A conversation with Prof. Caesar Atuire about country ownership and pandemic response

Prof. Caesar Atuire is Ethics Lead for the MSc in International Health and Tropical Medicine at the University of Oxford, UK and Associate Professor in the Department of Philosophy and Classics at the University of Ghana, as well as a member of the Coalition’s Ethics Working Group.

We interviewed Prof. Atuire about an opinion piece published earlier this year in PLOS Global Public Health, entitled Country ownership in global health by Dr Abdisalan Mohamed Noor, currently Wellcome Trust Research Fellow at the Kenya Medical Research Institute/Wellcome Trust Research Programme (KEMRI-WTRP) in Nairobi, Kenya and a Visiting Professor, University of Oxford, UK. Dr Noor was working with the Global Malaria Programme, World Health Organization when this interview was conducted.

In his short paper, Dr Noor shares ten lessons learned in the last 20 years on how to think about country ownership. Prof. Atuire shared his perspective on these lessons, what they could have contributed to the COVID-19 pandemic response, and their importance for a fairer, more global response to future pandemics.

Prof. Atuire, what was your initial response to the paper “Country ownership in global health” by Dr Abdisalan Noor?

He has hit some very important issues. He has captured the tension in global health between subsidiarity and coloniality. What I mean by subsidiarity is making sure that, for example, all sub-organizations are empowered to do what they’re supposed to do. This is a very important principle for global health, from a justice and ethics perspective. It means that bigger organizations should not come in and side-line or take over the role of smaller or sub-organizations. Subsidiarity is a justice-based approach that respects peoples’ rights to self-determination.

In global health, under the pretext of efficiency, we often have very large organizations trying to micromanage issues in remote places where they have very little competence – and not really empowering local organizations. If you group the 10 lessons raised by Noor, you will see that some highlight subsidiarity and others highlight decolonization, i.e., moving away from coloniality. Coloniality always creates a centre and a periphery, and the periphery is always subservient to the desires and goals of the centre. We need to move away from that model.

Which of Dr Noor’s 10 lessons on country ownership do you feel are most relevant to a truly global pandemic response?

Certainly lesson #3, “Have a dialogue, ask questions, listen to those who live with the problem”. That is so important, and it was so much missing in the COVID-19 pandemic response.

After China, the first countries hit by the pandemic in a severe way were Italy and, to some extent, Spain. Interestingly, these countries have no experts with living memory of managing a large pandemic. But they didn’t feel the need to consult countries that have been dealing with major epidemics in the last few decades. That would have meant listening to Africa. And that is not the habitual way to go in global health! Instead, from the beginning, we had this model where solutions were to be found at the central governance level, and then transmitted to the whole world.

From the beginning, there were debates about lockdowns in African urban and rural contexts, where they were just harmful and perhaps even pointless because people cannot observe them. And then we saw countries bringing out armies, and even violently imposing lockdowns on people who were just struggling for their livelihoods.

If you don’t listen to the local context well, you just do a copy and paste of what other countries are doing. Take the example of WHO’s recommendation to prioritize frontline workers in getting access to PPE and vaccines. When thinking about frontline workers in England, you might think of people who work in hospitals and maybe drivers and those working in the food chain. In Africa, to me, a frontline worker is a woman who sells products in the market. If you are selling fish at the market or fried plantains along the street in Accra or Lagos every day, you might enter into close contact with hundreds of people daily. And on the small buses (called tro-tro in Ghana or matatu in Kenya) which people use to get around, the driver’s mate (the person who collects the fares) might come into contact with 500 to 1000 people per day. And somehow we did not think of these people as frontline workers. So the idea of actually listening is very important.

Noor also made several points about the use of data for policy, including in lesson #4, “‘Evidentiary’ knowledge and control over funds create power asymmetries” and lesson #7, “The power of data to change minds is not simply in the ‘quality of the evidence’ but in the ‘change activism’ it catalyses”.  Throughout the pandemic, we kept hearing statements from leaders that they were following the evidence. Epidemiological data are empirical data, while policy is normative. And in the jump from data or data-driven models to a policy decision such as imposing a lockdown, you’re now moving to a normative decision, and once you move to a normative decision, there are ethical implications.

What was missing in this pandemic was a deeper embedding of the ethical dimensions in considering the data.

It’s not the job of the epidemiologist to calculate the fairness, the potential social damage, and the other consequences of a policy decision. And until you have all those on the table, you cannot take a good decision. This was missing in the response to COVID-19, and these kinds of decisions must be informed locally, not globally, because every context has its own peculiarities that need to be brought in. That is lesson #8, “One size doesn’t fit all, really!”

Another policy decision with major impacts was school closures. I mean, if you close down schools – and they were closed for nearly a year here in Ghana and for much longer in other countries – think of the households where there are no books at home and no internet access, so forget about online learning. Here we made photocopies of homework for parents to collect and take home for their children, but where parents cannot read or write, how can they help each child do the homework?

And what is more, in many African former colonies, the official system of education is in English, French or Portuguese, but that’s not the language spoken at home. So if you interrupt education for a year, children even lose the capacity to speak that language very well, and when they return, it’s like starting again from the beginning.

