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Gavin: Hello, welcome to the Lancer Voice. I'm Gavin Cleaver. It's June 2021 and we're very pleased to have you on board for another episode. This week we'll be discussing the thorny question, what's wrong with global health? We'll be talking about the colonial influences still dominating global health research, about the problematic language we all use when discussing health matters around the world, and what reforms could and should happen to remote health equity everywhere.
I'm very pleased to say that Mandeep Aujla, Senior Editor at The Lancet Global Health and our resident expert on all things decolonising global health, has selected the interviewees for us this time around. Later on, you'll hear Mandeep speaking with Leoba Hirsch, who has worked on a research project exploring the colonial history of the London School of Hygiene and Tropical Medicine.
But first, Mandeep spoke with Desmond Jumbam, a health policy consultant whose career has taken him from Cameroon to Harvard and then back to West Africa. He's currently working with Operation Smile, an organisation treating cleft lip and cleft palate. Desmond wrote a piece for BMJ Global Health last year, a satirical overview, entitled How Not to Write About Global Health.
His piece, which I stress is humorous and satirical, includes such gems as, Let sustainability worry about itself when the time comes. Your main task at hand is to develop and execute your project successfully by your standards. Write up the results and publish your manuscript. You need to meet those grant deadlines.
You can worry about sustainability after the project is complete, or better yet, let somebody else worry about it. We spoke with Desmond about his unique perspective on global health.
Mandip: Thank you very much for joining us today, Des.
Gavin: Hi.
Mandip: Okay, so there's been quite a lot of talk about the asymmetrical power structures that still dominate global health, and about ways to achieve equity in research both in our journal and in many others in the past year.
You wrote a very popular editorial that gives guidance on how not to write about global health. Can you tell us a bit more about the inspiration behind that?
Desmond: Uh, the paper was written out of frustration. My friends and I often talk about these things in global health. And often when we talk about it, it's really in a, in can you still believe that this is happening?
It's insane. Like it's ridiculous. That someone You know, would go to a country for one week, and then somehow they become experts of all things in that country, including the culture and the food and the intellections that the country should be developing. So we always talk about it in a ludicrous this is insane.
It felt I always wanted to write about it, but I didn't want to write a dry academic. Article. And there's an article that has been written by Binyawanga Wanaina from Kenya called How to Write About Africa. I read that article about it more than a decade ago. And I, I thought a lot of what he wrote could be applied to global health.
And so I always had it on the back of my mind. And so about, uh, about a year and a half ago, I was actually going through a moment of deep crisis myself and deep frustration, and that gave me the energy to be able to really speak my mind about global health and some of the things that I was observing that were not right and still deeply colonial.
But again, write it in a way that people would appreciate and see every anybody would see themselves in it, right? You know that I can see that I've done this myself and from the comments on Twitter, those are some of the reactions that I got. But the article itself, the contents of the article comes from, I think almost everything in the article are things that I've observed from my relatively short time within global health.
So for example One that I like to reference is the idea of getting community buy in. It's a language that we talk a lot about in global health, you have to get community buy in, you have to get the buy in of the locals for your intervention to be impactful, to be sustainable.
They have to accept it. And so this is something that has become convention in global health, but People don't, those in global health, many in global health don't actually really seek or don't, maybe don't even understand what it takes to get. So what I observed, was that, we would set up some facades, we already have the research idea or the intervention is mine.
The funding is in place, the staff is in place, everything is in place. And, but we still need to show that community how to buy in. somehow. So we set up this one to two day workshop. I don't know why they always wanted two days, but that's the convention. And once the workshop happens, it doesn't really matter what was said at the workshop.
The goal is to get those at the workshop to somehow agree to what you've already conceived. And then when you write that in your manuscript, It's given that you've got community ownership, but that's not really the case. And those in the community knows that. And those of us in the global health space talk about it as being utterly ridiculous.
So there are quite a number of things. Even the whole idea of sustainability, again, in many instances seems like a facade because we know we have to talk about sustainability of the projects. But. people don't really think about it up front, what does it take to get a community to own and sustain a project in the long term, that impact of your intervention is sustained for the long haul.
Mandip: So you're quite involved in the movements to decolonize global health. What have been some of the reactions to the whole idea?
Desmond: I think there are a couple of reactions. The first is Denial. I've noticed some denial, some pushback from, those in the NGO space or even in the academic space who say, this is the colonizing global health thing.
