When institutions in the United States and other high-income countries embark on collaborations to improve health or the delivery of health care in low-income countries, they do it with the best of intentions. But intentions aren’t good enough. Projects conducted by trainees at schools of medicine, public health, and other health disciplines in high-income countries can often make the problems they set out to address worse. Failing to create equitable partnerships can heighten structural violence and inequities and cause further harm.
That’s a shame for many reasons, first and foremost of which is that many low-income countries can benefit from equitable, carefully thought out assistance that fully integrates the expertise and talents of researchers in the country where the research is being conducted. Such projects could have huge impacts on trainees from high-income countries, providing a formative opportunity to instill values in the conduct of equitable research affecting low- and middle-income (LMIC) countries. Researchers from those countries could gain better access to and training in study design and analysis, rather than their contributions being more relegated to data collection, while also being offered more opportunity to formulate locally derived solutions.
We became increasingly aware of the challenges of global research when we began our collaboration nearly 10 years ago, one of us (Y.B.) based at the time at Epicentre in Mbarara, Uganda, the other (S.P.) at the Yale School of Public Health in the United States. Our overarching goal was to steer away from the prevailing model in which researchers from high-income countries typically dictate the formulation of study aims and the use of funding, high-income country trainees generally gain more skills during execution of the research than their counterparts from low- and middle-income countries, and investigators from high-income countries tell the final story.
Much has been written about the imbalance of global health research over the last few years. The influential journal Lancet Global Health published 16 reports in one issue aimed at answering the question posed by the journal’s editors, “What is wrong in global health?” The problems include, but aren’t limited to:
- Study priorities and design dictated by institutions in high-income countries
- Imbalance of financial resources between institutions in high-income and low- and middle-income countries, with a paucity of funding opportunities for the latter
- Exploitation of investigators in low- and middle-income countries by using their work for the benefit of high-income country investigators without tangible benefit for team members in the country or region where the research is being conducted.
- Dominance of the English language in the scientific literature and immodest assumptions that the English language literature represents “the sum of all available knowledge”
- More favorable authorship roles in publications for those in high-income countries, particularly in international peer-reviewed journals
Identifying problems, of course, is easier than solving them, though more than a dozen efforts have been made to rectify imbalances in global health research. While these iterations are useful, most have two main limitations. One is that the participation of investigators from low- and middle-income countries in developing these recommendations has not been optimal. Another is that previous efforts generally did not include practical steps that can be used as global health partnerships are being developed and implemented.
We must, however, point out two notable exceptions: One is the Global Health Decolonization Movement in Africa, an African initiated and led effort that provides concrete recommendations for global organizations, individual practitioners, funding agencies, academic and training institutions, academic journals, the media, and event organizers. The other is a “call to action” by leaders of five organizations focused on global health.
Sparked by a musing on internal checklists for global health by Maria Brunette, a health equity scholar at The Ohio State University, two trainees we have been working with, Daniel Z. Hodson and Yannick Mbarga Etoundi, spearheaded the idea of adapting our goals for improving global health collaborations to the checklist concept popularized by Atul Gawande, which is widely used in health care and other settings. Writing in the journal PLOS Global Public Health, the four of us proposed the Douala Equity Checklist for evaluating global health research projects as part of their processes for funding and screening projects.
The 20-item checklist below emerged from our years of living, working, and learning in low- and middle-income countries and jointly attempting to build more equitable collaborations between institutions in the United States and those in various countries in Africa. We want to emphasize, however, that the principles we describe here are applicable to global health collaborations in any part of the world, and are a work in progress.
These recommendations are built on four foundations: First, because health care is fundamentally a local endeavor, all collaborations should prioritize solutions derived from, and relevant for, the region in which the research is being conducted. Second, collaborations should pair high-income and low- and middle-income teams at as many levels as possible, from principal investigators to field staff and trainees. Third, budgets should move toward more equitable funding of investigators from all participating countries for bidirectional travel, attending conferences, dedicated research time, and the like. Fourth, collaborations should assign clear roles and responsibilities that value and leverage the strengths of all team members and institutions.
It is also important to address structural barriers at the time when results of a collaboration are disseminated, generally via the scientific literature. Researchers from low- and middle-income countries, especially women, must be given more opportunity to contribute meaningfully in the writing and publication process, including better access to language services, so men and native English speakers are not the dominant or exclusive voices in reports culminating from global health research. Such efforts will also promote more ownership of results by scientists in low- and middle-income countries, enabling better local uptake of the results.
Because institutions based in high-income countries tend to hold greater power in global health research partnerships, we believe they have an obligation to promote equity, building relationships based on trust and accountability. An excellent place to start is changing the way trainees are funded, initially by including funding for trainees in low- and middle-income countries in grants for global health collaborations made to trainees in high-income countries. It should also include partnering with regional science and other organizations to ensure that trainees are able to visit each other’s countries, as we did with Daniel Hodson and Yannick Etoundi.
Our aim for creating the Douala Equity Checklist is to help institutions in low- and middle-income countries decide on local issues, solutions, and goals; determine the terms of global collaborations in which they participate; decide how global health scholarship involving their institutions should take place; and ultimately decide whether a proposed collaboration should occur at all, as well as to help institutions in high-income countries assess project equity throughout the entire research process.
We believe that the Douala Equity Checklist should become part of the charter signed by all of those involved before beginning a global health collaboration. That would ensure that the ensuing solutions are truly innovative and homegrown, and they solve local challenges while strengthening the decolonization of global health research.
Yap Boum II is a biologist, epidemiologist, and the current executive director of the Pasteur Institute in Bangui, Central African Republic. Sunil Parikh is an infectious diseases-trained physician-scientist and an associate professor of epidemiology and medicine in the Department of Epidemiology of Microbial Diseases at the Yale Schools of Public Health and Medicine.
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