Disruptive Voices - Critical Global Health mini-series

Sahra Gibbon:
Welcome everyone. My name is Sahra Gibbon, I'm Professor of Medical Anthropology at UCL. On behalf of my fellow co-organisers Professor Megan Vaughan from the Institute of Advanced Studies, Catriona Gold from the Department of Geography, and Nina Quach at UCL Grand Challenges, I'd like to welcome you to this podcast series on Critical Global Health. It follows on from our highly successful virtual roundtable event that took place in July 2022.

The motivation for these activities arises in response to a moment of growing national and transnational widening health inequities. These are variably situated in specific histories and contemporary developments, which in turn dynamically shape global health challenges in complex and uneven ways. In thinking with and through the lens of critical global health, there are a number of key themes that are briefly outlined in this introduction to the podcast series.

First, this includes the need to reflect on the framing of global health and the issue of global quality in terms of its geographical reach, its inclusiveness, and considering who exactly contributes to, and benefits from global health. This links to a second theme, which in part recognises that global health is tied to economic and political institutions, which are mostly dominated by priorities, modes of assessment and standardisation from the Global North: a situation that reflects structural inequalities in the systems and infrastructures of global health that can, paradoxically lead to the perpetuation of health inequities.

It follows from this that considering how exactly global health knowledge is produced and used is vital. This requires seeking input from traditionally overlooked stakeholders or disciplines to think about ways of leveraging alternative contributions from underrepresented disciplines and other ways of knowing and experiencing health that would lead to more appropriate and equitable interventions. We also suggest that this requires further reflection on our role as critical scholars, and at the same time broader discussion of teaching curriculums and wider issues of decolonization in higher education teaching.

Finally, it's important to note that this podcast series focused on critical global health arises from a recognition that across UCL many individuals are engaged with these challenges from a variety of disciplinary questions and standpoints, both in their research, teaching and collaborations. We very much hope, therefore, that the podcast contributions we include here provide further fruitful avenues for collaboration, dialogue and engagement in relation to critical global health at UCL and beyond.

This podcast series is hosted by UCL Grand Challenge of Global Health, with support from the Faculty of Social and Historical Sciences, and particularly the Health, Mind and Society special initiative.

Catriona Gold:
Hello, everyone and welcome back to disruptive voices. My name is Catriona Gold, and today I'm speaking with Dr. Lu Gram, who is a Wellcome Trust Fellow and a Senior Research Fellow here at UCL. Thank you for joining me today, Lu.

Lu Gram 0:19
Thanks.

Catriona Gold 0:20
As you know, we're speaking today as part of UCL's Grand Challenge of Global Health, which is supporting an initiative to connect and advocate for critical global health scholarship at UCL. And as part of that, we're trying to establish what critical global health means to UCL scholars. So, Lou, that's my first question to you. What does critical global health mean to you? And perhaps you could also tell us a bit about how your work relates to it.

Lu Gram 0:44
That's the question, what does critical global health mean? It means quite a lot of different things. But I think for me, critical global health essentially means practising global health in a way, whether you're talking about research, teaching or to policy, with a clear view about the role of power and politics. For me, there are three different ways in which that plays out. One is going beyond the medical and ideological frameworks: looking at health and looking at social, environmental, commercial, political and economic determinants of health. Secondly, by going beyond looking at health outcomes, and solely achieving health outcomes at population level, but also looking at health, equity, justice. And thirdly, not shying away from more controversial issues such as racism, sexism, and other forms of oppression and the role they play in producing ill health. I mean, my research relates to this in many different ways. I am a Senior Research Fellow at UCL and my Wellcome Fellowship looks at collective action to address violence against women by grassroots communities. And so there are many ways in which this topic really tries to take a critical lens to global health. So for many years, violence against women wasn't even considered a public health issue in the first place, because it's not a clear sort of biological outcome, like a bacteria or a virus, but it's a social issue. So people would relegate it to sociology or other disciplines. Now, it is widely recognised US public and global health issue. But still, it's an issue which arises out of power inequalities and relates to issues of power at many different levels, including political, societal, economic, relational, psychological levels. And so it's really quite a challenging and complex problem to tackle. And so in my work, what I'm looking at is to what extent can ordinary people and ordinary communities play a role in tackling a quite entrenched societal issue. Here, we're talking about shifting the balance of power and engaging with these issues of power at multiple levels, including issues about power balances between men and women, between institutions and local communities, and even between different women who are intersectionally located at different levels of power and privilege.

Catriona Gold 3:11
I guess what you could tell us a bit about is where exactly are you working at the moment? Do you work across countries? Do you work in one country? Where's your work located? And what kind of issues do you need to be aware of in the context you're working in, specifically.

Lu Gram 3:26
So one very important part of my work is that it's locally sited. And it's quite deeply embedded in the local context. In epidemiology, we have a kind of slightly derogatory term about sort of work that takes place in lots of different geographies, lots of different contexts, but sort of more superficial level: we call it "helicopter research", where you just sort of like helicopter in for a week, do your research, and then leave again, and then draw some sweeping conclusions about the whole population based on it. So I have conducted work in South Asia for over 10 years. And the current work I'm doing with the Wellcome Trust takes place in Mumbai. We work in informal settlements - sometimes called slums - in Mumbai, where we work with quite poor and underprivileged women and men and communities to try to tackle issues around gender based violence. I think when you work locally like that, that allows you also to look into the complexity and take all those different factors into accounts, because obviously, if you work across many different contexts, it becomes way too complicated to unify.

Catriona Gold 4:31
So working in a specific context allows you to be more critically attentive, perhaps, to the specificities - that makes sense to me. I mean, it sounds like from talking to you earlier that your work is quite interdisciplinary. And I was wondering, since questions about coloniality and decoloniality loom large in your research - how do they play out in the other disciplines you straddle? Or, how do you approach bridging these critical concepts across disciplines - what do you take from the disciplines that you're drawing from?

Lu Gram 5:02
So I think that's a really important question. I've worked for many, many years in this local context to be really embedded in it, and to develop relationships with local NGOs and local populations that we've worked with. So in some sense, you can challenge or manage this kind of power differential that always comes in when you work as a researcher based in a rich, wealthy Western institution with more marginalised people in India. So the work I do currently, because we're looking at collective action, we're looking at what motivates populations and communities to take action together to address violence against women. In this research, we work quite interdisciplinarily. So we work together with psychologists and economists and people from many different kinds of disciplines. And it's interesting to see the same kind of dialogues that we're having in global health - about how to approach our fields critically, and how to decolonize the fields, how to address power differentials within that field - play out in other fields as well. So for example, in the field of psychology, there's long been a discussion that's still very lively, and it's been taking place for a long time, about the way in which the vast majority of classic research sort of like the classic textbook experiments that students learn about all taking place in to the predominantly white American undergraduates, populations, and based on experiments with these students, or these populations. Psychology textbooks teach you that this is universal human nature we are learning about, and this is teaching us about how people are everywhere. And so in 2010, there was a systematic review, a Nature paper that came out that had the title "The WEIRDest people in the world", and they coined this acronym "WEIRD", which means white, educated, industrialised, rich, democratic people, which are a very small and select subgroup of the whole population, the world. And they remarked how, when you look at the results of psychological experiments that people did with this particular type of people, they produced often quite different results from what you get when you do the same experiments with people from elsewhere in the world. And so there's, for the past 1020 years, there's been a real movement in psychology to try to address this. And to try to collect samples or do experiments with people from outside of the Western world, from outside of the rich world, in order to establish more generalisable, more sensible conclusions about how people behave, how people think and how people act in the world. Still, I think there's quite a long way to go. Especially during COVID, but even before COVID, there was a real shift within the discipline of psychology to what's doing online experiments, rather than experiments with people physically in the lab. And the danger of using online experiments is that you get a very select sample. And so people would often have online participants in Germany and the US and Sweden. And then they would add one online sample from India, and say: this represents Indian culture. That's very problematic, because you can see that, you know, very high literacy rate, given that not everybody has access to technology, especially into the technology in India, and that axis can be distributed along lines of privilege, like gender or caste or economic power, you get a very select sample of people that you're trying to establish conclusions about - in quotation marks - "Indian culture", when you do these experiments,

Catriona Gold 8:55
That's really interesting. So part of the question being about what assumptions, going into research, were being based on these inherently flawed studies. Right. I mean, obviously, no study is going to be perfect. But I would imagine that would apply similarly to say economics, or maybe some of the other disciplines that you work with, too.