It's really just wasting our time. All we want to do is You know, take care of Children and take care of these people. We have limited resources. Why are we wasting time on this? And that is very deeply problematic because it perpetuates exactly what the decolonizing. global health movements is about, this idea of saviorism and which ultimately is looking down at a certain group of people as being in Syria and you being the person that the only person that would save them.
And so that, that has been a reaction or even academics will say we just want to conduct research, good research too. to generate some evidence that, will have an impact on global health. And the saviorism thing is the issue, but sometimes it's just that those people who are in denial do not listen or do not want to listen to the concerns of the movements and the individuals within the movements.
The other response has been acceptance. So, there, there are those who say yes, that's great. Let's do something about it. And they rush and they're excited. It could be, because of social media or being political correct, or, whatever, or it could be rightfully but there is a rush.
Afterward, to develop superficial policies, superficial statements on the websites to bring people on the board or on the leadership, Africans or those in Latin America. Just, or authorships, right? Authorship is another example of this. Just again, so that we're meeting the criteria.
For inclusion and diversity, but those in these authorship positions, their opinions are not heard. Those in this leadership positions don't have a decision making capacity. Those statements remain on the websites are not really fully implemented within the policies within the organization.
So and so that is that is a reaction that I've seen. But then there are those who accept and work with those within the movements to listen carefully to try to understand. what these grievances are and come up with substantial policies for how to decolonize themselves and decolonize their institutions.
So those are the three reactions to the movement as I see it so far.
Mandip: What changes do you think would be needed to get to a system where academic global health is truly equitable? And it's a real level playing field for everyone.
Desmond: When I give this global health talks, they're quite different depending on the audience.
So if I'm giving the talk to students here in Cameroon I say the onus is on us to decolonize the movement. And this is in parallel to the decolonizing movements of the 40s and the 30s and the 50s. There were African leaders who led the charge. Kramen Kruma, Judas Nyerere.
And so I, the first thing I would say is we from the South need to stand up, speak up, and challenge these power asymmetries, challenge these injustices that, that do exist. Global health will not decolonize itself. We have to take a stand to it. But I also think those in the north have a role to play as individuals, but also as institutions, as an individual, if you're within your organization and that perhaps you're your supervisor at your university doesn't, really respect his or her collaborators in India doesn't really take their perspectives into account and has that, then you should also speak up against that, and even within the NGO spaces.
So we all need to speak up. We all need to challenge this, university students. Can challenge their leadership to change policies around the inclusion of students from LMICs within quote unquote global health programs that are arising all over the world that are too expensive for those from the South to be part of.
But we all have a stake to play in this. I wouldn't say it's necessarily just something for those of us in the South. to fight, we all within the global health space need to do that. And something that I think everyone needs to consider is what they're willing to lose for this, because if you're an institution and there are also power asymmetries between a supervisor and the supervisor or the mentee.
And so you need to really consider what you're willing to lose for justice and equity. Those researchers in the South consider You know, the partnerships that you're willing to let go off that may be beneficial to you as an individual but detrimental to the goals of global health.
Mandip: That's so true because so much of this is about power.
Desmond: It is. And I think power is something that is not so easily relinquished. I hear people say those in power need to so easily give up power. I don't think that will so easily happen. It was true of when African countries were trying to get the independence we had to fight for the power to be relinquished from the British and the French and, the Belgians and all the colonizers.
And so I think it's the same with, the global health movement. I think it's naive to say that those in power will just easily relinquish it. It'll be nice if they did but it's probably more unlikely.
Mandip: So can you talk a bit more about the challenges that you've come across in Tanzania or Rwanda or Cameroon while conducting that research?
Desmond: I have a kind of a unique perspective. Because while, I conduct research in, Tanzania or in Ghana or in Madagascar, Cameroon, I am employed by, I've worked for Harvard, I work for an international NGO based in the U. S. And there's a little bit of privilege that comes with that status of having the Harvard name.
But I do, from my experience in housing, I do realize that there's, there are quite a number of challenges that researchers in the low and middle income countries face. For example, and I see this even as I was doing my master's degree as a student at the University of Notre Dame, I as a student at the University of Notre Dame had more access to funding opportunities than my colleagues in Zambia.
And perhaps not even colleagues, my seniors in Zambia who, I experienced epidemiologists, they would never have access to that kind of funding. And so that's a certain privilege that even I as a Cameroonian who has studied abroad has, but it's even true of us. Not just me, but anybody who is working in the North, most people working in the North, there's a certain privilege, access to funds that's available.
