On the coloniality of global public heath

Knowledge transfer interventions on cancer in Africa and Asia: a scoping review

BACKGROUND

Cancer is a growing public health concern in Africa and Asia, where access to effective healthcare and resources is often limited. There is an urgent need for evidence-based cancer control policies in Africa and Asia, along with systems for prevention, early detection, diagnosis and treatment, and palliative care. This emerging issue has garnered growing interest from international institutions but there has been little visible action, and the existing knowledge remains scattered and fragmented. This scoping review aims to explore the breadth and scope of evidence regarding knowledge transfer interventions to enhance cancer care in Africa and Asia.

METHODS

We conducted a systematic search of Embase, Emcare, ERIC, APA PsycInfo, Medline, and Google Scholar, supplemented by expert bibliographies and references. Peer-reviewed empirical studies in English or French from January 1978 to September 2024 were included. Data were organised using the AIMD (Aims, Ingredients, Mechanism & Delivery) framework. Study quality was presented using the Mixed Methods Appraisal Tool.

RESULTS

The scoping review examined seven articles providing evidence on five unique interventions. The interventions included target both decision-makers and health professionals and aim to strengthen evidence-based cancer control policies and implementation strategies. The interventions documented have all been initiated by external actors, mainly international institutions or researchers from high-income countries, in collaboration with African and Asian stakeholders. In addition, some researchers have been involved in participatory research projects designed to enable decision-makers to implement evidence-based cancer control policies and programmes.

CONCLUSIONS

This scoping review highlights a critical lack of evidence on knowledge transfer interventions in cancer care across Africa and Asia, partly due to limited funding for non-communicable diseases. It calls for the integration of knowledge transfer components into all cancer research and interventions, supported by robust evaluation strategies, to develop evidence-based, economically feasible, and culturally appropriate policies, guidelines and interventions that can be used in nations with limited healthcare resources to improve cancer outcomes.

Bioethics Recommendations to Increase Culturally Informed Global Health Survey Research: A Framework for Centering Community Engagement

Global health projects-a source of inspiration and collaboration for applied human biology-benefit scholars, governments, NGOs, and aid organizations. While such research is intended to improve population health, direct benefits to individuals and communities are often excluded from published works and/or not considered in study designs and framing. This exclusion is increasingly recognized as a colonial legacy that hinders global health equity, particularly for Indigenous and other marginalized populations. Collaboration and community engagement are avenues for addressing these injustices, but they require planning, intention, and resources. Drawing on our collective experience and ongoing dialogues about community engagement in human biology, we propose six recommendations to increase equity in global health research. These include: (1) Incorporating trusted local specialists and stakeholders at all project levels; (2) disseminating health information to participants in strengths-based and culturally meaningful ways and contributing to solutions wherever possible; (3) investing in local healthcare, research, and infrastructure; (4) making study results/data available to stakeholders; (5) working within data frameworks that respect community sovereignty; and, (6) applying culturally informed bioethics frameworks. Our discussion highlights persistent needs to address community rights and benefits and to dismantle colonial legacies within global health and human biology while recognizing structural barriers to implementing these needed changes, particularly within the context of global health projects wherein human biologists are not the main power brokers or resource holders. When interfacing with global health, human biologists must continue to pursue health equity and decolonization through implementing critical, culturally informed bioethics frameworks centering community engagement.

'God knows why these Sanghaalis are so rabidly against C-section!': spectre of medical coloniality haunts doctor-patient relationship in Guruprasad Kaginele's Hijab (2020)

Through the lens of Guruprasad Kaginele's novel Hijab, the issues of intolerance and distrust that exist in American rural hospitals-where the Indian immigrant doctors fail to understand the inhibitions and apprehensions of the African immigrant birthing mothers, turning them into objects of mockery and disgust, despite sharing colonial histories of racialised discrimination, biases and prejudices-are examined. The ruptured relationship between Indian immigrant doctors and Sanghaali Muslim immigrant birthing mothers dramatised in the novel provides an insight into how Indian immigrant doctors' psyche is unconsciously imbued with medical coloniality, which has not received much scholarly attention. Drawing on critical approaches such as various orders of gaze-male, medical, colonial and imperial-and the concept of intersectionality, the hybrid subjectivities of the Indian immigrant doctors, ruptured doctor-patient relationship, and non-agentic status of the immigrant birthing mothers as represented in the novel are analysed. In light of the issues highlighted in this study, it is recommended that the novel Hijab could be a potential addition to the critical medical humanities curriculum to help medical students understand the cultural roots of racialised prejudices and discriminations, the spectre of which has continued to haunt caregiving in rural American healthcare settings.

Health security-Why is 'public health' not enough?

There is a growing tendency in global discourse to describe a health issue as a security issue. But why is this health security language and framing necessary during times of crisis? Why is the term "health security" used when perhaps simply saying "public health" would do? As reference to 'health security' grows in contemporary discourse, research, advocacy, and policymaking, its prominence is perhaps most consequential in public health. Existing power dynamics in global health are produced and maintained through political processes. Securitisation of health, which facilitates urgent and exceptional measures in response to an event, is a politically charged process with the tendency to further marginalise already marginalised individuals, groups, and nations. By exploring the ethical and practical consequences of a powerful actor's move to securitise health, the essay highlights the importance of considering the perspectives and well-being of marginalised individuals, groups and nations who may be impacted by the move. The essay challenges the assumption that securitising health or framing health as a security issue necessarily leads to good outcomes. It highlights the historical roots and explores the contemporary implications of "health security", and invites critically informed discourse on its use within global health.

