sociopolitical factors. So if you’re working to strengthen that system, it’s important to think not just about the resources it needs. Often policymakers don’t take the need to create enabling environments for those systems seriously. That may mean issues around decentralising authority, so that people in the community can make decisions for themselves. Or it may mean encouraging collaboration between government departments, because they need to work together to address the causes of ill health. Government bureaucracies often operate in an isolated way, they are very rigid and their authority flows from the top. That can undermine local initiative.

Q: What is the major global challenge for public health policies right now?

A: The global economic situation and the way we think about economics is important when we talk about planetary health. I think we need to think about the nature of global economic forces and the influence of neoliberalism and its fiscal policies on what governments do. We need to be concerned about how commercial forces influence health and healthcare systems. The pharmaceutical industry influences who has access to vaccines and medicines, for example. Also, commercialization and the increasing acceptance of the profit motive in healthcare systems is being strengthened. I see healthcare systems as networks of care rather than machines that need to be incentivized to deliver a service.

Q: So, to have more humane health systems, we need more humane economic systems.

A: We need to think differently about our economies and how we care for the world, just as we care for our personal health and the health of our community. And we need to think differently about how we regulate access to what we call global public goods, such as pharmaceuticals. There needs to be greater equity in the distribution of global public goods so that the needs of everyone are met, not just those with the most wealth and the most power.

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