African voices in global health: Knowledge, creativity, accountability

ABSTRACT

In this article we offer an introduction to a special issue of Global Public Health on the theme of ‘African Voices in Global Health: Knowledge, Creativity, Accountability’. This special issue explores Africans’ self-understood roles – and voices – in global health (as both researchers and interlocutors in relation to various global health institutions/policies). We argue that the special issue’s focus on African voices in global health is critical in view of the legacies of colonial medicine and public health for contemporary narratives, discourses, and practices. It is important to acknowledge that Africans continue to address the structural injustices facing them in relation to global health policies and practices on the continent. In the face of this they have demanded that donors, NGOs, governments, and intergovernmental organisations be politically, fiscally, and ethically accountable to the people they serve on the continent. As the special issue highlights, critical scholars of global health based in Africa are increasingly offering challenges to the frequent positioning of African patients and study-participants as either invisible, or disempowered, in understanding and shaping their own lived experiences of health in a transnational context.

KEYWORDS:

• Africa and global health
• decolonising global health
• African researchers
• global health activism
• local approaches to global health

Introduction

This Global Public Health special issue on the theme of ‘African Voices in Global Health: Knowledge, Creativity, Accountability’ examines Africans’ self-understood roles – and voices – in global health (as both an academic discipline and sets of institutions/policies). This focus on African voices in global health is imperative given the legacies of colonial medicine and public health for contemporary narratives, discourses, and practices. Africans continue to address structural inequalities they face in global health policies and practices on the continent, challenging donors, NGOs, governments, and intergovernmental organisations to be politically, fiscally, and ethically accountable to the people they serve. It is in this context that critical scholars of global health on the continent are increasingly challenging normative disciplinary framings of African patients and study-participants as either invisible, or passive, in constructing their own healing narratives and experiences.

It is published as a collection of articles at a peculiar juncture in the history of global health. The current Director-General of the World Health Organisation (WHO) is an African, and the United Nations Special Rapporteur on the Right to Health is an African and has released a report on ‘Racism and the right to health’ re-igniting the WHO’s attention toward structural discrimination (Mofokeng, 2022). All the while, anti-black racism persists in both media coverage, popular discourse and, most worryingly, in global health institutions themselves. Perhaps the most visible manifestation of this occurred in May 2022, when multiple cases of Monkeypox were identified in the United States and Europe and media outlets in these countries used stock images of black African patients in their coverage of the outbreak. As the Foreign Press Association, Africa (FPAA) pointed out, like all diseases Monkeypox could occur anywhere and its transmission had no correlation with the colour of people’s skin. This is far from unique to journalists based in the Global North: as those calling for the decolonisation of global health have argued, racialised depictions of unnamed black African patients as passive sufferers of disease are frequently used by global health NGOs (such as MSF) and foundations (such as the Gates Foundation) to marshal resources and claim moral and political authority in scientific, diplomatic (PEPFAR) and multilateral spaces (WHO). It is in this context that the time could not be riper for Africans’ thought and intentioned practices – their knowledges and agencies – to receive further analysis in the burgeoning global health politics literature.

Legacies of colonial medicine

It is impossible for us to consider the under-representation of Africans in global health multilateral institutions, academia, philanthropic entities outside the context of the legacies of colonial medicine. During the colonial period, Africans’ access to biomedicine was most often via a limited number of missionary facilities and those connected to mines, plantations and factories (Packard, 1989; Vaughan, 1991). Public health arguments were martialled by colonial governments to justify racial segregation in urban areas (Digby, 2006; Swanson, 1977). At best, such facilities legitimated colonial medicine as the ‘White Man’s Burden’: a concept which can be linked to the ‘White Saviour Complex’. Much of the provision of medical care to Africans was aimed at facilitating the colonial extraction of wealth using their labour (which was radically under-paid).

Critics of global health research and governance institutions have highlighted the underrepresentation in the leadership of black Africans in powerful scientific institutions (including academia), and multinational foundations. While there have been gestures towards Equality Equity Diversity and Inclusion (EEDI) there have been questions as to whether these are, at best, tokenistic (Olusanya et al., 2021).