Water, sanitation and hygiene (WASH): the evolution of a global health and development sector

Despite some progress, universal access to safe water, sanitation and hygiene (WASH) by 2030-a remit of Sustainable Development Goal 6-remains a distant prospect in many countries. Policy-makers and implementers of the WASH sector are challenged to track a new path. This research aimed to identify core orienting themes of the sector, as legacies of past processes, which can provide insights for its future. We reviewed global policy, science and programmatic documents and carried out 19 expert interviews to track the evolution of the global WASH sector over seven decades. We situated this evolution in relation to wider trends in global health and development over the same time period.With transnational flows of concern, expertise and resources from high-income to lower-income countries, the WASH sector evolved over decades of international institutionalisation of health and development with (1) a focus on technologies (technicalisation), (2) a search for generalised solutions (universalisation), (3) attempts to make recipients responsible for environmental health (responsibilisation) and (4) the shaping of programmes around quantifiable outcomes (metricisation). The emergent commitment of the WASH sector to these core themes reflects a pragmatic response in health and development to depoliticise poverty and social inequalities in order to enable action. This leads to questions about what potential solutions have been obscured, a recognition which might be understood as 'uncomfortable knowledge'-the knowns that have had to be unknown, which resonate with concerns about deep inequalities, shrinking budgets and the gap between what could and has been achieved.

The Coloniality of drug prohibition

There have been several recent commentaries which have highlighted the relevance of the postcolonial perspective to drug prohibition and called for the decolonisation of drug policy (Daniels et al., 2021; Hillier, Winkler & Lavallée, 2020; Lasco, 2022; Mills, 2019). While these are significant interventions in the field, sparse drugs scholarship has engaged more directly with well-developed literature and concepts from Critical Indigenous Studies (Moreton-Robinson, 2016) and Indigenous Standpoint Theory (Moreton-Robinson, 2013; Nakata, 2007) and reflected on its applicability to the drug and alcohol field. In contrast to the postcolonial perspective, which understands colonisation as a historical event with contemporary impacts, Indigenous scholarship conceptualises colonisation as an active and ongoing part of how the settler-state continues to impose itself. From this vantage point I explore coloniality as a system of power and reflect on the way prohibition acts as a key arm of the settler-colonial state. The paper explores the way concepts like vulnerability, marginality, overrepresentation, disproportionality and addiction involve colonial violence, knowledge practices and narratives which are central to the way coloniality is maintained and continues to assert itself in contemporary settler societies.

Critical perspective on infodemic and infodemic management in previous Ebola outbreaks in Uganda

This research investigates the complex dynamics of Uganda's recent Ebola outbreaks, emphasizing the interplay between disease spread, misinformation, and existing societal vulnerabilities. Highlighting poverty as a core element, it delves into how socioeconomic factors exacerbate health crises. The study scrutinizes the role of political economy, medical pluralism, health systems, and informal networks in spreading misinformation, further complicating response efforts. Through a comprehensive analysis, this study aims to shed light on the multifaceted challenges faced in combating epidemics in resource-limited settings. It calls for integrated strategies that address not only the biological aspects of the disease but also the socioeconomic and informational ecosystems that influence public health outcomes. This perspective research contributes to a better understanding of how poverty, medical pluralism, political economy, misinformation, and health emergencies intersect, offering insights for future preparedness and response initiatives.

Ineffective responses to unlikely outbreaks: Hypothesis building in newly-emerging infectious disease outbreaks

Over the last 30 years, there has been significant investment in research and infrastructure aimed at mitigating the threat of newly emerging infectious diseases (NEID). Core epidemiological processes, such as outbreak investigations, however, have received little attention and have proceeded largely unchecked and unimproved. Using ethnographic material from an investigation into a cryptic encephalitis outbreak in the Brong-Ahafo Region of Ghana in 2010-2013, in this paper we trace processes of hypothesis building and their relationship to the organizational structures of the response. We demonstrate how commonly recurring features of NEID investigations produce selective pressures in hypothesis building that favor iterations of pre-existing "exciting" hypotheses and inhibit the pursuit of alternative hypotheses, regardless of relative likelihood. These findings contribute to the growing anthropological and science and technology studies (STS) literature on the epistemic communities that coalesce around suspected NEID outbreaks and highlight an urgent need for greater scrutiny of core epidemiological processes.

Representations of an Ebola 'outbreak' through Story Technologies

BACKGROUND

Attempts to understand biosocial phenomena using scientific methods are often presented as value-neutral and objective; however, when used to reduce the complexity of open systems such as epidemics, these forms of inquiry necessarily entail normative considerations and are therefore fashioned by political worldviews (ideologies). From the standpoint of poststructural theory, the character of these representations is at most limited and partial. In addition, these modes of representation (as stories) do work (as technologies) in the service of, or in resistance to, power.

METHODS

We focus on a single Ebola case cluster from the 2013-2016 outbreak in West Africa and examine how different disciplinary forms of knowledge production (including outbreak forecasting, active epidemiological surveillance, post-outbreak serosurveys, political economic analyses, and ethnography) function as Story Technologies. We then explore how these technologies are used to curate 'data,' analysing the erasures, values, and imperatives evoked by each.

