Category Archives: Trickle Down Science

Pandemic schmandemic

I was disconcerted to read that the last of the formal Pandemic Accord meetings for 2024 closed tonight (6 December 2024) without reaching an agreement. My colleague, Professor Nina Schwalbe, summed it up perfectly in her bluesky post. “Member States have missed a once-in-a-generation opportunity to make a difference because national interests prevailed over global solidarity”.

The World Health Assembly established the Intergovernmental Negotiating Body (INB) almost three years ago to “draft and negotiate a convention, agreement or other international instrument under the Constitution of the World Health Organization to strengthen pandemic prevention, preparedness and response”. When the WHA established the INB, we were in the middle of the COVID-19 pandemic. There was a visceral urgency to figure out better ways to work together globally to prevent and manage the next pandemic. Now, it’s all a bit “meh“.

In the last month, we have been gifted non-ignorable data points by the fates, which should have focused the mind. We did not need special skills to read the tea leaves at the bottom of the cup or divine the future from goat entrails.

  1. The American people re-elected Donald Trump as President of the United States and handed him a clear mandate. He campaigned on a populist America First policy and has declared (and demonstrated) an antipathy towards global treaties and accords that threaten global health.
  2. Trump also announced that Robert F. Kennedy Jr. (RFK Jr), a vaccine denier, would be the Health Secretary. RFK Jr is also on record that there is too much focus on infectious diseases.

Together, these will create geopolitical friction in negotiating a pandemic accord that may be impossible to overcome. Fate has also been teasing us with news of infectious diseases among those geopolitical tea leaves.

  1. A mystery infectious disease has appeared in a remote area of the Democratic Republic of Congo. According to the Ministry of Public Health, there have been 394 cases and 30 deaths.
  2. Influenza A subtype H5N1 is the stuff of infectious disease specialists’ nightmares. It has a very high case fatality rate–typical ‘flu’ has a fatality rate of <1%. H5N1 has a case fatality rate of around 50%. The saving grace has been that it had not adapted to human-to-human transmission. Human transmission might be about to change. It has swept through U.S. dairy herds and is found in raw milk. Did I mention that RFK Jr. is a fan of raw milk?

This failure is particularly bitter because they’re walking away from the negotiating table when the stars are aligning for potential future crises. We have a new U.S. administration openly sceptical of global health cooperation, an increasingly complex geopolitical landscape, and emerging pathogens testing our surveillance and response capabilities. The window of opportunity that opened during COVID-19–when the world’s attention was focused on pandemic preparedness–appears to be rapidly closing.

Research brain drain from the global south

The Director of the School of Oriental and African Studies (SOAS) in London, Dr Adam Habib, recently argued that universities in the global north are taking the best and the brightest from the global south and failing to return them.

360info asked me to reflect on this for a special issue on the education brain drain, and write about it from the perspective of research in the global south. What I wrote builds on previous ideas I’ve published and blogged about around the idea of “trickle down science” and decolonising research. This is an edited version of the 360info article.

The indigenous Bajau Laut of southeast Asia live a nomadic existence at sea. They have lived on houseboats for more than 1,000 years, free-diving for marine resources to sustain themselves. Research on the human genetic changes that allowed the Bajau Laut to adapt to this life at sea was published in 2019 in Cell. All but one of the article’s authors came from developed economies. The one Indonesian researcher had no relevant disciplinary background and appeared to be logistical support. The Indonesian government saw the study as exploitative and legislated to restrict overseas researchers from fly-in, fly-out, “grab the data and run” research. 

It’s an example of a common problem: the world’s poorest economies suffer health and development deficits that require research, but they are least likely to do research. When they do research with developed economy collaborators, it is often not the most relevant research to the developed economy.

The highest-income economies graduate the most PhDs per capita — the principal qualification for researchers — whilst the poorest economies graduate the least. The current stop-gap solution, critiqued by Dr Habib, is for developing economies to send their best and brightest students away to overseas PhD programs, often in developed economies. But the PhD experience in developed economies is usually geared towards research training involving sophisticated techniques and equipment unavailable at home. The student cannot replicate the research environment when they return to their home institutions and fall into an intellectual suzerainty. 

