Scrambling for Africa – an Interview with Johanna Tayloe Crane

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Anita Chary

Anita Chary

Anita Chary, MD PhD, is an anthropologist and resident physician at the Harvard Affiliated Emergency Medicine Residency. She is Research Director of the non-governmental organization Maya Health Alliance | Wuqu' Kawoq, which provides health care and development services in rural indigenous communities of Guatemala.

Johanna Tayloe Crane has a PhD in medical anthropology and is an assistant professor at the University of Washington-Bothell.  Her research has examined urban health in HIV in the US as well as global health research partnerships between US institutions and Ugandan clinics and universities. 

Scrambling for Africa

Crane recently published a book, Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science, which examines how political and economic inequalities influence the ways that HIV/AIDS research is carried out in Africa.  This book also grapples with how knowledge about AIDS is generated on a wider scale.  Over several years, Crane conducted ethnographic research to study a HIV research partnership between a prestigious US university and Ugandan universities and clinics.  By exploring American and Ugandan researchers’ and clinicians’ perspectives about the project, within the broader context of international AIDS research, the book reveals the problematic nature of global health research partnerships.  Populations of treatment-naïve patients with AIDS in Africa become a major draw for university researchers and students seeking to experience global health, and the boundaries between research, development, and care become very blurry.  Authorship and ownership of data are not shared equally between foreign (Western/Global North) and local (LMIC/Global South) partners.  Local partners have different levels of access to the opportunities and benefits that research projects bring.  Global health institutions rely upon the very inequalities that they hope to fight in order to establish their authority and presence—as experts and as researchers.  Crane shows us that negative stereotypes about Africa, as well as the scientific privileging of HIV strains common in the US and Western Europe, guide health policy decisions, research funding, and infrastructure development.

Scrambling for Africa is an engaging read and an excellent resource for anyone interested in global health partnerships and education, HIV/AIDS, and clinical and scientific research conducted in the Global South.  The following is part of a conversation that I had with Crane about the book.

 

The title of your book, Scrambling for Africa, is very provocative.

I intended it to be a little provocative. Classically, the “scramble for Africa” refers to European colonialism and the Berlin conference, in which European countries scrambled to politically divide up the African continent.  They were already economically invested and involved in Africa at that point, but the scramble was political and related to officially occupying what became various African countries.  I saw some shades of that in what’s happened in the last decade in American universities’ and medical schools’ involvement in research in African countries.

While there has always been some international research going on, there really has been such a sharp upturn in the last decade.  There’s been exponential growth in doing global health research and education in the US.  Suddenly, it seemed like US universities were scrambling to establish a partnership or program in an African country, usually English-speaking, and it almost became a little bit competitive at points.  I saw this as another way in which Western countries were now scrambling to get a piece of Africa for their global health programs.  That makes it sound a bit crude and insidious, and I don’t mean to say that global health equates to colonialism.  I don’t think that’s the case. I think that a lot of these global health programs are very welcomed by African countries and African partners.  But I do think the good intentions of global health programs and the humanitarian intent can mask a way in which they can be somewhat extractive—in terms of using African facilities, African doctors, and African patients to first and foremost meet the needs of American universities, students, faculty, and maybe sort of secondarily benefit the African partners.  Again, this is not true in all cases.  I’m speaking broadly, but that’s what the title refers to.

 

One of the points that you make in the book is that these “partnerships” between Western and African institutions are often rife with inequalities.  How did that play out in your research?

It’s very tough to have an equal partnership when you have an American institution that’s extremely powerful and well-funded, such as, say, University of Washington or UCSF, coming to an institution that may have much fewer resources.  In Uganda, Mkerere University is one of the oldest and best-known and best universities in East Africa, but it has suffered a lot in terms of funding and infrastructure.  Mbarara University of Science and Technology is a great university, but it doesn’t have the funding and capacity level that, say, UCSF or UW would have.  So you end up with the Americans tending to carry the purse strings, and whether or not they want to have that power, they do have that power to dictate the parameters of the research, especially if it’s a research project to prioritize the needs of their students.

