“Western scientific medicine, which has been such a dominant and successful force in the world, is no longer by itself capable of continuing to improve our health.”

That was the conclusion of Nigel Crisp, former Chief Executive of the UK’s National Health Service, after decades serving in the world’s largest health system. His argument is not a dismissal of scientific knowledge, but a sensitive engagement with its limitations, as explored in his 2010 book, Turning the World Upside Down: The search for global health.

A decade ago, Crisp argued for a “paradigm” shift in the way we approach health: treating patients as participants in, not recipients of, healthcare; understanding scientific discovery within social contexts and norms, not over and above them; recalibrating the role of the private sector in healthcare delivery; and measuring health in terms of its outputs, not merely money spent.

Those conclusions came from what some at the time regarded as an unlikely source: low- and middle-income countries which, in spite of scarce resources, had pioneered effective, low-cost, community-based ways of offering quality healthcare without the technology and latest medicines on offer in the global north.

Ten years on from the publication of a landmark text in thinking about global health, Apolitical spoke to Crisp on what has changed since his book first appeared, and whether the world is any closer to an equitable, holistic understanding of global health.

This interview has been edited and restructured for clarity.

What drove you to write Turning the World Upside Down?

Prime Minister Tony Blair asked me, in the 2000s, to prepare a paper on how we could use our experience and expertise in the UK to support health systems in developing countries. My very first realisation was simply that we needed to stop telling people what to do, and start supporting them in doing what they already know.

Brits and Americans and Canadians were turning up in Africa and trying to “sort out their problems” and going about it in totally the wrong way. Good, local people are the experts on what they need.

But the more time I spent in countries across Africa and in India, I realised they had developed many ideas that were immensely relevant to problems richer countries were facing. They didn’t have the same baggage that said, ‘we can’t do this’ because of outdated regulations, or just because it was new.

Then, when I worked with clinicians who had been to work in Africa, they saw huge benefit in different ways of doing things, different ways of thinking. In resource-poor countries, they had to return to first principles. They didn’t have 10 other people to help them make decisions, or the resources they might have turned to back home.

The global south may need more of our clinicians, but we need more of their ideas.

Which ideas?

Some are macro, some are much smaller.

On a grand scale, for example, why after 40 years of saying primary care is the future do we still invest so much in hospitals and so little in primary care? In developing countries, much of the care is delivered outside of hospital settings, and it works extremely well.

On a micro level, it can even be as small as the materials we use. When someone has a hernia, you insert a small grid to hold the tissue together. In some countries, they literally use mosquito nets for that purpose, which cost around a penny a piece.

When those materials were tested alongside much more expensive, clinically-approved materials used in rich countries, the results were just as good. But mosquito nets didn’t meet the medical specification requirements — one of which was being heated up to 100 degrees centigrade, which is rather irrelevant when this is meant to be stuck in your stomach.

What’s impeding those changes?

Institutions breed institutional behaviour, and they breed both inertia and momentum. Momentum in the continuation of their path, and inertia to change. It’s not just a problem of scale, as in the NHS for example, but a problem of institutions in general.

But reforms also run up against economic power bases that are unwilling to give any ground.

There are people who don't want to see changes made, because it will impact on their resources and their income. That’s true in the case of nurses taking on roles traditionally performed by doctors, and it’s true of medical suppliers who make a large amount of money.

In my forthcoming book, I talk about precisely this problem: part of it is power, part is prejudice.

Prejudice in what sense?

There are all kinds of barriers to people accepting innovation from people in low-income countries whose expertise, in a sense, they don't value.

In the US, for example, everyone is catheterised after an operation, which can lead to infection. In South Africa, they only catheterise those who need it, so the prevalence of infection is lower. But when that idea is floated in the States, there’s a sense that, ‘well, that might be ok for poor people in South Africa, but you wouldn’t get away with it here.’

There’s a prejudicial element in whether or not people are willing to accept evidence from elsewhere, and whether they’re willing to trial it.

And at a national level, how can health systems begin the process of reform?

I don’t know — if I did I’m sure I’d be making lots of money as a consultant!

But it’s about changing mindsets, creating an openness to change and a willingness to adapt.

For that, I think you need to back your pioneers. Every organisation has them. They need to be encouraged to change things in every team or every department, and then share their learnings. Those small changes can lead to much bigger changes, if those people are empowered.

(Picture credit: UN Photo/Stuart Price)