For the first time since 2019, the glitterati of geopolitics gathered recently at the Raisina Dialogue in New Delhi. Why, I asked a senior Indian diplomat, did most of them fail to even mention health. Had they learned nothing from the pandemic? The pandemic, he thought, was the problem. “They’ve had over two years of being forced to talk about health. Now, they want to get back to things they’re really interested in.”
Our global leaders may regret not paying more attention to what is happening in health: in the geeky panels where I lurked, there was a conviction that health technology and artificial intelligence may help middle income countries to leap past their more fossilised advanced counterparts within a decade.
The oppressive silence
President Ursula von der Leyen of the European Commission set the tone in her opening remarks: democracy versus autocracy; the climate emergency and; helping global trade to recover and reorganise. She did mention health once, but only in the context of a pandemic that was now waning. And, President von der Leyen is a doctor by training, with a master’s degree in public health! The assorted foreign ministers and heads of development finance institutions did not, as far as I could tell, have a medical degree between them, so it’s maybe unsurprising that they glossed over the topic too.
In fairness, Tadashi Maeda, the Governor of the Japan Bank for International Cooperation did talk about investment in Indian vaccine and small molecule production. I may have missed other contributions: each day began at 9am and ended 10.30pm; there were multiple breakout sessions twice a day and; all of the lunches and dinners were by invitation only. To no-one’s surprise, I was invited to the mealtime discussion on health issues around cooking oil rather than the exclusive meal hosted by the Indian foreign minister.
Overall, though, I’m fairly sure that economy and finance leaders from across Africa, Asia, Europe and Latin America skipped any mention of the transformative approach to health that was the subject of so many promises from so many leaders throughout the pandemic. Geoffrey Onyeama the Minister of Foreign Affairs of Nigeria even managed about fifteen very eloquent minutes on the post-pandemic economic architecture without once touching on prevention, diagnosis or treatment of anything.
Silence is sometimes welcome. In mediaeval Madrid or Rome, it must have been a relief not to be required to appease the Inquisition by applauding yet another lecture on how the sun revolved around the Earth; at Raisina, we were spared too many doctrinal lectures on the need for vaccine and medicines production in every back yard. At a meal in an outside restaurant, where each of us looked over our shoulder frequently to check that our heresy wasn’t being overheard, I spoke to a senior adviser to an African president who agreed that there was no sign anyone would pay a premium for products produced in Africa and that those products would inevitably be much more expensive than vaccines and medicines from highly efficient factories in India and in the advanced economies. Just look at South Africa’s Aspen, he said.
Why it was better to be with the geeks
The Raisina organisers had made sure that, wherever the attention of the geopoliticians wandered, health would have protected sessions. The briefing book had a number of thought-provoking articles and I was lucky enough to be on the panel of a discussion about “Healthcare, Technology and a Coalition of the Willing” (warning: it’s an 85-minute video).
The G20 will be chaired by emerging economies for the next three years (assuming a compromise can be found over Russia’s position in it). Indonesia’s turn is first. Dino Patti Djalal, the Chairman of Foreign Policy Community of Indonesia, and a former ambassador to the US, said that data and the rules governing access to it would be a focus of its presidency. In a world that has become used to COVID apps as a prerequisite to normal life, he saw vast opportunities for technology to transform healthcare delivery, but no guarantee that it would — more about this in a moment. Indonesia is also pushing for an “IMF of health” that would act as a shared funding pool for countries facing health crises and the G20 is establishing a continuing task force that brings together health and finance ministers. As workforces age, health becomes an ever more vital prerequisite to economic growth.
India, which takes over the G20 in 2023, has committed massively to digitisation transforming health in a country that will very soon be the world’s most populous. At a Federation of Indian Chambers of Commerce meeting on a road map for universal health care earlier this year, experts defended plans to have many fewer beds per thousand of population than the global norm by saying that screening and remote management would mean that every bed would be used efficiently. It’s not a pipe dream: multiple emergency rooms in Gujarat are already managed by one specialist supervising local teams of doctors and nurses who act as arms and legs; across Bihar, one of India’s most deprived states, kiosks staffed by paramedics with very basic training link to a call centre staffed by GPs and specialists in Delhi who can send prescriptions, order diagnostic tests or refer the patient immediately.
Preeti Sudan, the Health Secretary who oversaw India’s initial forceful response to COVID, said that the country could not have managed the pandemic without AI predicting emerging hotspots. Nor could it have delivered 1.85 billion vaccine doses of COVID vaccines.
India takes the potential of artificial intelligence in health so seriously that it has seconded a full ambassador to run I-DAIR, a Geneva-based international collaborative. In the future, massive databases are likely to be more prized assets than a collection of patents or closed collaborations with academic centres. Ambassador Amandeep Gill foresees an alliance of small states and large low and lower-middle income countries. The Switzerlands and Singapores will bring money and expertise; the populous countries will bring data and the chance to find patterns that will transform diagnosis treatment (and fast-emerging health tech hubs in countries such as India and Kenya).
Change, though, is frightening. In many situations, AI can already predict more accurately than humans which pathogen is likely to be responsible for a patient’s infection and can predict which antibiotics are likely to work against it. Why do you need a doctor? This kind of change will be even more profound in areas such as cancer and management of cardiovascular disease. Ss Ambassador Djalal said, “doctors are enormously egotistical, especially when it comes to their revenues”. We need, he said, to prepare for political and social resistance from those who’ve benefited from the current system.
The last time I saw the figures, Indonesia had fewer than 200 medical oncologists for about 270 million people. If they are worried, imagine how the average American oncologist will feel: there are about 13,000 of them for a population that is only 20% bigger than Indonesia’s. They earn an average of $300,000 a year, according to Glassdoor. As South African minister Kwati Candith Mashego-Dlamini told the panel, health technology will allow South Africa to spread its few oncologists more thinly; that should be what worries the office-based oncologist in Topeka. No one is suggesting that there will be no role for oncologists or cardiologists in the future; just that their role will be different, and probably less well paying.
The Americans and the Europeans are likely to resist for longer: there are more of them and they account for a much larger percentage of GDP than do their counterparts in middle income countries. Today, Indians can get some cardiovascular surgery with a better chance of survival and at prices as low as two percent of the cost of the procedure in the USA. This achievement was reported by INSEAD, Europe’s leading business school in 2012, but the Indian model has yet to be replicated in Europe or North America. It is likely, then, that AI-driven healthcare will reach its full potential in India and Indonesia before it does in the United Kingdom or the United States. The advanced economies will probably be late adopters, not refusers, though.
Power will shift in medical research too. A New Scientist article explained it beautifully in 2019. “Because all humans originated in Africa, groups that later migrated elsewhere took only a fraction of genetic diversity with them. Two individuals within an African population will be much more different than two individuals within a European population…The higher level of genetic diversity within Africa gives researchers the opportunity to investigate whether particular gene variants are associated with particular diseases. “For example, if you had a gene that was not variable at all in Europeans, you could not find an association with disease,” says [a researcher]. If there was variability in the same gene in people of African descent, that could lead to the development of a drug that could be used globally.”
In the new era, Europeans and North Americans will discover that their majority populations are genetically impoverished, while minorities at home and — even more so — people still living in Africa and South Asia hold the key to new medical interventions. Imagine an American HHS Secretary begging a Mozambican health minister for access to the country’s genetic databases. Those geopoliticians will regret missing our session!