Lu Gram 9:15
I mean, there's also a long been a - economists have also, which they are trying to address - but which they have long complained about is how if again, do you do a study on economic behaviour in the US, then it gets published in a general purpose economic journal, high impact economic journal; that's sort of like new discovery about economic behaviour of people in general. But if you submit a study of economic behaviour in a not traditionally Western population, even if it takes place in the West, but you're studying like immigrant populations in the West, then the editor might desk reject your paper and say that oh, no, I think in your paper there's been two special interests and why don't you send it to a journal that focuses on develop Women's Studies or on non-Western populations or a different journal rather than a general interest journal. But I mean, they are trying to address it. I would say it's really unfair to say that this is - you know - it isn't the field in general, but it is something that people have been complaining about.

Catriona Gold 10:13
I think that cuts across a lot of disciplines, right, the idea of that you've got the universal figure who's actually part of the global minority, like Western. When I was talking to David Osrin for this same podcast, he was talking about a move towards - instead of talking about "the global South", "I do research in the Global South", or a region, or whatever - to talk about the specific city tha you're working in. To try to avoid certain sorts of sweeping generalisations, maybe this sort of "helicopter factor" that you were referencing earlier. Being attentive to that specificity. And that's something that obviously, people can be equally attentive to whether they're working with Northern or Southern populations, or populations anywhere in the world. So I think there's a really interesting point.

Lu Gram 11:03
No, it's true. I mean, ultimately, there's always a tension within academic research. There's a tension between trying to establish theories and trying to develop interventions and solutions. And so when you're trying to establish theory, you're trying to say something general, because that's the point of having a theory. So you're trying to say something general about how populations behave, or how diseases behave, or how people engage with health issues. But when you're designing interventions, you're always designing an intervention for specific contexts. And so you want to add as much specificity into it as you can. Because ultimately, your intervention is judged on whether it was helpful to people or not helpful, regardless of how elegant or beautiful your intervention design is. And so global health has to grapple quite squarely with this tension between theory and intervention. Because as an academic, your goal is to produce theories, because theories can be used more widely, and you can design an intervention that works fantastically for one context. But if it only works for that one context, then you're really a program planner, and you're not in the business of doing research. Whereas research is more about coming up with ideas that people can use across different contexts and can use in many different places.

Catriona Gold 12:21
And that's a key tension for a lot of us I think, in our research. And perhaps leaving that question open or on the table is something that we should be thinking about, perhaps, as we go forward with this project, too. That would be a good place for us to end. There's a lot more we could discuss - but for now, thank you so much for sharing your insight with us, Lu.

Lu Gram 12:41
Sure. Thanks so much.

Catriona Gold 12:43
This podcast was hosted by Catriona Gold and produced by the UCL Grand Challenges team, with the help of Professor Sahra Gibbon, Professor Megan Vaughan and Nina Quach. Today's guest was Dr. Lu Gram, and the music is by David Szestay. If you'd like to hear more perspectives on this concept of critical global health, please check out the other short podcasts in this series. For a longer listen, you can head to the UCL Grand Challenges YouTube page to find our recent interdisciplinary roundtable discussion on this topic with scholars from across UCL. For more episodes of disruptive voices, visit UCL Minds or follow us on Twitter at @grandchallenges.

Catriona Gold:
Hello everyone, and welcome back to Disruptive Voices. My name is Catriona Gold, and you're listening to the UCL Grand Challenges Mini-Series on Critical Global Health. Today I'm speaking with Professor Ama de-Graft Aikins, who is British Academy Global Professor at the UCL Institute for Advanced Studies. Thank you for joining me today Ama.

Ama de-Graft Aikins 0:24
Hi Cat.

Catriona Gold 0:26
Alright. As you know, we're speaking today as part of UCL's Grand Challenge of Global Health, which is supporting an initiative to connect and advocate for critical global health scholarship at UCL. And as part of that, we're trying to establish how UCL scholars are understanding and working with the concept of critical global health. So that's my first question to you: what do you see as a critical approach to global health? For you, what are the key issues we need to be thinking about? And perhaps we could talk about that first by getting into your current project at UCL, Chronicity and Care in African Contexts, if you'd like to tell me a bit about that to start with.

Ama de-Graft Aikins 1:04
Okay, let's start with the definition. And I'll talk about my project. I think we have to begin by defining global health. I mean, there've been lots of different definitions of global health. But I like this one by Beaglehole and Bonita: they propose a definition of global health as collaborative transnational research in action for promoting health for all so across nations. And I think the critical global health approach really suggests a subfield of global health that prioritises the value, agency and power of local. So those who work within the critical global health field will be open and committed to interdisciplinarity participatory methods, equitable partnerships, and meaningful social change. I thought I'd say that to bookend to my little spiel about Chronicity and Care in African Contexts. So yeah, my current project is funded by the British Academy. It has two strands. I'm interested, first of all, in how we draw on social responses to chronic conditions in African contexts - and how these social responses can help us to think through context specific, locally-relevant models of chronic care, and also public engagement. One big strand is public engagement. I'm trying to think about how to bring the diversity and the creativity of the social to bear on how people make sense of illness - long term illness, and the burden of care. The other bit is an empirical study based in London, focusing on Londoners of West African heritage, and really asking new questions about chronic illness experiences, chronic care practices, and what this means for Health and Social Care policy in the UK. So these are two things that I'm doing to look at Chronicity and Care in these contexts.

Catriona Gold 3:05
Right. That's fascinating. I'm wondering what the geography of this project is. You mentioned that you're working with people at West African origin in the UK - what sites are you working in?

Ama de-Graft Aikins 3:16
I'm actually just following people who have illness. And I mean, the empirical base, or the London study is basically looking at chronic illness writ large. I'm interested in the chronic illness experience. I'm focusing on a wide range of chronic conditions, diabetes, hypertension, dementia, cancers. And what I'm doing is using a typical, snowballing approach where one person leads me to another. So we've interviewed people across London, living in West London, North London, South London, East London - but also, through their experiences, trying to understand for instance, how the NHS works: what kinds of care do various trusts in London provide to people living with chronic conditions, but also to minoritized communities in London. So really, I'm following people. My geographical scope is London and where people live, and where people are willing to talk to me about their everyday experiences and long term care issues.

Catriona Gold 4:15
That's really interesting, because I think often when we hear the term global health, we think of "elsewhere". And I think that's been true of a lot of people I've spoken to so far for this podcast - it's been work that's been done, quote unquote, "elsewhere" - critically, but "elsewhere".

