Dream Widely: the aspirations of Generation Y

A preliminary briefing on research findings from the multi-disciplinary Millennium Cohort Study (MCS) offered an insight into the aspirations of the Millennial generation in the UK, defined as a sample of individuals born during the year 2000 in Wales, Northern Ireland, Scotland and England. Originally established to assess the influence of early family context on child development and outcomes through childhood, adolescence and into adulthood, the MCS is starting to yield a fascinating snapshot of Generation Y.

Indeed, participant responses to surveys at the ages of 7 and 11 years showed an increase over that time in aspiration or ‘dream’ levels, with a gender disparity with girls citing a proportionally greater wish to work in high level management or traditionally vocational careers (including ‘teacher’, ‘doctor’, ‘vet’). By comparison, ‘sportsman’ was the overall career aspiration for boys at both 7 and 11 years, a trend supported by a 2012 retrospective questionnaire completed by 8000 adults via business-orientated social networking platform LinkedIn. Such findings prompt interesting discussions of whether boys of the Millennium need to be targeted with more wide-reaching career options and role models. To my view, this dream should not be subject to an educational or parenting approach that encourages a move towards more technical careers so devaluing a goal that may appear untenable and unrealistic.

The UK primary schooling system should increasingly seek to offer an ‘education in the school of dreams‘ to re-appropriate Jennifer Lynn Peterson’s phrase and taking inspiration from the recent new wave Japanese early learning system. Child aspirations recorded in the MCS were sub-categorised by ethnicity including children of Asian heritage living in the UK. Asian boys were less likely than their peers to rank ‘sportsman’ as their number one life aspiration, instead citing ‘making money’ as a motivation and ranking associated work positions accordingly (including ‘banker’). However, the recent shift in Japan’s early age education suggests a sustainable adjustment in infrastructure, promoting prosperity and diversity in youth aspiration.

The introduction of compulsory elementary and early secondary education has been critical in sustaining the rapid economic growth Japan has witnessed since the end of World War II characterised by a rigorous ‘heads-down’ curriculum and teaching structure. Indeed, as Peter Cave notes in Primary School in Japan: Self, individuality and learning in elementary education ‘the expectations placed on schools are as high in Japan as in other rich, modern countries, if not higher. Japanese schools have long been entrusted with a major role in the production of “desirable human beings”‘.

However, since 2000 this national classroom attitude has been flipped. Cave concludes that ‘although recent reforms have tended to stress individuality and independence, teachers in [Japanese] primary schools continue to balance the encouragement of individuality and self-direction with the development of interdependence and empathy’. The teachers within this framework are increasingly prioritising an holistic, aspiration-centred approach to studies, with a regular programme of dream identification, setting and exploration. By ‘dream’ we here mean professional and personal life goals. Such an investment in the emotional and life-sustaining role of aspirations (from Latin nominative aspiratio meaning to ‘breathe in’) will surely create a generation of citizens aware of who or what they wish to be in the present and on-going.

Moreover, there is synergy between health and education – if you want to have an influence on one you have to be cognisant of the other. Sustainable Development Goal (SDG) 3.7 (‘by 2030, ensure universal access to sexual and reproductive health-care services, including […] education’), 4.4 (‘by 2030, substantially increase the number of youth and adults who have relevant skills, including technical and vocational skills, for employment, decent jobs and entrepreneurship’), and 4.7 amongst others all link education and equity in health. This is situated within a mass of literature on the social determinants of health across the live course, often projected to the year 2030; the end-point of the SDGs and the focus of UCL’s Centre of Longitudinal Studies Countdown 2030 project.

Image Credit: A Bow-Bertrand

Image Credit: A Bow-Bertrand

It can therefore be shown that education is a good vehicle for health improvement globally. There has been a rapid expansion of education across the world since 1970 and health is increasingly part of the core business of schools. In their systematic review of adolescent health and adult education and employment, David Hale et al found that poor health in adolescence predicts 25% to 72% greater odds of lower attainments or NEET (not in education, employment or training). Put simply, health predicts gains in attainments and life chances across adolescence and into adulthood.

Visual source: UNESCO Institute of Statistics

‘Global Education Levels’. Source: UNESCO Institute of Statistics

It could be argued that what appears to be globally lacking is a pre- and adolescent (definable as the the start of puberty to acquiring a stable position is adult society) awareness of the world and aspirations that locate themselves within a non-individual, and even non-ethnographic locus. The MCS recorded scarce awareness of climate change nor career aspirations of ‘environmentalist’ or ‘geologist’. Indeed, even ‘politician’ ranked low on the career list suggesting an introversion of vision and energy. But the picture is not quite so transparent.

Indeed, researchers Helene Joffe and Victoria Zeeb are studying the aspirations of connectedness and autonomy of Millennial [defined here as anyone between the ages of 18-30] city-dwellers. Against the background of an urban environment (with correlating positive and negative influences) they have sought to dispel findings from research such as Twenge, 2013 and the below cover of Time Magazine that suggest Millennials are narcissistic and self-entitled citizens.

Image reproduced with permission from time. Cover photography: Andrew B. Myers

Image reproduced with permission from ‘Time’. Cover photography: Andrew B. Myers

Their work indicates that connectedness plays a key role in Millenials’ envisioned futures and is crucial for their wellbeing. Moreover, they report that simply the act of aspiring to ‘connection’ (familial, companionship, weak ties: ‘relationships involving less frequent contact, limited intimacy and minimal emotional intensity’) is linked to wellbeing. Such data does not bear out studies showing Millenials to be self-orientated. Instead, Generation Y aspire to ‘connection’ in the same manner that non-millennials (cohort X) did, but they are different in forming weak ties in the workplace rather than within the community (these are becoming increasingly harder to form and safeguard within urban lifestyles and aspirations) which may be detrimental to wellbeing in the long-term.

