Critical perspectives on global health partnerships in Africa

Celso A. Inguane

15 May 2018
doi.org/10.17157/mat.5.2.615

On 8 February 2018, the colloquium ‘Critical Perspectives on Global Health Partnerships in Africa’ was held at the University of Washington (UW), Seattle. It was sponsored by UW’s Simpson Center for the Humanities and organized by Lynn M. Thomas (UW Seattle, History), Johanna Crane and Ben Gardner (UW Bothell, Interdisciplinary Arts & Sciences), and Nora Kenworthy (UW Bothell, Nursing & Health Studies). The colloquium was a discussion between Iruka Okeke (Pharmacology, University of Ibadan) and Paul Farmer (Partners in Health, Brigham and Women’s Hospital, and Harvard University) with an audience of faculty, students, and community members interested in global health, and it was moderated by Gardner and Kenworthy. The colloquium addressed issues raised by the collaborative project ‘Humanistic Perspectives on US Global Health Partnerships in Africa and Beyond’[note 1]‘Humanistic Perspectives on US Global Health Partnerships in Africa and Beyond’, Walter Chapin Simpson Center for the Humanities, University of Washington, https://simpsoncenter.org/projects/humanistic-perspectives-global-health-partnerships.
, and was preceded the night before by the Katz Distinguished Lecture in the Humanities[note 2]Jonathan Hiskes, ‘Stopping Infectious Disease Requires “Staff, Space, Stuff, and Systems”, Paul Farmer Argues (with Video)’, https://medium.com/@simpsoncenter/stopping-infectious-disease-requires-staff-space-stuff-and-systems-paul-farmer-argues-with-8f59e5ad79d4.
, given by Farmer, and, earlier in the day, by a discussion between Farmer and medical anthropology and global health students[note 3]‘UW Students Reflect on Equity, Race, And Global Health with Paul Farmer’, 15 February 2018, Health News, Department of Global Health, University of Washington, https://globalhealth.washington.edu/news/2018/02/15/let-s-talk-uw-students-reflect-global-health-paul-farmer.
, and a working lunch with members of the collaborative project.

From left to right, Ben Gardner, Paul Farmer, Iruka Okeke, and Nora Kenworthy; photo courtesy of the African Studies Program, The Henry Jackson School of International Studies, UWFrom left to right, Ben Gardner, Paul Farmer, Iruka Okeke, and Nora Kenworthy; photo courtesy of the African Studies Program, The Henry Jackson School of International Studies, UW

Background and opening remarks

Thomas opened the colloquium by introducing its rationale and providing biographical sketches of the key speakers. Kenworthy described the history of the collaborative project, mentioned the essays that were published in the blog ‘Africa Is a Country’ (Gardner and Krabill 2017; Hoffman 2017; Thomas 2017) and the essays that were forthcoming in MAT, and noted the project’s successes and challenges regarding equity and inclusion, which she hoped would be addressed by the colloquium. Gardner explained the colloquium format and outlined the main themes that emerged from the project’s publications: the various types of inequities in global health and funding access, the multiplicity of terms used to describe global health engagements, the deep entanglement between global health research perceived as extractive and interventions regarded as seemingly more benign, misunderstandings in partnerships due to lack of clarity in those relationships, and the role of the global health industrial complex and political economic forces in shaping global health partnerships.

Rethinking global health partnerships and the role of the public university

Gardner opened the discussion by asking the speakers to discuss the value of the term ‘partnership’ and why in their previous work they had expressed preferences for alternative terms such as ‘collaboration’ and ‘accompaniment’.

Okeke explained her discomfort with the term ‘partnership’. She noted that collaborations are common in science, while partnerships most often come into play when African and non-African scientists and researchers work together. She argued that with collaborations, funders are less central to the relationship than with partnerships, and partnerships usually don’t make lasting investments in Africa. She prefers collaborations because they tend to be more about ideas and intellectual engagement, whereas partnerships tend to direct her attention and energy to more practical and instrumental tasks. Farmer suggested building equitable and just social relations. He discussed how his organization’s building of hospitals in Haiti and Rwanda are examples of ‘reparative partnerships’. He highlighted how unpredictable and unequal partnerships can be, noting that partnerships should entail accompaniment, meaning that you start with someone, you walk with them, but you don’t know where it will end. Farmer cautioned against the ‘faux parity’ of some partnerships.