Ama de-Graft Aikins 4:28
Exactly. But that's why I started with that definition, right: promoting health for all across nations. And I think the thing about global health is that it often becomes a project of gathering data in the Global South to produce theory in the Global North. But what happens then is when we actually then gather data in the Global North, particularly with marginalised, minoritized ethnic communities, it doesn't have a name, really, does it? I mean, it's - what is it? Is it public health? And you know, is it global health? What is it? We need to define that, right? I think this project actually allows me to tease apart some of these sorts of silences and non-definitions of what we do in global health. Another thing that's emerged very clearly in this research, and it's something that's been reported across a new and growing sort of field and research on diaspora African communities in the Global North, is this idea of people taking therapeutic journeys and drawing on transnational therapy networks. So you might be living in London, dealing with diabetes and hypertension, and seeing your doctor in London - but you're also drawing on family advice, support from your country of origin. You might go on medical holidays to your country of origin and seek some additional care. And so these are really important, because I think it also draws on what happens when people leave the Global North: how then do we think about collaborations across health systems, for instance, and how health policies are geared towards this? How people move, move around globally, in search of health, in search of healing - in search of cures, really.

Catriona Gold 6:16
Right. So then this approach of following the individuals involved - that's really interesting. You do also have another project - a long project, which is a more sort of, would it be fair to say it's more traditional, in that it's based in Accra? Would you be able to tell me more about that project?

Ama de-Graft Aikins 6:34
Absolutely. So this project is called Tsui Anaa - the Tsui Anaa project - and Tsui Anaa is a Ga term which means "take heart". It started in 2010, began really with a traditional demographic health project. I was based at the Regional Institute for Population Studies at University of Ghana - RIPS for short - as you know, it's called RIPS at UG. RIPS that basically got this huge funding to set up a demographic surveillance site in a community called Ga Mashie. Ga Mashie is a twin township, Jamestown/Usshertown - both are called "old Accra" because they were there before Accra became the capital of Ghana in 1877. And so the idea was to just conduct periodic epidemiological surveys, demographic surveys, gathering data on health development, climate change - these sorts of really topical issues at the time - and to use the data to inform policy, health policy, social policy, public policy for the community. Now, I had just joined RIPS at the time in 2010. I left the UK, joined RIPS, and my work has always been on chronic illness experiences. So I began by gathering interview data with women living with diabetes. And it was really just - I'm just going to embed myself in this demographic project and see what I can find, you know, with women dealing with chronic illnesses. And over a 12 year period, it's kind of developed into something way bigger. I mean, we got seed funding to do more research on people with hypertension, cardiovascular diseases, we incorporated chronic disease questions in the demographics of survey instruments, we were able to gather larger scale sort of quantitative data around perceptions, attitudes, and what people do with food and things like this. And then we were able also to support graduate students at the University of Ghana across disciplines, population studies, social policy, pharmacy, and psychology. And so I think it became the kind of project that I highlighted in my definition about critical global health, which is that it kind of began locally: it started with a RIPS project, led by University of Ghana, academics, demographers and population scientists, and then even the expansion of it really was very much a Global South-led project, as all the local leads were based at University of Ghana. We got funding from colleagues, partners at NYU, for instance, but it was very much "we're giving you this money to think through this project and develop the questions, and we'll come in when there's data to be gathered and interpretation of data to be done" and so on. I think, for me, it's been the most exciting project I've been in - well, I've led, really, I mean, in terms of just the ticking all the boxes of partnerships, or of products of transformation, of capacity building, really.

Ama de-Graft Aikins 9:46
Something that I've talked about with some of my other interviewees for this podcast is this question of equitable collaboration - I think maybe coming at it from a slightly different angle. So you were yourself working in Ghana at the time this project started?

Ama de-Graft Aikins 10:00
I was, yes, I was working in Ghana at the time. It's interesting, as I think I've always done this straddling thing, where am I, you know, based in the UK and doing research in the UK and Ghana - or based in Ghana and collaborating with ... ? That's been my career, really, over the last, I would say 20 years. But yes, at the time, when I began the Tsui Anaa project, I had just joined University of Ghana as a faculty member. And I needed something to do that, because - okay, I'll go back a little bit. So my PhD focused on diabetes experiences in rural and urban Ghana. Again, I was based at LSE, but gathering data in Ghana. I'm British of Ghanaian parentage. So I kind of see myself - I think I work the hyphen, you know, that's what I do. So I gather data in Accra, and the middle belt of Ghana, a region called Brong-Ahafo region. I would shuttle between Accra and Brong-Ahafo gathering data. And of course, it led to my PhD thesis and a series of papers that came out of that. And I always have been a social psychologist; I trained for my PhD in social psychology. And I always wanted to really do community health development. My PhD supervisor, Catherine Campbell, is a professor of social psychology. She had done a lot of work on HIV AIDS in southern Africa - really grounded, grassroots, working with local communities, building interventions from the ground up, you know, developing theory out of data collection. And I wanted to do a similar thing in Ghana with chronic illness. So I'd always wanted to go back and gather data and really think through interventions that matter. But when I went back in 2010, I didn't have funding to actually shuttle between Accra and Brong-Ahafo; it was a six hour drive to go up there. But then this Ga Mashie project presented itself and I thought: well, hey, Jamestown/Usshertown in Accra, 30 minute drive when the traffic isn't that bad - I can actually go and gather data on a weekly basis and just learn with the community as I go along. That's how it started, really. So I probably would call myself then a local researcher, because I was based at University of Ghana. I was teaching there, I was supervising students, you know what I mean. And the initial push to start a project came from RIPS, which is a local institution. But I think over the years, I've kind of shuttled from being a local researcher to, you know, Seye Abimbola talks about the foreign gaze in global research and global health - talks about the local gaze and the foreign gaze and all of these things. And there are times when I think researchers with hyphenated identities like myself find ourselves on opposite sides of a hyphen. We're either Global North researchers, or we're Global South researchers. And it's fine; I think it's okay to move in between these sorts of positions.

Catriona Gold 12:06
Right. Thank you. And thank you also, for bringing a citation in there. I love when people do that! Who's influenced our thinking, right? I wonder if you would be able to say a little, before we close, about your more recent project about mental health and the arts - that's something you've been working on? Has that been here - in the UK, that is, or has that been ... ? Tell me more.

Ama de-Graft Aikins 13:18
It really started because - when locked down London 2020, sitting in my flat bored, a little depressed, as we all were, I kept getting these WhatsApp messages from friends in Accra. It'd be a comedian with a very funny skit on COVID. I mean, I remember the one that really struck me was a comedian/actor in Ghana called Clemento Suarez - that's his artistic name. And he had created this really fascinating ABCs of COVID. But obviously, it was spoken, presented in the Twi language - but really, really funny. Funny, informative, drawing on the Ghana Health Service messaging around COVID prevention and so on. And I thought: gosh, this thing is way more impactful than the generic GHS messaging, and there would be skits also about really funny market women. Just inverting the names: COVID, or face masks, or ... very funny stuff. I mean, Sandra Jovchelovitch, so social psychology again, somebody - a mentor - talks about the creativity of the social, right - how everyday lay people can turn difficult life circumstances on their head, just through humour. Humour, jokes, creativity - and I thought a lot of that was happening in Ghana. You know, in the UK - the emotional tone in the UK in 2020 was really sombre, angry, you know what I mean? Despair, even, I would say - there were lots of deaths, and coming from an African-British community, that was something that hit you really hard in terms of looking at the rates of mortality, and so on. But in Ghana, the tone was light, light hearted, fun, jokes. I mean, Ghana wasn't as deeply affected by COVID as other parts of the world. Of course, Africa is still the least affected by COVID, in terms of prevalence, and deaths, and so on. And so I thought, well, since my current project, Chronicity and Care, is interested in the social responses, I thought: gosh, this is a really good way of understanding the social. So I just began tracking the arts: tracking music, comedy, the use of textiles, and telling COVID messages, and so on. Right. So I wrote a paper about that. But that got me thinking about how art can be used in my current projects to communicate about chronic illnesses, both chronic physical illnesses and chronic mental illness. I have a longstanding interest in the arts. About 10 years ago, I curated an exhibition on mental health and arts in Accra. And it just got me thinking about the utility and the functions of using the arts in public health engagement. I have a few papers on COVID arts, but I'm really thinking - now that I'm nearing the end of data collection for Chronicity and Care - about how we use the arts to tell the message, the stories that we're gathering on chronic illness experiences.

