PHP sat down with the fellows of the 3-D Commission to learn about their research, their experience at the fellowship, and the importance of the 3-D Report.

It’s not often early career researchers and doctoral students have the opportunity to collaborate extensively with global public health leaders, publish a significant report, and see it launched in conjunction with the 76^th United Nations General Assembly.

Seven fellows—Opeyemi Babajide, Olivia Biermann, Diogo Martins, Meggie Mwoka, Bishnu Thapa, Irene Torres and Zahra Zeinali—recently did just that.

The fellows were a part of the Commission on Health Determinants, Data, and Decision-Making—also known as the 3-D Commission—led by BUSPH and the Rockefeller Foundation.  The Commission produced a report which issues recommendations on how to use data about social determinants of health to drive effective decision making.

The report is extensive, and some of the research has already been additionally published in journals. The seven fellows from around the world connected virtually multiple times per month with Salma Abdalla, 3-D Commission Lead Project Director, starting in April 2020, to contribute to the research basis for the recommendations with the 3-D commissioners and BU researchers. Their diverse experiences across different areas of public health, data sciences, and policy, created a multi-sectoral environment for mutual learning and growth and enriched the report’s findings. 

“It was not a token situation where we were just there so that they could say we have young people as well. Our voices were really heard, our input was even leading some of the discussions,” said Zeinali, a physician from Iran who works as a Global Health 50/50 researcher. She also chairs the Intersectionality Working Group of the Gender Equity Hub of the WHO’s Global Health Workforce Network.

Zeinali’s role was to assist the BU team to organize and produce the report, creating the “scaffolding” as she describes it, with ongoing feedback from 3-D Commission chair Dean Sandro Galea and the rest of the commissioners.

“The whole process was iterative and really interesting in terms of how we have to move different bits around and how to give more or less space to different topics,” Zeinali said.

She appreciated the commissioners’ more experienced perspective, learning along the way about presenting the information with awareness of “the politics of it…the intricacies of how you approach a subject, especially if it is sensitive, if you’re being too pragmatic or if you’re being too ambitious.”

Zeinali summed up the report, “In a good government’s model, determinants, data and decision-making should intersect with the purposes of promoting health, equity, and social justice. We’re not there yet.” The recommendations and principles produced by the commission provide a framework on how to get there. 

The other six fellows were each assigned to working groups studying one of the 3-Ds—data, decision making, and determinants.  

Thapa and Torres wrote both conceptual and empirical papers as a part of the data working group. Torres is member and technical director of Fundacion Octaedro, an Ecuadorian NGO, and has led several public health studies in Ecuador. Thapa is a Brown University School of Public Health doctoral student from Nepal who researches health economics and financing.

“For the conceptual paper, we came up with a HEALTHY (H=Healthcare, E=Education, A = Access to Healthy Choices, L = Labor/Employment, T = Transportation, H = Housing; and Y = Income) framework and applied the framework in the context of Kenya and the Philippines where we investigated the different sources of data that are used to study [social determinants of health],” Thapa wrote about his work with Torres. “For our empirical paper, we focused on the topic of depression in the context of Brazil and India. We applied the same HEALTHY framework to see the different types of data that are currently being used to study depression.”

Thapa wrote that the biggest takeaway from the experience is thinking more substantially about social determinants of health.

“It has become more and more clear to me that health is a lot more than just healthcare. Health equity, supposedly the sexiest concept in the health policy world now, is intricately related to [social determinants of health]. Without addressing [social determinants of health] we cannot address inequities in health,” Thapa wrote.

Babajide and Martins collaborated with the decision-making working group. Martins, a medical doctor from Portugal and DrPH candidate at the London School of Hygiene & Tropical Medicine, was in charge of producing a theoretical understanding of the complexity of decision-making, the variables that influence decision-making, and the role of social determinants of health data in that process. COVID-19 came up naturally as the global pandemic began just as the commission began its work, though it did not intentionally seek to address COVID-19, Martins said.

“We were actually validating a lot of the things that we were finding in the literature on things that were actually happening on TV, happening on decision-making at the country level, as we were developing that work,” Martins said. “I think it really makes it really timely, really attached to reality.”

Babajide is a recent doctoral graduate at the Faculty of Public Health, University of Ibadan in Nigeria, and currently works as a government and community relations specialist with the West African Gas Pipeline Company. Babajide analyzed the transportation sector specifically to understand how data can “be leveraged to promote equitable decision-making and multisectoral collaboration,” she wrote.

“In one word, my experience with working with all the high-level commissioners was upgrading. I came in as an early career researcher and I believe I can now say I reason with a stretched mind from a multi-perspective and sight of those that have a 360-degree view of health, determinant, and data science…Health care, Non-health industry, and technology sector of the society,” Babajide wrote.

Mwoka and Biermann assisted the determinants working group to understand the history behind the social framing of health and to provide a holistic overview of housing as a determinant of health in three different contexts: the United Kingdom, Kenya, and Singapore. 

Biermann, a postdoctoral researcher in transformation for sustainable health at the Department of Global Public Health at Karolinska Institutet in Sweden, worked on a paper, among other things, that provides background information.

“It’s a bit of a theoretical paper, but I think it’s helpful for somebody who would like to know a little bit of background on the social determinants of health in general, which frameworks are out there, and what are maybe the gaps in these frameworks and some ways forward,” Biermann said.

Mwoka is a physician and global health specialist who has worked in Africa to strengthen health systems and sexual and reproductive health and rights. Mwoka took the lead on the empirical paper with the goal of making the social determinants of health “concrete” and “practical”.

“The idea is we wanted to look at housing and how housing impacts health, and how health or one’s health can also impact the kind of housing you have,” she said.

The research and discussions using the housing example also allowed exploration of other social determinants of health through the lens of housing, such as food access, roads and other neighborhood attributes that affect health.

“Largely our health and well-being are outside the hospital,” Mwoka said. “We are trying to understand the failures in the different systems outside this hospital system … that are leading you to go into the hospital.”

The fellows all mentioned gaps and challenges at the intersection of the 3 Ds. These included the need for strong political will and the need for a common language shared by researchers and decision makers. Fellows mentioned the need for data generators and funding avenues in low-and middle-income countries to get beyond reports to promote action; knowing why determinants matter is important, but how do we change them?

The 3-D fellowship presented a unique opportunity for early career researchers to participate in a commission and work with people across academia, policy, technology, and business. Fellows developed new skills in research and writing, expanded their thinking on social determinants of health, and grew their personal networks. “Just like we have precision medicine, we need precision public health,” Biermann said, summing up the significance of the commission’s work. “It’s amazing to imagine how we could improve population health if we used big data on the social determinants of health to make efficient decisions.”