Category Archives: Equity

Related to the fairness of distribution of goods, opportunities, and processes.

Indonesia pushes back against trickle down science

A recent article in Science Magazine (July 2019) described changes to Indonesian laws regulating the way that foreign scientists can do science in Indonesia. The laws are, in essence, a push back against “trickle down science“, in which scientist in Global North Institutions engage in colonial science. This is what happens when Global North researchers engage local institutions to provide service scientists and easy access to samples without any genuine consideration for their Global South collaborators.

The implications of the new law are still uncertain, but it may affect one of the studies on which I am in investigator. The change in the law means that

[Foreign scientists] need to get ethical clearance from an Indonesian review board for every study (although some types of studies may be exempted), submit primary data and published papers to the government, involve Indonesian scientists as equal partners, and share any benefits, such as the proceeds from new drugs, resulting from the study. Researchers can’t take samples or even digital information out of the country, except for tests that cannot be done in Indonesian labs, and to do so, they need a so-called material transfer agreement (MTA) using a template provided by the government. (Rochmyaningsih, 2019)

A Bajaut Laut community in Sabah, Malaysia. It was a study in a community like this one in Indonesia that sparked a debate about subaltern science.

It is hard to fault any of the new requirements. Of course there should be ethical clearance and of course the clearance should come from the country in which the science is being done. Lodging the data and the papers seems like a reasonable idea. The Indonesian governments wants papers and data lodged with the them; a bolder and more constructive approach may be for data and papers to be lodged in accessible repositories. Of course Global North researchers should have in-country scientists as partners and of course the collaborators should be equal partners — not pretend equal partners, but actual, equal partners. Of course the benefits of the science should flow to all the countries engaged in the science. These are not high hurdles to jump unless the scientists from the Global North thought they should be able to arrive, collect samples, and run … which would never happen, right?

I could have predicted the kind of response that has already begun with the announcement of the Indonesian law, because I have heard the responses before. Indonesia (or insert the name of your favourite Global South country here) doesn’t have the capacity to do the research that we want to do. It wasn’t the research idea of the scientists in Indonesia, it was our idea. These new laws will destroy science in Indonesia, because any credible Northern researchers will move to a more accommodating country; i.e., a more readily exploitable country. Every single one of these responses condemns the person who utters them, because each one shows a complete lack of commitment to genuine, scientific collaboration.

The issue of #trickledownscience seems to have come to a head in Indonesia with the publication of an article in Cell — the high impact factor (36.2) journal in experimental biology. The article, reported a study of genetic adaptations to hypoxia in the Bajau Laut people, a nomadic, sea-dwelling community in Southeast Asia. The article is fascinating and well worth a read, and the authors should be congratulated on a great piece of science! The problem is not with the findings, it is with the process of Northern Scientists going to far flung places to do their research without any genuine engagement or collaboration with local scientists. There are 17 authors listed on the paper and with only one exception they come from Denmark, Germany, the Netherlands, the UK and the US. The exception is author #15, an Indonesian who is and education researcher and has no background in genetics or cell biology, and whose contribution was to “provide logistical support”. Author #15 comes from Tompotika Luwuk Banggai University — a small, private institution in Central Sulawesi; underscoring the lack of genuine collaborative intent, Tompotika’s university ranking is 498 in Indonesia and 12,999 in the World. This is a far-cry from, to give one example, the more relevant and credible Eijkman Institute for Molecular Biology in Jakarta.

The publication of the article received good coverage in The New York Times, and less desirable coverage in Science Magazine. The heart of the problem is revealed in a comment by Melissa Ilardo, who was the doctoral student on the study and the first author of the Cell paper. Commenting on the controversy, she said, “I did everything I could to conduct this research ethically and properly, and this is breaking my heart”. I truly feel for her. To be a young (post-)doctoral student and have to go through this kind of scrutiny would be awful. But just think about Ilardo’s idea of “doing everything” to conduct the research properly. What does it mean to conduct oneself properly when the #trickledownscience relationship is a profoundly colonial one. The study looks a lot like the modern day equivalent of the Elgin Marbles; however, instead of retrieving (stealing?) ancient artefacts, Global North reseaerchers collect biological samples.

