Addressing power asymmetries in global health: Imperatives in the wake of the COVID-19 pandemic

Competing interests : I have read the diary ’ sulfur policy and the authors of this manuscript have the follow compete interests : MP serves on the column circuit board of PLOS Medicine. none of the other authors have competing interests to disclose. copyright : © 2021 Abimbola et alabama. This is an open access article distributed under the terms of the creative Commons Attribution License, which permits nonsensitive manipulation, distribution, and reproduction in any medium, provided the original generator and source are credited. We recognise that HIC versus LMIC, North versus South, and coloniser versus colonised are crude dichotomies that obscure more than they reveal. Hence, we pay care in this article to the fact that every group has its own internal might hierarchies ( as displayed in the Fig 1 ), with intersectional systemic disadvantages caused, among others, by race, caste, class, ethnicity, sex, and religion. Coloniality is but one manifestation of domination. therefore, undoing domination will require much more than decolonization [ 19 ]. In this article, we, a divers, gender-balanced group of 13 public ( global ) health researchers, teachers, and practitioners ( all born in, and 11 of 13 presently living in the alleged global South ), delineate our wish list for change in a post-pandemic world—at the individual ( including among ourselves ), and at the organizational degree. Most of us are researchers. Our perspectives, consequently, are more concenter on addressing world power asymmetries in ball-shaped health research and education, and ultimately drill.

