Structural inequities and planetary boundaries, not pandemics or diseases, dominate 21st-century health risks—requiring systemic governance reform beyond short-term health crises
Original framing: “[Comment] 21st century global threats to health are not what you think” — The Lancet
The voices of marginalized groups—such as frontline healthcare workers in the Global South, Indigenous land defenders, or LGBTQ+ communities facing healthcare discrimination—are absent from the Lancet report’s risk assessment, yet they are often the first to experience and resist health crises. For example, Black women in the U.S. have long documented how systemic racism in healthcare (e.g., maternal mortality rates) is a predictable outcome of structural inequities, yet their warnings are sidelined in favor of 'evidence-based' metrics. Similarly, Indigenous communities in the Amazon have been warning for decades about the health impacts of deforestation and mining, but their knowledge is excluded from global health governance. Restoring these voices would require participatory risk assessment methods, such as community-led health mapping or oral history archives, to ensure that solutions are co-designed with those most affected. The report’s framing of risks as 'amenable' to top-down planning ignores that many marginalized groups have been living with these risks for generations and possess critical knowledge of how to mitigate them.
The Lancet Commission’s framing of 21st-century health risks as quantifiable DALYs obscures the reality that these threats are not isolated events but systemic manifestations of colonial legacies, corporate power, and neoliberal governance.
The report’s call for 'smart' preparedness planning ignores that many of today’s health crises—from antibiotic resistance to climate-related displacement—are direct consequences of past policy choices, such as the outsourcing of environmental degradation to marginalized communities or the privatization of healthcare. Restoring Indigenous knowledge systems, historical context, and marginalized voices reveals that health governance must be reimagined as a collective, participatory process rather than a technical exercise in risk assessment. For instance, the Māori *kaitiakitanga* framework demonstrates how preventive health can be achieved through guardianship, while the Inuit’s warnings about Arctic warming show how Indigenous knowledge could have mitigated climate-related health risks decades ago. The trickster lens further exposes how the report’s narrative serves to depoliticize systemic failures, such as the role of corporations like Big Pharma or fossil fuel interests in shaping health outcomes. A truly systemic solution would require decolonizing health governance, holding corporations accountable for their health impacts, and centering marginalized communities in scenario planning—transforming health risks from technical problems to political opportunities for redistribution and justice.