Of course, dreams are not merely the domain of the youth of today, nor are they the reserve of the privileged, developed world persons. I would argue that every human has some aspiration referent whether that be to acquire a safer settlement as Hans Rosling identified amongst the families living in absolute poverty in this podcast, or those who seek to earn a postgraduate qualification. Even Kanye West has dreams. They are the very substance that gives our lives meaning and, sometimes, purpose. Putting this meaning into practice might become more challenging as one ages but at every stage of the life course our mental and physical wellbeing can be embraced through a process of ‘dream’ recognition.

I recently attended a ‘what I wanted to be when I was younger’ themed 25th birthday party. Of the aspirational careers that studded my childhood (figure skater, Post Office sorting officer, lighthouse manager and doctor), the latter loomed overwhelmingly large. Donning my old scrubs and borrowed stethoscope I realised I was typical of the Millennials in having regularly changed my life aspirations during childhood, but I was unusual in initially pursuing medicine as a profession (only 30% of adults are expected to be working in the career area their 7 years old selves identified as number one choice, and the figure is much lower in other studies).

My dreams changed and will no doubt continue to shift and develop. So will those of my fellow party-goers. From clowns to athletes, celebrities to teachers, such aspiration must be consistently celebrated, addressed and, arguably, pursued at regular stages in life development. As Rudyard Kipling advocates in his infamous poem ‘If’: ‘if you can dream – and not make dreams your master’ from childhood onwards, then the next generation of professionals and global citizens will enjoy a healthy self-reflexivity of understanding and ideology.


Image Credit: Airwolfhound, Flickr

The Economy in Health

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. (Attributed to Margaret Mead)

Recently I heard Professor David Taylor  of UCL speak for fifteen minutes on the far from limitable topic of the ‘economy in health’. Choosing to break his exploration into a tripartite structure that: 1. considered economy as the driver of increased longevity and greater wealth 2. associated with the emergence of universal health care systems and 3. the knock-on threats to and opportunities for ongoing improvement in health and wellbeing, Taylor’s talk captured prescient ideas pertinent to us all.

The world’s economy is influenced by the demographic and epidemiological shift (shown below) popularised by sociologist Daniel Bell, which suggests a non-finite post-industrial future in which society has developed to a point at which the service sector generates more wealth than the manufacturing sector in an economy. In the UK,  we have already arrived at this post-industrial stage, which is definable not only in terms of economy but also in relation to relatively low birth and death rates.

Demographic and Epidemiological Transition in Western Europe


Visual courtesy of StudyBlue.com

As discussed in a recent MdM article on the Sustainable Development Goals which continue to prioritise reducing infant mortality, the social consequences of this and also of increased adult longevity (i.e. reduced mortality) are numerous. Indeed, Taylor linked this trend to more equal gender roles at home and in work, more intense patterns of child care, a rise in average IQ levels, the rise (and fall) of professionals such as pharmacists and doctors, changing international relationships, the evolution of universal health care systems and improved life opportunities for people with disabilities and for older people. Of course, the reality and feasibility of such consequences is material for a completely separate discussion, but such projected outcomes are useful in further exploring the role of economy in health, and vice versa.

While more children than ever before are surviving beyond 5 years of age, 2015 sees fewer children being born and national level introduction of incentives to revive something of the baby boomer generation. Indeed, as of earlier this year, China has lifted its one-child only policy in part to augment the fertility rate (births per woman) to support the ageing population the world over. For it is not problematic in terms of health related treatments and care that the population is ageing per se, but rather that there are insufficient working age individuals to carry out these services. Meanwhile, the graph below shows that in under 50 years, the percentage of the UK’s population aged over 65 doubled from 7 to 14%. More recent statistics from the United Nation’s 2003 report on World Population Ageing show that this process is accelerating.

Kinsella K., He W., An Aging World: 2008. Washington DC: National Institute on Aging and U.S. Census Bureau, 2009.

Source: Kinsella K., He W., An Aging World: 2008. Washington DC: National Institute on Aging and U.S. Census Bureau, 2009.

Such trajectories demand questions of what drives health improvement, what are the most important threats and opportunities facing us today, and specifically relating to Kinsella’s graph, how well has the world done in achieving continued improvement in health and wealth or welfare since the 1940s?

There are many ways in which to address such questions, appropriating both post-modernist and historical ideas in particular the philosophical argument proposed by David Hume’s ideology of economic growth focusing on what we now term ‘demography’ and ageing. In Political Discourses (1752), Hume sets out a case for modern populations being larger and wealthier and refuted the idea of more powerful ancient governments and peoples. For Hume, the modern age and its peoples were better off, enabling more people to survive and exist with a better level of socio-economic wellbeing. Now considered iconic for being included in his volume of political-economic (Essays, Moral and Political) writings, his work pioneered demography as a factor in economic analyses, and is commonly incorporated in such work ever since, as Professor Roger Emerson notes.

Looking in more detail at the role of economy in health in 2015, it is apparent that globalisation is at a cross roads. While local trade talks are in confusion, multilateral talks gain ground (such as the Comprehensive and Economic Trade Agreement between Canada and the European Union), so threatening to introduce a further wave of privatisation in key sectors such as health and education as public services and government procurement contracts come under competition from transnational corporations. Liberalisation, deregulation and privatisation have caused disarray at the local level.

Meanwhile, trade agreements (such as the Transatlantic Trade and Investment Partnership), while positive in providing access to new markets for those products that can compete in the global economy such as commodities from China, Brazil, Thailand and South Africa, can have negative consequences on health. Indeed, as poorer producers are exposed to extraordinary competition from more efficient counterparts both locally and internationally, they are forced to restructure or fold which in turn erodes preferences in the the third market again with knock-on effects for health. For instance, intellectual property such as patents frequently conform to rules that favour corporations over patients which sees access to medicines under serious attack.