A supplementary approach to improving research capacity is through research collaborations. Many developed economy researchers enjoy the opportunity to collaborate with developing economy researchers. The developed economy researchers offer much-needed injections of capital and equipment; they can also provide experience using the latest collection techniques or analytic methods. Through the collaborations, developing economy researchers grow their skills and their networks. They are also much more likely to become authors of well-cited journal articles, which improves their international standing. 

However, significant concerns have been raised recently about the nature of the research collaborations between developed and developing economies. The concerns pivot on whether the relationship is exploitative. Are the collaborators from developing economies equal partners in the research, or are they logistical support, as in the case of the Bajau Laut study? Improving research capacity in developing economies needs to be realistic about the challenges and the structural deficits. There needs to be mutual respect. And it needs to be resilient to foreseeable and unforeseeable shocks. 

Around 10-years ago, the Wellcome Trust funded a project to establish a virtual institute for interdisciplinary research of infectious diseases of poverty in four countries (five institutions) in West Africa. Two developed economy institutions provided support. Nigeria and Mali had Boko Haram insurgencies during the project, and Côte d’Ivoire had a coup. Unfortunately, these external shocks are not atypical examples of the challenges of research capacity strengthening.

Political upheaval notwithstanding, the North-South-South (NSS) approach taken in developing the virtual institute was promising. The project networked developing economy institutions with some developed economy institutions, and it focused on the institutes, not on individual researcher capacity—which is easily lost. It is more holistic and looks to the development of infrastructure, governance, and human capital. Because the approach is based on a multilateral partnership, there are opportunities for mutual support within and between institutions and individual researchers. Governance developments in one institution can be replicated and adapted in another. Depending on the nature of the research, infrastructure can also be shared, such as cloud computing and gene sequencers.

The Norwegian government uses this approach, as does the World Health Organization, albeit in a slightly different form. The NSS approach also stands in marked contrast to supporting one-off projects or funding individual research degrees. The NSS PhD training is based in the developing economy institutions with support from the developed economy institutions in the network, including support from supervisors in the developing economies institutions. The approach simultaneously builds the developing economies’ supervisory capacity and decreases the likelihood of brain drain. The research is also driven by the relevance of the research to the developing economies and utilises technology that is available. 

It is not possible to mandate mutual respect. Developed economy institutions that have been successful over the past half-century in the traditional engagement models — “send your brightest and we will train them”, or “here’s some money, send the data” — may find changes in the status quo unappealing. However, there is no doubt that the NSS approach requires a different mindset, particularly in the institutions of the global north. The research capacity needs of the global south are enormous. The traditional approaches can not meet the needs because they do not scale. New global north institutional players will be needed, and they won’t have the baggage of past practice to weigh them down.

The original article was published under Creative Commons by 360info™. This is an edited version.

Local causation and implementation science

If you want to move a successful intervention from here (where it was first identified) to there (a plurality of new settings), spend your time understanding the context of the intervention. Understand the context of success. Implementation Science—the science of moving successful interventions from here to there—assumes a real (in the world effect) that can be generalised to new settings. In our latest (open access) article, recently published in Social Science and Medicine, we re-imagine that presumption.

As researchers and development specialists, we are taught to focus on causes as singular things: A causes B. Intervention A reduces infant mortality (B1), increases crop yields (B2), keeps girls in school longer (B3), or…. When we discover the new intervention that will improve the lives of the many, we naturally get excited. We want to implement it everywhere. And yet, the new intervention so often fails in new settings. It isn’t as effective as advertised and/or it’s more expensive. The intervention simply does not scale-up and potentially results in harm. Effort and resources are diverted from those things that already work better there to implement the new intervention, which showed so much promise in the original setting, here.

The intervention does not fail in new settings because the cause-effect never existed. It fails in new settings because causes are local. The effect that was observed here was not caused by A alone. The intervention was not a singular cause. A causes B within a context that allows the relationship between cause and effect to be manifest. The original research in which A was identified had social, economic, cultural, political, environmental, and physical properties. Some of those properties are required for the realisation of the cause-effect. This means that generalisation is really about re-engineeering context. We need to make sure the target settings have the the right contextual factors in place for the intervention to work. We are re-creating local contexts. The implementation problem is one of understanding the re-engineering that is required.

