The feudal structure of global health and its implications for decolonisation

Global health as a field has its epistemological roots in related fields of tropical medicine and international health.1 2 These fields are not only products of colonialism, they also enabled imperialism through the destruction of traditional knowledge and consequent capture of the knowledge ecosystem.2–4 Efforts to decolonise global health are therefore much needed. Calls to reform global health institutions, global health education, agenda setting, resource allocation, the problem in ‘gaze’ and equitable institutional partnerships have been made.1 5–7 Unfortunately, diversity, equity and inclusion (DEI) remains a dominant framing of ongoing discussions on decolonising global health.5

Efforts around DEI are indeed necessary—as a part of anti-racism and other social movements promoting inclusiveness of all forms of minorities in decision-making8 9; but they do not effectively address the structural imbalance of power between high-income countries (HICs) and low/middle-income countries (LMICs). To undo the persistence of colonialism in global health, it is necessary to understand how feudal structures helped imperial forces to sustain political colonisation.

In this editorial, Dr Soumyadeep Bhaumik and his colleague highlight the similarities of those feudal structures to the current global health ecosystem, and why DEI efforts alone may only strengthen this feudal structure. Moving forward, dismantling the feudal structure of global health should be a target for efforts to decolonise global health.

Read the full article (open access ) in BMJ Global Health here (click).

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Individual responsibility: a red herring that lets the fossil fuel industry off the climate catastrophe hook

On the eve of the United Nations High-Level Political Forum, Kent Buse, Soumyadeep Bhaumik and colleagues argue that the health of people and planet can only be rescued through government led, structural transformations—but for that to happen we need to re-frame the narrative away from indivividual efforts.

Read the article in BMJ (open access) here.

Facilitators and barriers of life jacket use for drowning prevention: qualitative evidence synthesis

Drowning is a public health problem globally, with over 90% of deaths occurring in low- and middle-income countries . Unintentional drowning was estimated to cause about 295,210 deaths in 2017worldwide. The true burden of drowning is expected to be much higher owing to challenges in classification, reporting and data collection. The World Health Organization has identified several interventions to prevent deaths due to unintentional drowning, including the use of life jacket in high-risk recreational and occupational settings.

Despite substantial evidence on the effectiveness of life jackets and the subsequent adoption of laws in several countries, the use of life jackets has largely remained low, including in high-income countries.However, there has been no qualitative synthesis of evidence to understand the context and internal perceptions and experiences that may influence life-jacket use. The study, published in Journal of Safety Research this week filled this important knowledge gap and found :

  1. Life jacket use was shaped through complex interactions between lived experience and cultural norms which influenced the risk-perception of life jacket utility in preventing deaths.
  2. The high cost of life jackets was almost always a barrier for its usage
  3. Adoption of laws and its subsequent enforcement was perceived to be an important facilitator for life jacket use.
  4. Design issues around comfort, fashion-sense, and shelf life influenced usage of life-jackets

Read the full study here.

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COP26 Special Report on Climate Change and Health

The World Health Organization(WHO) has released a special Report on Climate Change and Health propose a set of priority actions from the global health community to governments and policy makers, calling on them to act with urgency on the current climate and health crises today (11th October 2021). The report lists 10 recommendations for priority action and is available here.

Prior to the publication a public consultation was conducted by the WHO in which I provided feedback in individual capacity (acknowledged in WHO report) . The feedback revolved around the following themes(full submission available for download):

  1. need for developing global, regional and national agendas for climate crisis preparedness, support for more interdisciplinary/transdisciplinary collaboration,
  2. recognition of rights and dignity of health workforce in our path to climate resilience,
  3. greater recognition of the impact of climate change on non-communicable diseases and injuries, particularly chronic kidney disease, snakebite, and cardiovascular diseases needs priority attention.
  4. higher taxation of app-based food delivery business which has higher carbon footprint;
  5. stop promotion of vegetarian diets which amounts to cultural imperialism by suppression of food practices of minorities, tribal, Adivasi and Indigenous populations who are being being attacked for their traditional meat-based food practices by removing words like “eating less meat” & “largely plant-based diet”;
  6. ensure food security of vulnerable people by providing guarantee against price fluctuations through development of appropriate investment and legal mechanisms.

