Sects, Money and Global Health

An article on #decolonization that originally appeared in SciencePolitics

The incredible Emily Mendenhall started SciencePolitics a little while back and they put together a series of top-notch essays around the demise of USAID. Here is mine, but do check out the others—links to all the essays at the bottom of this post!

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On the anniversary of the stop-work order for USAID, it’s safe to say that aid for global health is not coming back in any substantial way. Although the U.S. may have been particularly cruel and unusually swift in its withdrawal, it is not alone. Countries around the world are pulling back from global health.

In the short-run the loss of foreign aid is a tragedy. But in the longer run the reduction of foreign aid in global health also implies that countries now have greater freedom to determine their own trajectories.

As economist Angus Deaton has argued, foreign aid has often allowed leaders to access funds without acquiring the legitimacy of the local population necessary to raise taxes. This “aid Dutch disease” has permitted corrupt and authoritarian governments to continue long past their due dates.

In the longer run, the reduction of foreign aid in global health implies that countries now have greater freedom to determine their own trajectories.

With greater accountability to their local populations, governments now have to deliver health programs that local populations must be willing to fund. This shift implies that health programs need to better match the needs of the local population while at the same time working to improve access and quality with less money.

In the best of worlds delivering health programs that meet people’s expectations is a difficult task because healthcare is one of those curious cases where wants and efficiency often clash — people may want antibiotics but the efficiency of healthcare does not increase by giving antibiotics where they are not needed.

In an environment ridden by crises and a need for immediacy, the task of delivering tailored, affordable health programs becomes doubly difficult. At the minimum, it will require a fundamental change in the way that research and knowledge is generated in health, with far more attention to the local needs and context.

Rushing to action only risks entrenching one poorly functioning system of knowledge acquisition with another.

Unfortunately, rushing to action only risks entrenching one poorly functioning system of knowledge acquisition with another. Developing systems of knowledge and research that are locally grounded and sensitive to the local context requires us to take a breath, step back, and deliberate.

Ultimately, we must ask the question: Can foreign aid increase the production of locally relevant research and knowledge on health systems? And if so, how?

Invitation to a Discussion

To be honest, I do not know.

Some people believe the way forward is through the decolonization of knowledge and greater funding for researchers working in the countries where the research is produced. See, for instance, Seye Abimbola’s discussion of decolonization.

But initiatives like decolonization, mandated local authorship, and mandated funding to local researchers rarely invite inquiry into whether these initiatives lead to greater equity or better knowledge. Instead, they rely on a heavy dose of moral persuasion that must, to be effective, remain steadfast in its certitude.

Such moral persuasion leaves little room for ambiguity, little room for nuance. And, in this particular case, it divides the world into North and South, sweeping aside the complex collaborations that have emerged over two centuries and disregarding the wide differences within each.

I worry that the knowledge and research systems now being put into place are insufficient for the massive task that is at hand. Instead of spurring better, more locally relevant research, I am now concerned that these systems will end up cementing an elite cabal that controls all the funds and research.

My own impression is that moral persuasion rather than empirical argumentation has silenced many top researchers who have a lot to contribute to this debate. At this critical time, we cannot afford that silence and we must work hard to spur an honest discussion of how to produce locally relevant research and knowledge, especially as authoritarian tendencies slowly but surely gain ground in many of the countries we work in.

Instead of spurring better, more locally relevant research, these systems may end up cementing an elite cabal that controls all the funds and research.

In the spirit of starting that discussion (and obviously leading with my chin….) here are five topics with my own answers that will hopefully establish a starting point for greater debate about the role of foreign aid in the production of knowledge in global health.

Should foreign organizations mandate funds to local organizations for research?

The Tinbergen principle in economics says that you cannot efficiently achieve two policy goals with one policy lever. If funders want to build local researchers, it is best not to enmesh that goal with the second goal of funding research — unless that is shown to be the best way to do so.

For instance, if the idea is to build local capacity, the best option may be to fund scholarships for students. Or, to provide unrestricted funds to institutions with a proven track record.

Take for instance, the case of the Center for Economic Research in Pakistan, a global South organization that revolutionized economics research in Pakistan. The center did so by working with local collaborators only when these collaborators were the best for the project, and by hiring local research assistants, each of whom worked for two to three years.

Some research assistants went on to do PhDs, almost entirely in the U.S. Then, some stayed on in academia. My guess is that 1 in 50 research assistants eventually became a researcher — and that was more than enough to build Pakistan into a powerhouse in development economics.