RESULTS

We call attention to the instrumental-in addition to the descriptive-role Story Technologies play in ordering contingencies and establishing relationships in the wake of health crises.

DISCUSSION

By connecting each type of knowledge production with the systems of power it reinforces or disrupts, we illustrate how Story Technologies do ideological work. These findings encourage research from pluriversal perspectives and advocacy for measures that promote more inclusive modes of knowledge production.

Rapid ethnographic appraisal of community concepts of and responses to joint pain in Kilimanjaro, Tanzania

INTRODUCTION

Musculoskeletal disorders, experienced as joint pain, are a significant global health problem, but little is known about how joint pain is categorised and understood in Tanzania. Understanding existing conceptualisations of and responses to joint pain is important to ensure both research and interventions are equitable and avoid biomedical imposition.

METHODS

Rapid ethnographic appraisal was conducted in a periurban and rural community in Kilimanjaro, documenting language used to describe joint pain, ideas about causes, understandings of who experiences such pain, the impacts pain has and how people respond to it. We conducted 66 interviews with community leaders, traditional healers, community members and pharmacists.Photographs were taken and included in fieldnotes to supplement the interview data and develop thick descriptions. Data were analysed by constant comparison using QDA Miner software.

RESULTS

Across the sample, dominant concepts of joint pain were named ugonjwa wa baridi, cold disease; ugonjwa wa uzee, old age disease; rimatizim, disease of the joints; and gauti, gout. Causes mentioned included exposure to the cold, old age, alcohol and red meat consumption, witchcraft, demons and injuries/falls. Age, gender and occupation were seen as important factors for developing joint pain. Perceived impacts of joint pain included loss of mobility, economic and family problems, developing new health conditions, death, reduction in sexual functioning and negative self-perceptions. Responses to joint pain blended biomedical treatments, herbal remedies, consultations with traditional healers and religious rituals.

CONCLUSIONS

Conceptualisations of and responses to joint pain in the two communities were syncretic, mixing folk and biomedical practices. Narratives about who is affected by joint pain mirror emerging epidemiological findings, suggesting a strong 'lay epidemiology' in these communities. Anthropological methods can support the decolonisation of global health by decentring the imposition of English language biomedicine and pursuing synthetic, dignified languages of care.

Global health photography behind the façade of empowerment and decolonisation

Global health photography has historically been commissioned and, therefore, dominated by the gaze of Western photographers on assignments in the Global South. This is changing as part of international calls to decolonise global health and stimulate 'empowerment', spawning a growing initiative to hire local photographers. This article, based on interviews with global health photographers, reflects on this paradigm shift. It highlights how behind the laudable aim of 'empowerment' of local global health photography there is a simultaneous exploitation of precarious photographer labour and the emergence of 'glocal' photography elites. The paper argues that empowerment of local photographers can become a euphemism for reducing image production costs and maintaining control over the image content, while extending the scope of mainstream global health visual culture without challenging it. Finally, the article amplifies the growing concern that uncritical engagement with institutionalised empowerment becomes a warrant for the reproduction of local inequalities behind the fashionable façade of cooperation and care.

Kansa talk: mapping cancer terminologies in Bagamoyo, Tanzania towards dignity-based practice

This paper reports and examines the results of qualitative research on the use of local cancer terminology in urban Bagamoyo, Tanzania. Following recent calls to unify evidence and dignity-based practices in global health, this research locates local medical sociolinguistics as a key place of entry into creating epistemologically autonomous public health practices. We used semistructured ethnographic interviews to reveal both the contextual and broader patterns related to use of local cancer terminologies among residents of Dunda Ward in urban Bagamoyo. Our findings suggest that people in Bagamoyo employ diverse terms to describe and make meanings about cancer that do not neatly fit with biomedical paradigms. This research not only opens further investigation about how ordinary people speak and make sense of the emerging cancer epidemic in places like Tanzania, but also is a window into otherwise conceptualisations of 'intervention' onto people in formerly colonised regions to improve a health situation. We argue that adapting biomedical concepts into local sociolinguistic and knowledge structures is an essential task in creating dignity-based, evidence-informed practices in global health.

Accounting for historical injustices in mathematical models of infectious disease transmission: An analytic overview

Differences in infectious disease risk, acquisition, and severity arise from intersectional systems of oppression and resulting historical injustices that shape individual behavior and circumstance. We define historical injustices as distinct events and policies that arise out of intersectional systems of oppression. We view historical injustices as a medium through which structural forces affect health both directly and indirectly, and are thus important to study in the context of infectious disease disparities. In this critical analysis we aim to highlight the importance of incorporating historical injustices into mathematical models of infectious disease transmission and provide context on the methodologies to do so. We offer two illustrations of elements of model building (i.e., parameterization, validation and calibration) that can allow for a better understanding of health disparities in infectious disease outcomes. Mathematical models that do not recognize the historical forces that underlie infectious disease dynamics inevitably lead to the individualization of our focus and the recommendation of untenable individual-behavioral prescriptions to address the burden of infectious disease.