These challenges to health improvement and the economy of our age can be fundamentally addressed by what Mead calls ‘committed citizens’; able to critique data, assess projected trends and propose solutions. Some potential actions include transitioning from trade talks to a prioritisation of environment-centred policy with the complementary introduction of educational and training policies such as Mexico’s sugary drink tax.

Such measures, while new and therefore subject to future assessment, aim to manage the growing cost of dietary related disease which is one of the biggest changes happening globally with fluctuating prices (healthy items are costing more), changing availability and access, shifting food culture, corporate domination and impacted health services.  Both at the delivery and ideological levels, one must always ask: who is in control of my health and economy? We must vote with our feet and actions, electing to create a sustainable and healthy economy for both the current and future generations.


Image Credit: AMISOM Public Information, Flickr.

MdM Talks: Daniel Flecknoe on Darfur

Daniel Flecknoe is a Specialty Registrar in Public Health and a senior tutor at Leicester Medical School with over a decade of emergency nursing experience across the South of England and overseas. He worked with a mission team for Médecins Sans Frontières (MSF) in Northern Darfur between 2008-2009 at a critical time prior to the retrospective identification of this zone by the International Criminal Court as a genocide situation.

While there he was also involved in health education, teaching and training for the local nursing team which demanded making information context appropriate. For instance, one of his most memorable teaching sessions discussed the differences between sympathy and empathy and he relates the satisfaction of finding a common inter-cultural understanding of these concepts with the local staff via an Arabic interpreter.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe (Dan second from right, front row)

How can MSF communicate and deliver aid with integrity in hostile and complex humanitarian situations? By extension, when does one identify that a field mission and its aims have become untenable?

Fundamentally MSF is a non-partisan organization which operates for the benefit of all those affected by conflict and emergency situations. But not taking sides can cause it’s own problems in maintaining safe access to those who need medical care. For example, the MSF Kunduz hospital, which was recently bombed by coalition forces treated wounded Afghan Government fighters, wounded Taliban fighters as well as sick and wounded civilians, Treating enemies can be a very tricky affair, and working on a shifting frontline makes it hard to keep the service running, let alone to stay in all sides’ good books. Unfortunately, the rules of war regarding the rights of injured combatants to treatment are not always respected, and humanitarian organisations can become a target. It is getting harder and harder for humanitarian groups to operate in places like Syria, Afghanistan, Iraq, because the warring parties do not abide by their obligations under international law to let them do so safely. This is a matter of very serious concern.

My current interest is in the primary prevention of armed conflict, and how healthcare professionals can get involved in this effort, but it is very clear to me that MSF and similar NGOs will always be required. Somewhat like A&E departments, however much we all agree the demands upon them need to be reduced by prioritising preventative health measures. Even if we get much much better at the primary prevention of armed conflict, there will still be a global need for humanitarian work.

When to withdraw from a situation is always going to be a bit of a judgement call, and often a very traumatic one for people who have put their heart and soul into a project. You have to consider the way things are trending, so a one-off event such as an armed robbery may not be enough in isolation, but cumulatively, as part of a general escalation in violence, it may warrant the withdrawal of an NGO from the area.  Of course gradual change can be difficult to detect, so it is sometimes easier to assess the situation with external or fresh eyes. MSF capital teams take on the role of wider security and contextual surveillance while the project teams on the ground focus more on the situation in front of them.

Some people think of humanitarian aid work as a wholly positive endeavour, but there are situations where it is possible to unnecessarily endanger yourself, or to do more harm than good. Prospective aid workers should be aware of the necessary compromises and contradictions, issues of wrongly imposing our own values, culturally-relative medical definitions, advancing the interests of Big Pharma, and confronting White or Western privilege, which may be brought up by the experience of working overseas with an NGO. 

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe


Image courtesy of D. Flecknoe

In terms of being heard, how can indigenous care providers best receive coverage and credit for their work?

Their stories definitely deserve to be told, and their hard work recognized. Unfortunately I don’t think that such stories would sell very well in the Western media, because we (as a media-consuming population) are generally more interested in stories about people like us doing things that we would not normally do. […] Unfortunately this means the amount of column inches that someone will get does not correlate to the amount of good work that they have actually done because they don’t fit the right demographic to generate media interest. I don’t think this is really a racism issue; it’s like the prioritization of stories that you see in local news […] we are all drawn to narratives that pertain to us in some way. Nevertheless it remains an injustice, in terms of media coverage, done to a lot of indigenous aid workers who do a lot of difficult and dangerous work.

NGOs don’t always do enough to promote the stories of their indigenous staff because their priorities include, of course, fundraising. Personally I consider myself as an international volunteer for MSF to be much more useful on my return from missions in terms of spreading the word and raising awareness, and for me that definitely includes representing my brave Darfurian colleagues.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

One of the supposed changes between the Millennium Development Goals and the Sustainable Development Goals is the role of UN member state or country level actioning of goals. But what about those goals that require cross-country efforts? How should these be coordinated?

The public health experience on behaviour change at both the individual and the population level seems to show that giving people information, especially when it is unpleasant information often doesn’t work. People tend to block it out […] and not identify with it. We are pre-disposed to accept pleasant information, which is congruent with what we already believe or how we already behave, and reject the unpleasant information. The “Nudge” concept in public health takes a different approach, byincentivising positive health behaviours and de-incentivising negative behaviours without banning or limiting or criminalising anything. This makes it easier, cheaper and more appealing to make healthy choices, and the technique may also have some wider democratic applications. For example, as citizens it is possible to make global health and human rights into political priorities through our votes and democratic engagement. We all have the power to incentivize political change in our countries towards peace, equity and positive health care policies through democratic action, and I would encourage everyone to consider how they can contribute to the goal of making their country not only a better place to live, but also a more ethical actor on the world stage.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

What do you think is the priority of the sustainable development agenda?