The new Indonesian law is probably too heavy handed, but it is in the right direction. There is little doubt that there is a problem with #trickledownscience, and governments in the Global North, funders, and institutions need to push the nascent dialogue with the Global South about how appropriate, collaborative science can develop that addresses the needs of the Global South and not the whimsies of scientists in the Global North.

I predict it will be those Global North institutions that tackle this issue head-on that will be the most successful. It does require that they give up a little power to retain a little power, and it begins by negotiating genuinely, collaborative arrangements that address (1) the most pressing scientific questions in the Global South, (2) the building of capacity in the Global South, (3) sustainable funding for research in the Global South, and (4) sustainable, collaborative research relationships between the Global North and the Global South.

I was trying to imagine what the response in the US would be if a group of Indonesian, Nepali, and Tanzanian scientists arrived in the US to collect saliva samples from a Hasidic community in upstate New York or an Amish community in Pennsylvania. A young academic at a local community college would provide “logistical support” and facilitate obtaining ethical clearance from the college’s Institutional Review Board. The samples would be collected from the community and shipped back to the Eijkman Institute in Jakarta for analysis. A paper would subsequently appear in Nature detailing some interesting genetic variations associated with the communities. Would the science be celebrated in the The New York Times or would someone have a WTF moment and question how this could ever happen?

I am looking forward to that studying being done. Will NIH fund it, I wonder?

Globalisation and health

The past has already been written and the accolades distributed. We now need to decide whether the next century is going to be good or bad for our health, and the role of globalisation in helping us to determine our destiny. People living in failed states do not enjoy utopian, anarchic freedom. They die young. Healthy populations need the goods and services of society to be shared in a broadly inclusive fashion. They need health systems that can respond rapidly and flexibly to emerging disease. They need environments that support human life.

The zombie apocalypse is our least likely but most entertaining future. [image from proprofs.com]

70,000 years ago our ancestors took their first steps out of Africa. With those steps they initiated the binding link between globalisation and health. The difference between then and now is a matter of temporal and geographical scale. Then, nothing moved faster than a walking pace. Now, a person can traverse the globe in 24 hours. A city thousands of kilometres away can be destroyed in 30 minutes. An idea can be everywhere in seconds.

The technological advances of the last century have been kept pace by extraordinary improvements in human health. Average life expectancy barely moved until the beginning of the last century, and over the next hundred years, it doubled. In 2016, the global average life expectancy was 71.4 years of age. We had achieved the biblical entitlement of three score and ten years promised in Psalm 90. The improvements in health were achieved because of globalisation. Reductions in poverty. Improvements in food supply. Advances in healthcare. Sophisticated infrastructure was delivering clean water and carrying away waste. Those advances have also been accompanied by large inequalities in health outcomes and significant environmental degradation.

I suggest there are three broad intersections between globalisation and health. First, there is the real (and sometimes imagined) disease outbreaks: Ebola or the Zombie apocalypse. Infectious disease, however, is only one part of the health and globalisation relationship. The second, very modern concern is the interconnection between our global activities and environmental change, and by extension the impact on human health. The final idea is our relationships with each other, and how these relationships can shift, and the effect the changes may have on the availability of health supporting resources.

I sketched these ideas out in a 3,000 word essay in early 2017 at the invitation of the Editors of “Vaguardia dossier” a Spanish language, Catalan magazine. Many people (including myself) cannot read the published, Spanish version, but you can get the slightly rough, English language preprint here.

Reidpath DD, Globalización y salud [Globalisation and health]. Vanguardia dossier. 2017; 65:76-81

Fat on the success of my country

When I first visited Ghana in the early 1990’s, there was a very noticeable relationship between BMI and wealth. Rich people were far more likely to be overweight and obese than poor people. That visit took place about ten years after the 1982-1984 famine. Some of the roots of the famine lay in natural causes resulting in crop failure and some lay in local and regional politics, and it was small children that bore the brunt of it. Less than ten years after the famine it was perhaps unsurprising to see that (on average) the thinnest were the poorest, and the fattest were the richest.

Working in Australia in the early 2000s, however, there appeared to be exactly the opposite relationship. It appeared that the poorest were more likely to be overweight or obese and the wealthiest, normal weight. This observation was certainly borne out at an ecological level when my colleagues and I found an unmistakable relationship between area level, socioeconomic disadvantage, and obesogenic environments — fast food chain “restaurants” were more likely to be found in poorer areas.

