NEW DELHI — A paper called “The Impact of COVID-19 and Strategies for Mitigation and Suppression in Low- and Middle-Income Countries” was recently released in the journal Science. It lists 49 authors, from 5 prestigious universities in the U.K. and United States. Missing conspicuously was local representation from the countries that the paper talked about.
Researchers from low-income countries are “never at the table,” said Senjuti Saha, a microbiologist working at the Child Health Research Foundation in Bangladesh. “There’s not a single author from within our countries. It’s a really good paper but my thing is, who in Bangladesh is going to read a Science paper? Who is going to get that information? Is my policymaker going to read a Science paper unless they have some representation from Bangladesh? Absolutely not,” Saha told Devex.
On Twitter, the paper’s authors fielded similar reactions, with many using the hashtag #DecolonizeGlobalHealth
Colonizing in this sense refers to the idea that western researchers and practitioners impose solutions and decisions on countries that are under-resourced without involving people from those places. As countries around the world struggle to contain the coronavirus, inequalities brought about by existing imbalanced power structures are resurfacing, resulting in growing calls to decolonize global health.
COVID-19: Mirror and a magnifying glass
In April, two French scientists suggested conducting trials in Africa to test the effectiveness of a tuberculosis vaccine against COVID-19, causing an uproar.
World Health Organization Director-General Tedros Adhanom Ghebreyesus called the remarks appalling and a disgrace, coming from scientists. “Africa cannot and will not be a testing ground for any vaccine. The hangover from colonial mentality has to stop. WHO will not allow this to happen,” he said in a press conference.
The experience of racism and discrimination is not new in development, experts say, especially in global health, and the pace of the COVID-19 crisis is only exacerbating the situation.
“COVID-19 is more of a mirror and a magnifying glass — it’s just reminding us and it’s just magnifying to us what is already defective in the system. French scientists insinuating that Africans should be the guinea pig for the new COVID vaccine? That’s not right and that has happened before and that’s still happening now and it just got magnified,” said Renzo Guinto, a Filipino physician and public health expert.
This kind of attitude from the West is not limited to the continent of Africa alone. In the first week of June, the U.S. sent 2 million doses of hydroxychloroquine to Brazil — touted by President Donald Trump as a possible cure for COVID-19, only to suspend its own authorization for emergency use for the drug a few days later.
“COVID-19 has exposed ourselves to ourselves in a way that I hope you cannot unsee.”— Seye Abimbola, senior lecturer, University of Sydney School of Public Health
“We do not need a more infamous instance of colonialism than this. Brazil [is] being treated as a toxic waste repository,” said Deisy Ventura, a professor of ethics at the Faculty of Public Health at Brazil’s University of São Paulo. “With the likely decline of multilateralism, bilateral relations tend to break alliances in the developing world more easily and perpetuate various forms of colonialism,” she added, warning of its impact on global health.
Some experts argue that initial safety measures against the coronavirus advocated by WHO were ill-conceived and did not consider the real situation on the ground for most of the world’s poor.
The idea of social distancing assumes a very middle-class world, said Seye Abimbola, a Nigerian-born scholar who is a senior lecturer at the School of Public Health at the University of Sydney and the editor of the medical journal BMJ Global Health. “But inequality itself is a vector,” he said.
Even washing hands several times a day with soap can be a luxury for those without access to water, and policymakers did not consider that, he said. “I was thinking to myself: Do they have a sense of how people actually live on a day to day basis? This is a mechanism that works in colonial attitudes. There’s a blindness of superiority,” Abimbola told Devex.
Researchers and practitioners from LMICs also criticized other measures to prevent COVID-19, such as stringent lockdowns.
In Bangladesh, for example, the lockdown forced the shutdown of the country’s garment industry, which accounts for over 80% of its exports.
“We are influenced by what we’re told to do. When Bangladesh decided to lockdown, they did not think about what's going to happen to our garment industry which is the main source of remittance — what about the garment industry workers who are daily wage earners?” Saha said.
Race an ‘absent presence’
Colonial approaches are not just what is advocated for other countries, experts told Devex. Colonialism is also rampant within international NGOs that work in LMICs.
“Even when you work with the same INGO, it’s just that you’re national staff, and obviously in terms of salary, and decision-making, your opinions are secondary to the staff who are based in the headquarters. But I don’t know if it’s going to change at the rate that we want it to,” said Ifeanyi Nsofor, director of policy and advocacy at Nigeria Health Watch.
