Book Review: African Health Leaders: Making Change and Claiming the Future

Oxford University Press; October 28, 2014; 368 pages

There have been several complaints about how the story of the response to the Ebola outbreak in Liberia, Sierra Leone and Guinea is being told in the media; about how the stories sometimes do not match reality on the ground. That you are more likely to hear about volunteers from the US or Europe and of donations from global health agencies, than about frontline African health workers and community volunteers doing much of the work. The US journalist and academic Howard French wrote in an open letter to the producer of 60 minutes (a US TV programme), criticising their feature on Ebola in Liberia by correspondent Lara Logan:

“In that broadcast, Africans were reduced to the role of silent victims. They constituted what might be called a scenery of misery: people whose thoughts, experiences and actions were treated as if totally without interest. Liberians were shown within easy speaking range of Logan, including some Liberians whom she spoke about, and yet not a single Liberian was quoted in any capacity. Liberians not only died from Ebola; many of them contributed bravely to the fight against the disease, including doctors, nurses and other caregivers, some of whom gave their lives in this effort. Despite this, the only people heard from on the air were white foreigners who had gone to Liberia to contribute to the fight against the disease.”

There’s nothing new about this. Indeed, it is the reason for the collection of essays African Health Leaders: Making Change and Claiming the Future edited by Francis Omaswa (himself an African Health Leader) and Nigel Crisp (a former CEO of the NHS in England). They invited a cast of several global health stars from Africa to reflect on their work; and it’s quite a feast. They had Nigerian Uche Amazigo (winner of the 2012 Prince Mahidol Award for her work on the control of river blindness through community volunteers) and Kenyan Miriam Were (winner of the 2008 Hideyo Noguchi Africa Prize for pioneering community health worker programmes long before they became popular). There were former and current health ministers Gottlieb Monekosso (Cameroon), Aaron Motsoaledi (South Africa), Pascoal Mocumbi (Mozambique) and Agnes Binagwaho (Rwanda). And they also included several former and current bureaucrats and advisors at ministries of health and global agencies such as the WHO, UNICEF and the World Bank.

The authors reflected on their work and achievements, public health challenges in Africa and what must be done to address them now and in the future. The book gives a vivid sense of the public health landscape in Africa, and of the similarities and differences in challenges and potential solutions over time and across the countries: from the immediate post-colonial period to Alma Atta, from HIV to the MDGs. However, the book is long on challenges and short on how they came to be; long on achievements, but short on personal stories of the journeys that led to them; long on potential solutions but short on why they are not already in place. In some parts, the book read almost like a journal article, a policy statement, or an NGO report.

But in the parts where it comes alive, the book was deeply satisfying; for example Chapter 4 in which Peter Mugyenyi details the early years of the HIV response in Uganda; in Chapter 8 where Miriam Were wrote about initial scepticism about her community programmes in Kenya; and Chapter 5 where Chisale Mhango gave an account of her work combating maternal mortality in Malawi. As director of reproductive health services, Chisale Mhango “decided to take injectable contraceptives to the community [rural communities] using trained but non-medical providers”. But because she anticipated objection from her minister of health, she did not seek permission. When she was criticised during a review meeting, she cited the evidence on task shifting to support her decision. Contraceptive prevalence continues to rise in Malawi. Some others gave examples of encounters and decisions that enhanced or limited their work. I wish there were more.

However, my favourite chapter in the book was written by one of the editors. In Chapter 2, Francis Omaswa discussed health leadership in Africa, tracing the current phase of weak leadership to when Africans went “begging for advice and money and [] got both in exchange for… self-respect, self-confidence and self-determination… and were forced to accept and implement solutions they knew would not work.” He traced this “legacy of humiliation” to “centuries of slavery and colonialism” which “accelerated the entrenchment of this new disempowerment and demoralisation”. For him, “until and unless we Africans… feel the pain and the shame of our situation we will not have the commitment to take the actions needed.” There was a certain bite and clear-headedness to this chapter; a commitment, it seems, to tell it like it is.

Omaswa proposed that African health leaders establish vibrant and independent think tanks to generate local evidence and hold corrupt governments to account. Notably, he mentioned that “when countries are clear and strong about what they want to achieve, donors actually follow” and added that such countries are the ones making the most progress in achieving health goals.” One such country is Rwanda. In Chapter 17, Rwandan health minister Agnes Binagwaho described impressive progress in the Rwandan health sector and added this throwaway comment: “now that our system has been independently evaluated… those who did not think that it would work in the past are starting to look at our vision in another way.” The three paragraphs that followed were about the need for donor confidence. I wish she discussed what she meant by this in more detail. I wish more authors were as candid as Omaswa.

