Are Public Health Initiatives Neocolonialist?

So argues a recent commentary in Science:

The pursuit of novel scientific interventions for AIDS, malaria, and tuberculosis has been supported for decades by the traditional public-sector research funding bodies, such as the U.S. National Institutes of Health, the U.K. Medical Research Council, the Agence nationale de recherches sur le sida, and the European and Developing Country Trial Partnership, with additional contributions from the private sector and charitable bodies. These major public-sector funding bodies are located in developed countries and, although the situation is changing, direct access to funding from almost all of these agencies has historically been very difficult (or legally impossible) for researchers from developing countries. As a result, even where developing-country researchers have received research funds from such agencies, most of the funding has been channeled through the host country institutions. This creates a dependency relationship, as well as multiple bureaucratic hierarchies in administering such grants. Although certain developing countries have research bodies that fund research into the neglected diseases, the quantity of funding is generally very small....

However, on examining the Internet-available data, we question whether the current PPPO [public-private partnership organizations] paradigm has, in fact, perpetuated research disparities and power inequities and possibly accentuated the dependency relationship of developing-country researchers rather than contributing to correcting the disparity. Data show that the notion that PPPOs are global organizations with equal (or at least significant) representation from all regions of the world is false. Although all health-related PPPOs focus on neglected African diseases, they are distinctly first-world entities with differing levels of outreach to developing countries. Every major PPPO is headquartered in the United States or Europe, and most are based in the United States.... As a result, almost all monies raised by PPPOs are channeled through first-world head offices, and any decisions made regarding how these are spent in developing countries are made by the CEOs, together with their senior staff and boards (statutory and advisory). A great majority of CEOs are male, all are Caucasian, and all are residents of either the United States or Europe. Not one "global" PPPO is led by a person who is a developing-country national, and not one resides within one of the developing countries severely affected by neglected infectious diseases.

Only a very small proportion of senior staff at the executive director level has non-U.S. or non-European origins. The PPPO boards of directors, who have ultimate responsibility for the organization's actions, show similar trends, with Africans generally making up a small proportion of statutory board membership (0 to 20%). The advisory boards (or leadership council) generally have better representation from Africa than statutory boards, but representation remains low (0 to 24%). The main advisory boards tend to have fewer representatives from Africa than the less influential subadvisory committees or boards. In addition, the main advisory boards of PPPOs mostly have no people representing "on-the-ground" communities in Africa, despite the fact that this input is critical if large studies are to have cultural sensitivity in resource-poor environments....

However well-intentioned these individuals and organizations are, the traditional imperialist power dynamics remain, in which African researchers have very limited executive decision-making ability within PPPOs, and Africans are only able to access resources that (predominantly) non-Africans decide are appropriate. It is the dominant neocolonial structure of funding and operation that characterizes all PPPOs irrespective of grant sizes that is of major concern.

There is no doubt that African research groups and communities play a meaningful role in PPPO work. They perform critical clinical work associated with product development, which often cannot be performed in the developed countries. However, the nature, scope, and budget of that work are almost always ultimately decided upon by the PPPO head offices, not the African researchers, and thus executive decision-making remains outside Africa.

I have to agree: I've seen and heard discussions by developed country researchers that really are incredibly patronizing. One of the major mistakes most PPPOs make is that they equate a lack of resources with the inability of developing world researchers to know what to do with those resources were they to arrive. The other issue is that many of these PPPOs have very ambitious research agendas; when these agendas fail (as local scientists often suggested they would), the local researchers are blamed for the failure. This is not to say that developing world researchers aren't also at fault:

The African research leadership community must also ask whether they are not, in part, responsible for this situation as well. African countries have been notorious for corruption, and much donor funding remains unaccounted for. Yet, many institutions appear not to be taking adequate steps to counteract such corrupt practices. We have played senior roles in the South African AIDS Vaccine Initiative (SAAVI), and we believe that it is a positive example of financial accountability. It is likely that there will be far higher levels of willingness shown to fund African PPPO efforts if more attention is paid to issues of corruption. In addition, African states have not contributed sufficiently to creating career structures for clinicians and scientists within the African institutions, so there is a relative lack of available capacity to build PPPOs in Africa. If more of these career paths were available to African scientists, fewer would be drawn away from the continent, and thus, the establishment of PPPOs in Africa would be easier.

African states should themselves be investing in health-related PPPOs, as too few examples of successful African-funded science programs exist. Global financiers would likely be more willing to fund African-based initiatives if individual African countries or the African Union structures led the way in establishing and funding PPPOs to address important health issues. Having greater African leadership in this is critical.

African scientists and clinicians also need to address power imbalances when establishing their own individual relationships with the large PPPOs. Although many African researchers are desperate for any funds that become available, others who are relatively well resourced appear to perpetuate the power imbalances by accepting contractual relationships with PPPOs that are continuing the old dependency paradigms. African researchers themselves need to take a more proactive stance on these matters and to ensure that their relations with the large PPPOs and funders are better balanced.

A colleague who does lots of work in South America (and Africa) has recounted for me how U.S. representatives at these meetings are often accused of colonialism. It was hard to believe this until I heard U.S. researchers discuss African researchers, and sometimes it was one step removed from "bone through their noses." I don't think most developed country researchers think this way, but all that's needed is for a few prominent researchers and funders to behave like this, and relationships can sour quickly.