More than an deadlock or a simple enemy within the sector, the real number concerns around coloniality and might and privilege hold the potential to reorient the field, in the context of deep doubt created by, among other large-scale disruptive processes, the COVID-19 crisis. The impacts of pandemics are irregular, and previous country-level epidemic-preparedness indicators have proved inadequate [ 18 ], based on defective assumptions rather than a nuanced understand of local strengths and weaknesses which can only be understood from the bottom up, and without a supremacist lens on the universe [ 1, 7 ]. however, COVID-19 has put a limelight on existing inequalities and on processes of coloniality ( mind, torso, cognition, and power ). It has created conditions for further inequities, with growing democrat patriotism and isolationism, widening income disparities, and fractured systems of global cooperation [ 15, 16 ]. The pandemic continues to enable those with money and baron to expand their influence—making decoloniality, solidarity, and distribution of power, cognition, and resources ( for example, vaccines ) even more pressing. The fact that HICs have reserved adequate COVID-19 vaccine doses to vaccinate their own population multiple times over is a austere indication of power asymmetry in global health [ 17 ]. These conversations are happening in many settings, and it is clear by now that they can not be brushed away. They have increased, as expressed in countless editorials, studies, conferences, and webinars. even before the COVID-19 pandemic, there was significant but underappreciated discontentment among public ( global ) health practitioners in low- and middle-income countries ( LMICs ) over discriminatory activities by fund agencies, universities, and individuals from high-income countries ( HICs ). The Coronavirus Disease 2019 ( COVID-19 ) pandemic, the Black Lives Matter motion, and the growing calls to decolonise and address reports of morphologic racism within humanitarian, development, external help, and global health agencies are opening doors for uncomfortable but authoritative conversations [ 1 – 14 ]. They are revealing unplayful asymmetries of power and privilege ( Fig 1 ) that permeate all aspects of ball-shaped health. however, we must hold ourselves accountable to avoid elite get. There is limited value in building newfangled networks and platforms in the global South if they are captured by the local elect like us, such that things remain colonial, and the needs of the center and the privilege stay prioritised over the periphery and less privileged in policymaking and implementation. To shift the center of graveness of cognition production and use, we need domestic fund opportunities and local anesthetic platforms for cognition product and habit ( for example, academic institute and journals ) that take autochthonal cognition, local needs, and languages into history, particularly because current platforms are frequently inaccessible ( in English, dearly-won, elitist, and distant ) [ 3 ]. For exemplar, the holocene announcements by Springer Nature and Elsevier about high article process charges is an exercise of how elitist, single, and exclusionary prestige journals can be [ 34 ]. But without our governments moving towards autonomy, looking within to maximise the use of local anesthetic cognition and capacity, such bursts of confidence will be short lived. Moving from the receiving end of interventions into fund, designing, and implementing local solutions requires local anesthetic resources and alliances ( for example, through global South networks ) —for which we must hold our governments to account [ 32, 33 ]. Claiming space requires confidence. It requires that we believe that “ we can, ” and we already hold and have the capacity to produce cognition. however, our confidence in the likely of our ideas and actions is weakened by the weight of asymmetry that comes with being on the receiving end of ( sometimes valuable ) support, cognition, and interventions. Often, we just assume we are not good enough or trained enough and person with more experience, in a “ better ” establish in the ball-shaped North will do something better, without considering the migration of skills from the global South. sometimes, that impression is foisted on us by colleagues in or funding from the global North. The COVID-19 pandemic has demonstrated the importance of LMIC scientists in generating and using cognition locally [ 30, 31 ]. This has shown us that “ we can ” —we have had no choice but to get on with it ( as our “ collaborators ” were busy with their own response or had to return home quickly ), thus boosting confidence that “ we can ” [ 31 ]. Those of us who have a forte spokesperson in ball-shaped health should jointly affirm our ownership of the battlefield. We need to claim the space in ball-shaped health that belongs to us and is proportional to the size of our populations, cognition, and problems. We need to convert the opportunities we receive into opportunities we give, weave networks of solidarity with peers ( for example, Emerging Voices in Global Health [ 27 ] and Women in Global Health with several nation chapters [ 28 ] ), and build collaborations across the global South, without necessarily decreasing “ North-South ” partnerships. In many ball-shaped South settings ( for example, in Africa ), universities and research institutes are more likely to have ball-shaped North than in-country or in-continent collaborators, which are essential for solidarity and learning across settings. even within southern networks, there is a need to engage women, frontline workers, and people with live experience since they are often invisible in national consultations and committees [ 29 ]. Those of us with larger audiences and spaces of charm should disrupt, call out, or shift away from neocolonial practices when we see them in ourselves and in others, including those, who, like us, are working to decolonise global health. man, in particular, need to “ lean out ” and create space