Africa was historically treated as a kind of ‘living laboratory’ from which data (including medical and public health data) was extracted (Abrahams, 2000; Legassick et al., 2015). Racist paternalism often denied the subjectivity of African people and patients as objects of knowledge. Here, we can note that the sophisticated and self-reflective piece by Salmen et al. in this special issue, aims to address the need to recognise the contributions of African community health workers (CHWs) and members of community advisory groups (CAGs) in countries on the continent in co-developing locally relevant public health research methodologies and interventions. The article ‘Rethinking our Rigor Mortis: Creating space for more adaptive and inclusive truth-seeking in community-based global health research in Kenya’ emerges from the authors’ experience in conducting HIV/AIDS and maternal and child health interventions among the remote island communities of Lake Victoria in Kenya. This is vitally important in terms of dismantling dominant extractive models of global health conducted by Global North-based researchers in Africa. While they recognise the importance of global public health studies with rigorous reproducible results in diverse country contexts, they also argue for contextualised studies drawing on local knowledge and addressing the self-defined needs of community members (in this instance safe drinking water, latrine construction, and CHW training) (Salmen et al., 2019).

Similarly, in their piece, Salmen et al. (2019) highlight the unintended consequences of their global public health research: while the local Ministry of Health struggles to retain adequate staffing levels, their project receives an excess of over-qualified applicants for entry-level positions. Moreover, members of the community they study have ‘rightly assessed that nearby Kenyan Universities often lack ‘global health’ funding and resources compared with their international counterparts’ (2019); ironically enough, this means that while they are geographically close, local universities are far less able to partner with local communities to conduct global health research.

In this special issue Sathyamala’s article, ‘In the name of science: Ethical violations in the ECHO randomised trial’ (2019) illustrates the continued influence of the legacy of colonial medicine in Africa today. The article concerns the ethics of a ‘clinical’ trial that enrolled women and girls to participate in research in nine sites in South Africa, and one each, in Kenya, Swaziland and Zambia. Sathymala’s article provides an overview of the history of debate, starting in the 1990s, on the possibility of increased transmission of HIV with use of the 3-month injectable contraceptive Depo-provera^®. The contraceptive is widely used globally, and particularly in Africa. The article details the drug’s regulation, including by the WHO and the context in which the trial emerged. It also explains the drug’s use, including during the apartheid period, and today’s context of sexual reproductive health in Africa where its use, and the prevalence and transmission of HIV, is highest globally. The aim of the trial is of global significance, namely to determine if the increased risk is causal.

The article interrogates the design of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial’s research protocol and in particular the ethics of the trial’s recruitment, enrolment and retention of research participants. The article covers three key areas: recruitment; care of participants’ health needs and interests; and the findings and implications of the trial. Sathyamala finds ‘the use of incentives, coercive language and concealing the real nature of the clinical trial’ led to the researchers’ successful participant recruitment (2019). Sathyamala argues that the ECHO trial’s uniqueness, by studying a contraceptive drug, not to find out whether it is efficacious as a contraceptive, but to find out how risky or life-threatening its use could be for the groups of healthy girls/women it subjected it to equates violating one of the central tenants of the Helsinki Declaration: privileging knowledge over research participants' interests. This article is useful for scholars interested in participant research, and drug regulation. In particular, it offers a template for how to analyse and think through the complexity of ethics in health research, including existing legal frameworks.

Furthermore, addressing the legacies of colonial medicine in Africa requires the equal treatment of African researchers, including equal access to publish their research in high-impact peer reviewed global public health journals. In recent years, many prestigious international journals have changed over to making their content exclusively ‘Open Access’: this is certainly admirable in terms of increasing African researchers’ access to cutting-edge biomedical and public health research. However, it must be noted that African researchers are not mere readers and teachers of scientific studies: they are producing research themselves and have the right to share it with their colleagues in more affluent countries. Here, it must be noted that the introduction of Article Processing Charges (APC) without exceptions for authors who are unable to pay for them are blocking publishing opportunities for African researchers based on the continent of Africa. While these journals typically offer differentiated pricing based upon the country where the researcher is based, these often rely on deeply flawed World Bank classifications as to where a country lies on a spectrum between ‘high income’ and ‘low income’.