It is pleasing to note that the WHO has involved stakeholders meaningfully and inculcated feedback in letter and spirit. The removal of terms “eating less meat” is welcome, but more work needs to be done to prevent climate action being used as an opportunity for cultural imperialism. Continuing to work with stakeholders to understand the several issues better, as evidence evolves will be key to climate action. We have to grapple the defining issue of our generation together.

Mitigating the chronic burden of snakebite: turning the tide for survivors

The International Snakebite Awareness Day has taken place annually on Sept 19 since 2018. Snakebites kill an estimated 137 880 people each year and three times as many survivors live with life-changing disabilities. ,,Since 2018, there has been some increased funding for research and development of antivenoms and other therapies. But there is a pressing need to additionally focus on the chronic aspects of snakebite care. The WHO strategy for snakebite envenoming aims to decrease not only mortality but also morbidity by 50% by 2030.

In a comment piece in The Lancet , Soumyadeep Bhaumik & colleagues propose a system-oriented approach with multi-component interventions to address chronic aspects of snakebite care, together with social support and investments in multidisciplinary research to end the neglect of snakebite. It highlights that the NTD community’s goal to “end the neglect” can be truly achieved in the snakebite domain only if snakebite survivors are at the centre of the response here (free but needs registration by e-mail) .

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Maternal Mortality in Afghanistan: a critical review to understand strategic priorities

Afghanistan, a landlocked mountainous nation, situated strategically between Central and South Asia, has been in conflict since the Saur Revolution in 1978 when  the socialist People’s Democratic Party (PDP) of Afghanistan seized  power from the then secular government (Gascoigne, 2015; BBC, 2015) . This led to a civil war between PDP, supported by the Soviet Union, and the Mujahidin, supported by the United States vide Pakistan. The vicious cycle of conflicts continued till November 2001 when the Taliban (a radical offshoot of Mujahidin) was routed out, ironically by military action of United States(BBC, 2015) .

In 2001, as multi-pronged reconstruction efforts started, it brought hopes that conflict, social upheaval, and food shortages would end(Castillo, 2013), and Afghanistan would march towards the Millennium Development Goals (MDG), along with the 191 other countries that had adopted it .  Among the eight ambitious MDG’s , adopted was the goal to “reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio (MMR)”(United Nations, 2015)  . Afghanistan however was accorded the unfortunate title of being the “riskiest place on earth for health of mothers” a few years back (Save The Children, 2010) .

The report aims to critically analyse maternal mortality in Afghanistan from the year 2000 to 2015. –  a period roughly corresponding to the era of US-led reconstruction action (Castillo, 2013).  

The report written for an academic purpose to analyze a post-conflict state is being released publicly on 31st August 2021 as Afghanistan potentially faces conflict again. The report, it is hoped, serves as a reminder to democratic nations that : Peace is the most important determinant of health. There is no health without human rights.

Stronger together: a new pandemic agenda for South Asia

The global increase in COVID-19 cases in 2021 has primarily been due to an uncontrolled surge in South Asia. It is estimated that by 1 September 2021, approximately 1.4 million in South Asians will die due to COVID-19 alone. The total number of excess deaths will be much higher—including non-COVID causes, as health systems are on the brink of collapse. With 33.4% of South Asians being extremely poor and the large-scale loss of livelihood being reported, the region faces a potentially catastrophic future for the ongoing decade. However, countries in South Asia continue to remain divisive. This differs from other geographic ‘blocs’ that frequently cooperate on mutual interest issues. Tensions in South Asia are shaped by complex domestic, bilateral, intra-regional and international geopolitical factors, despite the region’s obvious geographic, economic and cultural interdependence. A key lesson from the current pandemic is that countries need to share lessons and actively coordinate, complement and supplement each other’s public health responses, especially between neighbours.

Read the Editorial published in BMJ Global Health with Dr Soumyadeep and his colleagues which presents a pragmatic ‘Stronger Together’ agenda on critical areas of concern for political, social, medical and public health leaders in South Asia to consider and build on here (open access)

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Ethical issues for e-cigarette control policies in Australia

Australia has seen a sustained decrease in smoking for many decades by implementing a comprehensive multi-level tobacco control strategy . The proportion of Australians who smoke tobacco daily has decreased from 24% in 1991 to 12.2% in 2016, and 11.0% in 2019 . However, it is seen that proportion of Australians who have ever used electronic cigarettes (e-cigarettes) has increased from 8.8% in 2016 to 11.3% in 2019. The policy and regulatory space around e-cigarette is currently evolving in Australia, even amidst the Covid-19 pandemic.