And something that I've also realized in my research is that there are, power asymmetries. between those in the Global North and those in the Global South. So typically, researchers, in the South, or, here in, in Africa, are seen as data collectors. They're not really seen as equals with researchers in the North.
And the way I've observed it is that typically, researchers, At Harvard or at UNC or wherever, don't necessarily mean to just point out Harvard, but that's where I've been, there are, there's a research opportunity that comes in. They have access to even know that this call for proposals have come in.
They put in the research proposals and the ideas for research to be conducted in, for example, Zimbabwe, and sometimes without consulting the researchers in Zimbabwe. When they do get access to the funds sometimes on quite often, that's when they reach out to the researchers in Zimbabwe to say, What do you think of this idea?
We read some papers, and we think that this could be a life changing, impactful solution that would radicalize the health system of Zimbabwe. And at that point, the funding is already available. And so even if the researchers in Zimbabwe think this is absolutely important. Nonsense.
They'll still say let's try it out, right? We know what will work for our people. The funds are there. And so they accept it and they try that. And I've noticed this even with ministries of health, right? Sometimes an NGO brings funds. funds that bring an idea to a minister of health to say, we would like your permission to implement this.
Even if the minister of health doesn't think it's a health priority for them who make the priorities for the country, they still will accept those ideas, those those funds. And so those power asymmetries do exist. It even comes down to who gets to the papers, where they are published who gets to be first author and last author on the papers.
Recently there's a lot of talking global health about authorship and it's a fundamental problem. But I always like to say that it's not really about the position of the office in themselves. They represent something that represent decision making, that represents the knowledge that is prioritized.
within global health, and Shea Ambimbola, the editor in chief of BMJ Global Health, talks about it in his article, The Foreign Gaze, Authorship in Global Health. And he says that the fundamental problem is not necessarily the authorship, right? It's the way that the knowledge that is being prioritized.
If the knowledge that we prioritize within global health does not reflect the realities on the ground, then there's something fundamentally wrong with the information that we're using to come up with interventions and to implement. So it's a fundamental problem, not just about the authorship positions.
But it's about, it's a colonial problem, and so what tends to happen with the authorship issue is that we tend to go towards gift authorships for fear that, you're going to publish a global health paper and, you're going to be attacked on Twitter for not having enough.
African sounding names or, and so that doesn't really solve the issue to get just look at it as an authorship, like position issue, but it's more fundamental than that.
Gavin: Great to hear from Des there. And I think we'd be remiss not to include an excerpt of his piece, which we talked about there, which you'd be able to find online just by searching Desmond Jim Bam and BMJ.
So I'm joined by Mandeep and my co host, Jessamy Baganal. This is a great passage. They're all great passages, but here's one. Never forget to include the old African proverb. If you want to go fast, walk alone. If you want to go far, walk together. Or the Chinese proverb, give a man a fish and you feed him for a day.
Teach a man to fish and feed him for a lifetime. How else will your readers know yours is a global health paper? It will also show that you've taken the time to understand local customs and have connected with the community on a deep level. Amandeep, it's a really striking use of satire.
Mandip: It was inspired, obviously, by the very famous essay by the Kenyan author Binyavanga Wainaina, who talked about how to write about Africa, which I think was published in 2005, but it's still really relevant today.
I thought all of Desmond's editorial was really relevant and just very timely and relatable for most people that are involved in academic global health in one way or another. So whether it's about sustainability of research projects, collaborations in countries and international collaborations, understanding cultural and social contexts in countries, and just, yeah, how to write authentically about global health.
Gavin: And Des himself is equally personable, isn't he? And he's doing some really interesting work at the moment.
Mandip: Yeah, very personable, very positive, just very inspiring, I thought.
Jessamy: I was just wondering, outside of sort of academic global health, these conversations that happen within a particular sect of medicine or, public health between academics, they inform the wider conversation societally.
What do you think the lessons are there that we can translate to how we as a sort of as the UK or more broadly the, European Union or whatever deal and think about global health?
Mandip: I think the overall lessons, even though he takes a really satirical approach, are to be humble. So the importance of humility, to be respectful, if you are a policymaker from a high income country, is going into a less well resourced setting and giving due credit and acknowledgement to the people who help to make everything possible.
Jessamy: And what, I guess what I'm trying to get at is how do you think that also reflects on how we deal with lower middle income countries? on other projects outside of global health, whether it's, economics or technology or whatever. Do you think that there are all of these sort of similar traits and trends that we all do in basically every single category?
