Natasha Howard¹, Jin Ye Yeo²

¹Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore; ²JPHE Editorial Office, AME Publishing Company

Correspondence to: Jin Ye Yeo. JPHE Editorial Office, AME Publishing Company. Email: jphe@amegroups.com

Expert introduction

Prof. Howard (Figure 1) has a dual associate professorship at the National University of Singapore Saw Swee Hock School of Public Health and the London School of Hygiene and Tropical Medicine (LSHTM). She is based in Singapore since 2020, with ongoing research and teaching through both institutions.

As an interdisciplinary health policy and systems researcher, Prof. Howard works on applied, equity-oriented research in challenging contexts, namely socio-political aspects of infectious disease control and issues affecting communities marginalized by chronic adversity (e.g. conflict, emergencies/displacement, structural vulnerabilities). Under this broad theme, her research fits predominantly into two areas: (i) infectious disease control policy and practice; and (ii) health services provision and access. Her work is informed by critical approaches and includes themes of health equity, dialogue/voice, participation, and capacity-development, with a focus on marginalised groups and constrained environments. It advances knowledge in methodological and policy implications of the intersections of marginalization, conflict, voice, and public health (particularly infectious disease control). Recent research includes COVID-19 responses in West Asia, health system adaptation and governance in Syria, strengthening health system responses to mass displacement of Rohingya refugees in Bangladesh, and exploring the health-seeking experiences of women affected by FGM/C in Asia and Europe.

Figure 1 Prof. Natasha Howard

Interview

JPHE: Could you share what motivated your decision to base your research in Singapore after spending more than a decade researching in the UK? Are there any differences in your research and teaching experience in these two regions?

Dr. Howard: I started my career in Asia (ie, Jordan, Afghanistan, Myanmar), so my heart has always been in the region. Why I chose Singapore was because of National University of Singapore’s globally recognized reputation and the partnership that has continued between London School of Hygiene and Tropical Medicine (LSHTM) and Saw Swee Hock School of Public Health (SSHSPH) that made that transition easier to formalize.

There are differences in my research in terms of ensuring our specific studies address questions of potential strategic relevance to Singapore and the region rather than to the UK or Europe. However, issues of health equity and infectious disease control will remain important everywhere, as the recent COVID-19 pandemic has shown. Another difference is that SSHSPH is a smaller and younger institution and, therefore, the work that I focus on here is social science and humanities-informed public health research as there are fewer people doing that kind of research here, so there is a need to develop such a portfolio.

In terms of education, there is also broader scope of teaching here, since SSHSPH is still relatively young. There are many courses and modules that have not been developed, but can be, particularly in the area of social sciences. There is a lot of openness to new ideas and innovation but not yet a track record in public health social sciences and humanities. While the school here is smaller than where I came from, it is much more integrated within a large world-class university. Thus, the scope for developing additional teaching has included a new public health social sciences course and the ongoing development of a Doctor of Public Health (DrPH) program, which is exciting.

JPHE: Having worked in different roles in different parts of the world (reproductive health technical officer for the WHO country office in Myanmar before 2005, 2005-2020 in the UK, and now in Singapore), how do you comprehensively apply your diverse experiences in your daily research and teaching?

Dr. Howard: This is a somewhat difficult question because I am not sure you can comprehensively apply all such experiences, as each topic, location, and methodology requires differences. However, I guess what I bring is many years of experience while still being curious to learn, adapt, and practice new research methodologies and topics. Having had this broad diversity of experience means that I am much less focused on a particular research niche and I tend to prefer working across a range of topics, methodological approaches, and geographical areas.

JPHE: Have you faced any challenges in your cross-cultural work? How did you overcome these challenges?

Dr. Howard: There are always challenges in academic research, whether cross-cultural or not. Challenges arise when one approaches issues with a closed-off mindset and focuses on what you cannot do, instead of focusing on what you can do and how to do it. Being sufficiently flexible and pragmatic is what I have found to work best in dealing with issues as they arise, as none of us has all the answers. Hence, it really depends on maintaining your curiosity, and if you lose that, there is little point being in academia.

