While the COVID-19 pandemic has made the past year difficult for individuals and communities everywhere, it has also compounded and revealed at multiple levels the impact of inequities created by long histories of oppression. While these systems of oppression are not new, revived discourse and greater attention paid to demands for justice have prompted a sense of urgency for us all to take deliberate action to reflect, learn, and reimagine the ways we can combat these systems of oppression – on an individual level, and by pushing institutions of power to do the same.
At Possible, the team has pivoted its work to focus more actively on collaborative research that seeks to build the evidence-base needed to address implementation and policy gaps in healthcare equity, quality, and accessibility. Simultaneously, all team members are taking this opportunity to continuously reflect on, critique, and improve how we operationalize our work; central to this is acknowledging the asymmetrical systems that we work within, and actively striving to uproot injustice and inequality when and where we see it. Though committing to this work is an important first step, actualizing it remains a work in progress.
During my time interning at Possible during the summer of 2020, I was lucky to enter a team in the midst of this change. I immediately felt a buzz from team members, who were striving to re-imagine their role, while also pushing me to ask the big-picture questions about our work. This included frank conversations about what Possible had done well in the past, and where we had fallen short; this included sharing visions for where Possible could end up in the future, and how this path could be radical in its pursuit of increased equity and inclusion. We also collectively thought outside of Possible’s walls, reflecting on academic global health at large. This is what I hope to explore in the coming paragraphs, with the guiding question: as academics in global health, how are we collectively doing in our pursuit of conducting anti-colonial global health work?
Anti-colonialism is a framework for thinking about and seeking to dismantle systemic injustice, and it asserts that our world today still requires active colonial resistance; this is explicitly contrary to other schools of thought that incorrectly assume an end to colonialism.
An anti-colonialist framework is particularly important when thinking about biomedicine and global health, both of which have been frequently and aptly criticized as ‘tools of colonialism.’ In this role, global health work has historically been oppressive, failing to mitigate the power imbalance inherent in itself. This takes many forms: conducting research on rather than with local communities; setting international priorities from Western academic offices rather than in partnership with local stakeholders; launching interventions in the name of implementation science without specifically grounding the work in intricate and unique local and national geopolitical realities; the list goes on.
Despite this fraught history, academic global health is facing an overdue reckoning, in part as a result of the prominent movement to ‘decolonize global health.’ In my role as a medical student at the Icahn School of Medicine at Mount Sinai, I have attended lectures and seminars applying this framework to our global health in-class studies. For example, scholars are increasingly publishing critiques of traditional global health models and the power imbalances they benefit from and perpetuate in the academic literature. In applying this lens to our teaching and scholarship, we are certainly taking steps in the right direction; but this fails to provide insight into whether theory makes it into practice. How are scholars and organizations doing global health work translating anti-colonialism into their day-to-day practices?
Before answering this question, it is important to recognize my positionality in writing this piece. I am a white cisgender male, a second generation American, first generation college student, and a medical student at an urban academic medical center. From this position, I fear that writing this piece risks intellectualizing anti-colonial global health, which in itself is antithetical to anti-colonialism and a form of intellectual imperialism. This fear is well articulated by Lawrence & Hirsh et al. 2020, quoted below:
“It is often easier for researchers in HICs [high income countries] to discuss neo-colonial aspects of global health research but it is far more intimidating for the majority of African researchers to do the same, particularly among their international collaborators. This reluctance is yet another colonial aspect of global health…. there is a need for spaces and forums for debate across the continent where African and international researchers are able to have frank, open discussions about these power imbalances and develop solutions going forward.”
Accordingly, I strive here to reflect on the questions above in a way that is a de-intellectualized work in progress, a starting point not limited to the confines of this written piece, but rather one that will continue to take shape in less academic spaces, for example dialogue with my future global colleagues. I do this reflection in the context of my internship with Possible, where I was tasked with supporting two grant applications for the National Institutes of Health (NIH), America’s largest public funder of biomedical and health systems research.