Propagating Visions of a Forest Reservoir: A Supposed Zoonotic Outbreak in the Brong-Ahafo Region of Ghana

When examined closely, the backgrounds of some of the most widely cited origin stories for zoonotic disease outbreaks have been found to be irreconcilable with empirical data. Stated simply, these explanatory landscapes do not appear to have existed. Here, I present a detailed case study of one such fictional landscape, that of a monkey-filled forest which was identified as the source of a suspected zoonotic outbreak in the Brong-Ahafo Region of Ghana in 2010. Taking my approach from cultural epidemiology, I elucidate the mechanisms by which this fictional landscape was constructed and transmitted among the professionals involved in the response.

Decolonisation initiatives at the Institute of Tropical Medicine, Antwerp, Belgium: ready for change?

In a global context, the pernicious effects of colonialism and coloniality are increasingly being recognised in many sectors. As a result, calls to reverse colonial aphasia and amnesia, and decolonise, are getting stronger. This raises a number of questions, particularly for entities that acted as agents of (previous) colonising countries and worked to further the progress of the colonial project: What does decolonisation mean for such historically colonial entities? How can they confront their (forgotten) arsonist past while addressing their current role in maintaining coloniality, at home and abroad? Given the embeddedness of many such entities in current global (power) structures of coloniality, do these entities really want change, and if so, how can such entities redefine their future to ensure that they are and remain 'decolonised'? We attempt to answer these questions, by reflecting on our efforts to think through and start the process of decolonisation at the Institute of Tropical Medicine (ITM) in Antwerp, Belgium. The overarching aim is to contribute to closing the gap in the literature when it comes to documenting practical efforts at decolonisation, particularly in contexts similar to ITM and to share our experience and engage with others who are undertaking or planning to undertake similar initiatives.

Why 'elevating country voice' is not decolonizing global health: A frame analysis of in-depth interviews

Recent calls for global health decolonization suggest that addressing the problems of global health may require more than 'elevating country voice'. We employed a frame analysis of the diagnostic, prognostic, and motivational framings of both discourses and analyzed the implications of convergence or divergence of these frames for global health practice and scholarship. We used two major sources of data-a review of literature and in-depth interviews with actors in global health practice and shapers of discourse around elevating country voice and decolonizing global health. Using NVivo 12, a deductive analysis approach was applied to the literature and interview transcripts using diagnostic, prognostic and motivational framings as themes. We found that calls for elevating country voice consider suppressed low- and middle-income country (LMIC) voice in global health agenda-setting and lack of country ownership of health initiatives as major problems; advancing better LMIC representation in decision making positions, and local ownership of development initiatives as solutions. The rationale for action is greater aid impact. In contrast, calls for decolonizing global health characterize colonialityas the problem. Its prognostic framing, though still in a formative stage, includes greater acceptance of diversity in approaches to knowledge creation and health systems, and a structural transformation of global health governance. Its motivational framing is justice. Conceptually and in terms of possible outcomes, the frames underlying these discourses differ. Actors' origin and nature of involvement with global health work are markers of the frames they align with. In response to calls for country voice elevation, global health institutions working in LMICs may prioritize country representation in rooms near or where power resides, but this falls short of expectations of decolonizing global health advocates. Whether governments, organizations, and communities will sufficiently invest in public health to achieve decolonization remains unknown and will determine the future of the call for decolonization and global health practice at large.

Reflecting on our good intentions: A critical discourse analysis of women's health and empowerment discourses in sexual and gender-based violence policies relevant to southern Africa

Decades of 'feminist' sexual- and gender-based violence (SGBV) policies have produced limited change in southern African SGBV rates. Recent critiques highlight ongoing colonial legacies in such policymaking, arguing that these legacies limit the potential for liberatory change. Further, reflecting on such discourses can highlight reasons behind global public health intervention failure. To promote reflexivity among public health actors who create, reproduce, and implement SGBV policies, this paper presents a critical discourse analysis of how women's empowerment is constructed in foundational global and national health and development policies bearing on SGBV in Zambia. The analysis identifies neoliberal feminist discourses of empowerment: (i) the protection of women, which perpetuates a saviour complex; (ii) the promotion of equality to men, which excludes those deemed unworthy; (iii) the eradication of harmful cultural norms, which challenge the preservation of African values; and (iv) (neoliberal) empowerment through women's attained employment and capital, which empowers women within unequal economic relations rather than liberating women from those relations. The author critiques such neoliberal empowerment discourses for failing to structurally transform the conditions for women's liberation. This paper offers a first step to the dismantling of colonial structures in SGBV policies by unpacking and promoting reflexivity about such discourses.

Transforming global health education during the COVID-19 era: perspectives from a transnational collective of global health students and recent graduates

Inspired by the 2021 BMJ Global Health Editorial by Atkins et al on global health (GH) teaching during the COVID-19 pandemic, a group of GH students and recent graduates from around the world convened to discuss our experiences in GH education during multiple global crises. Through weekly meetings over the course of several months, we reflected on the impact the COVID-19 pandemic and broader systemic inequities and injustices in GH education and practice have had on us over the past 2 years. Despite our geographical and disciplinary diversity, our collective experience suggests that while the pandemic provided an opportunity for changing GH education, that opportunity was not seized by most of our institutions. In light of the mounting health crises that loom over our generation, emerging GH professionals have a unique role in critiquing, deconstructing and reconstructing GH education to better address the needs of our time. By using our experiences learning GH during the pandemic as an entry point, and by using this collective as an incubator for dialogue and re-imagination, we offer our insights outlining successes and barriers we have faced with GH and its education and training. Furthermore, we identify autonomous collectives as a potential viable alternative to encourage pluriversality of knowledge and action systems and to move beyond Western universalism that frames most of traditional academia.