So which is it? Are the poor more likely to be overweight and obese, or is it the rich? One of the challenges in working out this relationship is that it appears to be different in different countries. Neuman and colleagues conducted a multi-level study of low-and middle-income countries (LMICs) looking at this very problem using DHS Survey data. They found an interaction between country-level wealth, individual-level wealth, and BMI. Unfortunately, the study was limited to LMICs because the DHS surveys do not operate in high-income countries. While it would be tempting to extrapolate the interaction into high-income countries, without the data, it would just be a guess.

We don’t have the definitive answer, but a recent paper by Mohd Masood and me, based on his PhD research, provides some nice insights into the issue. We were able to bring together data from 206,266 individuals in 70 low-, middle- and high-income countries using 2003 World Health Survey (WHS) data. The WHS data are now getting a little old, but it is the only dataset we knew of that provided BMI and wealth measures from a sample of all countries, using a consistent methodology, all measured over a similar period of time.

Mean BMI of the five quintiles of household wealth in countries ranging from the poorest to the richest (GNI-PPP). [https://doi.org/10.1371/journal.pone.0178928]

The analysis showed that as country-level wealth increased, mean BMI increased in all wealth groups, except the very wealthiest group. The mean BMI of the wealthiest 20% of the population declined steadily as the wealth of the country increased. In the wealthiest countries, the mean BMI converged for the poorest 80% of the population around a BMI of 24.5 (i.e., near the WHO cut-off for overweight of 25). The wealthiest 20% had a mean BMI comfortably below that, around 22.5.

It is obviously not inevitable that as the economic position of countries improves, everyone except the very richest put on weight. There are thin, poor people and fat, rich people living in the wealthiest of countries. Nonetheless, the data do point to structural drivers creating obesogenic environments. My colleagues and I had argued, at least in the context of Malaysia, that the increasing prevalence of obesity was an ineluctable consequence of development. The development agenda pursued by the government of the day decreased physical activity, promoted a sedentary lifestyle, and did nothing to moderate the traditional fat rich, simple carbohydrate diet associated with the historically rural lifestyle of intensive agriculture.

We really need more data points (i.e., a repeat of the WHS) to try and tease out the effect of economic development on obesity in the poorest to the richest quintiles of the population. I would suspect, however, that countries need to think more deeply about what it is they pursue (for their population) when they pursue national wealth.

Does global health need a ‘red team’?

Looking at population health, time-series data it is easy to imagine that everything is getting better and better. What is more, as your eye tracks the line into some imaginary future, it is easy to believe that things will continue to get better and better. It is a soothing balm to the more insidious thought, that doom awaits us around every corner. In the world of stock pickers and equities experts, the balm is the Ying of the bull to the Yang of the bear. Hope versus despair.

The late Hans Rosling has done more to ground people in that hopeful view of the future than any other person. The gapminder website, his creation, provides clear, firm evidence of global improvements in health and well-being across a wide range of outcomes. As you follow the motion picture trends, countries improve. Some occasionally collapse, horribly. Then they recover. And on average, all improve. Poverty, life expectancy, education, the infant mortality rate — it does not matter what you focus on, the world has been getting better and better

Figure 1 is a quick snapshot of this improvement in life expectancy from 1915 and 2015. In both years, higher national wealth was associated with better life expectancy. In 1915, a country with a GDP/capita (adjusted for inflation and price) of $1,000 had a life expectancy of 30 years. In 2015 a country with a GDP/capita (adjusted for inflation and price) of $1,000 had a life expectancy of 60 years.

Figure 1. The left and right panels show the countries’ life expectancy in relationship to the GDP/capita (adjusted for inflation and price) 100 years apart. In 1915 a country with a GDP/capita of $1000 had a life expectancy around 30 years. In 2015 it was around 60 years — a difference of about 30 years. Source: Gapminder

In contrast, in the middle of the 18th Century, life expectancy was similar across all countries, without regard to national wealth. Little had changed by the middle of the 19th Century. Sixty years later (1915), there was a strong association between national wealth and life expectancy; and over the next 100 years, things became much better for everyone.

Will this continue?