These classifications are deeply flawed: in South Africa 40% of the population survives monthly upon social grants, the most common of which is the Child Support Grant of R480 (US$26.20) which falls under the elementary poverty threshold of a person living under US$1 per day. For illustrative purposes, the following journals charge South African researchers extremely high APC to publish research articles: PloS Global Public Health (US$ 2100); BMJ Global Health (US$ 3000) and Global Public Health (US$ 2650). By contrast, we must note that PhD fees at institutions such as UCT R23 370 (US$1275) for a year of study in the Faculty of Humanities: South Africa is desperately short of people with PhDs and the advance of science in the country is inconceivable without this being addressed. While South African institutions may, in some instances, provide some funding for such APC, the University of Cape Town’s own subsidy barely covers half of what such journals are charging, even at the lowest rates for South African contributors.

These developments have concerning intellectual and ethical implications not merely in an African context, but globally: if researchers from, and based in, countries deemed ‘middle-income’ are unable to publish in such journals, it becomes hard to avoid the conclusion that they continue to have an extractive understanding of research in developing countries. Nor is this state of affairs inevitable, the journal Health and Human Rights based at Harvard University’s François-Xavier Bagnoud Centre for Health and Human Rights has a model policy which only asks for APCs from those who can afford them based on the institution where they are located. Perhaps, most importantly, it has an explicit policy that it will not refuse to publish an accepted piece based upon the author’s inability to pay.

Structural inequalities

As is the case with medicine in general, global public health institutions and projects are fundamentally driven by humanitarian impulses: it is axiomatic that preventing and healing disease are social goods which fundamentally benefit societies and improve individuals’ quality of life. While recognising this, African scholars of global public health have critiqued global health donors and institutions’ narrow foci on goals such as preventing infant mortality while ignoring the need to simultaneously improve African children’s quality of life which is significantly, also, socially determined (Olusanya et al., 2021). For instance, despite Africa’s large population of disabled children there is insufficient global health funding for development assistance for Early Childhood Development (ECD) programmes (Olusanya et al., 2021). Similar critiques are made with regards to the preventable and disproportionate rates of maternal mortality and morbidity in so-called developing countries. South Asia and southern Africa have consistently high rates of maternal mortality as compared to the rest of the world, and rather than concerted efforts to address poverty and economic inequality global attention is narrowly focused on the solution of birth spacing, through contraceptive uptake.

In this regard, we can note that while it is correct to emphasise the need for universal access to medical technologies, medicine and public health cannot be reduced to the mere implementation of ‘magic bullets’ such as, perhaps most prominently, ARVs or (Mbali, 2020; Reed, 2018), more recently COVID-19 vaccines. Here, we must not underestimate the value that Africans committed to global public health place on the importance of such medical interventions being accessible on the continent. Indeed, African human rights lawyers and activists have been tireless in demanding intellectual property and trade policy and law reform in relation to essential medicines.

In particular, activists such as Tapiwa Kujinga of the Pan-African Treatment Access Movement AM (PATAM, which is based in Harare) and Allan Maleche of the Kenyan Legal and Ethical Issues Network on HIV and AIDS (KELIN) have been heavily involved in advocating for the incorporation of TRIPS flexibilities into African regional trade policy and the work of legal entities such as the African Regional Intellectual Property Organisation (ARIPO). Since the arrival of COVID-19 on the continent their work has taken on a new urgency as they have demanded affordable access to biosimilars to COVID-19 vaccines and therapeutics (which should, they argue, be produced on the continent of Africa).

It is, however, also important to note that the notion of ‘ending’ COVID-19 needs to be interrogated with reference to the problematic, dominant idea of ‘ending AIDS’. As Mbali (2020) and others (Kenworthy et al., 2018) have argued, the media framing of leading scientists and activists as ‘celebrities’ often fostered by organisations such as the International AIDS Society (IAS) and the promotion of ARVs (especially PrEP) as miracle interventions can overlook the more messy real life barriers of preventing new HIV infections. While, these more prominent figures typically agree with the idea that new HIV infections are significantly driven by social factors, the IAS publicity and media-driven emphasis on their roles, as individuals, can detract from this less triumphalist, longer-term, more complex narrative.