Robtel Neajai Pailey, a Liberian academic and activist, calls race an “absent presence” in the discourse, policy, and practice of development. In her paper, “De‐centring the ‘White Gaze’ of Development,” she highlights the hierarchies of dominance in development.
“Who controls the levers of development? It’s really white people in the so-called global north. While global domination and structural inequality is inbuilt as constituted by economic power, it is reinforced and justified by racial power,” Pailey said recently, while discussing her work on a podcast.
Guinto, who has a doctorate from Harvard University, said he was invited to meetings at foundations and INGOs in the U.S. where he was often the only Asian person, as “a representation of the uninvited.”
“Gates has an opportunity to do the right thing. That means, having African people in his organization who have a say on the way he does things.”— Yap Boum, epidemiologist and the regional representative, Epicenter Africa
“I took advantage of those moments of tokenism and turned them into opportunities for a meaningful engagement. That’s kind of the way I describe my decolonizing global health journey,” Guinto said, speaking from Manila where he works on planetary health.
Yap Boum, an epidemiologist and the regional representative for Epicenter Africa, the research arm of Médecins sans Frontières in Cameroon, places the onus of ensuring equitable decision making on organizations working in LMICs.
“A lot of the time, organizations are unhappy that their money has been spent without having the results that they were expecting. That happens because they did not engage with the community and also the local government in whatever they want to do,” Boum said.
He also called for setting a narrative that focuses on the need for local knowledge and expertise. He recently wrote about it in the journal Jeune Afrique with 12 other African researchers.
“The idea was that it has to be in those journals, in those fora, so that the African stakeholders, shareholders and the philanthropists see it. If we all make noise and at the end of the day it’s Bill Gates who’s funding our research, it’s hard to say we want to decolonize global health,” he said.
“Maybe we are not telling, shouting, crying out enough. There are people who have money on the continent and those people are giving. There is a story that we’re not telling well,” Boum said.
In addition to hiring, empowering local staff is also crucial.
“Gates has an opportunity to do the right thing. That means, having African people in his organization who have a say on the way he does things. He has very talented people, but are they really in a position to make big decisions? Sometimes, I’m not sure,” Boum said.
A decolonized world?
The process of decolonization will take effort from both sides, experts say.
“The global north must be willing to give up power, and also listen to the global south. And the global south must also begin to take responsibility to say, we should be able to do this on our own. Why are we still dependent on Gavi to immunize our children?” Nsofor said.
Clinical trials underway for COVID-19 are a case in point. Only two African countries — Egypt and South Africa — are hosting trials, out of over 1,000 currently being conducted globally. Nsofor believes it is reflective of where the power and funding lies, and LMICs need to start thinking about research and development.
“COVID-19 is affecting every country. Why couldn’t there have been other sites in developing countries? So when you generate your data, [it] will actually be representative of everybody,” he said.
Writing in the journal CSP with seven other authors, University of São Paulo’s Ventura highlighted the need for greater effort to set research priorities according to local interests and urged Brazilian scholars and practitioners to “challenge the Northern Hemisphere’s predominance in the global health research agenda.”
Making the argument about the problems with inequality is much easier in the light of COVID-19 than it was before, Abimbola said.
“In a crisis, you actually see people for who they are. COVID-19 has exposed ourselves to ourselves in a way that I hope you cannot unsee. And in a way that I hope will compel us to react and behave differently going forward,” he said.
Some of the change is already beginning to happen. With rising exposure and educational opportunities, more and more people from the African continent who have been trained in different countries abroad have gone back to their respective countries.
“They are decolonized. They have no complex,” Boum said. “In Africa, things are changing. So for you to come and impose just because you’re Western, that’s no longer working everywhere.”
But Saha said her biggest worry is what happens after. Knowing that COVID-19 is not a disease that can be eradicated or eliminated completely, travel restrictions will be made more stringent. Traveling to conferences will perhaps require a COVID-19 test, further reducing access for people from countries like Bangladesh where testing capacities remain low.
“We are already underrepresented in international conferences. This will impact that severely,” Saha said. “They will probably figure out a way to meet again, maybe in outdoor spaces. But we will not be invited.”