Let’s hope that it will. There are however significant threats visible on the horizon — and I would argue that Global Health needs a strong Red Team to make plain that dreadful prospect, often and forcefully. And as the Red Team argues their side we should hope fervently that they are utterly and comprehensively wrong! We should nonetheless listen to the arguments and not glaze over or dismiss them as we would Cassandra.

Red Teams arose in the US military and intelligence communities. They were there to argue against self-satisfied complacency. If the majority view was purple, they argued orange, if Winter, then Summer. Their purpose was to find the weaknesses in the status quo. One of the most extraordinary examples of the power of a contrarian view was the Millenium Challenge 2002, in which Paul van Riper showed that a demonstrably weaker force (the Red Team) could be devastatingly effective against the powerful (Blue Team) when they were prepared to play outside the constrained paradigm of accepted norms.

In Global Health the situation is, of course, entirely different — we do not battle each other, but we do struggle with (and against) nature and the environment. What is not different between Intelligence agencies and Global Health agencies is that views become entrenched. The Philosopher of Science, Thomas Kuhn, described the entrenchment of scientific ideas in terms of normal science: “the regular work of scientists theorizing, observing, and experimenting within a settled paradigm or explanatory framework”. These “settled paradigms” can permit significant new developments, but they brook no serious opposition (only tinkering at the margins). They are the VHS manufacturer to the plucky Betamax.

“Beta what?”, I hear you ask, and the point is made.

Global Health has large, powerful groups that are in danger of playing a form of technocratic hegemony — Global Health, normal science. It’s incremental, unabrasive, and potentially wrong or ineffectual. Some of the possible threats to global health are well known, and if we focus only on those related to climate change and population growth the following is a reasonable starting list:

The global expansion of humans over the past 10,000 years was made possible by the growth of agriculture, which in turn was made possible by a stabilisation in the climate about … 10,000 years ago. Our current success is again a product of agricultural developments. Paul Ehrlich, in his 1968 book The Population Bomb wrote a Malthusian tale of global starvation. His prediction failed to take account of Norman Borlaug’s green revolution, and the development of semidwarf wheat, which saw grain yields triple in the 1960s and 1970s. The predicted cycle of devastating starvation was averted.

Success in the past, unfortunately, does not tell us anything about the future. Timely science then does not predict timely science now. Although Borlaug’s work saw Ehrlich’s predicted threats displaced in time, towards the end of his Nobel Prize acceptance speech, Borlaug said:

Malthus signaled the danger a century and a half ago. But he emphasized principally the danger that population would increase faster than food supplies. In his time he could not foresee the tremendous increase in man’s food production potential. Nor could he have foreseen the disturbing and destructive physical and mental consequences of the grotesque concentration of human beings into the poisoned and clangorous environment of pathologically hypertrophied megalopoles. Can human beings endure the strain? Abnormal stresses and strains tend to accentuate man’s animal instincts and provoke irrational and socially disruptive behavior among the less stable individuals in the maddening crowd.

We must recognize the fact that adequate food is only the first requisite for life. For a decent and humane life we must also provide an opportunity for good education, remunerative employment, comfortable housing, good clothing, and effective and compassionate medical care. Unless we can do this, man may degenerate sooner from environmental diseases than from hunger.

So far, the international, multilateral approach to a possibly gloomy future is to seek hope — it does, after all, spring eternal. We will reduce greenhouse gas emissions, tackle global poverty through economic growth, and increase food production. We will not need to tackle population growth, nor will we have to make do with less. We write about planetary health, but we do not develop strategies for a planet that is less human-friendly tomorrow than it is today.

I hope that global health and well-being will improve well into the future, well past my life and I hope well past that of my children, (and their children, …). In case it does not, I would like to think that there is a Global Health Red Team that does not just echo gloomy news in the halls of power, but argues for and develops strategies suitable for the world in which we are all worse off. What should our goal be in that worse off world? Is it a global goal, an equitable goal of mutual pain, or is it a “My Country First”, Shakespearean tragedy of the commons?

There is an ironic twist to the use of Red Teams in the US military that may have some bearing on their use in Global Health. In the Millenium Challenge 2002 when the Red Team devastated the Blue Team in the first few days of a fortnight-long exercise, the judges reset the clock. They hamstrung the Red Team, and then let everything play out in a way that would ensure that normal (military) science came out unscathed.

Global Health needs to be intellectually braver.