Perhaps the reason why the book was not as confronting as it might is its double audience. The book is addressed to Africans, although it is not clear which category – health workers, policy makers, researchers, politicians, emerging leaders et cetera. And the book is also addressed to foreigners. The editors wrote that the book is “about Africans re-claiming their place as leaders in health” because, like the Ebola feature on 60 minutes, “most accounts of health and healthcare in sub-Saharan Africa are written by foreigners.” Having such double audience however necessitates what the African-American social scientist W.E.B. Du Bois (1868 – 1963) described as double consciousness: “this sense of always looking at one’s self through the eyes of others, of measuring one’s soul by the tape of a world that looks on in amused contempt and pity.” I wonder what this book would read like, if all the authors had intended to address primarily if not only Africans. The expatriation of voice, in which an African health leader for example adopts a foreign gaze, perhaps makes it easy to discount or ignore what one knows. It is inevitable. Omaswa and Crisp certainly must (or should) have contended with this in compiling and editing this volume.

We rarely got to meet the authors, and they did little to help emerging global health leaders in Africa and elsewhere think through a path for bringing improved population health to their people. Until we take control of our narrative, others will do it for us in self-serving ways, just like the 60 minutes Ebola feature. Even when we tell our stories, we may do so in ways that do not serve our best interests. In his 1957 Nobel Prize Speech, French-Algerian writer Albert Camus (1913 – 1960) said: “Whatever our personal weaknesses may be, the nobility of our craft will always be rooted in two commitments, difficult to maintain: the refusal to lie about what one knows and the resistance to oppression.” Here Camus was referring to the plight of European writers in the bleak post-World War II Europe. But every bit of this statement applies to my reading of this book, and my perception of power within global health.

In Chapter 2, Francis Omaswa wrote that: “For years I have participated in conversations among African leaders talking about our disempowered status. We have talked loudly when we are alone, but in whispers when non-Africans are in earshot. It is now time for this conversation to come out in the open, moving from whispers to genuine dialogue for all concerned.” This book could have started this dialogue more robustly, but what it’s done is great, and a good beginning. I can’t wait for another book, a sequel perhaps, which takes on these issues more directly. There are too many things we don’t talk about in global health.

First is a blog post by Griewe Chelwa, titled “Economics has an Africa problem.” The author, a PhD candidate in economics at the University of Cape Town, showed that the most important journals in the field of economic development (e.g. the Journal of Development Economics, the Journal of Economic Growth, and the Journal of African Economies) do not have editorial board members who are based in Africa. The blog is worth reading in full. Things are not as bad in global health, but we definitely can do much better than we do now.

Second is an editorial statement on negative findings made by elite health economics journals, all eight of them based in Europe or the US, pledging to publish studies “regardless of whether empirical findings do or do not reject null hypotheses.” This promise to stop distorting the literature will hopefully lead to better policymaking, and I wish journals in global health and development will make such a commitment. These health economics journals will now welcome studies, as long as they are “well-designed, well-executed empirical studies… compatible with each journal’s distinctive emphasis and scope.” I lingered on that phrase “distinctive emphasis and scope” and wondered who determines the “distinctive emphasis and scope” of a journal.

This leads to the third item. In next month’s editorial in Health Promotion International, the editor Evelyne de Leeuw asked readers (including “activist health promoters”) for ideas on how to establish “a user panel that would advise on urgency, prominence and relevance of the material we should cover.” She gave the example of the BMJ which recently established a patient panel to advise on the “end user relevance” of what the BMJ publishes. Kudos to these two journals. But why did it take these well-established journals so long to seek the input of their end users, and why have others not yet done the same?

Who are the end users of global health journals, and do they have a say in determining the “distinctive emphasis and scope” of the journals? The answer, whatever it is, will say a lot about the balance of power, of knowledge and of influence in global health. The colonial heritage of global health and development makes it such that the balance often tilts in the favour of perpetuating colonial relationships with poor countries. The days of colonial medicine are over; so should colonial practices among journals in global health and development.

One strong argument of the Open Access movement was that journals were denying access to researchers and policymakers in poor countries for which many publications will be most useful. Now is time for a new movement, to push for transparency in the process by which journals determine their “distinctive emphasis and scope,” a movement about Open Agenda Setting. It is not enough to have people from poor countries on editorial boards; many global health journals already do. It is more important to have a commitment to not privilege one kind of evidence, methods, results, audiences or authors over another, but to primarily take into account the kind of knowledge that is useful for policymakers and implementers in poor countries, the supposed end users.

Health Promotion International is trying out some sort of crowd sourcing. They are inviting ideas on how to engage their end users. They also want nominations from the “next generation of scholarly and activist health promoters” to join their editorial board. Please consider contacting the editor, Evelyne de Leeuw (EIC-HPI@vichealth.vic.gov.au) to make your ideas and intentions known. I hope other journals, particularly in global health and development, will follow their example. Bottom line is we need to start shining a light on the policies of global health journals and holding them to account for their practices. The health and development of people in poor countries may be better for it.