African public health researchers, physicians and activists have, however, been keen to emphasise the importance of addressing the socio-economic causes of the disproportionate burden of disease among the world’s poor, many of whom live in Africa. They have recognised the concept of social medicine as being of utmost importance in addressing the structural drivers of ill-health. Activist-scholars have also noted this issue when it comes to ethical review board standards on the continent and the barriers they place in front of ensuring research is carried out for the public good (Rucell, 2018). Since the late nineteenth century this idea has been particularly influential in generating understandings of ill-health as socially determined (Farmer, 2003).

Here we can note that there are strong traditions of social medicine on the continent, not least, in South Africa where progressive doctors such as Sidney and Emily Kark invented important approaches to community-orientated primary health care; traditions which shaped thinking at the WHO and, later progressive health organising (which later provided a basis for early doctor-led AIDS activism, as evinced in the work of Mervyn Susser and Zena Stein). Physicians such as Paul Farmer who promoted social medicine have received a great deal of attention in the Global North. However, also deserving of attention are the ways in which social medicine is catalysing new forms of social activism and medical training, as Olirus Owilli et al. (2022) have documented in relation to their training intervention in Northern Uganda.

Africans’ own healing narratives and experiences

In global public health there is a rich literature dealing with the ways in which African doctors and patients have also worked together to popularise science around new medicines: a prominent example of this has been studies dealing with the HIV treatment literacy of activist groups such as the Treatment Action Campaign (TAC) in South Africa and PATAM. In particular, we can note how these social movements have successfully generated support for the rollout of ARVs at both local community-based, and global levels. Here, we can note that their work has adopted locally appropriate metaphors and strategies for activist organising promoting access to healthcare on the continent and around the globe. However, as articles in this volume show, in some African contexts, local cultural institutions and understandings of health have had mixed and, at times, contradictory outcomes in terms of improving global public health.

As we know, there has often been a heavy emphasis on preventing and treating infectious disease in global public health studies and interventions. There is, however, a burgeoning number of studies dealing with the issue of the rise of chronic diseases on the continent. In their article in this special issue dealing with the use of comics as a form of global public health intervention in Egypt, Hamdy and Nye (2019) describe a new approach to representing ethnographic research. Discussing their role in the creation of a comic called Lissa: a story about medical promise, friendship, and revolution, they offer an approach to translating ethnographic research on patients’ medical decision-making in Egypt and the United States. In particular, they discuss how they translated their ethnographic research in those two countries into a comic showing political injustice and global health inequities in access to health care to prevent cancer (in the US) and treat kidney disease (in Egypt).

While drawing on approaches to graphic medicine, they express a desire to ‘extend beyond its individualistic person-centred narratives, in order to understand the complex social relationships that cohere around global public health concerns’ (Hamdy & Nye, 2019). A particularly interesting facet of their project is that it was produced against the backdrop of the Egyptian popular uprising of 2011 and its aftermath. There are two particularly politically significant aspects of the project: its depiction of what Hamdy and Nye’s key informants said about their understandings of the relationship between authoritarianism, kidney disease and general ill-health in Egypt; and, the ways in which it brings their work into conversation with Nye’s research on global health injustice in patients’ access to medical choices based on where they live. As they highlight, while Nye’s key informants who are affluent American ‘previvors’ of breast cancer have an abundance of medical choices, Hamdy’s interlocutors in Egypt who live with kidney disease have a relatively limited number of medical interventions available to them.

During their travels to Egypt they were keen to avoid an extractive approach of ‘academic tourism around the Arab Spring’ and they were acutely aware of the power they held as academics, working with artists, all of whom are based at American institutions (2019). Following their iterative conversations with, and observations of medical students, doctors and artists, following their fieldwork, they used the ‘formal dimensions of the comic to cite Egyptians’ intellectual work’ (Hamdy & Nye, 2019, p. 3). Moreover, far from being voiceless key informants such as Dr. Amr Shebaita (of Tahrir Doctors) and Dr. Dina Shokry (who documented protestors’ injuries) are named and their leadership is acknowledged in the comic book.