Catriona Gold 16:31
So there's some further reading for our listeners. I mean, there always is, if you care to investigate! That's super interesting. I think we're reaching the end of our time today, even though there is much more, obviously, we could discuss - but I think that's a great place for us to end for now. Thank you so much for sharing your insight with us, Ama. And thank you everyone for listening.

Catriona Gold 16:57
Thank you, Cat. Take care.

Catriona Gold 16:59
This podcast was hosted by Catriona Gold and produced by the UCL Grand Challenges team with the help of Professor Sahra Gibbon, Professor Meghan Vaughan and Nina Quach. Today's guest was Professor Ama de-Graft Aikins, and the music is by David Szestay. If you'd like to hear more perspectives on this concept of critical global health, please check out the other short podcasts in this series. For a longer listen, you can head to the UCL Grand Challenges YouTube page to find our recent interdisciplinary roundtable discussion on this topic with scholars from across UCL. For more episodes of Disruptive Voices, visit UCL Minds or follow us on Twitter at @grandchallenges.

Catriona Gold:
Hello everyone and welcome back to disruptive voices. My name is Catriona Gold, and today I'm speaking with Professor David Osrin, who is a Wellcome Trust Senior Research Fellow in Clinical Science and Professor of Global Health here at UCL. Thank you for joining me today, David.

David Osrin 0:22
Thanks very much for inviting me.

Catriona Gold 0:24
Great. So as you know, we're speaking today as part of UCL Grand Challenge of Global Health, which is supporting an initiative to connect and advocate for critical global health scholarship at UCL. And of course, when you start talking about critical global health, one of the first questions which tends to arise is: well, what is that? So David, that's my first question to you - an easy one! What does critical global health mean to you? And how does your work relate to it?

David Osrin 0:53
Thanks for that really easy question - I don't find it easy at all, in the sense that until recently, I wasn't familiar with the term critical global health. I suppose it is a way of looking at global health critically. And I guess, for me, that has two implications. The first thing is kind of structural. So issues around structural aspects of health globally - but also structural questions about research, since this is a little bit what we're talking about, like the structural nature of the funding and reporting that surrounds that research, or in which that research takes place. And then I guess the second dimension is to approach our own work critically, in the context of this larger argument. So I guess one of the really obvious issues - and you see it in the literature - is the evolution of different terms, from the old and fairly unpleasant term "tropical medicine", through "international health", to "global health". And quite a lot has been written about "what is global health?". And I find that a little confusing, because it sometimes mixes up "global health" with global health research. And indeed, one of the more recent definitions that's been proposed to researchers in New Zealand is around collaborative transnational research and action to promote health for all. So there's a bit of lack of clarity for me around, you know: are we talking about the research we do? Are we talking about the way that research is framed? Or are we talking about the actual health of the people all over the world who are involved in it, irrespective of that research? So that's one confusion. I mean, I think that a fairly clear thing in my mind is that global health - or critical global health - is looking at health worldwide. And implicit in it - and explicit in some definitions - is equity and equality. Explicit in it is issues that cross national boundaries, and that go beyond governments from the local to the state, to the region to the world, and then issues around structural determinants. So areas of people in - I'm going to use the word vulnerable advisedly, but people in various socio-economic and socio-cultural groups that are at the sharp end of health inequalities and determinants of ill health.

Catriona Gold 3:55
Right. There's potentially a lot we could get into, and I'm wondering how you approach this in your work. How do you consider these aspects in the work you're doing? Do they inform how you structure your research? If you could talk a bit about that, that would be great.

David Osrin 4:12
I want to say something - I suppose personal, but maybe a bit provocative - here, which is that the vast majority of the people that I work with don't really talk about global health. So when I'm working with my colleagues in India, I don't even recall anyone ever using that terminology. Because what they're talking about is important issues. And the groups that I work with are really interested in inequalities and structural inequalities and structural violence. And yet, I don't hear that articulated in terms of global health - and I wonder how much this is a product of a North-centred focus on these issues. We've actually seen quite a lot of pushback in the journals in recent last couple of years about inequities in the structure of global health and global health research, and I think that that's coming from people in perhaps non-Northern countries who themselves feel like they're at the sharp end of an international discourse that isn't truly international. Let me be specific: the people that I collaborate with at SNEHA in India talk about urban health, they talk about inequalities, they talk about women's and children's health, and they do talk about the global ramifications of that. But generally speaking, they don't articulate it in terms of global health.

Catriona Gold 5:44
Right, that's really interesting. So there's a question of whether this term translates across contexts when we're collaborating with people in different countries?

David Osrin 5:54
Yeah, I think that's absolutely right. And some of it is to do with the way you present yourself, and the way that you present yourself as someone in the service of potential funding, so that, you know, people may be applying for money within some scheme that's got "global health" in it. And that's where they will locate themselves. But generally, they'll be interested in a specific issue, such as menstrual hygiene, for example, or urban inequalities, or even an infectious disease like tuberculosis, and they'll see all of those things in the global context. But I don't know how much of a need people feel to express that in terms of global health. Where it gets expressed, I guess, is in my other job as a teacher, where we are teaching on and developing the content and structure of courses on global health and development. And so then it becomes relevant. But I think it's good to be critical about this - and I guess maybe I am being?

Catriona Gold 6:58
Well, yeah - if you're trying to structure teaching on what we're calling global health, or you can, you know, be more specific - talk about... I mean, what kind of teaching are you doing at UCL? And how would you try to approach that critically, or with these kind of structural or global inequalities - that kind of thing - in mind? How do you approach that?

David Osrin 7:21
Well, I suppose the easiest way to think about this is since specific examples. So at UCL, I'm involved in teaching urban health. And so it's a prime example of a global phenomenon. But when we started maybe about 10 years ago, one of the things that we thought we should do, that we didn't see in other courses, was make it global: in the sense that some courses talked about urban health, and they were thinking about places like London, but other courses specifically talk about global health in countries like Bangladesh, and issues such as slums and informal settlements, which became - in a way, it's a cottage industry. And when we started this, we made the provocation that actually, we didn't agree with this way of seeing urban health, we thought that the experiences and problems of peoples in cities, and the people that try to run cities and contribute to them, are global. So that a city in North America faces certain urban health issues, and those are the same issues as a city in South Africa, or Malawi, or Sri Lanka. And so we said: we're going to try to look at these things across the world, comparing places with other places, quite specifically, to look at commonalities and differences. And what happened was, I guess, that idea was amply-supported by reality. And I think that you know, what I've just said, people might be listening, going: "yeah, right", you know, "what's so great about that?" - but that wasn't the case 10 years ago. But - as we've seen in the recent COVID 19 pandemic - it's an obvious example of a lack of differentiating between swathes or groupings of different countries in the face of the pandemic. And a lot of it was about the urban experience, and that urban experience showed - had - commonalities in all cities. So that was easy. The other thing that's easy in terms of global health is that urban health is obviously structural. And I mean that slightly jokingly in two ways. I mean, it's physically structural, because it's about the built environment and buildings and roads and water supply, etc. But it's also structural in that it's about government. So it's about who runs your city, how formal or informal are certain aspects of the way things are provided within that city. And so these issues about health or the notion of global health are implicit in the idea of urban health, which is why I'm saying it's really easy. So when we teach urban health, we rarely talk about specific diseases. We tend to talk about health as - not an abstract concept, but we talk about social determinants of health. And we talk about the way that your environment -well, your interaction with your environment - connects with health, rather than, you know, "tuberculosis is like this". Although tuberculosis is a good example of an infectious condition that we see all over the world, and again, illustrates what I said before, I suppose, which is that, you know, it's not that there isn't any tuberculosis in New York City, there's loads; just as there's loads in Lagos.