Understanding antimicrobial use in subsistence farmers in Chikwawa District Malawi, implications for public awareness campaigns

Drug resistant infections are increasing across the world and urgent action is required to preserve current classes of antibiotics. Antibiotic use practices in low-and-middle-income countries have gained international attention, especially as antibiotics are often accessed beyond the formal health system. Public awareness campaigns have gained popularity, often conceptualising antimicrobial resistance (AMR) as a problem of excess, precipitated by irrational behaviour. Insufficient attention has been paid to people's lived experiences of accessing medicines in low-income contexts. In Chikwawa District, Malawi, a place of extreme scarcity, our study aimed to understand the care and medicine use practices of households dependent on subsistence farming. Adopting an anthropological approach, we undertook medicine interviews (100), ethnographic fieldwork (six-month period) and key informant interviews (33) with a range of participants in two villages in rural Chikwawa. The most frequently used drugs were cotrimoxazole and amoxicillin, not considered to be of critical importance to human health. Participants recognised that keeping, sharing, and buying medicines informally was not the "right thing." However, they described using antibiotics and other medicines in these ways due to conditions of extreme precarity, the costs and limitations of seeking formal care in the public sector, and the inevitability of future illness. Our findings emphasise the need in contexts of extreme scarcity to equip policy actors with interventions to address AMR through strengthening health systems, rather than public awareness campaigns that foreground overuse and the dangers of using antibiotics beyond the formal sector.

Global health wars: a rhetorical review of global health critique

The critique of global health is a longstanding tradition in the global health humanities (GHH). Typically, this critique takes an expected tack: critics take a slice of global health, identify its rhetoric, expose its power, and elucidate its unanticipated consequences. Here, I subject global health critique to its own approach-conducting a 'rhetorical review' of global health critique in order to ascertain whether it has rhetoric, power and unanticipated consequences of its own. Following this review, I find that global health critique has a rhetoric, and that this rhetoric can be organised into three types: (1) 'global health as mere rhetoric', (2) 'splitting global health', and (3) 'figuring global health war.' Ultimately, I argue that the rhetoric of GHH critique, like the rhetoric of global health, is a rhetoric of consequence-and a rhetoric worth revisiting.

Towards a participatory framework for improving water & health outcomes: A case study with Maasai women in rural Tanzania

Rural communities in sub-Saharan Africa (SSA) are disproportionately burdened by a pervasive lack of access to safe drinking water. Widespread programmatic failure in the water, sanitation, and hygiene (WaSH) sector has resulted in particularly slow progress in alleviating these challenges in the region. Drawing from decolonial and participatory methodological scholarship, this research demonstrates how geographically and demographically specific, locally controlled, and long-term educational programming can improve health and wellness outcomes when associated with a technological intervention. Specifically, consultations between January 2015 and August 2018 were followed by an iterative and community-driven program development process between January and July 2019. Fifty Maasai women were subsequently recruited to participate and were provided with a point-of-use water treatment technology in August 2019. These women engaged in a series of three 14-week WaSH education programs over an 18-month evaluation period. Results showed that 38% of participants reported regular diarrhea at baseline, decreasing to 8%, 0%, and 3% immediately after each of the three WaSH education programs were provided at 3, 12, and 18 months. Interim measurements taken between WaSH programs showed 35% of participants (at 6 months) and 5% of participants (at 15 months) reporting regular diarrhea. A trend of improvement was thus observed over the study period, though the increase in reported diarrhea at 6 months demonstrates the need for long-term commitment on the part of WASH practitioners when engaging with end users to achieve sustained change. Further, this research highlights the importance of participatory program development and pedagogical approaches in WaSH interventions, where local control of study objective determination and implementation, combined with consistent and long-term engagement, can facilitate sustained technology use and associated reductions in diarrhea.

SARS-CoV-2 antibody prevalence in Sierra Leone, March 2021: a cross-sectional, nationally representative, age-stratified serosurvey

INTRODUCTION

As of 26 March 2021, the Africa Centres for Disease Control and Prevention had reported 4 159 055 cases of COVID-19 and 111 357 deaths among the 55 African Union member states; however, no country has published a nationally representative serosurvey as of October 2021. Such data are vital for understanding the pandemic's progression on the continent, evaluating containment measures, and policy planning.

METHODS

We conducted a cross-sectional, nationally representative, age-stratified serosurvey in Sierra Leone in March 2021 by randomly selecting 120 Enumeration Areas throughout the country and 10 randomly selected households in each of these. One to two persons per selected household were interviewed to collect information on sociodemographics, symptoms suggestive of COVID-19, exposure history to laboratory-confirmed COVID-19 cases, and history of COVID-19 illness. Capillary blood was collected by fingerstick, and blood samples were tested using the Hangzhou Biotest Biotech RightSign COVID-19 IgG/IgM Rapid Test Cassette. Total seroprevalence was estimated after applying sampling weights.