for women [ 26 ]. This requires courage, and it may be costly or uncomfortable to do so. In playing these roles, we must be persistent in practicing reflexivity, submit ourselves to ceaseless challenge, and surround ourselves with people who will demand accountability of us, with a rebuff nudge or kind admonisher when we go wide towards ( re- ) enacting colonial attitudes and practices. Dismantling oppressive might requires more than one group of people demanding switch. Undoing marginalization requires more than the marginalize speaking up. many marginalize groups ( to which some of the authors of this newspaper belong ) —e.g., Black, Indigenous, and people of color ( BIPOC ), sex workers, migrants and refugees, women and girls, ethnic minorities, people with disabilities, and lesbian, gay, bisexual, transgender, hermaphrodite, and questioning ( LGBTIQ ) people—are systematically denied platforms for political, social, and cultural reasons. But researchers, policy makers, implementers who show solidarity ( politically, financially, and emotionally ) must allow the marginalised to determine the conditions of engagement in their spaces, recognising, as we straddle spaces, that we must act responsibly and that marginalize people are the experts of their own lives. To avoid elite capture, we must constantly reflect on our own positionality, behavior, and unconscious biases, in an ongoing preferably than one-off serve ; lest in the pursuit of equity and justice, we end up perpetuating colonial malpractice. We must be intentional around the complex negotiation that we undertake every day between the different positionalities that we hold. As Senait Fisseha noted, “ We are all separate of a break arrangement. Doing good work in the field requires … taking a critical eye to one ’ s own identity and how one has benefited from a system that oppresses indeed many others [ 25 ]. ” We need to be able to recognise when we are character of creating the trouble and when our choices and actions serve or enable, preferably than challenge the status quo that perpetuates othering and dehumanization. Reimagining ball-shaped health in the post-COVID-19 world requires that we address the intersecting systems of domination that continue to limit our ability to achieve equity and judge. Inequities are not lone about the needs and concerns of the deprived, but besides the systems that create disadvantages. Privilege is complex and relational, [ 22 ] as displayed in Fig 1. The social structures that create disadvantages are the lapp ones that create the advantages from which many of us—including some of the authors of this article—benefit. It is an uphill battle to unthink and unlearn the dominant models that for many of us have been easy shortcuts for making sense of the worldly concern and making build up in our own education ( e.g., some of us earned higher degrees in the global North ) and careers ( for example, some of us now work in HICs and in privileged LMIC institutions ). These actions require that we are accountable to and support one another as we seek to see the universe and our rate in it afresh. further, we must bring our authenticity, our experiences, our background, our proximity to the work, and the kind of influences that inform our ideas into the spaces in which we engage—turning into forte things that have traditionally been used to make us feel like imposters, for example, being a woman, or a person of color, or a local, being locally trained, or not having English as a first gear linguistic process [ 23 ]. We must refocus our care to the local anesthetic gaze, to local needs, priorities, communities, and decision-makers, so that we are more responsive to those than to external “ Requests for Proposals ” in our choice of focus. ultimately, we must learn from Black, Indigenous, and feminist movements how to shift aside from the colonizer ’ s mannequin of the worldly concern, and to help us unlearn, unthink, and undo the logics and doings of coloniality [ 9, 24 ]. Our function as researchers and practitioners is to be allies and solve in solidarity with marginalize people in the process of achieving the changes that they seek. Learning and practicing critical allyship is not lone for changing our own behavior, but besides for basically shifting the systems that oppress people [ 22 ]. effective allyship will require us to recognise the privileges, opportunities, resources, and exponent we have been accorded while others have been overtly or subtly denied them. To do then, we must build deep and collective awareness of how our colonial histories have shaped our think and continue to influence our way of seeing and doing. We must make conscious efforts to unlearn the idea of western inquiry and cognition systems, as opposed to local research and traditional/indigenous cognition systems, as being the only way to advance healthcare or effect transfer. We must constantly pay attention in our speech ( for exemplar, use of terms such as “ beneficiaries ” or “ third base global ” ) and in our daily lives and sour, to reject the ill-conceived cheer to fix the lives or problems of people who are oppressed or disadvantaged—and alternatively, use our voice and influence to redistribute exponent in ways that enable the legitimisation and acknowledgment that marginalised people are the experts of their own lives. many of us need to intentionally decolonise our minds. The most dangerous locus of colonization is not physical, but our minds [ 20 ]. Colonisation was designed to insidiously permeate every aspect of our respect judgment as humans. As Ngũgĩ wa Thiong ’ o observed in his book Decolonising the Mind, “ the colonial classroom became a tool of psychological conquest in Africa and beyond… and it made the conquest permanent wave ” [ 21 ]. Many of us are products of such deliberate and persisting colonial education policies, often reinforced by the higher education many of us have been privileged to receive. It is time to undo the colonial mentality of inferiority that many of us were raised to possess .