Catriona Gold 11:01
Right. And especially, I mean, connecting and drawing those - maybe not parallels, but considering together those Northern and Southern contexts makes more and more sense in a context of increasing inequality. As we've seen in the pandemic, as well. I mean, I was in Manchester for much of the first part of the pandemic, and that had its own struggles with COVID, which related to that urban infrastructure and those structural questions. I think that's really interesting that you do include Northern cities, and you don't sort of bracket them off in a way. And I think there's a broader question there about this framing of globality, right, like: does globality mean "somewhere else"? Should it mean "somewhere else"? I think that's really fascinating stuff. What are you teaching at the moment? Are you still teaching the urban...?

David Osrin 11:51
Yeah, that's right. And we are just starting an online masters in Public Health at UCL that I'm contributing to, and that's starting this upcoming semester. I think something that you mentioned is interesting, which is you might have noticed me being a bit mealy-mouthed, and saying things like "the North" and "the South". And there's - again, in the context of critical global health - there's a load of discussion about that. It's not "developing" and "developed"; everyone started saying "low-" and "middle-income" countries; and recently, there's been some pushback against that. And one of the recommendations has been that, as far as possible, we should just say, a place. So we shouldn't say "low and middle income countries", we should say "Bangladesh", or we should say "Greece". And I guess I'd entirely agree with that. Because if you think about, as you were saying, COVID and Manchester, I mean, where you are in a region of the world doesn't dictate what your city is like. And there are loads of different political structures, and structures of urban governance, that would decree that a city in another country might be very similar to Manchester. And that, in fact, cities in two adjacent countries might be completely different. So I think that push to be specific about things is something that I welcome. I pity everybody, because like, what word are we going to use? And that's why I've kind of fallen back on this recommendation that well, if possible, don't use anything and just say a place. Another one that people talk a lot about is Sub-Saharan Africa - it's a giant tranche of a continent. And South Africa is not the same as Mali, etc, etc. And so again, I mean, I get away with this, because, you know, I work mainly in India, and India as subcontinent, which is home to a huge amount of diversity in itself. But I mean, it's probably okay to say India. And I think that's right.

Catriona Gold 14:05
Right. Yeah, absolutely. I think that's a really interesting point you make about that specificity. And of course, maybe some things are lost when we take it down to a too-specific level, and there's a place for the abstraction too, right - but these are the questions we have to grapple with. I really appreciate that insight. I think that's something that hasn't come up so far in our discussions, actually. There's a lot more we could say about it. But I think for now, that's a great place for us to end. This is a short podcast! So thank you so much for sharing your insight with us.

David Osrin 14:34
Thank you.

Catriona Gold 14:35
This podcast was hosted by Catriona Gold and produced by the UCL Grand Challenges team with the help of Professor Sahra Gibbon, Professor Megan Vaughan and Nina Quach. Today's guest was Professor David Osrin, and the music is by David Szestay. If you'd like to hear more perspectives on this concept of critical global health, please check out the other short podcasts in the series. For a longer listen, you can head to the UCL Grand Challenges YouTube page to find our recent interdisciplinary roundtable discussion on this topic with scholars from across UCL. For more episodes of Disruptive Voices, visit UCL Minds or follow us on Twitter at @GrandChallenges.

Catriona Gold:
Hello everyone, and welcome back to Disruptive Voices. My name is Catriona Gold, and you're listening to UCL Grand Challenges' mini-series on Critical Global Health. Today I'm speaking with Dr. Rochelle Burgess, who is Associate Professor at UCL's Institute for Global Health. Thank you for joining me today, Rochelle.

Rochelle Burgess 0:24
Thanks for having me.

Catriona Gold 0:26
As you know, we're speaking today as part of UCL's Grand Challenge of Global Health, which is supporting an initiative to connect and advocate for critical global health scholarship at UCL. And as part of that, we're trying to establish how UCL scholars are understanding and working with the concept of critical global health. So Rochelle, that's my first question to you: what do you see as a critical approach to global health? For you, what are the key issues we need to be thinking about?

Rochelle Burgess 0:54
Well, I must say, I was really excited when you guys told me about the initiative. Because even though I had never seen the term put like that before, I immediately felt that it resonated with what is required of global health for the future. And I say that in full acknowledgement of the tensions in the field at the moment. I think the term decolonization and decoloniality has come into this moment in the field as if the term is a tabula rasa, and I've really struggled with seeing its use in being increasingly applied in all of these different spaces around the academy. And the reason that I just found such a - not a problem with it in global health, but just a bit of a like - I don't know - a crawly thing on my skin - is because of where global health comes from. You know, global health is a lineage of health interventionism that is linked to histories of colonialism and extractivism, basically, and when you start to look at the critiques that global health has faced over the last few years, it's very much been about the fact that there hasn't really been a true decolonial turn in the field. Because if you think of decoloniality or decolonialism as a space where we are free of imposed theories - as Jairo Fúnez, he is an academic from the States, and he writes a lot around the colonialism in general, not specifically in relation to global health - but he talks about it as a world free of imposed theories. And that very much is what decolonial activists from the African continent, from South America and Latin America in the 60s and 70s, were about: this sort of shedding of the imposed theories and concepts and practices that have been forced on them by external forces. And if you think about global health interventionism, for lack of a better word, that's all it is. Global health is very much this idea of the transposition of solutions to global health inequalities, that - for better or worse - at the moment come from high income, country locations, to use a very sort of rough division, or categorization of place. And it seemed really strange and inappropriate for anybody from those places doing the imposition to use that term. Because by proxy of that positionality, nine out of 10 times you can't really be overthrowing anything, because you're the thing that theoretically should be overthrown. Those are very heavy words. But, you know, that is basically the roots of decolonialism: the overthrowing of a colonial power. So when this idea of critical global health comes up, it says, to me, that was like: oh, well, that's what everybody else should be doing. Unless you are from the historically dispossessed in your sort of bodily form, then you need to be doing something else - you shouldn't be using that word. But there's still so much work to be done. There's so much important work to be done, like in collaboration with bodies, and people and places from the quote unquote "South". You should be critical of your positionality, critical of your power, critical about the concepts and theories that you use, critical about your way of engagement with others; critical about everything, questioning it. So it's about a constant process of not just reflexivity, because reflexivity doesn't automatically lead to different practice. So what I like about this idea of a critical engagement, sort of feels like it brings the questioning a bit closer to action. And I guess I have a sort of natural inclination towards that term of criticality be because my background and my training is in a branch of psychology that is critical of itself. So I'm a community health psychologist and a critical health psychologist, which basically says: health psychology and community psychology are wonderful disciplines - but there are problems within them that we must constantly be aware of in terms of how we engage in our practice. So it felt like a very welcome term for me to sort of negotiate with and, I guess, in a way, find a home for the types of practice I was already engaging in, that was critical by nature of the fact that I'm trained in critical theory to begin with, or critical praxis to begin with.

Catriona Gold 5:42
So critical global health is potentially a useful alternative to framing things in terms of decolonization - maybe a more appropriate way to frame things. Would that be an accurate characterization?