And it's all, it's basically just exactly the same pattern happening over and over again.
Mandip: Yeah, I can't speak with any great expertise in any other areas, but there's certainly been loads of discussion happening about inequities. in global health research, just the overall continuation of practices that have their roots in European empires of the 19th century.
And I guess that applies to everything. And these discussions have certainly got much louder in the last year or so. And there's just this continuing idea. I think the expertise can only be found. in elite institutions in Europe or North America. So I think these cycles continue, really, with producers and gatekeepers of knowledge, technologies, interventions, continuing to mirror historical colonizers.
Thanks, Mandeep. Thanks, Jessamy. And,
Gavin: Mandeep, we're going to hear you talk now with Leoba Hirsch of Liverpool University, who recently finished a research project looking at the colonial history of LSHTM. Leoba is also an author on the recent Lancet Global Health comment, The words we choose matter. Recognizing the importance of language in decolonizing global health.
And that's one of four comments in this month's issue on the same topic as this podcast, What's wrong with global health? You can read all these comments online now for free at thelancet. com. And here Mandy speaks with Leoba a little bit more about her work and about the problems with global health.
Mandip: Okay, thank you for joining us today, Leoba. The relationship between colonial history and the modern practice of academic global health has been receiving a lot of attention recently, both at universities and in the published literature. And you wrote a powerful perspectives piece on this subject that was published in the Lancet earlier this year.
Can you tell us what triggered the growing interest in this area?
Lioba: I think one very simple reason really is that there's an increasing number of people of color working in global health institutions in Europe, but also in North America and around the world, really. So I think an increasing number of people of color and I would say still I don't know.
Yeah. I was going to say predominantly people of color who grew up in, in the global north or in, in high income countries are increasingly infiltrating if you want to use that word global health institutions. And I think that brings about a sort of a different perspective that was previously absent in those institutions because they were largely and still are largely led by by white people of European descent who have less experiences with racism, have less experiences with with coming from countries that have been colonized by Europe or North America.
So I think that's a, I think that's it's quite a simple thing really, but I think that's a really important. shift that, that leads to these issues around colonial power dynamics and continuing colonialism, really, or coloniality and being brought to the forefront and entering discussions.
So I think maybe that's the long term trend. I think more recently, last year's recurrence or I guess resurgence of the Black Lives Matter movement also created a really big impetus for global health organizations to see to say, Ooh, yes, something is wrong. And in effect to listen to the things that, that people of color have been saying for a really long time.
And so I think last year was really a moment when suddenly white leadership started listening and said Oh yeah. Okay. We do recognize now that there is a racism problem and there is a coloniality problem in global health. And I think those two factors together are probably.
And I'm sure that there are many other factors, but I think those two were really strong factors for this being a conversation that we can't really escape or avoid anymore today.
Mandip: Okay, and can you tell us a bit more about the parallels between historical colonizers and the current system of global health today?
Lioba: I think there, there are a variety of continuities and I guess factors that perpetuate colonial inequalities in global health today. So I think what's important to bear in mind is that although formal colonialism ended in a majority of countries between the 1940s and 1960s, especially in Asia and Africa, South America obviously had a, had an earlier wave of independence.
economic structures and spheres of influence, of political influence continued very much after the end of formal colonialism. I think another thing that's important to to bear in mind is that colonialism very much in my opinion, in any case, founded the basis and the foundations of current global health inequalities in the sense that money that was extracted from colonized countries was not invested in health infrastructures.
It was not invested in health education. It really was extracted for economic gains of European countries. And that obviously left left a hole if you want to if you want to call it that financially, but also in terms of socially, in terms of education and left those countries, yeah, with a, I would argue a gap in a way.
At the same time, indigenous forms of medicine were often discriminated. They were often made illegal by colonial countries. So I think all of those factors led to, to, yeah, to current global health inequalities. And so I think that's one thing on the other hand, moving forward from the colonial period it's important to note that the people who held power during colonialism still hold power in global health today.
So a majority of global health institutions are still headquartered in high income countries. And the global health 50 50 report from 2020, illustrate this really nicely. That's some great charts that I would encourage everyone to check out. That really show where power is situated in global health and it is situated in Europe and in North America to the extent that if you want to become a global health leader, if you are a global health leader today, I think 92 percent of global health leaders today have have a degree from a university in the global north.