RESULTS

The overall weighted seroprevalence was 2.6% (95% CI 1.9% to 3.4%). This was 43 times higher than the reported number of cases. Rural seropositivity was 1.8% (95% CI 1.0% to 2.5%), and urban seropositivity was 4.2% (95% CI 2.6% to 5.7%).

DISCUSSION

Overall seroprevalence was low compared with countries in Europe and the Americas (suggesting relatively successful containment in Sierra Leone). This has ramifications for the country's third wave (which started in June 2021), during which the average number of daily reported cases was 87 by the end of the month:this could potentially be on the order of 3700 actual infections per day, calling for stronger containment measures in a country with only 0.2% of people fully vaccinated. It may also reflect significant under-reporting of incidence and mortality across the continent.

Barriers to decolonising educational partnerships in global health

Global health partnerships between high-income countries and low/middle-income countries can mirror colonial relationships. The growing call to advance global health equity therefore involves decolonising global health partnerships and outreach. Through decolonisation, local and international global health partners recognise non-western forms of knowledge and authority, acknowledge discrimination and disrupt colonial structures and legacies that influence access to healthcare.Despite these well-described aims, the ideal implementation process for decolonising global health remains ill-defined. This ambiguity exists, in part, because partners face barriers to adopting a decolonised perspective. Such barriers include overemphasis on intercountry relationships, implicit hierarchies perpetuated by educational interventions and ethical dilemmas in global health work.In this article, we explore the historical entanglement of education, health and colonialism. We then use this history as context to identify barriers that arise when decolonising contemporary educational global health partnerships. Finally, we offer global health partners strategies to address these challenges.

Epistemic injustice in academic global health

This Viewpoint calls attention to the pervasive wrongs related to knowledge production, use, and circulation in global health, many of which are taken for granted. We argue that common practices in academic global health (eg, authorship practices, research partnerships, academic writing, editorial practices, sensemaking practices, and the choice of audience or research framing, questions, and methods) are peppered with epistemic wrongs that lead to or exacerbate epistemic injustice. We describe two forms of epistemic wrongs, credibility deficit and interpretive marginalisation, which stem from structural exclusion of marginalised producers and recipients of knowledge. We then illustrate these forms of epistemic wrongs using examples of common practices in academic global health, and show how these wrongs are linked to the pose (or positionality) and the gaze (or audience) of producers of knowledge. The epistemic injustice framework shown in this Viewpoint can help to surface, detect, communicate, make sense of, avoid, and potentially undo unfair knowledge practices in global health that are inflicted upon people in their capacity as knowers, and as producers and recipients of knowledge, owing to structural prejudices in the processes involved in knowledge production, use, and circulation in global health.

Obligation or Desire: Variation in Motivation for Compliance With COVID-19 Public Health Guidance

Why do people comply with coronavirus disease 2019 (COVID-19) public health guidance? This study considers cultural-psychological foundations of variation in beliefs about motivations for such compliance. Specifically, we focused on beliefs about two sources of prosocial motivation: desire to protect others and obligation to society. Across two studies, we observed that the relative emphasis on the desire to protect others (vs. the obligation to the community) as an explanation for compliance was greater in the United States settings associated with cultural ecologies of abstracted independence than in Chinese settings associated with cultural ecologies of embedded interdependence. We observed these patterns for explanations of psychological experience of both others (Study 1) and self (Study 2), and for compliance with mandates for both social distancing and face masks (Study 2). Discussion of results considers both practical implications for motivating compliance with public health guidance and theoretical implications for denaturalizing prevailing accounts of prosocial motivation.

Decolonising human rights: how intellectual property laws result in unequal access to the COVID-19 vaccine

The recent rapid development of COVID-19 vaccines offers hope in addressing the worst pandemic in a hundred years. However, many countries in the Global South face great difficulties in accessing vaccines, partly because of restrictive intellectual property law. These laws exacerbate both global and domestic inequalities and prevent countries from fully realising the right to health for all their people. Commodification of essential medicines, such as vaccines, pushes poorer countries into extreme debt and reproduces national inequalities that discriminate against marginalised groups. This article explains how a decolonial framing of human rights and public health could contribute to addressing this systemic injustice. We envisage a human rights and global health law framework based on solidarity and international cooperation that focuses funding on long-term goals and frees access to medicines from the restrictions of intellectual property law. This would increase domestic vaccine production, acquisition and distribution capabilities in the Global South.

Reparations for Black American descendants of persons enslaved in the U.S. and their potential impact on SARS-CoV-2 transmission

BACKGROUND

In the United States, Black Americans are suffering from a significantly disproportionate incidence of COVID-19. Going beyond mere epidemiological tallying, the potential for racial-justice interventions, including reparations payments, to ameliorate these disparities has not been adequately explored.

METHODS

We compared the COVID-19 time-varying Rt curves of relatively disparate polities in terms of social equity (South Korea vs. Louisiana). Next, we considered a range of reproductive ratios to back-calculate the transmission rates βi→j for 4 cells of the simplified next-generation matrix (from which R0 is calculated for structured models) for the outbreak in Louisiana. Lastly, we considered the potential structural effects monetary payments as reparations for Black American descendants of persons enslaved in the U.S. would have had on pre-intervention βi→j and consequently R0.