Feldman-Savelsberg’s article ‘Strange expectations: Cameroonian migrants and their German healthcare providers debate obstetric choices’ (2019) brings to bear parallel sets of assumptions ‘where misrecognition is at least as common as mutual recognition’. Feldman-Savelsberg’s recent body of work, including this article, interrogates the encounters of mutual othering in the field of global health through the experience of European providers and African patients. The author brings the reader on a journey of observing the peculiar dance of mutual stereotyping and expectations of the other, including what services, compliance, and modes of interaction they each want.

The article opens with a detailed history of the political and demographic diversity of Cameroon, including how reproductive risks shape migration. An overview of the receiving country context is also outlined. Feldman-Savelsberg’s research is based on rich, in-depth ethnographic fieldwork in a variety of community and health service settings.

Then the perspectives of African women on their new country, as well as the sexual and reproductive healthcare they receive in Germany, are interrogated. The foundations shaping German health providers’ opinions of their African migrant patients are also elucidated. The article offers the finding that migrants’ expectations that bearing children is medically easier but socially harder than in Cameroon are shaped by stories among their fellow migrants. Feldman-Savelsberg finds that most migrant mothers praise the medicalisation, thoroughness, and even bureaucracy of German perinatal care.

In contrast, Feldman-Savelsberg finds German healthcare providers draw on opinions based on nationality, education level, as well as feminist critiques of Western biomedicine, as well as dehumanising stereotypes of Africans as ‘nature-near’ to perceive what may be their patients’ perceptions. The article finds providers expect African patients to find the highly regulated and bureaucratic health system to be alienating from their knowledge of ‘natural’ childbirth, which providers presume they have.

While Feldman-Savelsberg’s article demonstrates that often the understandings made between her research participants were off the mark, the story that is explained is not couched in clear cut easy boxing. Rather she situates the mutual misrecognition found in the humanity of each individual's histories, desires, and also the social processes that lead to their misinterpretations and expectations. This article is useful to scholars interested in the dynamics of migration, cross-racial and socio-demographic sensemaking, and ethnographic methods.

Since the mid-1980s, international organisations such as the WHO and UNFPA have advocated for a reduction in maternal mortality under the rubric of ‘Safe Motherhood’. Their understandings of it have, however, not always mapped onto African women’s lived experiences: for example, Adeola Oni-Orisan has shown that despite the availability of hospitalised childbirth many women in Nigeria elect to have children in Pentecostal ‘mission homes’ which reject biomedical interventions in favour of prayer alone (2017). She argues that the mission homes need to be historically contextualised in terms of the role of Christianity in colonial medicine and that we need to reject the idea of these women as all making dichotomous choices between either biomedicine or Pentecostal healing (2017). Instead, many of these women of all social classes use both, either at different points in their pregnancies, or simultaneously. The Nigerian government does not, per se advocate for secularism except to obtain approval from international funding agencies. Instead, she argues, we should rather see them as wanting liberal reform of religious practices (2017).

The importance of being attuned to local understandings of disease transmission is also demonstrated by the article by Mojola and Angotti (2019) in this special issue. Their study draws upon a wealth of qualitative data obtained from men and women between the ages of 40 and 80 and rural health workers in a community in Mpumalanga, South Africa. Its data was collected within the Agincourt Health and Socio-Demographic Survey (ADSS). They found that while the ADSS had shown high rates of self-reported sexual activity among these older women, at a community-level, HIV infections among women between the ages of 50 and 70 such transmission was typically ascribed to their normative roles as caregivers of relatives living with the virus.

They found that the rural healthcare workers found this dominant local community-level discourse useful in promoting HIV testing and access to treatment in such older women. However, while recognising its usefulness from a public health and clinical point-of-view, Mojola and Angotti adopt a critical posture in relation to this discourse. In particular, they found that the desexualisation of these older women could lead to a lack of discussion of condom usage in HIV counselling. Moreover, they are critical of the ways in which this ‘caregiving discourse also reproduces a patriarchal double standard’ because it ‘reinforces expectations of celibacy for older women’ in a context where older men enjoy sexual liberty to engage in relationships with younger female partners outside the confines of marriage Mojola and Angotti (2019).

