World challenges are at least three-fold:

• Climate change: In stating This Changes Everything, Naomi Klein has it right.⁹ For near-equatorial countries, increasing temperatures are game-changing now. Rainfall and temperature changes affecting mosquito populations, the vector for dengue, have contributed to dengue crises in Bangladesh, Vietnam, and the Philippines in recent months.

• Geopolitics: As Zia Haider Rahman exemplifies in In the Light of What We Know, in the big picture, countries targeted for cancer work are “just another chessboard.”^10(p33)

• Economic development and trade: Chinese-supported development activities are having huge impacts across Asia.

We live in the world that we notice and remember; this is availability bias. As a result, we tend to ignore big-picture issues that are of major importance.¹⁰

All health care challenges matter and can swamp long-planned and carefully constructed targeted efforts—as in the current dengue crises mentioned above. More comprehensively, the work of the Hans Rosling et al,¹¹ “Factfulness,” is worthy of attention. A local issue is whether, in the face of suggested genuine positive economic development, disposable income for health is available, because most health care in low- and middle-income countries is paid for out of pocket. In general, polemics about addressing primary care and global health are painfully ignorant of the local politics of clinical medicine and of the sore need for implementation research at the grass-roots level.

Make no assumptions about similarities between one’s own culture and those of the foreign country where assistance is being offered.¹² The multiple, currently used strategies noted above appear to start with assumptions about these as effective approaches, absent any sense that they, in fact, are culturally acceptable and realistic.

Often, national experts with privileged backgrounds have no idea what is really going on in their countries. In my field experience, college-educated Bangladeshis interviewing residents of their own villages found levels of squalor that astounded them. Katherine Boo has opened the eyes of many to the circumstances of the urban poor in India, but we seem to ignore such lessons when we talk about intervening for cancer.¹³

Our colleagues in low- and middle-income countries often have personal agendas in collaborating with international project efforts—agendas that are not at all compatible with those understood by Western leaders. The only rational approach to this conundrum is to go slowly in project development and do homework that addresses grass-roots lessons.

“How you define the problem determines whether you solve it.”¹⁴ The late Jonathan Mann put it similarly, asserting that the way you frame the problem dictates how you approach it and whether you will have any success. As noted above, one always needs an applicable socioecological model in which to operate.

As Easterly⁴ has documented, the history of development is littered with prescriptions that have been counterproductive. As noted in the opening paragraph here, we pursue educational approaches (particularly conferences), seemingly because this is what we have always done in the West and absent any compelling evidence of their relevance or efficacy in addressing meaningful goals. More broadly, Bryan Stevenson’s comment about Samantha Power’s memoir, The Education of an Idealist, is applicable: “Problem solving in a complex world can challenge idealism.”¹⁵

As Alfred Sommer has so engagingly described in Ten Lessons in Public Health,¹⁶ we are increasingly concerned with global health without attending as much as is needed to what is involved. And, as Tom Friedman¹⁷ has written, we have increasingly deep capacities, but—as noted in the so-popular song, Shallow—“we’re far from the shallow now.”¹⁸ We need to think hard, big, and deep about the social change involved in improving cancer outcomes for our fellow planet travelers.

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