“Decolonising organisations”: What change do we want to see in global health organisations?

Real diversity and inclusion

presently, global health is neither ball-shaped nor diverse [ 4, 35 ]. It is consequently not shocking to see growing number of reports of systemic racism, White domination, and discrimination in many organisations [ 12 ]. primarily headquartered in HICs ( 85 % in North America, Europe, and Oceania ) where major decisions are made, data show that 70 % of leaders ( CEOs or Board Chairs ) in a sample of about 200 global health organisations are men, more than 80 % are nationals of HICs, and more than 90 % were educated in HICs [ 4 ].

Global health journals lack diversity [ 36 ], and research publications and commissions focused on LMICs are dominated by authors from HICs, who much take the spark advance and/or senior writing [ 37 ]. The Lancet commissions, for example, are dominated by HIC experts, and a huge majority have secretariats based in HIC universities [ 38 ]. Awards in ball-shaped health are by and large given to men and experts from HICs [ 39 ] .
In short, most global health organisations are run out of HICs, largely by men, and with staff dominated by people ( by and large White ) from HICs. And HICs account for a majority of ball-shaped health spend, and by merit of controlling the purse strings, they efficaciously control the ball-shaped health agenda [ 40 ]. If address inequities is a cardinal finish of ball-shaped health, should we continue to entrust that finish to elite HIC institutions who might not reflect the people being served ?
All global health organisations ( in the global North or global South ) must commit to real diverseness, fairness, and inclusion ( DEI ) as part of their core deputation and ensure that their leadership and staff are divers and sex balanced without which ball-shaped health organisations are bound to fail in their mission. even the most well-intentioned people who claim to not have racist or supremacist biases behave in ways that undermine the expertness and cognition of ( other ) local researchers, practitioners, communities, and individuals. Organisations ( for example, universities, bilateral and multilateral agencies, nongovernmental organisations [ NGOs ], beneficent organisations, etc. ) tend to scapegoat individual staff members when issues of bias originate ( for example, bullying and withholding opportunities ). But they need to be held accountable for structures and processes that prevent any imprint of discrimination by staff—e.g., training for staff, a detail action plan, and mandates on how the administration will stand by marginalize communities and how to advocate for their rights .
It is easy to invite people from marginalised groups to join advisory boards or to add African- and Asian-sounding names as coauthors on research articles to please journal editors and peer reviewers. beyond that, global health organisations need to be held accountable for government structures and processes that include local partners, and people who are broadly underrepresented, in ways that go beyond the cosmetic. For example, reports from communities and local partners may be included in staff performance evaluation. Funding agencies in HICs must make certain they directly fund LMIC organisations that are addressing their own local research priorities. Global health programs in HICs must ensure reciprocity and host trainees and experts from LMICs [ 41 ] .
These processes of accountability need to be implemented in a context that takes the transformation, liberation, and decolonial agenda seriously [ 42 ]. If not, these interventions will become Band-Aids, quite than structural shifts that distribute power and resources. As Themrise Khan warns us, decolonization is immediately becoming a “ comfortable buzzword for those in the North, driven by the need to not give up baron and remain relevant ” [ 43 ]. The Global South, she emphasises, must end inequality on its own terms—not the North ’ s .
Global health exercise needs a new politics of accountability. Shifting the geography of cognition from “ foreign expertness ” to local and autochthonal cognition holders is function of this new politics [ 42 ]. Shifting ball-shaped health leadership from White-led, White-dominated HIC institutions to BIPOC-led, BIPOC-dominated LMIC institutions is besides critical [ 42 ]. Drawing on intersectional Black, woman and feminist movements, and Indigenous knowledge systems can facilitate new leadership and organizational practices and theories and processes that centre our humanity through values of radical love, care, compassion, and the redistribution of resources and world power .

Localising funding decisions

much excessively much, international donors and funding organisations who come as “ saviours, ” prefer to fund projects that address their own interests, on their own terms. This, in turn, leads to a godforsaken of resources, loss of local research interest, and miss of trust between grantees and donors .
flush when research or implementation work is focused wholly on LMICs, much of donor funds are given to agencies and institutions in HICs, and HICs hold the bag strings [ 40 ]. For model, less than 2 % of all humanitarian fund goes directly to local anesthetic NGOs [ 44 ]. About 80 % of USAID ’ mho contracts and grants go directly to United States firms [ 45 ]. furthermore, 70 % of NIH Fogarty grants go to US and HIC institutions [ 46 ], and 73 % of the total international grant portfolio of the Wellcome Trust supports United Kingdom–based action [ 47 ]. even with funds are given to LMIC agencies, HIC donors often set the agenda and micromanage the work, leaving little room for LMIC groups to innovate .
Funders need to be held accountable for developing structures and processes for engaging with grantees, for letting grantees guide them on the importance of diverse projects, and for opening the doors of decision-making to people on the margins, who hold the key to driving transfer and are closest to the work—i.e., moving away from chute research and projects towards centring local cognition and organic processes. LMIC institutions and researchers need to speak out more against parachute research and demand greater control of fund and research end product ( for example, publications ). They besides need to ensure that reciprocality and bidirectional partnership is included in grant agreements and memoranda of understanding .
With abruptly fund cycles, and the distinctive insistence on “ immediate wins ” and “ low hanging fruits ” from many funders, ball-shaped health initiatives tend to be “ surgical ” as opposed to “ organic ” in their approach, resulting in superficial and ephemeral initiatives that fail to sufficiently take the local context into account or have fundamental and prolong impact [ 3 ]. The danger of these “ flying wins, ” which come with their own agenda, accountability processes, and needs, is that they can shift local organisations ’ processes away from their core goal .
Funders and donors need to be held accountable for building real, long-run, mutually beneficial, and reciprocal collaborations, with people on the footing in the drive induct, and a distinctly defined shift in decision-making power on what is to be funded to local partners .
The persisting bequest of short-run fund is that it reproduces inequalities in local anesthetic health systems in the form of vertical programming. The tempt of the “ surgical ” is besides there in how home governments in the ball-shaped South shift in tandem to more real problems quite than those that require organic processes to tackle. It is seen in how the jobs, promotions, and fundability of academics in the ball-shaped North ( and increasingly in the ball-shaped South ) are based on tangible measures such as publications in high-impact journals and winning research grants, with much less ( if any ) focus on the ethics and ( epistemic ) justice implications of the work, the use of local anesthetic cognition, capacity construction, or implementation .
a lot of global health is conducted through universities and alike entities. It is a major problem that academics in the global North ( and increasingly in the ball-shaped South ) are incentivised to focus chiefly on personal development ( for example, tenure, awards, publications, and grants ), frequently at the expense of real affect [ 48 ]. Universities and academic institutes involved in ball-shaped health motivation to be held accountable for creating structures and processes that incentivise academics to be better allies ( for example, give credit to HIC and early privileged LMIC colleagues for their supportive, allyship work ) and be responsive to decision-makers on the land, engage with constituent local processes and Indigenous cognition, and engage with local partners as leaders of the process of cognition production and function .
LMIC governments and institutions must invest more in their own healthcare manner of speaking, research, and discipline, in orderliness to reduce their addiction on HIC donors, universities, and philanthropies. Building quality inquiry and teach institutions in LMICs is critical, to reduce reliance on HICs and to improve the overall quality, depth, and relevance of scientific education and research [ 31 ] .