Conclusion

As the articles in our special issue show, adequate recognition of African contributions to global health research, policy and practice is long overdue. While recent pandemics of infectious diseases such as COVID-19 and Monkeypox have shown the inherent global good of improving public health in so-called developing countries, there is a humanitarian imperative for the specific self-defined clinical and public health needs of particular parts of the world to be met. Where black Africans are crudely depicted as passive patients who are the recipients of Euro-American global health largesse, target readers and audiences are deprived of the insights of African researchers, health professionals, CHWs and health activists on how to tackle our common human challenges at local and global levels. Furthermore, the decolonisation of global health as it pertains to Africa poses a set of fundamental challenges to the ethics of the scientific practice of global health knowledge-producing institutions. Perceptions of global health research on the continent as extractive and inequitable are only reinforced when African researchers based at universities in Africa cannot publish in prestigious international global health journals due to unaffordable APC or access adequate global health research funding to address research topics relevant to their own contexts. Moreover, when randomised trials in Africa funded by, and carried out in partnership with, the Global North and multi-lateral institutions involve the conduct research at inferior and unethical standards, the validity of global public health’s virtue is torn.

Traditions of social medicine and community-based primary health care have also informed the types of research African global health specialists wish to conduct and the types of interventions for which they come to advocate. However, as the papers in this special issue show, there is sometimes a mismatch between the priorities of global health researchers and practitioners based in Africa and the Global North. While the latter are often focused on the efficacy of particular medical interventions (such as ARVs or vaccines) to address particular diseases (e.g. HIV/AIDS or COVID-19) or population groups (such as pregnant women and young children), African health workers and patients are, in many instances, also concerned with very immediate needs such as the need for adequate water and sanitation, nutrition and dignified livelihoods. African global health researchers and activists have also argued that the mere provision of a specific intervention to treat a specific disease is inadequate, in and of itself, to meet the health needs of patients and communities.

The quality of the care provided is also of utmost importance: here, health systems issues such as the need for adequate human resources for health care in communities, regions and countries comes into the frame. If global health researchers from the Global North pay health workers more than what they can earn working in their own government’s health facilities, it may aid the success of their own study but not, in the long term, have an optimal impact on the health of the African populations they serve. This then creates the onus on all global health researchers to join Africans who are organising for adequate health expenditure and human resources for health. Moreover, the perspectives of African health activists from across the continent on the links between geo-political injustice and health inequity need to be heard. For instance, we need to listen carefully to both Zimbabwean and Kenyan human rights lawyers’ demands for affordable generic and biosimilar drugs and Egyptian doctors and medical students who struggle against the torture of those protesting against disease-causing authoritarianism.

The pieces in the special issue also show the importance of global health researchers being attuned to local and culturally specific understandings of disease and healthcare provision in African contexts: in particular, they need to have nuanced understandings of their impact on the efficacy of public health interventions. In African contexts, people’s locally situated sense of themselves in terms of spirituality, gender, kinship and generationality can shape their norms in relation to their behaviour in ways which can sometimes be surprising to global health researchers, even if only initially. For instance, while secrecy or social narratives of self which do not fit with scientific evidence may seem to be inevitably poor for health outcomes, in some instances they are deployed by patients and public health actors on the ground to facilitate access to biomedical interventions without the threat of stigma and discrimination.

We believe that this special issue, while modest in length, speaks to fundamental concerns in terms of challenging power inequities which hinder the development of global public health research and practice in our African context. It is our wish that with increased funding and support for global health research by Africans based on the continent and larger audiences for their work in the Global North, any such future special issue of a global health journal may include even more research by such African academics. In the meantime, we hope that the articles published have proven provocative, and even disruptive, of accounts of global health on the continent which fail to adequately recognise African knowledge-production, creativity and advocacy in reducing human suffering through ill-health.

Acknowledgements

The views expressed are those of the authors.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work has been supported in part by the African Studies Institute, University of Minnesota (African Voices in Global Health Grant) and the South African National Research Foundation [grant number 120420].