RESULTS

Once their respective epidemics begin to propagate, Louisiana displays Rt values with an absolute difference of 1.3-2.5 compared to South Korea. It also takes Louisiana more than twice as long to bring Rt below 1. Reasoning through the consequences of increased equity via matrix transmission models, we demonstrate how the benefits of a successful reparations program (reflected in the ratio βb→b/βw→w) could reduce R0 by 31-68%.

DISCUSSION

While there are compelling moral and historical arguments for racial-injustice interventions such as reparations, our study considers potential health benefits in the form of reduced SARS-CoV-2 transmission risk. A restitutive program targeted towards Black individuals would not only decrease COVID-19 risk for recipients of the wealth redistribution; the mitigating effects would also be distributed across racial groups, benefiting the population at large.

Descolonizando a saúde planetária

Resumo Intimamente conectada com decisões políticas e interesses de mercado, a pandemia de Covid-19 é uma calamidade crônica agudizada que assola o mundo inteiro, desestabilizando conhecimentos e práticas biomédicas hegemônicas e revelando a precariedade dos sistemas de saúde pública, assim como a impotência profunda das redes de seguridade social e a fragilidade dos laços de solidariedade que imaginávamos estáveis. O artigo reflete sobre os desafios impostos aos cientistas sociais e profissionais da saúde em contextos neoliberais e à beira da autocracia num momento em que seus métodos e conceitos-chave são chamados a dar conta de forma mais adequada aos complexos enredos territorializados pela emergência generalizada e a cultivar micro, meso e macromodos de resistência. Assim, instrumentos analíticos da antropologia médica e da saúde global crítica, como vulnerabilidade estrutural, determinantes políticos, racialização, farmaceuticalização e descolonização do saber, podem ser valiosos recursos para leitura do presente e de intervenção nele, mas são também desafiados pela dinâmica realidade que se desdobra. Contra o pano de fundo de uma crescente tensão entre a tecnocrática produção de microdispositivos humanitários e o desenvolvimento de uma ciência integrada de saúde planetária, o artigo ilumina a urgência da articulação de uma ética amazônica de cuidado.

Decolonising global health in the time of COVID-19

The persistent influence of coloniality both from external actors and from within threatens the response to COVID-19 in Africa. This essay presents historical context for the colonial inheritance of modern global health and analyses two controversies related to COVID-19 that illustrate facets of coloniality: comments made by French researchers regarding the testing of BCG vaccine in Africa, and the claims by Madagascar's president Andry Rajoelina that the country had developed an effective traditional remedy named Covid-Organics. Leveraging both historical sources and contemporary documentary sources, I demonstrate how the currents of exploitation, marginalisation, pathologisation and saviourism rooted in coloniality are manifested via these events. I also discuss responses to coloniality, focussing on the misuse and co-optation of pan-Africanist rhetoric. In particular, I argue that the scandal surrounding Covid-Organics is a reflection of endogenised coloniality, whereby local elites entrench and benefit from inequitable power structures at the intersubjective (rather than trans-national) scale. I conclude with a reflection on the need for equity as a guiding principle to dismantle global health colonialism.

Structural competency and global health education

Structural competency is a new curricular framework for training health professionals to recognise and respond to disease and its unequal distribution as the outcome of social structures, such as economic and legal systems, healthcare and taxation policies, and international institutions. While extensive global health research has linked social structures to the disproportionate burden of disease in the Global South, formal attempts to incorporate the structural competency framework into US-based global health education have not been described in the literature. This paper fills this gap by articulating five sub-competencies for structurally competent global health instruction. Authors drew on their experiences developing global health and structural competency curricula-and consulted relevant structural competency, global health, social science, social theory, and social determinants of health literatures. The five sub-competencies include: (1) Describe the role of social structures in producing and maintaining health inequities globally, (2) Identify the ways that structural inequalities are naturalised within the field of global health, (3) Discuss the impact of structures on the practice of global health, (4) Recognise structural interventions for addressing global health inequities, and (5) Apply the concept of structural humility in the context of global health.

Literacy is power: structural drivers of child malnutrition in rural Liberia

BACKGROUND

In Liberia, an estimated 32% of children under 5 are stunted. Malnutrition and hunger worsened during the country's civil war and were further exacerbated by the 2014-2016 outbreak of Ebola virus disease. Studies examining adherence to recommended infant and young child feeding practices frequently do so with an emphasis on the knowledge, attitudes and beliefs of mothers and caregivers. Often overlooked are the structural factors that enable or constrain their agency to practise evidence-based recommendations.

METHODS

Between July and December 2017, we surveyed 100 Liberian mothers to assess the sociodemographic factors associated with the risk of severe acute malnutrition in children in Maryland County, Liberia. We also conducted 50 in-depth interviews at two government health facilities to qualitatively explore mothers' experiences, as well as health workers' understandings of the determinants of malnutrition in the region. We applied logistic regression to analyse quantitative data and inductive content analysis to thematically interpret qualitative data.

RESULTS

Mothers were less likely to have a child with severe acute malnutrition if they had an income greater than US$50 per month (adjusted OR (aOR)=0.14, p<0.001), were literate (aOR=0.21, p=0.009) or exclusively breast fed during the first 6 months of life (aOR=0.18, p=0.049); they were more likely to have a child with severe acute malnutrition if they were married or in domestic partnerships (aOR=8.41, p<0.001). In-depth interviews elucidated several social, economic and programmatic factors that shaped suboptimal feeding practices, as well as decisions for and against seeking formal care for malnutrition.