As an intern, I set off to understand what defines a ‘successful’ NIH grant application. I learned that NIH has a numerical scoring system and procedure used to quantify grant applications, including those that are global health focused, on a scale from 1 to 9. This system evaluates each submission across five categories: significance, investigators, innovation, approach, and environment. Although many often view quantitative processes like this one as objective, NIH funding is fraught with inequity: a review of 2000-2006 funding data published by Ginther et al. found that white scholars were more likely to be funded than Black and Asian scholars, and that scholars with a medical school academic affiliation were more likely to be funded than those without. These data are now 15+ years old, and NIH has since put in significant effort to improve, for example devoting a section of their website to showing decreases in racial disparities in funding.
Secondly, the above data covers all NIH projects, and is not specific to global health work. Within the Fogarty International Center (FIC), an arm of NIH that is focused on funding global health work, 20% of awards since 1988 have been to principal investigators from low-and-middle-income countries (LMICs), according to a 2020 opinion piece published by FIC director Dr. Roger Glass. The same piece shows that in 2019, this rose to an all-time high of 31% of awards. Personally, this is higher than expected, and can be partially attributed to a 2006 policy change that allowed for multiple principal investigators on grant applications, thereby recognizing western: non-western partnerships by allowing for the inclusion of LMIC-based scholars as co-principal investigators. Notably, no known, publicly available source has broken down what percent of FIC awards go to exclusively LMIC-based scholars, without Western partners.
During my internship, I frequently sat in on NIH application team meetings, which provided me insight into team dynamics and the unwritten rules that were guiding our application process. I observed that the ‘investigator’ section from the aforementioned scoring system garners a disproportionate amount of attention: who comprises the team, and what skills and expertise do they bring to the table? To meet NIH’s informal metrics for success in this category (which we learned about by word-of-mouth, from a team member who had served as an NIH reviewer before), we sought to curate a team that possessed both (1) subject-matter expertise, typically held by US-based scholars who had met traditionally Western proxies for academic success, for example high publication count, ties to prestigious US-based academic medical centers, and/or previous receipt of funding; and (2) local and national content expertise, typically held by scholars from the country of study able to provide familiarity with the study site pragmatically, and with the historical, cultural, social and political realities that will ultimately govern the study on-the-ground.
Hearing that the NIH, and funders with similar rubrics, take local and national content expertise into account immediately felt to me like a step in the right direction. This pushes organizations like Possible to strive for inclusivity in their submission, increasing the chance that scholars from the country of study are granted a seat at the table, having at least some say in study design and implementation. Further, this ensures an application takes local realities into consideration rather than merely exporting a Western academic idea without consideration of context.
However, this alone is not sufficient to translate anti-colonial global health theory into practice. First, I fear this form of inclusion of scholars from the country of study is self-limiting; for example, to include these scholars only as experts in local and national context implicitly asserts that they are not subject-matter experts in their own right, thereby depriving them of equal partnership with their Western colleagues who more traditionally check this box. In this sense, these local and national context experts risk being included, not in the name of partnership, but rather in the name of ‘capacity building’ – which is a colonial concept in itself, for its unidirectional nature, with flow thought to be from Western (assumed to have capacity) to non-Western (assumed to lack capacity) colleagues.
One important way to reframe this dichotomy is by re-imagining how we define subject matter expertise and academic success more broadly. How can we think outside of publication count and prior receipt of NIH funding, which are inherently exclusive because they have been historically less accessible for scholars in LMICs? Criticism of global health authorship as inaccessible and exclusive is not new discourse; for example, Mbaye et al. 2019 demonstrated via meta analysis <50% of research on infectious disease in Africa (1980-2016) was first-authored by an African scholar. With this in mind, how can we not just improve authorship recognition on global health publications, but even further create metrics for success that are specific to more heterogeneous notions of expertise, rather than biased measures of proximity to academic capital? To operationalize this re-imagining would require the bold buy-in of stakeholders across global health – academics, government bodies, funders, not-for-profits, and more.
Secondly, the funds for global health grant applications, and the intellectual epicenter for most projects, continue to be rooted in Western academia. Successful grant applications almost exclusively have affiliations with academic institutions, and once funding is secured, the majority of it often goes directly to these academic centers, for example funding faculty salaries and departments to administer the grants, rather than reaching the site-of-study. Project meetings are conducted and grant applications are drafted in English, creating potential barriers for team members from the country of study with limited or no working proficiency. More specifically, language barriers serve to advance inequity on the ground in the country of study: local community members with access to the educational resources needed to gain the English language proficiency requisite to enter into partnership with Western academic global health are typically privileged by class, caste, education, and other forms of capital. These infrastructural challenges, typically put forth by policies of the academic medical centers themselves, pose barriers for even the most thoughtful teams who aim to be as inclusive and anti-colonial as they can be.