The most pressing imperative for me right now is promoting and also reinforcing the responsibility of warring parties to prioritise the health needs of the civilian population […] Whenever that doesn’t happen I think it is deplorable, because while it is easy for political actors to get bogged down by their own priorities, the health and safety of the civilian population should always be paramount [… They] have a right not to have their health impacted because of political goals being pursued by violent means, however pressing those goals may be.

I don’t mean that humanitarianism is automatically a pacifist philosophy. Prioritising humanity does not necessarily exclude supporting military interventions sometimes. There are circumstances where you could advocate a military invasion on humanitarian grounds. It’s not unthinkable.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

You said preventative medicine should be the focus of future MSF work. What does this mean in practice?

I’m not sure that this is a job for MSF. MSF has its own sphere of competence and expertise, and as Jose Bastos recently said, humanitarian action is a visceral impulse, motivated by outrage and empathy. That is not at all the same as primary prevention.

I could use the analogy of parenting (and bear with me here, because I am not a parent). Obviously as a parent you would be motivated to reduce the risks to your children, to forbid that dangerous playground or this unsafe skate park. That’s primary prevention, and it’s incredibly important work. But you would also be driven to hold them on your lap and give them caring first aid for the wounds they have already received, which you cannot prevent because they have already happened. That’s humanitarianism, and they are two separate fields, which I happen to have a dual interest in.

Primary prevention in this case requires tackling the root causes of armed conflict – stopping them before they get started, in other words. MSF is focused upon the tertiary prevention of armed conflict – minimizing the collateral damage.  But either way, it’s important for healthcare professionals to have a voice at a political level, and to advocate for the universal right to health and security.


Image courtesy of D. Flecknoe

So why public health rather than global health?

I don’t think that there necessarily needs to be a distinction. Public health in the UK already has to cross inter-professional boundaries, and we have to engage with people across the spectrum of disciplines if we are to tackle the root causes of health problems. For instance, in the case of TB coming back into high prevalence in some parts of this country [UK], it isn’t just about screening immigrants, it is about housing, deprivation, overcrowding and other social and political issues not traditionally within the domain of health […] As public health professionals we have to get involved across the spectrum in order to address the problem.

Just raising our focus from the local, we can see the same interconnectedness requiring a broader view and engagement at the global health level. Climate change, armed conflicts, political instability, infrastructure breakdown – all of these things, which predominantly directly impact on other parts of the world, will also have an effect on the health of the UK population if they are not addressed. Whether through mass population movements, interruption of food supplies, exported diseases, we will feel the effects here. There were incredibly pressing humanitarian reasons to fight the Ebola outbreak in West Africa, for example, but there were also selfish reasons, because we live in a globalized and interconnected world where you can’t just close the doors to your own country and expect to stay safe. Western countries had to get involved with tackling Ebola at the source, because they couldn’t afford to let it spread further.  I would prefer that the humanitarian motives were more dominant, but if self-interest ultimately motivates the right course of action then,… well, I’ll take what I can get!

It’s commonly and rightly said in my profession that “there is no health without mental health”.  It’s very true, but I would also say that in the longer term there is no local health without global health either.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

What key learning from operational work with MSF could you pass on?

It’ll probably be different than you expect. It’s not a rescue mission. The main goal of Western aid workers, as I see it, should be to learn as much as possible from their local colleagues who have far more experience and who know the culture and context better than we ever will. Our job is to support them as best we can, and to come to terms with the fact that we may be of more assistance to them and their struggle once we return from the field. While you’re out there, you can definitely be useful, applying and sharing the medical skills and knowledge that you’ve been lucky enough to gain through your education. You also demonstrate solidarity with them and their cause, which is a valuable and important thing. However, once back home you can bear witness to what you have seen, and be involved in raising awareness and money for their ongoing efforts, and in some ways that is the best thing that you can do for them.

Image courtesy of D. Flecknoe

Image courtesy of D. Flecknoe

Where next? 

At the moment I am professionally focused on my public health training, although in my own time I can also pursue projects which have an international and conflict-prevent slant. I would also like to work with MSF again in the future because it is an organization that I really love and respect. I get very uncomfortable with simplistic portrayals of aid workers as saintly and selfless altruists, because that’s not really me, and I’m sure many of my colleagues in the field would also dismiss such one-dimensional stereotyping. People are complicated, and we do this work for a variety of reasons […] There are certainly many reasons why I want to do it again, some of them selfish and some of them less so.  But working with MSF was one of the most satisfying things that I have ever done, I benefitted from it enormously in terms of my personal resilience and capabilities, and I think with the benefit of my public health experience I’d probably be better at it now too.  Maybe I also want to have some good stories to tell my grandchildren!’.

Going back to MSF may also help me to clarify my ideas about a possible synthesis of humanitarianism and primary prevention, which at the moment seems to me to be an interesting and important area of work to get involved with.

Fundamentally, aid work is about coming to terms with what you can do and what you can’t and what you might have to sacrifice along the way […] It is like fighting massive forest fires with buckets of water. It absolutely has to be done if you’re going to save even a few houses from the flames, and it can look sort of heroic while at the same time being massively inadequate to the scope of the problem. As a species, it is incredibly important that we devote more energy to preventing these fires from burning out of control in the first place. 

Narratives of globalisation

Is globalisation good for the health of populations?