Kenworthy next asked about the role of universities in global health partnerships. Okeke noted that universities need to rethink their social function and become spaces of diversity where giving back to society through teaching, mentorship, and other forms of service is as valued as doing research. She noted that she never heard anyone say, ‘I got tenure for doing service’; instead, she usually hears admonitions such as ‘she did not do her research [because] she got distracted by doing service’. Farmer agreed with Okeke, and added that universities and global health practitioners should not be intimidated by arguments that investing in service is not sustainable. He noted that such definitions of sustainability have been created by development economists, and unfortunately have permeated global health thought and discourse. Instead, universities should redirect their efforts towards service, perhaps using the tremendous teaching, research, and service work done by ‘teaching hospitals’ as a model.

Of global health funding constraints and cross-disciplinary fertilizations

The audience pushed the speakers to think further about three major points: (a) how to determine the volume of global health funding actually spent in the countries in whose names funding is requested; (b) how administrators can be trained to understand the need to fund ‘staff, stuff, spaces, and systems’ (health systems strengthening); and (c) how private funding logics and priorities currently influence the mandates of public universities.

Okeke challenged colloquium participants to deepen their interrogation, by also asking ‘how much is spent on the cause we are trying to address?’ She added that most of the money is spent in the United States, not because of US institutions’ greed, but because US federal funding institutions stipulate payment structures that reimburse US institutions for indirect research costs (which support facilities and administration) at rates of 60 percent or more, and severely limit these rates for African and other foreign institutions to less than 10 percent. Okeke stated that funders need to understand that African institutions can do very little without higher rates of indirect cost reimbursement, and certainly cannot work on broader institution-building efforts. Farmer agreed with this assessment, and called for the growing field of implementation science to help trace global health funding expenditures. To illustrate, Farmer cited research that shows that the problem is even deeper: only a portion of the international funding pledged to address the recent earthquake in Haiti or the Ebola outbreak in West Africa was delivered to those countries. The speakers ended by noting the need for improved cross-disciplinary collaborations, particularly with the social sciences and the humanities. And, Farmer singled out the role of history to reveal ‘things that have been done, but forgotten’. 

Afterthoughts  

As a Mozambican pursuing graduate education in the United States, I wonder what different issues might have been raised, and what different insights might have been gained, had this collaborative project taken place elsewhere in the world. Only four of the fourteen first authors in the essays published here and in Africa Is a Country are based outside of UW, and all project events, including the colloquium described here, were held at the UW. Repositioning the project outside the UW would have likely involved resource commitments beyond those available for this work. Yet, I wonder whether with a different composition and location of this collaboration, the project would have become an opportunity for meaningfully transforming the inequitable funding and institutional practices that structure global health partnerships between the United States and African entities.

Acknowledgements

The author is grateful to Nora Kenworthy, Johanna Crane, and Lynn Thomas for their support and guidance in preparing this report.  

About the author

Celso A. Inguane is a PhD candidate in sociocultural anthropology (concentration in medical anthropology and global health) and an MPH student (global health track) at the University of Washington, Seattle. His dissertation research explores politics of knowledge and sociality in the context of global health interventions in southern Mozambique. He is a Wadsworth International fellow, funded by the Wenner-Gren Foundation for Anthropological Research.

References

Gardner, Ben, and Ron Krabill. 2017. ‘Against the Romance of Study Abroad’. Africa Is a Country,5 July, https://africasacountry.com/2017/07/against-the-romance-of-study-abroad.
Hoffman, Daniel. 2017. ‘African Military Partnerships in the Age of the “Enemy Disease”’. Africa Is a Country,6 July, https://africasacountry.com/2017/07/african-military-partnerships-in-the-age-of-the-enemy-disease.
Thomas, Lynn. 2017. ‘Of Gag Rules and Global Partnerships’, Africa Is a Country, 7 July, https://africasacountry.com/2017/07/of-gag-rules-and-global-partnerships.