Policy critique and analysis of evidence on e-cigarettes is substantial, but analysis of the ethical issues in Australia is scant. Previous analysis of ethical issues control e-cigarettes in Australia has been either based on principlism (the ethical principles of autonomy, beneficence, non-maleficence, and justice) or through the prism of harm reduction. Principlism is not well suited to analysing ethical issues around public health policies. Public health decision making is inherently more complex, involves larger numbers of stakeholders with different value systems, and is contextual in nature. Harm reduction, though a key tenet to guide e-cigarette policies, has its roots in libertarianism, a value system which might fundamentally not align with the moral beliefs of many stakeholders. As such, using a single philosophical lens for analysing public policy is not desirable.

This article analyses ethical issues around all aspects of e-cigarette control in Australia using a three-step public health ethics framework . The three-step framework does not presume superiority of any set of moral norms over another and helps clarify ethical issues contextually and comprehensively. The approach in brief consists of analysing ethics and contexts around the issue at hand, analysing ethical dimensions of alternative courses of action and a final stage of justification for a particular public health decision. The need for a comprehensive policy framework to tackle e-cigarette use has been identified, and as such, an ethical analysis of all aspects of control is necessary. To ensure comprehensive coverage of e-cigarette control policies, the ethical analysis is structured within the World Health Organization’s WHO-MPOWER framework of tobacco control. The WHO-MPOWER (Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, Raise taxes on tobacco) is a comprehensive framework to monitor implementation of control policies . To the best of my knowledge, such a comprehensive approach for understanding ethical issues around e-cigarette control policies has not been undertaken globally.

Read the full article published in Indian J Med Ethics here (open access)

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From trials to the bedside: convalescent plasma during the COVID-19 pandemic [Seminar]

Convalescent plasma has a long history in treatment of infectious diseases – being used  when other therapies are available .The use of plasma from patients who have recovered from COVID-19   was  used similarly as it can neutralize  viral particles and hence help patient care.   But many randomized controlled trials have now been completed and it is time now for using evidence to inform not only clinical care but also future research.

The International Severe Acute Respiratory and emerging Infection Consortium is organizing a seminar titled “Use of convalescent plasma in patients hospitalised with COVID-19” as a part of the Oxford University Tropical Medicine Seminar . The seminar is on Jun 10, 2021, 13:30 -14:30 hours Indian Standard Time.

The talk will have presentation’s from Dr Aparna Mukherjee (ICMR) and Professor Peter Horby ( Oxford University) and Dr Soumyadeep Bhaumik (The George Institute for Global Health, India). The seminar is moderated by Bharath Kumar Tirupakuzhi Vijayaraghavan (Apollo Hospitals, India)

Dr Soumyadeep Bhaumik will talk about ” From trials to the bedside: convalescent plasma during the COVID-19 pandemic

Abstract of talk

The use of convalescent plasma in hospitalized COVID-19 patients has started from the beginning of the pandemic. However, during the second wave of the COVID-19 pandemic – with a failing health system , with exhausted doctors and desperate patients – this meant  widespread irrational use . Patient and care-givers had to run pillar-to-post to secure plasma from COVID-survivors. The national guidelines remained unchanged and many doctors were confident about its utility . I will discuss the sum-total of evidence (from a systematic review), discuss about how confident we are about the results (through GRADE), and put it in the evidence-to-decision framework in the Indian context. I will also touch on problems in our current guidelines which exist in form of mere flowcharts.

Event is free to attend but requires pre-registration: Click

COVID-19 vaccination in India: we need equity

Just a few days after starting its own COVID-19 vaccination program , India provided vaccines as grant- in-aid to other countries1 . This was in sharp contrast to some high-income countries which stockpile vaccines,  and block proposals to suspend intellectual property rights in World Trade Organisation2. India now is in the midst of a humanitarian crisis 3 but its vaccination rates continue to fall. While it is not possible to go back in time and make amends to ensure availability for all, revising the current vaccination strategy (which is riddled with equity issues) can save lives ,  prevent health systems burdening and ensuring a functioning ecosystem during the pandemic .