Any such question demanding a response of limited scale must be caveated as an inquiry that cannot be determined definitively nor conclusively. Moving away from the universalities invited by the terminology of this question, we turn instead to a recognition that globalisation is a process occupying an historical trajectory in which this discussion must also position itself. Globalisation as a concept and word is the creation of a post-modernist age; one in which the ‘-isation’ suffix captures this sense of process. Fundamentally, globalisation is not static. Nor is it necessarily easily recognisable or identifiable at any period point. Rather, it is a steady process of assimilation and absorption akin to the commonly cited parable of the frog who leaps into then immediately out of a pot of boiling water, but which reaches a hot and messy death when it finds itself in cold water that is then heated. The nature and matter of globalisation has been the prompt of much academic discourse over the past quarter century since it was identified as a worldwide trend that is contested and characterised through cultural, ecological, economic and political dimensions. As Allen and Skelton (2010) have noted, since the mid 1980s people have become ‘fascinated by their interconnectedness variously considered through matters like the radical changes in financial transactions […while] other scholars have viewed globalisation as a more pervasive phenomenon which is transforming, or may be about to transform, virtually everything’ (Allen and Skelton, 2010, p.1). Globalisation is the flow of commodities, currency, health provision, technology and systems of belief. It is simultaneously a process and a condition. With such a macrocosm of effect and possibility, this consideration will map globalisation’s documented benefits and disadvantages to the health of the world’s citizens, before narrowing to a consideration of identity. Inextricably bound up in an anthropocentric sense of self harkening back to Descartes’s concept of ‘cogito ergo sum’ (Voss, 1993), is a psychobiosocial construct, which at both individual and collective population levels is subject to erosion due to globalisation’s potential to alienate, marginalise and mutate. The attention paid to mental health conditions has emerged almost simultaneously to globalisation, and affords an interesting parallel in this discussion.

Globalisation has now distanced itself from early associations with a neo-colonial concept of Westernisation (Steger, 2009), and is increasingly seen holistically as a process that may benefit the health of a significant proportion of the world’s population through monetary re-distribution and sharing of medical services, techniques and professionals. However, the UN Secretary-General Ban Ki-moon’s adage associated with the Sustainable Development Goals (SDGs), of ‘leave no one behind’ (Anderson, 2015) indicates that populations have been – and could continue to be – excluded from these processes. Globalisation’s impact on health can be traced along two frequently converging trends: on the one hand, since the Renaissance and its precursors through Industrialisation (Steger, 2009) it brings a rapid dissemination of new health conditions and sees the re-emergence of previously contained diseases such as tuberculosis or Ebola. On the other, improvements in biomedical technology prioritise preventative medicine evidenced by the current focus of the Global Vaccine Alliance which is stockpiling Ebola vaccines as a preemptive measure for a relapse (GAVI, 2015). Comparably, globalisation seeks to absorb every nation state within an overarching economy whose very sustainability is questionable in the absence of a worldwide system of governance. Notwithstanding the World Health Organization’s (WHO) apparent global guidance on health provision in the current and future ages, countries and their governments are not answerable in practicable ways and WHO’s methodology is open to critique as Richard Howe commented in a recent interview published on MattersduMonde: ‘The problem: the nature of WHO leadership. Bureaucrats, medical doctors and academics take the lead in an operational matter […] treating the symptoms while ignoring the problem’ (2015). The result is a collection of national silos attempting to out-compete the global economy often with damaging effects on health in terms of job loss, reduction in self-esteem and associated physical health deterioration. One might consider such victims of globalisation to be those of the developing world, the disabled, those who cannot triumph in Charles Darwin’s ‘survival of the fittest’ system (Francis, 2016). But, as Allen and Skelton note, ‘marginalisation is not simply a matter of being on the fringes of the global economy. It includes those at the heart of the system too’ (Allen and Skelton, 2010, p.72). Globalisation seeks to introduce an Orwellian ‘1984’ style surveillance of peoples and habits, but, inadvertently, hiding places are created through time. As people change identities, cross boundaries, seek refuge or are forcibly subject to witness protection schemes, the traditional sense of citizenship is lost as populations are increasingly definable by mental health conditions, at times linguistically becoming the only labels to be certain of.

It may appear anachronistic to here appropriate the final stanza of Simon Armitage’s poem True North, but it registers these considerations:

As the guests yawned their heads off I lectured

about wolves: how they mass on the shoreline

of Bothnia, wait for the weather, then

make the crossing when the Gulf heals over (Armitage, 1992).

Framed within a dinner party setting, the activity of lecturing conveys a sense of exchange of cultural ideas, contextualised within a geographical locus subject to transitions in capital, climate and personnel. The lexicon of ‘heals’ prioritises a globalisation that affects the individual, the local and the ability to be damaged and restored through change. Migrations of both peoples and aspects of their population has seen writers such as Steger pronounce the rise of ‘a borderless world [in which] hyperglobalizers [sic] seek to convince the public that globalization inevitably involves the decline of bounded territory as a meaningful concept for understanding political and social change’ (Steger, 2009, p.63). In this view, the ‘crossing’ of Armitage’s poem is a transition from the current standpoint to a place of financial and personal improvement enacted both through the physical performance of spatial transition and documentation. This imperative is not new. F. Scott Fitzgerald’s ‘The Great Gatsby’ (TGG) struggled to quantify the abstraction of the so-called ‘American Dream’. This novel sets itself up to be about money. Indeed, ‘money’ (that is to say the medium of exchange which defines the economic stock of a nation, in this case, the US) is the explosive trigger of the narrative – Nick Carraway moves to New York with the view to learn about the bond business. But like a gun, once the trigger has been pulled, the ensuing movement of bullet through time and space into an ultimate site of rest points to an inescapable demise or corpse. Fitzgerald’s personal and fictional experience of modern America was as a nation that promised unlimited possibility and immortality; an almost fantastical offering which people could literally buy into through activities on Wall Street, or by emigrating and identifying themselves as one of the denizens of the Americas. What TGG’s superficial story of love and loss parallels is how the American dream and money are interconnected and that the commodification and marketplace of that dream could be destroyed with or without record. The larger meaning of TGG lies within the failure of a nation to deliver on its promise of globalisation or, perhaps, of its citizens to create and fulfill the possibilities offered.