So again, that sort of shows the disparities. Funding is another huge issue. Who decides on funding? Funding decisions and programming decisions and program design are all made in Europe and in North America and are made about Africa and Asia and South America and the Caribbean to a certain extent.
So I think who is included and excluded from global health decision making is a, is really a legacy of colonialism and that's something that we live with still today and that people have to deal with on an everyday basis.
Mandip: Okay, so we recognize the weight of history and the impact of colonial legacies on global health today.
What do you think we can do with that knowledge? What's the goal of the movements to decolonize?
Lioba: Yeah, it's a tricky question. I think and again I'm aware that other people don't necessarily share this opinion or I think maybe I'm a little bit of a pessimist in the sense that I don't think that we actually can fully decolonize global health institutions.
I don't think that decolonization in itself should be should be a a finite process that we can start and we can tick several boxes and we know, okay, in five years we will have achieved that. So I think for all those who are very hopeful that's what it's all about I personally don't think that that is possible or that will bring about the change that, that we really need to see.
The decolonizing global health movement is fundamentally about power and about us. That means people who live in high income countries who have a lot of privilege, who have benefited from colonial legacies, even if only by the power of our passports and how we can move around the world and whether we have to pay international fees or home fees in order to study at very prestigious universities.
I think it's about us having to give up our power. And that's really difficult. And that's also a really uncomfortable conversation and of course, position to be in. And speaking for myself, that's a very, Yeah. Uncomfortable thing to consider, right? To say, okay actually I'm going to take a step back and, like hand over.
But I think fundamentally, if we want things to change, we need to learn to listen more. And again, that means taking a step back and making room for other voices and other perspectives and other people. It also means that we need to be really critical and self reflective when it comes to this decolonizing global health movement, because again it's a movement that.
I guess, where voices, whose voices are loudest or are most heard in the global North. And again, I think that's something that we need to critically reflect on. Yeah, ultimately, I think decolonizing global health is about a wider variety of perspectives and fundamentally, hopefully, structural change in the sense that funding program design, program implementation, who is heard and who isn't, who is published and who isn't, need to fundamentally shift away from the, regions of the world that have held that power for centuries, really.
Mandip: We can highlight the issue in our pages, but do you think there's more that journals can and should be doing to help promote structural change?
Lioba: Yeah, I think so. I think one really easy. Oh, not easy, but one, one very straightforward way that, that journals can act is by accepting a greater variety of formats in their publications.
I think that I was taught to write a certain way. I think if you've been to LSHGM or Harvard or Oxford or whatever big university that has a lot of power in global health, you have been taught to write in a certain way. And that's the way that will get you published. And I think accepting a greater variety of language or forms of expression or formats.
So yeah, peer review is very important, but so are commentaries. And accepting that not everyone has the same access to university libraries and journal articles that are often behind a paywall is something that we need to accept. So I think that, yeah, I think to me that's an easy way that could encourage and allow more people from a diverse number of backgrounds to be heard and for us to read about their perspectives again and to learn from them that and I think fundamentally a lot of them are now being excluded because of the way in which peer review is structured because of what we look out for, what we think a journal article, a scientific article should look like.
Yeah. Again, not easy, but quite a straightforward thing to do. Yeah.
Mandip: Could you tell us who or what has inspired you to work in this area?
Lioba: Yeah, gosh I think I've been interested in health and racism for a really long time and I think I actually started being interested in it by reading Rebecca Kloot's book The Immortal Life of Henrietta Lacks.
Is that what it's called? And I think I read that when I was doing my master's and that is such, a deeply sad and horrifying story of how racism and, medical development intersect in a way that harms one particular family and exploits ultimately exploits one woman's cancer cells.
But I think also, I think that sort of got me going. And yeah, got me interested in, in, in health and health justice. But ultimately I guess it's just talking to people and talking to students and listening to people in Africa and in Asia, talk about their experiences.
I think ultimately it's about health justice. It's about working towards. A world in which health is more equitable, but in which we also look at medical practice and health practice more critically, and in which we remove it a little bit from the pedestal on which it stands, which sort of proclaims that it can't do no harm.
And I think as a person of color, and I think as many black and brown people the world over know that. That's not true. Yeah.
Mandip: Great. Thank you. very much for joining us, Loba.
Gavin: Thanks so much for listening to this episode of The Lancet Voice. We'll be back in a couple of weeks with more stories from the world of health. If you're somehow not subscribed already, you can subscribe to The Lancet Voice wherever you usually get your podcasts, and we look forward to seeing you again next time.