DISCUSSION

The lived experiences of Liberian mothers and health workers illustrate that child malnutrition is a direct consequence of abject poverty, food insecurity, illiteracy, the precarious nature of formal and informal work, and the lack of robust social protection. Behaviour change and health education interventions that do not seek to alleviate structural barriers to compliance are unlikely to be effective.

The Impact of Different Types of Violence on Ebola Virus Transmission During the 2018-2020 Outbreak in the Democratic Republic of the Congo

BACKGROUND

Our understanding of the different effects of targeted versus nontargeted violence on Ebola virus (EBOV) transmission in Democratic Republic of the Congo (DRC) is limited.

METHODS

We used time-series data of case counts to compare individuals in Ebola-affected health zones in DRC, April 2018-August 2019. Exposure was number of violent events per health zone, categorized into Ebola-targeted or Ebola-untargeted, and into civilian-induced, (para)military/political, or protests. Outcome was estimated daily reproduction number (Rt) by health zone. We fit linear time-series regression to model the relationship.

RESULTS

Average Rt was 1.06 (95% confidence interval [CI], 1.02-1.11). A mean of 2.92 violent events resulted in cumulative absolute increase in Rt of 0.10 (95% CI, .05-.15). More violent events increased EBOV transmission (P = .03). Considering violent events in the 95th percentile over a 21-day interval and its relative impact on Rt, Ebola-targeted events corresponded to Rt of 1.52 (95% CI, 1.30-1.74), while civilian-induced events corresponded to Rt of 1.43 (95% CI, 1.21-1.35). Untargeted events corresponded to Rt of 1.18 (95% CI, 1.02-1.35); among these, militia/political or ville morte events increased transmission.

CONCLUSIONS

Ebola-targeted violence, primarily driven by civilian-induced events, had the largest impact on EBOV transmission.

Linking humans, their animals, and the environment again: a decolonized and more-than-human approach to "One Health"

This article considers a broad perspective of "One Health" that includes local and animal knowledge. Drawing from various colonial efforts to link human, animal, and environmental health, it first shows that the current "One Health" initiative has its roots in colonial engagement and coincides with a need to secure the health of administrators (controlling that of local populations), while pursing use of resources. In our contemporary period of repeated epidemic outbreaks, we then discuss the need for greater inclusion of social science knowledge for a better understanding of complex socio-ecological systems. We show how considering anthropology and allied sub-disciplines (anthropology of nature, medical anthropology, and human-animal studies) highlights local knowledge on biodiversity as well as the way social scientists investigate diversity in relation to other forms of knowledge. Acknowledging recent approaches, specifically multispecies ethnography, the article then aims to include not only local knowledge but also non-human knowledge for a better prevention of epidemic outbreaks. Finally, the conclusion stresses the need to adopt the same symmetrical approach to scientific and profane knowledge as a way to decolonize One Health, as well as to engage in a more-than-human approach including non-human animals as objects-subjects of research.

Modelling the pandemic: attuning models to their contexts

The evidence produced in mathematical models plays a key role in shaping policy decisions in pandemics. A key question is therefore how well pandemic models relate to their implementation contexts. Drawing on the cases of Ebola and influenza, we map how sociological and anthropological research contributes in the modelling of pandemics to consider lessons for COVID-19. We show how models detach from their implementation contexts through their connections with global narratives of pandemic response, and how sociological and anthropological research can help to locate models differently. This potentiates multiple models of pandemic response attuned to their emerging situations in an iterative and adaptive science. We propose a more open approach to the modelling of pandemics which envisages the model as an intervention of deliberation in situations of evolving uncertainty. This challenges the 'business-as-usual' of evidence-based approaches in global health by accentuating all science, within and beyond pandemics, as 'emergent' and 'adaptive'.

A disconnected policy network: The UK's response to the Sierra Leone Ebola epidemic

This paper investigates whether the inclusion of social scientists in the UK policy network that responded to the Ebola crisis in Sierra Leone (2013-16) was a transformational moment in the use of interdisciplinary research. In contrast to the existing literature, that relies heavily on qualitative accounts of the epidemic and ethnography, this study tests the dynamics of the connections between critical actors with quantitative network analysis. This novel approach explores how individuals are embedded in social relationships and how this may affect the production and use of evidence. The meso-level analysis, conducted between March and June 2019, is based on the traces of individuals' engagement found in secondary sources. Source material includes policy and strategy documents, committee papers, meeting minutes and personal correspondence. Social network analysis software, UCINet, was used to analyse the data and Netdraw for the visualisation of the network. Far from being one cohesive community of experts and government officials, the network of 134 people was weakly held together by a handful of super-connectors. Social scientists' poor connections to the government embedded biomedical community may explain why they were most successful when they framed their expertise in terms of widely accepted concepts. The whole network was geographically and racially almost entirely isolated from those affected by or directly responding to the crisis in West Africa. Nonetheless, the case was made for interdisciplinarity and the value of social science in emergency preparedness and response. The challenge now is moving from the rhetoric to action on complex infectious disease outbreaks in ways that value all perspectives equally.