Rochelle Burgess 5:56
Yeah, I think so. And I think, you know, this idea of liberation and self determination that is part and parcel of a decolonial interest cannot be done by people, and places, truthfully, and honestly - or maybe can't be done, but I think it'd be difficult to do it - it just - I don't think it can be done from the outside. It has to be done from the inside. And so a critical global health is aware of that, but thinks about how you go along, or could potentially be helpful to those processes, and sensitive in your engagement with others who are going along with those processes. There's a sort of a methodological paradigm that I think is really important for global health. And I - shameless plug I talked about in my book that will one day and, Lord willing, be finished, - actually, now it's due like in three weeks, it will be finished! But it's transformative paradigms. And a methodologist, named Donna Martens - her book is on my shelf somewhere - it talks about transformative paradigms. It has a lot of resonance as a sort of epistemology, an ontological position towards research and knowledge production, that has some shared lineages with decolonial methods, but thinks about it actually more towards the fact that the research engagement is usually 90% of the time an unequal one. There's the researcher and the historically researched. And so how do you position yourself within that in a way that sees the research encounter as an opportunity to do something different - to transform power relations to transform the location of and ownership of power - and it thinks about that, not just between researchers, but also down to the level of communities. So I think there's lots of talk in global health right now about how we make global health research more equitable. And there's lots of people in our department who do amazing work in those types of practices, in those types of spaces. And I think the next level moving on to that is actually to everyday citizens on the ground. And so how do you work with communities - and as a community psychologist, that's my research, and that's my work - so that your research is also transformative for them in the short, medium and long term? And she gives us some nice direction in thinking about how to go about that.

Catriona Gold 8:18
Thank you for the further reading. That's always helpful, right? Where do we come from intellectually, right, this is something that we should be sharing. I'm looking forward to seeing the book down the line. I guess it would be nice if you could tell us a bit about how this plays out in your own work. So what are you working on at the moment?

Rochelle Burgess 8:34
Well, I am working on - probably my husband would say too many projects! But I think I'll talk about a couple of them. I mean, most of my work is around mental health in context of adversity. And I use this very broad framing on purpose for two main reasons. For one, it allows me to go where I think work is needed. So it doesn't pin me down to a particular context or or place - though I tend to get pinned down to context and places by the relationships I build anyway - but it keeps it broad. And the second thing it does is it allows me to do something that is still not really done in global health - which should be, and I think is another plus of this idea of critical global health as a space - it allows me to work with the South and the North. So that means it allows me to think about bodies that are historically marginalised and oppressed, that might live in quote unquote, "high income" settings, and to think about them within the boundaries of a global health lens. So upends that traditional directionality in global health - where it's, you know, high income doing stuff in low income - and it actually says, hang on, I look at the stories of communities that I've worked with in South Africa, and I have also done a lot of work with Black communities in South London. And the narratives of structural inequalities and oppression around mental health are very similar, because the vectors of oppression that create those challenges are similar. They just are directed in different locations and have different historicities. And I think that that has allowed me to sort of recognise that idea of the South in the North, and de Sousa Santos - Boaventura de Sousa Santos - has done a lot of amazing writing on decoloniality and all of that, and he wrote this book "The End of the Cognitive Empire", which very quickly became one of my favourite books. And in that book, he sort of pushes us - it's just one paragraph, but it stayed with me so deeply - that we must not forget that there is South within the North. People move, but also that Black, brown, marginalised groups of many different backgrounds and identities who experience marginalisation are found in rich countries - and their stories are similar, and their needs are similar, and in a way, our fights for justice can potentially converge. So for me in global health, throwing off those sort of normative ideals is a big part of saying I do global health work. And I also do it in London, because it needs to be done in London. It's not just about me going to Zimbabwe, or going to South Africa, or going to Colombia; it's also about me going to southwest London, it's also about me going to the North of England, and talking with people who are oppressed by the similar systems of injustice, and whose health suffered because of it. And so I guess the two projects I would talk about very quickly. So in Colombia, the work there that I think encapsulates a lot of what I've been talking about today, in terms of this idea of transformative paradigms - there's a project that we've been working on around bottom up mental health systems. And what we're doing there in a community in the Caquetá Department is that we are looking at how everyday citizens can become more involved in the organisation and the building up of mental health services. It's an ESRC-funded project. And what we have done is - after a year of sort of very deep dive with communities about definitions around mental health and mental ill health and more importantly, care and logics of care and treatment - sort of gathered this idea of what mental health means and what it would require to enable it. And now through PLA groups we're putting communities in dialogue with actors in the mental health service to build responses to challenges in collaboration with communities. So asking them about where they think services should go, and supporting small projects of change, that are then supported by the mental health services. So it's almost like saying: everybody in this community is a potential mental health service user, and everybody in this community is potentially at risk, because we live in worlds that expose us to mental health risks through structures and relationships. So how do we all take ownership of it? And how is that ownership recognised by the system? So can we put people in dialogue - systems and communities - in order to build responses together? And what we're hoping that does is not only get people to be more aware of mental health, which is a big important thing, and addressing mental health needs, but also getting systems to recognise the everyday knowledge systems of communities as valid contributors to driving solutions. So rather than saying: "okay, we're going to teach you about symptoms, and that's where the intervention stops", that's only the first part of the intervention - and the rest of it is about supporting projects of change that community groups build. And then in London, it's sort of a similar thing. I've been really lucky and honoured to work with community organisation in Wandsworth called the Wandsworth Community Empowerment Network for many years. And they do a lot of co-production work around mental health. And one of the big projects that they've built up to over about 15 years is something called the Ethnicity and Mental Health Improvement Project. And in this project, which is supported by local mental health trust, that's very much about shifting and transitioning resources into community hubs for the delivery of mental health support. So for example, there is a community hub that is located in a local church where people can go and access care delivered by lay health workers in the community - upskilled pastors and faith practitioners who have done specific types of training in different types of therapy, like family therapy is one particular modality. And then it's also added different bits to that structure, linking in different NGOs, different trusted families and communities and building up a constellation of interventions that work to strengthen and improve mental health in everyday community sites, in collaboration with the mental health trust, so that the mental health trust is still there, but it's actually - removed isn't the right word, but their ownership of everything is reduced. It's been distributed to people who have that embedded knowledge of community life, of cultural life, of religious and faith-based identities that are part and parcel of what enables good mental health to happen for some people. So it's about this moving of power, right. So like shifting these concentrations of power, and not just thinking of the shifting of concentration of power between like researchers and practitioners or practitioners and a board of community members, but to everyday citizens, everyday citizens who create the backbone of what a community is able to do and how it functions - and recognises the existing strength and the existing ability for self determination that exists in so many communities of every different type, and uses that as the starting place for building up systems and structures and support.

Catriona Gold 16:48
I think that's really interesting, and I think really valuable, to hear you talk about that, because I think sometimes people hear the word critical critique, and they think of a sort of tearing down. And that can be part of it - but I think what you're showing here is that critically-minded practice can also very much be about building up and organising and taking a holistic approach to these kind of broader questions. I don't know if you'd agree with that, I think that's really valuable work. Is there anything else you'd like to add on that project before we wrap up?