Phased self-decentralisation

We can not reform global health without interrogating the very theme of global health itself, its underlie values, and tied its vocabulary [ 1, 2 ]. We need to understand the ways in which the colonial legacies deeply entrenched in national and global health systems impede the accomplishment of health fairness .
The current ball-shaped health landscape is heavily centralised and homogeneous. Global health remains much excessively centred on individuals and agencies in HICs. Most “ celebrated ” global health leaders are White, able men with a academic degree from an elite western university, who lead organisations headquartered in the ball-shaped north with ground operations governed from a outdistance [ 4 ]. A representative heterogenous leadership and a decentralize mood of government and operation are long delinquent .
We would ideally hope that those at current global North centres of global health might will respond to our calls to decolonise global health by shifting office to people on the margins and the periphery [ 42 ] .
But we can not rely on this to happen by itself without a hold push or need. As Lioba Hirsch wrote, to be taken badly, any commitment from global health institutions to undo colonialism and fighting racism must be matched by demonstrated willingness “ to give up some or all of their power ” and “ a radical redistribution of funding away from HICs, a loss of epistemic and political agency, and a limitation to [ their ] power to intervene in LMICs ” [ 14 ] .
It is never easy for HIC organisations or any other privilege group or individual to give up their world power. We need commitments from ball-shaped health organisations to which they can be held accountable. These organisations ( for example, universities and early academic institutes, beneficent organisations, humanist organisations, and the academic publish industry that publish in fields related to ball-shaped health ) need to recognise the consequences of being centralised and homogeneous entities and take net steps to become divers and decentralized.

In particular, and as an case, universities and other institutes involved in ball-shaped health inquiry and training want to be held accountable for creating more opportunities for global health education and education which are designed, conducted, and imparted locally and are responsive to local context [ 49, 50 ]. These institutes, particularly schools of ball-shaped public health, need to commit to being held accountable for perpetuating colonial and exploitative practices—e.g., in the form of Masters in Global Health programs which are so expensive that they are obviously not designed for people in LMICs or without privilege and for research train programmes that are designed primarily for students in the ball-shaped North [ 51 ] .
The ball-shaped health classroom is now the populace, and global health courses in HICs can use the virtual format to amplify voices from the Global South, Indigenous scholars, and BIPOC individuals with live experience of oppression and resilience [ 52 ]. Remote education can be used to reach wide and divers audiences, including groups that may not be enrolled in traditional degree programs [ 52 ] .
Universities and academic institutes in the ball-shaped North need to commit to decentralising their global health operations, by moving and spreading their current ball-shaped union base to unlike locations across the global South, with ownership subsequently transferred besides. They may fold their operations into global public health education and train institutes in the global South or expand their field-based faculty so that LMIC scientists can stay at home and work domestically—arrangement made much easier due to remote learning driven by COVID-19 [ 52 ]. Their operations in the global North may become minor or even cease to exist, frankincense helping to shift the center of ball-shaped health to the periphery. however, in doing so, they must avoid recreating themselves, but alternatively enable varying entities that speak to local circumstances in different parts of the populace .

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