And there were other impacts of lockdowns. In the small fishing village where I live, we buried a dozen children who drowned in the sea. The beach where everyone would normally gather was closed due to the lockdown, and the children were at home and bored, so they went to a remote area where nobody would see them. But there’s an estuary there, with waves and currents, and they got into trouble in the water. Twelve children were lost between the ages of 11 and 13. This is what happens when you don’t take into consideration the local context. Some might say it’s an exaggeration to call this COVID-related, but I think it is. The place they normally play and swim is a safe area, and there are adults around watching. But if you lock them down and you don’t offer any alternatives, kids will be kids.

I also think Noor’s insights are reflective of the fact that he works with WHO. He says not to mix up the government with the country. International organizations tend to engage with governments, and of course, the principle of sovereignty that governs international relations requires that. But when this relationship is only between governments and international organizations, there are important voices missing because really, it’s the same people talking to each other.

And this is where the coloniality model comes in. When we think about colonization, we may think about Europe occupying and taking over countries, but if you think about it more in terms of centre and periphery, what is now happening today in the former colonies is that coloniality is being reproduced by national governments, with a centre and a periphery. So if you keep interacting with that centre, the periphery remains peripheral.

At one point, I jokingly told one of the high-level national COVID response teams I was working with that I was going to print photographs of rural people, people working in the markets, and come and paste them in their meeting rooms.

Because the problem is that those are the people who are not represented in the rooms where decisions are being made that will affect their lives. Someone said once that these experts, these decision-makers, were all trained with the same cookbook, so the only thing they can offer is variations of the same recipe.

And who is an expert? Today, we attribute the qualification of “expert” and therefore the power and the capacity to speak on certain things to a limited group of people. The people who end up at these decision-making tables are people who have certain credentials, and those credentials make them experts. And they just keep repeating the same things with different variations.

If we’re speaking about a global treaty to prepare for pandemics around the world, there should be broad consultation. Especially with the people who have really suffered, for example, during the COVID pandemic. And I’m not just talking only of people in low- and middle-income countries but also in higher-income countries. How many old peoples’ organizations are sitting at the table deciding on the contents of a pandemic treaty? Because the elderly really did suffer in this pandemic, and sometimes our policies were not very fair to them. This is the sort of broader engagement that is needed, instead of just calling in experts to come and sit around a room in Geneva or Brussels or New York, this is where the NGOs and civil society organizations could help, and really drive grassroots engagement. And this takes time. It takes longer. To bring all these perspectives and inputs together rather going into a room and coming out with a document and then going around looking for endorsements.

How could a future pandemic response differ if leading institutions and decision-makers followed some of the advice that’s captured in this paper?

Let me use the example of monkeypox. We need to understand that because we are all now highly interconnected, whenever there is a major health threat, we are all on the same team. It should not be a question of nations, it’s not a nationalistic game. When and where the threat comes up, it’s not a threat that we can address by raising up our national borders and our national identities or our group identities. That’s the kind of mentality we need to put aside.

The second thing is, let’s exercise greater intellectual honesty. Monkeypox has been around in Central and Western Africa since the 1970s. We’ve had various epidemics or flare-ups that have killed people, but the number of people affected has been low, and these countries have managed to live with and contain it for over 40 years. Don’t we have something to learn from them? Why are we once again centralizing the response far away from that context? They could say, you guys have been living with this for 40 years. Can we come together, learn from your experience and try to find ways to protect all of us against it? And the sad thing is that for somebody looking at this from Africa’s perspective, they think, oh, our lives do not matter. It’s only when this disease gets to Europe that it suddenly begins to matter. The WHO has declared it an emergency. Why wasn’t it an emergency before?

Is there anything that you felt was missing from Noor’s lessons? A lesson you would add to his list?

As an ethicist, I see that a lot of the points Noor raises are ethical points. So I guess my added lesson would be: Ethics and fairness need to have a formal seat at the table when we are discussing health policies, and it’s not something that should be an afterthought. It should be part of the process, and we should have people really qualified to be there. It’s interesting that Anthony Fauci said (during the WHO Pandemic Ethics and Policy Summit on 6 December 2021) that when they started discussing COVID-19 at the White House, that there was no ethicist. He said he was lucky because he’s married to an ethicist [Christine Grady, Head of the Dept of Bioethics at the US National Institutes of Health Clinical Center] and he was learning health ethics in the kitchen at home.

The UK SAGE [Scientific Advisory Group for Emergencies] were all scientists, but they were lucky, they had an ethicist in the group, Mike Parker. Many countries set up advisory committees without thinking about having an ethicist there.

So if you want what Noor calls country ownership, you have to have an ethicist who is embedded in the local context, not another international expert who is parachuted in from somewhere else.

And maybe another one: Beware of the policy development addicts! Even the international organizations represent the privileged few. If I go to Abidjan or Nairobi or any capital, these experts are there. But where do they live and how do they live? They’ve created a community of experts, and they’re everywhere, but they are nowhere.

Those small buses I mentioned that most people use to get around, how many experts have sat in those buses? If you moved the WHO headquarters and placed it in the centre of Lagos, and you denied WHO staff some of the privileges they have today, the type of person who would want to work for WHO would change, and the thinking would change. And why can’t this happen?

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