Rochelle Burgess 17:19
I guess if I'm saying that critical global health is about questioning, the final thing I would say is that there's two questions I've asked myself since my PhD. I've told this anecdote so many times before, but I'll tell it one more time: that when I went to do some interviews, in my work, I went to see this woman - this was in rural northern KwaZulu Natal, and I did life history interviews. So I spent entire afternoons sometimes a whole day with women, just talking to them. And when I finished the interview, we've been talking about her life and mental health and all these things. She said - and I have very bad Zulu, so she said to me through my translator - that when we had called about the interview, she thought that I was the electricity company, because that's what she told the last set of researchers who spoke to her that she needed. And in that question, I basically realised the implicit problem of work that is not about producing something. Because not only is it extractive, but it also is sort of - I think - a bit of a violation of this main contract that we're sort of making with society, as global health researchers and practitioners that we're saying: we're here to improve something and change something. And we talk to people, and they tell us what they want. And then it gets twisted around and turned into something else. Sometimes another research question, sometimes another project, sometimes a solution that takes a really long time to implement, because change is long. But that means nothing to the people who we spend that time with. And regardless of the methods you use, you will continue to come up against that if you aren't questioning your practice all the time to say: what is your work leaving behind right now for the people that you're engaged with? And I think there's been lots of changes that have seen more of that recently, which is great, particularly at the level of institutions and academic institutions that we partner with. There is this idea of like, what are the things that we are doing to upskill researchers and practitioners in communities that we work in? So what do we leave behind, but also for the everyday citizens that we're working with? And also, is this project actually needed right now? And that is the most dangerous question a researcher can ask yourself, because sometimes the answer to that is: no, actually, it's not. Your deviation of your question is very small, you're probably going to end up having to talk to the same people that somebody else has spoken to. And I think that kind of question is an important one for critical global health to ask because of the reality of the spaces where we're doing the work. And so as we ask these questions of ourselves, in a way, it feels like we hold ourselves accountable to the big overarching plan, which is change. So I think that's probably the last thing I will say.

Catriona Gold 20:20
Great. Thank you so much. I think that's a fantastic place for us to end - although, of course, there's much more we could discuss. Thank you so much for sharing your insight with us.

Rochelle Burgess 20:30
It's my pleasure. Thanks for having me Cat.

Catriona Gold 20:32
And thank you to everyone for listening. This podcast was hosted by Catriona Gold and produced by the UCL Grand Challenges team with the help of Professor Sahra Gibbon, Professor Megan Vaughan and Nina Quach. Today's guest was Dr. Rochelle Burgess, and the music is by David Szestay. If you'd like to hear more perspectives on this concept of critical global health, please check out the other short podcasts in this series. For longer listen, you can also head to the UCL Grand Challenges YouTube page to find our recent interdisciplinary roundtable discussion on this topic with scholars from across UCL.

Catriona Gold:
Hello everyone, and welcome back to Disruptive Voices. My name is Catriona Gold, and you're listening to UCL Grand Challenges' mini-series on Critical Global Health. Today I'm speaking with Professor Shabbar Jaffar, who is the Director of UCL's Institute for Global Health. Thank you for joining me today. Shabbar.

Shabbar Jaffar 0:23
Thank you.

Catriona Gold 0:24
Right. As you know, we're speaking today as part of UCL's Grand Challenge of Global Health, which is supporting an initiative to connect and advocate for critical global health scholarship at UCL. And as part of that, we're trying to establish how UCL scholars are understanding and working with the concept of critical global health. So Shabbar, that's my first question to you: what do you see as a critical approach to global health? What are the key issues we need to be thinking about for approaching global health critically?

Shabbar Jaffar 0:56
I think there are many. On the science side, I think it's critical that we address questions that are relevant to the settings that we're working in, and they are questions where we can have a health impact. And then I think it's also important - not just the questions that we address, and those questions need to be addressed rigorously - but not just the questions that we address, but the way in which we address them. So in other words, we address them in an inclusive way, in equitable partnerships with the different stakeholders, which includes other researchers, policymakers, patient groups, community leaders, and others.

Shabbar Jaffar 0:56
I know you have a lot of experience working internationally, which presents particular challenges - maybe opportunities - for pursuing work, or trying to pursue work, in an equitable fashion. I wonder if you could talk a bit more about how you've approached these questions in your recent work?

Shabbar Jaffar 1:52
Well, we've been very lucky - you know, we try to address areas that are really high priority diseases that cause a very high burden. We address those together with our partners, we discuss the priorities together - and our partners are of course research partners, policy makers - what's important to the Ministry of Health and the policymakers, but also patient groups, patient groups and communities. So we've been very lucky that we've been able to address questions that are really pertinent, and change as well over time, change as the disease profiles change. In - my work is in Africa - change: as the disease profiles change, we've changed as well. So for example, early on in my career, I was working mostly on HIV because that was the priority. More recently, I've expanded that: I still work on HIV, but now I work much more on non-communicable diseases and cardiovascular disease, on diabetes - and we're now actually moving towards mental health. And maybe much later on we'll be thinking about going into climate change and health.

Catriona Gold 3:03
Walk me through how you approached this question of creating an equitable partnership, or equitable partnerships, across various contexts in the big international project - if you could walk me through how you approach creating equitable partnerships, in a big international project. I know you have a really interesting short article in Times Higher Education from last year, which I think raises some really interesting general principles coming out of your work. Tell me about how you work those out in that project you're discussing.

Shabbar Jaffar 3:37
Yeah. So I think equitable partnerships - it's come naturally to me and people working in our group for a very long time. And I think the first thing in an equitable partnership is: why do you want to make it equitable? Why do you want to make it an inclusive partnership? Be very clear on that, and think about that, and discuss that with your partners. Lots of people go into what they call "equitable partnerships", but it's just words, you know? You've got to be very clear, why is it - you know, why is it going to make this partnership better if it is equitable? And in a sense, it is that you are going to be able to do better work and achieve higher impact. And then you've got to define: well, what is equitable? And then you do need discussion, and you do need to visit that discussion again and again. So what is equitable for the different partners - you know, how I define equitable might be quite different to how my partners define equitable. You've got to know, you know, it's like in any relationship: you've got to know what's important to me, and I've got to know what's important to you. And we've got to monitor that. So those are very basic principles. But I think there are also other things that you have to think about as well. You've got to be very clear on your mission and your scientific mission. So there's no point in being all equitable and inclusive, but not knowing what you're doing in the science and in the research. So you've got to be very clear: what is the mission? Why is it that mission? There's got to be a vision there, there's got to be a strategy linked to that vision. And I think you've got to keep talking about these things. And often what we do which is wrong is we just get straight down to the question, whatever the question is, and home in on that, but these higher level things need discussion, need consideration.

Catriona Gold 5:19
I mean, something you write about is the importance of this communication in even establishing what the project is setting out to do. And also, I think an interesting point that you raise is the question of - often research will be multidisciplinary, but there needs to be a conversation about why it's going to be multidisciplinary, and what each discipline is going to bring to the table, and how you're going to work together, right? You can't sort of just throw these commitments. I think the way you talk about these things is quite concrete, as something that needs to be worked out as part of producing a practical programme for research, is really compelling as well. And there's a certain amount of humility that's involved in having an equitable partnership, isn't there? I wonder if you could talk a bit about how you do approach finding out what is important or seeking the insight of different groups participating in projects. I think you've mentioned researchers, patients, healthcare providers and policymakers - how do you go about involving them in discussions, and people who might have quite different backgrounds or levels of training, what kind of challenges arise in those contexts - and what are strategies for actually having a more equal conversation?

