Q&A: 'Global health funding is far from being decolonized,' says Ngozi Erondu

In January, the U.S. President’s Malaria Initiative, or PMI, announced $30 million in new funding to PATH to support a consortium of institutions to improve the use of data for malaria eradication. But local organizations were conspicuously absent, as none of the consortium partners are from Africa.

In response, a group of African global health experts has now written an open letter calling attention to funding structures that undermine local agencies. It was published Thursday in the journal Nature Medicine.

The grant — and the letter — come amid increasing conversation about decolonizing global health, a movement that has gained momentum since the beginning of the COVID-19 pandemic, as well as the killing of George Floyd in May, which led to a reckoning among aid organizations.

Speaking to Devex, Ngozi Erondu, an associate fellow at Chatham House’s Centre on Global Health Security and one of the letter’s authors, discussed the need to focus on funding in the demand for decolonization.

The following interview has been edited for length and clarity.

What was the impetus for writing the letter, and what response are you expecting?

When I first tweeted about the grant in February, the responses from PATH and PMI were very generic. I think they know that this is a problem. To me, this is just super tone-deaf — and clearly this was in the works for some time since the George Floyd killing. So it’s super tone-deaf to come out with a grant for $30 million for seven partners in high-income countries. It just shows you how disconnected leadership can be from the actual people who work in the organization.

I know this decision didn't get made in the [U.S. President Joe] Biden administration, but I would call on them — especially people like Raj Panjabi, who leads PMI now — to rectify situations like this. This should be the last time something like this happens. It needs to be something that the new leadership takes on.

You’ve talked about how the predominant global health architecture favors Western institutions. How does this affect research on the ground?

We see it over and over again. There’s this inherent assumption that Western institutions can do things better, even if they may not be culturally and regionally appropriate. We can see it for COVID-19, too. Now we’re in a situation of inequitable vaccine distribution, which we know in the long run hurts everybody.

But specifically in research, which the letter talks about, it's just part and parcel of the current global health architecture. The U.S. is always said to give the most to international development — and that is true, but if you look at the funds that they give, almost 40% goes to American organizations to do work in low- and middle-income countries.

What happens is you get people making decisions for places that they’re not from. You have grant panels that are even assessing the research that are not made of the people from these countries. Most of the big decisions get made in Washington, D.C., or Geneva, and that’s why we continue to have these really flawed practices. And that’s why we’re not seeing the results we want to see. That makes you think: What is global health for? Is it really to improve health for everyone, or is it just to keep a machine going?

In the letter, you said that only 1% of past malaria funding went to in-country research institutions. Is the need for more funding also connected to the argument of investing not just for the sake of capacity strengthening but also to ensure that the research is rooted in local contexts?

If we say that foreign aid for global health is necessary, then the question is: How should that be done? That’s where we should start. It’s about effectiveness. Where should these monies go?

When I was on the front lines in Guinea working on Ebola, I realized that I was working on behalf of CDC [the U.S. Centers for Disease Control and Prevention]. I’m a Nigerian American person not from Guinea at all. I took a back seat as much as I could.

It’s silly for us to keep … doing this “parachute science.” I’m not saying that global health doesn’t have a role; I think it was really important for scientists from outside to come in. Guinea didn’t have a public health infrastructure in place. They were really medicalized, and they hadn’t invested in public health at all before Ebola happened.

So I’m not saying there’s no role for outsiders, but the role should be behind the local experts. And we don’t do that. Funding really has a role to play. And here is where funders can say: “You want to work in Guinea? Make sure that Guineans have to have a main role in this.” Funders have to go deeper to make sure that we’re not having this tokenistic approach to partnership, which is what we normally do. And it doesn’t solve the problem.

In Guinea, we lost months because we didn’t understand the culture. We didn’t even understand that, in some areas, Muslims wash the bodies before burials. Safe burial techniques should have been one of the first interventions that we recommended. But because we — Western institutions and leaders — thought that we knew best, we had a lot of challenges with interrupting transmission of Ebola.

And are you seeing the same dynamics play out now during the COVID-19 pandemic?

There’s two things I saw from COVID-19. One is that even though a lot of funders abandoned a lot of their responsibilities — especially for immunizations and things like that — the people on the ground did not. For a lot of countries that have endemic diseases and poor health systems, they have relied very much on community health workers, they have relied on public health infrastructure that’s very close to the ground.

So the things that the U.K. and the U.S. are learning about community empowerment are things that organizations and state actors in low- and middle-income countries such as India have already been doing. So one thing that we saw from COVID is that they can do this on their own. We don’t even need this colonial attitude. The African Union is one of the only regional organizations that have really pulled their member states together to have an effective response to COVID.

So COVID has shown us that even when the money isn't there and countries are kind of abandoned by their Western counterparts, they can do it themselves because they understand their communities.

Has anything changed in the decolonization global health movement in the last year of the pandemic, especially since it’s almost a year since George Floyd’s killing and since the conversation around racism and inequality in the aid sector really started taking off?

The most progress I see is that there are more institutions that are galvanized around this. My colleague Fredros [Okumu, director of science at Ifakara Health Institute in Dar es Salaam, Tanzania], who is also one of the authors of the letter, was saying that there are people like him — African researchers, based in Africa — who would have never spoken up about something like this before. So I think there is a change in the empowerment of people who are marginalized.

In terms of more structural change, in terms of funding organizations, I haven’t seen any change at all. Global health funding is far from being decolonized.