JPHE: What drove you to dedicate your research to equity-oriented research in challenging contexts, particularly in the areas of infectious disease control policy and practice, as well as health services access and provision?

Dr. Howard: Our research says a lot about who we are. We always bring ourselves to our research, especially in the social sciences and humanities. Consciously or not, my own background and experiences contributed to the focus on equity and challenging contexts. We never work in a vacuum, so how much of it is due to my background, experiences, and circumstances would be really difficult to untangle. If I were to ask myself how I ended up in infectious disease control, I volunteered in several rural areas of Ghana in the 1990s and we were planting trees and building teacher’s bungalows, which was not related to public health at all. Many of the volunteers developed all sorts of interesting illnesses, since our accommodations were basic, which I ended up learning a lot more from than the building works. This led to an interest in infectious diseases, but it was not my focus. My focus was very much on policy and economic development at that point. When I was in Jordan, a similar thing happened when I was recruited to work with women’s small income-generating projects and ended up volunteering in hospitals and other health-related spaces, simply because they were more interesting as not much was happening in the income-generating projects. This led to a Masters in Public Health, and my faculty advisor encouraged me to take advanced training on Epidemiology, something I did not know much about, which turned out to be very good advice. That is how I ended up in Infectious Diseases and the policy focus came after working with WHO [the World Health Organization] in Myanmar in the early 2000s.

JPHE: Could you provide an overview of the advancements in critical health justice approaches? How have these advancements impacted infectious disease control among marginalized communities?

Dr. Howard: Both critical and social justice approaches have been around for a long time. Thus, instead of advancements, we can think instead of their shifting to be less marginalized and more mainstream with the increased recognition of climate injustice, colonial/capitalist exploitation of indigenous lands and lifeways, and others. This could be due to greater access to social media and many other factors, but I think it can be mainly attributed to the greater awareness that equity matters, and that those with the funding and power should not automatically be allowed to make all the decisions, even though they tend to be given the platforms to do that. There is now greater scope to do research on some of these topics and take critical approaches to develop methodologies that are not just epidemiological and positivist but enable more qualitative and interpretivist approaches.

JPHE: What are some gaps in the research of infectious disease control policy and practice and/or health services access and provision?

Dr. Howard: In the areas where I focus, one gap would be that far too much of the research is still led by principal investigators from high-income institutions and funders from high-income countries. This encourages too much ‘parachute research’ and calling oneself an expert on a country after a short period of data collection. A lot of research that is turned into journal articles on different subject areas, includes appropriate methodological and topical expertise but not necessarily contextual knowledge – which can limit its relevance and long-term value. I see major gaps in contextual embeddedness. It is thus important to always include researchers and knowledge – in an equitable partnership manner – from within these globally diverse contexts in which we try to do research. If, as researchers, we are just coming and going extractively and not building relationships then the work we publish may get attention but it will not add value. Finding ways to do this effectively is still a huge gap because research funding cycles are not designed for this. While donors are starting to recognize this gap in equitable research partnerships, addressing it is not always appropriately funded.

JPHE: In your opinion, how can global health partnerships be improved to bridge these gaps?

Dr. Howard: Global health partnerships continue to favor organizations and individuals with funding and connections, what we can call ‘power.’ Partnerships are thus rarely designed to be as equitable or meritocratic as possible even if that is their stated aim. There is a lot more work that needs to be done at the global level within global health partnerships. We now see efforts to address this within global health, such as through various ‘decolonization’ and equitable partnership initiatives. I am very happy to see these debates being foregrounded but am not yet optimistic for real substantive change, as the incentives for those with power to relinquish or share it are not yet sufficiently strong. I expect this to be a long-term and contested process of power shifting. In the meantime, actions that ensure inclusion of a greater diversity of perspectives and experiences - and include those most affected - within global decision-making fora are crucial.