Steger writes ‘globalization [sic] refers to the expansion and intensification of social relations and consciousness across world-time and world-space’ (Steger, 2009, p.15). ‘Expansion and intensification’ are linguistically problematic, setting themselves up to be compatible but being oxymoronic. This is the very nature of globalisation – able to enact progress while simultaneously erasing standards of prior progress and well-being. Of course, TGG ends within a field of regret, not so much for what has happened, but because of a persistent unwillingness to acknowledge that the dream is not only void, but has literally been trampled underfoot with the ultimate limitations to health: suicide, addiction, mania. This is not universally the case in globalisation, but the frequency of stories of the individual, dislocated national experiencing mental health perturbation or restlessness is all too common. Indeed, we can continue this exploration in Manhattan, the birthplace of the infamous Brandon Stanton’s ‘Humans of New York’ photojournalist blog. Stanton’s original plan of ‘taking 10,000 street portraits to plot on an interactive map, creating a photographic census of the city’ (2014) has become a dynamite combination and has recently taken him to Iran to document life there. Back on American ground, he recently blogged the following:

Paul Ambrose, HONY

Notwithstanding the uncertainty regarding why Paul Ambrose has been unsuccessful in acquiring a new ID or whether he identifies as mentally disturbed, the coincidence of this event twenty years ago with his assumption that he does not exist is fascinating. Globalisation seeks to homogenise and diminish cultural plurality, yet it still demands classification and personal registration to identify as a citizen. Identity is a critical part of being a participant on the global stage, and not be forgotten within it. The account of transactional choice between New York and California, triggered by the decease of Martin Luther, a figure of difference yet seeking to be part of an equal future world, is evidence that every person, whether mentally cognescent of being so, is involved in globalisation, figuratively buying their way into and out of it. Psychologically it is, of course, important to acknowledge that mental disorders are related to a ‘quality of social environment […making it] difficult to predict the impact of globalisation on the prevalence and course of psychiatric disorders. What is certain, however, is that mental disorders can no longer be dissociated from the global context that frames our lives’ (Bhugra and Mastrogianni, 2003, p.10).

This all begs the question, ‘what is the sum impact of globalisation?’. As noted by Dollar in the Bulletin of the World Health Organization, ‘different sources of globalization [sic] have different impacts on inequality’ (Dollar, 2001, p.228). Inequality can present itself across fields of health, justice and individual freedoms. Globalisation is a process that is unlikely to be halted and that will continue until the resources and populations it employs and impacts reach an optimal point of health but will, surely, lead to crisis. It will take the health of populations only so far along the path of Amartya Sen’s development as freedom, as ‘the threat to native cultures in the globalizing [sic] world of today is, to a considerable extent, inescapable. The one solution that is not available is that of stopping globalization […] since the forces of economic exchange and division of labor are hard to resist in a competitive world’(Sen, 1999, p.240). This competitive world will win some health battles and lose others, with the alarming possibility of seeing populations ‘massing along the shoreline’ between liminal states of mental health and illness, physical firmity and deterioration, cultural history and dislocation.



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BHUGRA, A. and MASTROGIANNI, A. (2003) Globalisation and mental disorders: Overview with relation to depression. The British Journal of Psychiatry. [Online] 184 (1), p.10-20. Available from: http://bjp.rcpsych.org/content/184/1/10. [Accessed 11th November 2015].

DOLLAR, D. (2001) Is globalization good for your health? Bulletin of the World Health Organization. [Online] 79 (9). p.827-833. Available from: http://www.who.int/bulletin/archives/79(9)827.pdf. [Accessed 9th November 2015].

Figure 1. Paul Ambrose (2015) [Photograph]. Available from: http://www.humansofnewyork.com. [Accessed 1 November 2015].

FITZGERALD, F. (1998) The Great Gatsby. London: Penguin.

FRANCIS, K. (2006) Charles Darwin and The Origin of Species. London: Greenwood Press.

GAVI. (2015) Gavi to support rebuilding of immunisation programmes in Ebola-affected countries. [Online] Available from: http://www.gavi.org/Library/News/Statements/2015/Gavi-to-support-rebuilding-of-immunisation-programmes-in-Ebola-affected-countries/. [Accessed 10th November 2015].

HOWE, R. (2015) MdM Talks: Richard Howe on Malaria. [Online] Available from: https://mattersdumonde.com/category/mdm-talks/. [Accessed 6th November 2015].

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VOSS, S. (1993) Essays on the philosophy and science of René Descartes. Oxford: Oxford University Press.

Image Credit: The gaze of  Dr. T. J. Eckleburg, The Great Gatsby. Ciaran Roarty, Flickr.

Setting Goals: from Vision to Action

Since the release of the Sustainable Development Goals, 2015-2030 (SDGs) in mid September, the ensuing weeks have been studded with discussions addressing how to shape these targets into practicable actions that will effect meaningful change. This month, the annual UCL Lancet lecture invited guest Ms. Amina J. Mohammed (Special Advisor of the Secretary-General on post-2015 Development Planning) to speak on the new universal SDGs for 2030 with the catchphrase ‘from vision to action’.


Cruciform Lecture venue. Image courtesy of A. Bow-Bertrand

What does this emotive punchline really mean? It is here useful to revisit the precursor Millennium Development Goals (MDGs) from which this sustainable development agenda has arisen. Although widely berated for being static and failing to reach imposed standards, the culmination of the MDGs heralded some success stories. Fundamentally they represent the first instance of global partnership at a time when there was no common framework for global health promotion.

Indeed, over the past 20 years child mortality (dying before the age of 5) has been reduced by almost half. Arbitrarily this means about 17,000 children are saved every day. Meanwhile, globally, the maternal mortality ratio decreased by 45 per cent between 1990 and 2003. In terms of a disease specific result, the former World Health Organization (WHO) funded Roll Back Malaria Partnership has identified the fight to eliminate malaria as the cite of great progress. Indeed, between the millennium and 2012, an estimated 3.3. million deaths from malaria were averted due to substantial expansion of interventions and prophylactic programmes.

