In 1505, Poland’s parliament adopted a transformational piece of legislation. Translated as “Nothing new without the common consent,” the new law redistributed political power by forbidding the king from issuing decrees without first getting parliamentary approval.
This same principle, streamlined to “Nothing about us without us,” has underpinned popular social movements of our time. It’s the defining position of the global disability rights movement. It’s a rallying cry for people living with HIV/AIDS. And it’s become a guiding ideal in global health. In May, the World Health Assembly passed a resolution urging governments to ensure social participation in every area of health, with a focus on promoting voices of the vulnerable and marginalized.
Although the global health field has certainly taken steps toward more community inclusion, the power to drive agendas and shape interventions remains with the institutions. To choose an obvious example, the global response to Covid-19 has been largely top-down. A 2021 analysis of the World Health Organization’s Covid-19 interventions dataset showed that “bottom-up” approaches constituted just 7 percent of public health and social measures implemented. Even then, they mainly constituted “one-way information dissemination efforts via mass media and web-based channels; they were rarely reflective of bottom-up, participatory approaches to engage communities on the protective behaviours,” the authors wrote.
This centralizing of power impedes global health everywhere. To be sure, global health institutions possess an immense trove of critical knowledge and capabilities. But they don’t typically have intimate knowledge of how environmental, social, and cultural factors impact people’s health at the community level, where all implementation happens.
Further complicating the matter, research points to mismatched priorities between health professionals and community residents, while residents perceive few options for communicating with health officials. This creates harmful information silos and knowledge hierarchies on a macro level, too; it’s nearly impossible for local communities to share their needs or propose solutions via scientific journals and conferences, the traditional avenues for global health communications.
To make global health truly participatory, the world’s health institutions must adopt a radical approach to listening to everyday people. Listening must become global health’s lynchpin.
It’s nearly impossible for local communities to share their needs or propose solutions via scientific journals and conferences, the traditional avenues for global health communications.
With emerging practices like narrative medicine and participatory action research, clinical health care spaces, therapeutic environments, and nonprofit workplaces have begun to embrace radical listening as a discipline. The driving idea is that people closest to a problem are best positioned to find solutions, which health professionals can help implement by providing resources and critical technical capabilities.
A commitment to radical listening would transform global health for the better. Consider the experience of communities in Borneo — an island that’s home to poor, rural villages scattered throughout one of the world’s major rainforests, threatened by deforestation. Before attempting to implement any interventions, a team led by the nongovernmental organization Alam Sehat Lestari worked as a local partner with the international nonprofit Health In Harmony, which one of us founded. The team conducted more than 400 hours of listening sessions with nearly 500 community representatives, including farmers, religious leaders, teachers, women’s groups, and other community members.
Those listening sessions revealed a problem common across the region: Despite depending on their precious forests, residents often resorted to illegal logging to pay for access to basic health care. This insight led communities to design a holistic solution for themselves. They invited health professionals to help establish nearby health facilities, with a brilliant incentive: The cost of care would be discounted for communities that halted or reduced illegal logging. People could also barter for health services with seedlings or manure, to be used for forest restoration and farming.
A peer-reviewed evaluation of the approach found that it helped to improve health care access for local communities. At the same time, they found a 90 percent reduction in households relying on illegal logging as a primary income source — with greater access to health services corresponding to greater decreases in logging activity. Communities gave up logging to such an extent that it reduced forest loss by about 70 percent and saved $65 million worth of carbon compared with other protected areas in the country.
Holistic strategies like these are waiting to be unleashed in local communities all around the world. Even when communities have solutions, it’s hard for them to bring them to the attention of the professional global health community. As a result, we have enforced knowledge hierarchies that perpetuate information silos.
The good news is that in today’s digital age, it’s never been easier to gather and broadcast local perspectives. Instead of primarily broadcasting their own views, global health institutions can nurture communications networks that solicit local input and create opportunities for mutual learning. As one of us recently argued in the journal Nature Medicine, podcasting, as a medium, is especially well suited for bringing local leaders into public dialogue with institutions. Coincidentally, the pandemic saw audiences for global health podcasts, such as Public Health On Call, Public Health Insight, and Pandemic Planet, grow dramatically.
Even when communities have solutions, it’s hard for them to bring them to the attention of the professional global health community.
Seeing the opportunity, the Special Program for Research and Training in Tropical Diseases, or TDR, created the Global Health Matters podcast, which one of us hosts, as an intentional way to dismantle silos that have stifled global health dialogue. (TDR is co-sponsored by the WHO, UNICEF, the U.N. Development Program, and the World Bank.) The podcast has attracted listeners from more than 180 countries by featuring not just renowned experts but also emerging voices, with a focus on elevating perspectives from low- and middle-income countries.
At the time Poland’s Parliament wrested power from the king with its cry of “Nothing about us without us,” it was made up solely by men from the noble class. We’ve come a long way since then, but in most countries health authorities still occupy rarefied ground. While global health institutions, officials, and professionals are indispensable, we must broaden our perspective on who counts as an expert. Local communities have essential insights for addressing their health challenges. It’s time we listen.
Dr. Kinari Webb is the founder of the nonprofit Health In Harmony and completed her training in family medicine. She regularly speaks on health care, community involvement, and the link between human and environmental health.
Dr. Garry Aslanyan is Manager of Partnerships and Global Engagement at the Special Program for Research and Training in Tropical Diseases (TDR), and hosts the Global Health Matters podcast.
Paul Martin Jensen, a science communications consultant, assisted Aslanyan and Webb with editing, research, and sourcing for this piece.