While interning at Possible, I observed two small-scale interventions that sought to address these infrastructural challenges. First, the team divided the grant application workflow among smaller groups, with the goal to involve a greater number of LMIC-based stakeholders in the application process. Secondly, the team held a feedback meeting following application submission, where project roles and themes of colonialism were discussed, with the goal of improving the internal application process going forward. These interventions demonstrate the thoughtfulness and intentions with which Possible strives to go about this work, and provides some humble initial steps to build upon. However, the best intentions and small-scale organization-specific interventions cannot adequately overcome larger barriers that require broader systemic change from academic medical centers and grant funding organizations.
These reflections are an incomplete work-in-progress as I continue on my own journey to be an anti-colonial global health scholar and anti-oppressive medical student. In looking forward, I want to conclude with guiding questions and action steps, which are intended to push myself and readers of various perspectives to continue growing; I have organized these action steps by relevant stakeholder, below:
Western-Based Students and Researchers:
- Refrain from buying into academic global health’s current metrics of success. As students, we know that publication count and impact factor feel like currency, determining our specialty, our residency programs, future jobs, and more. We feel an ever-present pressure to publish, a pressure that does not lessen, but rather will intensify as we climb the ladder of traditional academic success. Try to re-imagine what academic success could look like outside of publication count. Ask yourself what other metrics should govern your success as a scholar, and reflect on how these metrics can scale globally in a manner that is more equitable than traditional metrics are today. And, when you are working within traditional metrics of success, center your LMIC-based partners, for example in positions of lead author on publications or sole principal investigator on funding applications.
- Avoid using phrases like ‘cultural competence’ and ‘capacity building,’ which are, in themselves, laced with colonialism and paternalism. Instead, strive for language that is founded on equal partnership and humility. Feel empowered to use your voice to respectfully challenge professors of medicine and global health who continue to use this harmful language while teaching you.
- Seek to de-intellectualize your anti-colonial global health work. Central to de-intellectualizing is centering your global partners in conversation about how your partnership has been, or has failed to be, anti-colonial to date.
- Remind yourself that successful anti-colonial global health no longer requires western scholars or students, no longer centers western academic institutions, and is no longer dependent on western sources of funding. This means that our work as global health academics from the global north, when done right, should be self-limiting, with the goal of becoming increasingly less central to the work with this passage of time. In this sense, we should aim to capacitate ourselves out of a job.
Global Health Grant Funding Organizations:
- Provide grant funding directly and solely for scholars from LMICs to design and implement projects independently; perhaps, operationalizing this would require earmarking a specific percentage of their funds for LMIC-scholar led projects, to hold themselves accountable. Pushback to this proposal might sound something like: “having projects tied to US-based academic medical centers ensures that the funds are used efficiently; these institutions have the experience required because they have done it before.” I challenge this pushback, as it is laced with colonial paternalism – the assumption that only Western institutions can efficiently use funds fails to recognize the expertise of LMIC-based scholars.
- Refrain from dictating funding priorities from academic, US-based offices; instead, leverage a community-based participatory process that engages scholars and community leaders from the country of study, on the ground, from the first steps.
- Accept applications submitted in using the language of the country of study. To be language agnostic will require both providing multilingual submission instructions, and hiring translators or multilingual reviewers. This will broaden access to a wider range of scholars from the country of study who are less proficient in English, but no less capable to conduct the kind of innovative health care systems research needed.
- Critically re-assess the language and frameworks your organization uses around funding diversity and equity, specifically centering feedback from LMIC voices.
Author Bio: Terence M Hughes is a second-year medical student at the Icahn School of Medicine at Mount Sinai (ISMMS), and a former intern at Possible
Acknowledgements: The author would like to graciously thank the Possible team for their mentorship and support in writing this article, namely Kim Lipman-White MSc, Duncan Maru MD PhD, David Citrin PhD MPH, Anant Raut MA, Srijana Shrestha PhD, Scott Halliday MS and Sabitri Sapkota PhD MPH.
Originally published Nyaya (Possible) Health: Source