Notwithstanding these burgeoning successes, the MDGs did not stand the test of time across the board. Over their duration, economic growth demanded reactive targets that accommodated inflation and trend analysis neither of which were implemented at a functional level. More importantly, perhaps, it is important to identify that what the policy-makers of the global community identify as MDG achievements are not necessarily representative of the opinions of country-level governments or civilians.

Any assessment of the MDGs and approach to the SDGs must be, as Sir Michael Marmot remarked upon publication of his latest work The Health Gap: the challenge of an unequal world, ‘culturally relevant’. To this one might add temporality and context dependent. After all, it is tricky to assess the achievements of the SDGs from our current 2015 standpoint. Instead, we must hold them to account in relation to their millennium world inception.

Image reproduced with permission from Bloomsbury Publishing

Image reproduced with permission from Bloomsbury Publishing

The transition between the MDGs and the SDGs is not necessarily clear-cut and there is merit in considering the SDGs as unique goals constructed out of their time and its demands. With 17 goals, one might question whether they are sufficiently specific but, as Mohammed noted, given the many existent worldwide health dilemmas and inequalities this is, in fact, a strongly condensed working pool.

Reproduced with permission from the UN

Reproduced with permission from the UN

These goals increasingly apply to developed countries, prioritising inclusivity of all UN member states and accessing hard to reach populations from the goal-setting process onwards which attempted to hear the voices from every societal strata. The transformative agenda of the SDGs looks at how to reach those most often forgotten while feeding a growing economy. Mohammed suggests: ‘we are not subject to the budget; we are the budget’, and as such we must be agents that simultaneously propel concrete action while protecting human rights.

In spite of the single goal pertaining solely to health (Goal 3: ensure healthy lives and promote well-being for all at all ages), the SDGs are collectively co-dependent, aiming to facilitate human and animal health in our world for the long-term. This agenda is the most ambitious yet, being simultaneously conscious of approaching development through synergistic and interdependent methods while recognising the limitless nature of setting environmental targets (something Mohammed is herself just coming to terms with following her surprise recent appointment as Environment Minister for Nigeria) alongside economic, partnership, and infrastructure aims.

The SDGs are about more than just ending poverty (Goal number 1: end poverty in all its forms everywhere); they are increasingly ‘planet sensitive’. The segue from the MDGs to the SDGs is marked by a question of ownership. No longer is this agenda the elitist property of the government. This time it is owned by the people, with targets of health for all everyone’s very personal business.

Which goals will be prioritised at country-level cannot be definitively predicted. Country governments will focus on laws and policy-making that best pertain to the most pressing or controversial needs of their nation. Local political concerns will always trump the comparatively vague, aspirational non-context specific ideas of the SDGs. This demands a creative engagement in the goals that transcends their terminology and content bounds. Comparably, Mohammed advocates talking about health and how it informs the goals rather than focusing on it as a discipline to which only goal 3 is immediately derivative.

Indeed, the SDGs are novel by responding to the United Nation member states’ express wish to manage things at the domestic level as part of a ‘global village’ which overwrites the divide between the ‘North’ and ‘South’. The SDGs seek to move from vision to action by addressing global economies and the social agenda beyond national borders guided by Secretary-General Ban Ki-moon’s fluid rather than prescriptive agenda which valued context specific goal setting.

The Financing for Development workplan that was agreed at the Third International Conference held in Addis Ababa, Ethiopia considered mobilisation concerns. More than ever before, if the SDGs are to be operational rather than merely aspirational, government expenditure that goes into leveraging the capital economy will need to  be supported by other monetary flows . ‘The financing framework of Addis Ababa is [according to Mohammed] doable’ and will raise awareness of the necessity of smart investment and seeing the SDGs and their achievement as more than just corporate social responsibility.

Mohammed concluded that ‘we have a shared responsibility and a shared future. […] It is about an international justice for peoples. The SDGs are transformative by showing that business as usual  is not possible on the development pathway’.


Mohammed in discussion. Image courtesy of A. Bow-Bertrand

MdM regularly prioritises work and figures that reflect the experience of the humanitarian context. Therefore it is pertinent to ask whether the humanitarian field can be addressed in the SDG 3. This question is still being addressed. The challenge to answering this in practice and conceptually arises from how to mobilise governments at the local level to make achievable change through sustainable action. Country-based planning over the short and long-terms will perhaps indirectly meet or absorb the priorities of the humanitarian context.

However, the most salient take away message from Mohammed’s lecture was that the SDGs must be fit for purpose: able to create an actionable plan for the modern world. To be temporally appropriate, a Data Revolution is an absolute priority. If we say that we do not want to leave anyone behind then we must consider where they are and who they are. Mohammed highlighted that we do not have comprehensive baseline data of peoples or fixed global indicators to measure development. Their acquisition will be essential, and will demand strategic and weighty investment enabling countries to measure their own development at a local level supported by global leverage.

By looking inwards, the vast and often disparate global health community can reflect on success stories and move forward through action, investment, and accountability. 


Image Credit: Nana B Agyei, Flickr.

Health in Conflict Zones

A few weeks ago I attended ‘Heal The Word: Many Disciplines, One Goal’ conference hosted by UCL Medsin. One of the central plenaries was titled ‘Health in Conflict Zones’ which afforded a useful sounding board for thoughts and reactions I have received second-hand from professionals with experience in active and post-conflict areas. Conflict is here identified as any singular or succession of events that threatens the well being and physical or psychological health of a population, whether pertaining to an internal or external cause.