 

The cartographic challenge of decolonising global health

A navigational chart from the Marshall Islands, on display at the Berkeley Art Museum and Pacific Film Archive. It is made of wood, sennit fibre and cowrie shells. From the collection of the Phoebe A. Hearst Museum of Anthropology at the University of California, Berkeley. Date not known. Photo by Jim Heaphy. (Wikipedia; CC BY-SA 3.0)

There are a growing number of papers in the peer-reviewed literature about decolonising global health (see). Pascale Allotey and I have discussed the problem in terms of “trickle-down science” (also see). That is, the way (global health) science is done, how it is prioritised, and who is advantaged. It is a description of science generally conceived and managed from powerful institutions in the global north, with implementing partners in the global south, their factories for data collection. We have also critiqued critiques that advocate a utopic version of global health, arguing that:

decolonising global health extends beyond relations between [low- and middle-income countries] LMICs and [high-income countries] HICs; it is also about the relationships within them. Decolonisation is fundamentally about redressing inequity and power imbalance.

The latest offering on the altar of peer review is a three-step roadmap to the decolonisation of global health and a call to join the authors on their journey. Maps, however, are tricky things. They are culture-bound and themselves tools of colonisation. Their design, content, and what they highlight and ignore require a shared and agreed understanding of the path and the goal. Woe betide the European sailor trying to navigate using the Marshall Islands stick chart.

Much as I applaud the idea of redressing the power imbalance in global health, this particular attempt is tone-deaf. It is presented as if decolonisation was waiting for six authors from three of the world’s wealthiest countries to explain it to “the colonies”. Readers will forgive the irony that the first and last authors of the roadmap are at the London School of Hygiene and Tropical Medicine (LSHTM) — an institution established to support the colonial administration of the world’s greatest empire — an institution that, to this day, encourages and benefits from neocolonial relationships with the global south. The authors note these kinds of relationships and bravely forge on.

In developing the roadmap, the authors draw parallels with the feminist movement. An apt analogy (tongue firmly in cheek) because who cannot recall the importance to the feminist movement of first having men in power explain how it should be done? The men were so quick to relinquish their power that one barely remembers the days of gender inequality. Who does not know (tongue back behind teeth) that women of privilege often powered the first and second waves of feminism? The movement systematically failed to account for class differences, colour lines, and culture — leaving many women behind—the voice matters.

Who has the right to speak for whom in global health is a challenge. In a previous article, I wrote about this very issue. Fighting over the legitimacy of the voice is always fraught, and passions can run high. Are voices from some countries/institutions with this or that history as a colonial master or servant more or less valued than others? Is it more or less hypocritical to privilege voices from LSHTM, Johns Hopkins University, or the University of Washington over those from Makarere University, the Tata Institute of Social Sciences, or the Oswaldo Cruz Institute?

“Decolonising” is ultimately about forgoing power and transferring power. It is something that has to happen between countries and within countries. There is a cacophony of voices, all of which should be heard — but they are not equally important. They do not all warrant the same time and space. The authors of “the roadmap” are neither transferring nor forgoing power. As the cartographers, they determine the path, the points of interest, and the rest stops.

The roadmap for decolonising global health should not be determined nor led by countries and institutions simultaneously holding the whip and the chum.

#decolonising #decolonising #globalhealth.

With any piece I write about decolonising global health, I always have two competing voices in my head: “this issue is important, say it” and “should I be the one saying it?” I will declare my conflicts, and you can decide if you want to listen to or shoot the messenger. I am a white male born in (not by choice) the British Colony of Southern Rhodesia. In virtue of privilege and choice, I have lived and worked in Australia and the UK, and for the last 12 years, Malaysia and Bangladesh. My partner and I moved to Southeast Asia. Then I moved to South Asia because we were committed to capacity building and decided it was no longer appropriate to work in the global health space while sitting in a high-income country. I have never held appointments at LSHTM, Johns Hopkins University, or the University of Washington.

The original article was first published on medium.com on 26 March 2021. This version is very slightly edited.