Shabbar Jaffar 6:34
So again, I think the starting point is that you have to know why you're doing that consultation, and you have to believe in it. If you feel you don't need that consultation, you don't need that voice, then don't do it for the sake of it, you know. So in our case, we consult with, for example, patients: patients sit on our steering groups, and they sit on our various committees, including decision-making committees, because we know and we've learned over the years that when they're involved, their input is valuable; they make the research better, they make us ask the questions better, and they make us do the research better - they help us. So you've got to have that kind of respect, and that level of understanding that by involving these different individuals, that you will learn something, and that you would do what you're trying to do better by involving them in in an inclusive way. So that occurs for all your stakeholders. And in my case, the stakeholders are patients, they're community leaders, they're healthcare providers, they're policy makers - so they're very different groups of people. But they do bring different things and different important things to the table. And you've got to respect that: you've got to understand that is adding something. Going back to the multiple disciplines, often our work in global health involves multiple disciplines, and those disciplines are actually at UCL. So it's usually our team that is multidisciplinary. And teams in my work, certainly in Africa, there are fewer disciplines. So we bring multiple disciplines. So we will have, for example, clinicians, epidemiologists, statisticians, health economists, social scientists working together. And the first thing you've got to do is get your own house in order and make sure that that relationship is equitable, and they feel equally valued. And that's really critical. You can't have a broader equitable partnership if in your group, they feel that they're being treated differently or being less valued than others.

Catriona Gold 8:49
Absolutely. And I think this maybe connects to another point I think we've previously discussed, which is the need for the partnership to be sustainable for the UK institution - or, sorry, not necessarily the UK institution, you could say Northern institution, but we're talking about UCL here - you can go in with very lofty ambitions, but you have to square them with the context in which you're working. So what kinds of constraints do you encounter when trying to put these sort of projects together?

Shabbar Jaffar 9:17
Yeah, I'm not sure if I see them as constraints. But I think what you have to consider is again, both sides have to be kept happy in this, both sides have to have equality. And so in the case of institutions, there has to be gain for UCL and there has to be gain for the partners - in my case, in Africa. And as long as that's balanced, that relationship will remain sustainable. And you know, it will never be completely balanced; it can have a little bit of up and down over the years, but it's got to even out. And as soon as, let's say, UCL starts to - there's a feeling that it's taking more than it's giving or more than its due - or the other way around, that the money is - much more of it is going to the African institutions than it is to us, and we're doing all the work, let's say as an example. As soon as that imbalance occurs, there's just much more going to one institution than another, and that puts that institution in difficulty, then that relationship starts to run into difficulty. So I have seen relationships where - with very good intents - partners in the North, in the UK, form that partnership so that 80, 90% of the funding will go to the African partners. In the long run, that's no good to the African partner, because that relationship is not sustainable. It works for a while, but it can't be sustained. You know, so you've got to work out a sustainable model here, in terms of how funding flows. I think that's also true of the outputs as well; that's got to be equitable, too. If, for example, we take all of the first authorship papers, and our partners in Africa, they're not getting that - they're kind of middle authors on papers - then that, again, is not sustainable. There has to be equality. And you have to work out how you're going to do that equality in both the funding and the research outputs.

Catriona Gold 11:19
Right. I mean, something else you discuss - which is, I think, related - is the importance of building trust - and trusting that duties and responsibilities, activities are divided up, and building trust that they will actually be done, right? It's not about one institution trying to spearhead everything and push it through - it really is about actually approaching things together, if I understand correctly, when you're trying to build trust across unequal contexts. And I think there's an interesting point you make on this question of sharing of outputs: that you need to be giving credit to different partners. But also, it's an opportunity to address different levels of training or different norms around presenting research, or what have you - that can be addressed by say, having people co-author or co-develop proposals, that kind of thing, so that it's not just: "okay, we're better at this over here, and we're going to do that - and you do this other thing that you're better at". That you actually you have an emphasis on co-developing things and on training and actually trying to have everyone working on the same page. Does that sound like an accurate summary?

Shabbar Jaffar 12:24
Yeah, no, I think in some ways, you know, going back to the trust question. So I think when I was much younger in my career - I've only ever worked in global health, and I would go to partners in Asia, I was then in Africa. And I'd be very impatient to get going on the research, I was very clear on my research question. I wanted to get going. And I had a plan for that question. And I had the plan for where that will go, what the next question will be in three or four years time, and where that could end up in five or six years time. And I learned over time, actually, no, the first thing you've got to do is to build trust between yourselves. And that actually does take time, it doesn't happen overnight. And in some cases, you know, the partners that you're working with have worked previously in difficult relationships with difficult partnerships. And so in those cases, it will take even more time. And you've got to understand that. So what we do now is we allow time for that partnership building. And then that occurs from meetings from in person contacts from regular meetings, frequent meetings, so that you know, you're talking to each other, the trust is building, you cement it, once you go on through funding, and you've gone through papers, and people can actually see that you have tried to be fair all along. But you've got to give time to it as well, and you've got to realise that actually, building trust here is the first and foremost important thing here, before I can do the things that I want to do in global health - which are very many - so give time to building that trust. In terms of sharing of papers and sharing of grants. I think I am better than writing - sorry to be immodest - I am better at writing both the grants and the papers. And I know that if I wrote all the grants in our partnership, the success rate would be much higher. But that doesn't build equitable partnerships. So what we try to do - I try to do - is we really help people, partners, write both papers as first authors and grants as first authors. And in some cases, you will get to a point where you see a grant and you think: this is gonna fail because of the skills of the partner. And if I had this in my hand, it would succeed, you know. So even when you feel that, it's really important to support the partner, see it through, even if it fails, because they and you have got to go through a certain level of failure to get good. So the easy thing to do is to write the thing yourself, but what's critically important is that it's shared - and through that sharing, you will build capacity, but you'll build trust as well.

Catriona Gold 15:07
So communication and trust building from start to end, really. In a nutshell, these sound like the crucial issues. But, I mean, I also found really interesting the way you stress the importance of giving people a place in structuring the project itself, rather than just giving them a sort of seat at the decision making table at a later stage. So it's about structuring things so that different stakeholders are involved in the planning stages, and not just in the final stages of decision making, or something like that, where it's like - that sort of reduces the amount of agency people have over the process. I wonder if you'd like to say anything about that, for us to close on?

Shabbar Jaffar 15:49
Well, I think many of my partners actually don't really care about a seat at the decision-making table. Whey do have one, don't get me wrong, and that is kept equal. But do they really care about it, you know, do they really want it? They do want it, they care a bit about it - what they care about more is that they get out of that partnership what they want. And what they want more than a seat at the decision making table, if you like, is, in some cases, it is the building of capacity, and is the working in partnership the working alongside each other. So you've got to be aware of that. And so I've seen so many examples where African partners will have a seat at the table - they'll have a great seat at the table - but they can't do anything with it, you know, because they've got no capacity, they've got no ability to be equal with you. And so you've got to kind of work on that: just giving them one bit of this equality aspect, as it were, is not enough. You know, equality is much broader than that: much, much broader than just decision making. And I think there again, you'll get it right as long as you're very clear why you're doing it.

Catriona Gold 16:58
Yeah, absolutely. Thank you for that. Well, there's so much more we could discuss. But I think that's a great place for us to end. Thank you so much for sharing your insight with us Shabbar. And thank you everyone for listening.

Shabbar Jaffar 17:11
Thank you. Thank you. I've enjoyed this. Thank you.

Catriona Gold 17:15
This podcast was hosted by Catriona Gold and produced by the UCL Grand Challenges team, with the help of Professor Sahra Gibbon, Professor Megan Vaughan and Nina Quach. Today's guest was Professor Shabbar Jaffar, and the music is by David Szestay. If you'd like to hear more perspectives on this concept of critical global health, please check out the other short podcasts in this series. For a longer listen, you can head to the UCL Grand Challenges YouTube page to find our recent interdisciplinary roundtable discussion on this topic with scholars from across UCL. For more episodes of Disruptive Voices, visit UCL Minds or follow us on Twitter at @GrandChallenges.