Conference location: The Cruciform building overlooking UCL Main Quad

There were two remarkably insightful responses to this theme from namely:

Dr Ang Swee Chai who asked: ‘who is it that defines [terror and a] terrorist’? Based on her experiences as both an orthopaedic surgeon at St. Bartholemew’s Hospital, London and the conflict zone of Gaza in the State of Palestine, Swee Chai reflected that war is constructed by air (‘bomb the hell out of everyone’) with a secondary wave of territorial invasion. She went further, asking whether it is a doctor’s job to speak up in a conflict situation. One school of thought asserts that health personnel are there to be passive providers, avoiding any self-expression that might jeopardise their ability to provide healthcare and relief aid. She argued that, as advised by the principle of ‘témoignage’ advocated by Médecins Sans Frontières (MSF) amongst others, that yes, they absolutely should.

Based on discussions I have held with professionals engaged in both preventative and crisis relief work, I would concur in most instances because global awareness of the truth and reality of what is going on in notoriously under – or worse, falsely – reported conflict situations, will invariably mobilise greater humanitarian and political action than keeping one’s head down and functioning to the best capacity within a framework of oppression and censorship. Kate Winslet’s performance in Contagion (2011), while remarkable for its artistic performance, is a creative engagement with these often contradictory pressures of vision and action. Swee Chai considered the anthropocentric quality of medical professionals, noting that the future heralds robots and technology that can practically carry out the same technical job, to a possibly better standard, than health professionals currently can. What these artificial doctors will lack is both the human heart and compassion to identify and raise awareness in instances where human rights are violated. 

Dr Ang Swee Chai. Image reproduced with permission from Tarek Charara/Kaleidos.

Dr Ang Swee Chai. Image reproduced with permission from Tarek Charara/Kaleidos.

Meanwhile, ex MSF doctor Dr Ana García Mingo asked when humanitarian organisations should intervene in zones identified with a conflict status. I would argue that any intervention should coincide with a recognition that the health or survival or a specific population is threatened. Importantly, García Mingo reminded us that the first thing that stops after any crisis is preventative care, notably routine vaccination programmes. So too, as Daniel Flecknoe, a former emergency care nurse dispatched by MSF to North Darfur at the end of 2008 (he speaks to MdM in a forthcoming post) identifies, local health professionals and staff that are citizens of these zones are often unfairly overlooked and their efforts receive sparse coverage.

Moreover, these individuals are invariably volunteers rarely receiving monetary compensation for their time and efforts because they are problematically acting within country for a third-party aid organisation. The 2009 film ‘Living in Emergency’ features some of these figures. Focusing in particular on settlements of both internally displaced persons and refugees, Mingo further highlighted the critical difference between these very peoples: across borders and between them and, by extension, the difference in the nature of refugee camps and the access of those who cluster in them to both healthcare (from medicines to vaccines) and technology (Internet connectivity and mobile reception).

'Living in Emergency' (2009). Image reproduced with permission from Doctors without Borders.

‘Living in Emergency’ (2009). Image reproduced with permission from Doctors without Borders.

As will be highlighted in my interview with Flecknoe, provision of healthcare in conflict zones is not as straightforward as applying a metaphorical bandage to temporarily stem the flow of chaos, bloodshed and political unrest. There must be a sustainability to any aid provision, with a careful balance that manages the governing factions of any such crisis while consistently focusing on the bigger picture. This large-scale world view will, in the long-term, safeguard lives even if in the short-term it appears to threaten the acute activity of damage control of lives, peoples and places.

Image Credit: UCL Medsin.


In the September sunshine, the trees in the park outside the clinic window shine like yellow and orange beacons. The healthy green of summer has turned to warmer hues, perhaps the trees’ homage to the summer heat that is quickly fading into memory as the cool morning mists descend. The colours are beautiful but I can’t help remembering that those jubilant shades are really a sign of something dying. It’s so noticeable because it’s in such stark contrast to the life and energy of the park-goers; children running around, teenagers shouting their way through games of football.

And as the weeks go on, the leaves will start to fall. As the wind blows and the rain falls and the sun dries the stems, the bright cloak will slip slowly to the ground. And why do I find it disturbing? As I look out on the busy park, day by day, as darkness comes earlier each evening, the trees lay bare their blackened skeletons and there is something morbid in that.

Perhaps what is really disturbing is that no one in the park seems to really notice the change. Life continues with the same vibrant energy: the footballers still argue angrily about penalties, the children still giggle and scream, couples still stop to embrace each other tenderly. No one seems to be put off by the naked, skeletal forms emerging around them. Although, one thing does seem to change; as the trees strip down, the people put on more layers of clothes – coats, scarves, gloves and hats.

Those leafy veils removed, all the blemishes, broken branches and odd entanglements are no longer masked. This is sad to see; it’s certainly far less beautiful and comforting for me than looking out on the beautiful yellow and orange glow. But now that the leaves are down, the tree surgeons can do their work, taking down branches that have grown into unhelpful tangles and stripping back suffocating ivy that has enveloped the trunk. They don’t make the trees immediately beautiful again, but I know they’re doing their best to create the circumstances, once the winter has passed, for all those trees to have the best chance of bursting back into a full and glorious life when spring comes.

Looking back at my computer screen, I see that my first patient today is Autumn. She is seventeen years old and has recently been diagnosed with anorexia. She enters my office for her first appointment, wearing a baggy orange jumper. She smiles nervously at me and I invite her to take a seat next to the window, preparing myself for our difficult conversations to begin.


David Neal. David’s work draws inspiration from his life as a final year medical student. He reflects on the nature of the self, society, health, politics and technology, primarily through flash fiction and short stories: small keys, designed to unlock big ideas and complex worlds of thought. In addition to fiction writing, David was shortlisted for the 2014 Wellcome Trust and Guardian Science Writing Prize. David is an Editor for mental health magazine This Space and is Head of Policy at student-run global health think tank Polygeia. Find him on Twitter: @DavidPNeal1.


Image Credit: sand_and_sky, Flickr