At no point was funding mandated. At no point were local authors put on a team other than for the reason that they were the best. I can think of no better way to spur locally relevant research than unrestricted funding to organizations such as this.

Local populations deserve the best possible research, for which we need the best possible team. I have always found that the best researchers from within the local context are eager to collaborate and learn from those with complementary skills, in a process of co-creation, collaboration and learning.

But that assumes that there aren’t already local researchers who would be just as good — if only they had the funds.

No, it does not.

For me, decolonization means that resource opportunities are equalized for foreign and local researchers. Local researchers who are just as good will go through a usual proposal process, and as long as the adjudication process is fair — which is admittedly quite difficult to do — they will do just fine.

We are not asking for handouts. We are asking for fairness — both in the funds, and in our access to conferences, visas, journal editors and the whole infrastructure of knowledge production.

But wait — doesn’t the proposal process privilege a foreign epistemic gaze?

The first lung of the problem.

What I call “horizontally differentiated” systems of knowledge require adjudication by a different set of peers without a dilution of quality.

So far, no model has done it well.

We are either in systems that privilege foreign adjudication (points for publishing in international journals) or in systems that are devolving into discussions about how our ancient texts held the secrets of all science.

Appropriate adjudication is a very difficult problem to solve, but mandated funding is just as likely to make it worse.

Again, we are not asking for handouts. We are asking for time to evolve our own systems of adjudication. The process will be messy and adversarial. Do not put your finger on the scale by funding elite cabals.

But what about impact?

The second lung of the problem.

Foreign aid for knowledge seems to be driven by a search for impact, and in many cases, the idea of impact is morphing into the notion that research should directly influence policy, instead of contributing to a broader democratic conversation.

Academia relies on adjudication by our peers, with every generation of judging peers appointed by the current judges. This system is far from perfect. But rewarding impact just replaces peers with another set of adjudicators, the policy makers, with their own set of biases and agendas on top of the existing problems.

For instance, the temptation to create impact by finding a so-called policy champion is enormous. But all a policy champion does is replace the judgment of our peers with the preferences and biases of one single person.

This narrowing of the adjudication process was never a good idea, and with increasingly authoritarian governments it is a grave mistake because it is precisely in authoritarian governments that the value of knowledge is at its highest. As researchers, we should strive for impact by changing the societal conversation, not by undermining democracy through foreign-funded influence over local officials.

How will we know if foreign funding is having a positive effect on the production of knowledge?

The effect of foreign funding on locally relevant knowledge production is very difficult to assess. One reason is because contextual high-quality research is very difficult to publish in the top journals because it will not satisfy the foreign gaze.

The idea that therefore we should look to systems with weak peer review like Reddit channels, predatory journals, or WhatsApp messages is equally worrisome precisely because we do not know how to curate knowledge without some expert judgment.

The difficulty of assessment is why I increasingly think that instead of focusing on knowledge directly, one way to gauge the effect of foreign funding is to think about it in terms of the availability of data and local resources for knowledge production.

If we find that over time the availability of public information is decreasing, that the diversity of local researchers is going down, that young people are not joining the field and local funding is not emerging, the elite cabal is probably winning — if it hasn’t won already.

Local Context Matters

Look, I am not arguing that things should just go on as before without greater attention to the local context. Quite the opposite. I have vociferously and publicly argued that too much work in development economics, my chosen field, is insufficiently grounded in local context and therefore abuses its epistemic authority.

What I am arguing, though, is that there is no simple solution to this problem.

Differentiated systems of knowledge require years of contentious debate (and bloodshed) to emerge. Rushing to right the wrongs of the past, spurred by a need for action with the reduction in global aid, is surely the correct thing to do for life-saving drugs and vaccinations, and just as surely the wrong thing to do for the production of knowledge.

Why? Because if foreign funds, driven by a need for impact, inadvertently cement an elite local cabal that controls the access to and production of knowledge, it will take years, if not decades, to undo.

Take my discussion, then, as an invitation to deliberate on how to create the institutions of adjudication that we will need in order to produce the locally relevant, high-quality knowledge and research to build our health systems for tomorrow.

Read the other articles in this series by Mara Evans (Georgetown University), James Pfeiffer (UW), Susan Erikson (SFU), Tom Frieden (RSL), Steve Radelet (Georgetown University), Pete Epanchin (USAID) and Matt Kavanagh (Georgetown University).