Equity enables maximizing benefits from scarce resources

India’s original vaccination strategy was to sequentially vaccinate priority groups healthcare workers, frontline workers, people more than 50 years. of age and younger people with associated comorbid conditions (diabetes, hypertension, cancer, lung diseases) 4. In principle this invoked equity – prioritising those at highest risk. However, the Indian government continually changed its strategy – announcing more inclusive eligibility criteria for vaccination every month. The last of these came suddenly in the last week of April 2021, when the Indian government announced a new “liberal policy” for vaccination5.In midst of the current crisis, while already being riddled with shortages the new policy announced that everyone above 18 years will be eligible, and effectively removed any distribution or price controls for manufacturers. This is unparalleled – no other federal democracy is making citizens pay for COVID-19 vaccines or have states competing to secure supplies. The huge demand amid all the death and despair in th current wave meant that the two Indian vaccine manufactures resorted to differential and predatory pricing. They fixed prices for state governments which are almost twice of the price paid by the union government ; it is four times for private hospital 6. An immediate consequence of this was that most state governments were not able to offer vaccines for high-risk groups , while even richer people(who can pay ₹ 1600-2400 , £ 15 to £ 25)  in non-priority 18-45 years age group are able to access vaccines from private hospitals 7. The “liberal policy” also perpetuates regional inequities, wherein richer state governments will be able to buy more doses for non-priority groups while poorer states (with weaker health system) will have to wait for revenues to accrue for buying vaccines for priority groups.

The realities of vaccine shortage need to first publicly acknowledged, and a pragmatic and equity-based strategy needs to be adopted. As per media reports, only 37% of frontline and health workers had been fully vaccinated by mid-April 8 .

India needs to prioritise people “who matter and are in need” over the “rich and elite”. Vaccination of non-priority people in 18-45 years of age, should be stopped until adequate coverage of priority groups is acquired. A moral, social, and human rights lens is essential for the purpose. Younger people with mental health conditions, informal sanitation and cremation workers, families of frontline workers and healthcare workers, hawkers,  home-delivery workers, prisoners , homeless people, people living in slums and field journalists who are at higher risk 9 10 11 need to be under priority groups. Some of the re-defining of priority groups has been done by states like West Bengal and Delhi – but this is not uniform across the country.

Adopting a “One Nation – One Price – One Vaccine Buyer” policy such that the Government of India buys and makes it free for all citizens of India is the need for the hour. To overcome shortage, it can issue compulsory licenses (under Section 92 of the Indian Patent Act for public health emergencies) for all COVID-19 vaccines. A single buyer and a fixed price of ₹ 150 (£ 1.5 ;  current price paid by the Union government) for the entire nation would prevent pandemic profiteering.

Putting equity in the heart and soul of COVID-19 vaccination policy in India
Digital health driven inequity

Vaccination in India require pre-registration through a centralized online digital system called Co-WIN. With only 20% of Indians using internet12 the implementation strategy is not in touch with ground realities. The “digital divide” is even greater in rural areas, particularly in women, tribal/Adivasi people, and the urban poor13 who remain clueless about the system. Urban youth are travelling to rural areas to get vaccines14 –potentially transmitting COVID-19 to villages. Micro-planning 15 and participatory community engagement16 is crucial for successful implementation. India has in the past used them successfully without any digital tools. The Co-WIN based registration and tracking system needs to be stop and time-tested walk-in and community outreach (for disabled, homeless, very old people and other equity groups) needs to be adopted.

Instead of investing in digital health, government needs to invest in employing more vaccinators and vaccination officers. The current strategy of drawing into existing human resources has led to disruptions in routine service delivery 17 18 .

The way forward

Mahatma Gandhi’s maxim that a “nation’s greatness is measured by how it treats its weakest members” should  guide the overhauling of the COVID-19 vaccination policy. Getting the vaccination program right in India is crucial for the pandemic endgame too. There is not a moment to waste.

About the Author

Dr Soumyadeep Bhaumik is a medical doctor and international public health specialist working in The George Institute for Global Health India. He is also associate editor of BMJ Global Health. Views are personal and not necessarily reflective of employer or the BMJ Global Health. He tweets at @DrSoumyadeepB

Competing interests: I have read the BMJ Group Conflict of Interests and declare no competing interests.

Funding : None

Acknowledgment : Dr Sambit Dash from Melaka Manipal Medical College, India with whom author had a discussion.

Provenance : The article is not peer-reviewed.

The article was originally published in BMJ GH Blogs and is published here under CC-BY-NC-SA


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