One of the things I talk about in the book in terms of the group that I follow is that sometimes these research projects actually see their work as humanitarian. They say, “we’re bringing all these research resources here to an underfunded university, we’re helping this university, and we’re helping this clinic.”  And all that is true. And Ugandans I interviewed don’t disagree with that.

In the example that I talk about in the book, Americans created a database for a Ugandan HIV clinic. The Americans framed their creation of the database as a donation to the clinic. But in fact, they wanted to retain some ownership of that database, because they were also forging their research partnership and their grants, and their grants depended on having access to a lot of clinical data. It became contentious when the database became very valuable as a research tool, as more and more and more data got entered, and other foreign partners wanted to join the project too. They started approaching the Ugandan clinic director, and not always going through the American PI who had set up the database. And he felt a little left out. He still felt like he retained some ownership over that database, even though he had technically donated it to the clinic. There was an unspoken power struggle over who really owns the data, and who is in charge of the clinical data.  Some observers said that wouldn’t have happened had there been an equal playing field, had it been Americans negotiating with other Americans.  In that case, there never would have been a situation where one side approached the other side as if they were making a charitable donation to them. And that creates a very unequal playing field on which to start a partnership—if one side views itself as a donor and sees their collaborators as recipients of aid.

 

You interviewed Ugandan healthcare workers who were participating in the transformation of their clinics into sites for research projects. What were some of their perspectives about the pros and cons of creating research infrastructure within the clinic?

They had a wide variety of views. It depended to an extent on their interest and involvement in doing research.  There were Ugandan physicians who are very involved in research, who had gotten PhDs in the United States, or who worked with US researchers, and felt the clinic really benefited from this type of partnership.  They really felt like it was opening up research opportunities that had not been there previously due to a lack of local funding.

Others were working more as clinicians but wanted to get involved in research.  They realized that in order to do so, one of the phrases that they used was, “I need to be attached to someone.” So they were seeking out American or other international mentors the partners who could essentially get them funding, because a lot of times, postgraduate medical students in Uganda have to self-fund their own research.  There just isn’t funding for them.  So they were trying to strategically get involved in these networks and saw them as an opportunity.  Some also had some critical things to say about this.  They felt it was frustrating, because they wanted to do a study of something that’s not related to HIV, TB, or malaria, but that’s where all of the international funding goes.  They did have opportunities brought by foreign partnerships, but those were also limiting in terms of what would get funding.

There are also people who are very clinically oriented.  Some of the medical officers in the clinics who had never been involved in research or who had done very little research felt resentful of the presence of the research project.  This was mainly because they felt like the presence of foreign researchers and the collection of clinical data meant that they had to change the way that they kept medical records. When the medical forms were standardized so that they could be entered as data, it was very different than the handwritten records they had been used to keeping.  And the providers felt they were being asked to do extra research work, but they weren’t actually being compensated for it.

It’s very clear that research brings in money.  People get involved in research for intellectual reasons, and also sometimes partly because you get paid quite poorly as a public-sector physician in Uganda.  Joining a research project is another way to make money to help make ends meet.  So some of the doctors in the clinic who were purely clinicians resented what they perceived as extra uncompensated work. And that didn’t change until the American research team actually addressed that.  They figured out a way to use the clinical data to give the doctors clinically relevant information on their patients, which actually became very helpful in providing care.

 

You also mention in the book a Ugandan physician’s critique that research projects actually cripple the local public health system.

There was one doctor who really felt that “this HIV money is killing our healthcare system.”  He was speaking there partly about the research money and partly about foreign money coming in for HIV treatment programs, although he was certainly not against providing treatment for people. But sometimes it can be hard to disentangle the effect of the global health research programs from the impact of all the other money that’s coming through PEPFAR and Global Fund and other kinds of treatment programs.

A lot of people have remarked that the research programs and global health institutions often don’t want to deal with the local channels of bureaucracy. They don’t want to go through the government.  There have been issues with corruption in the Ugandan Ministry of Health, so it’s a real concern.  But researchers sometimes don’t want to go through local university bureaucracies for funneling their grants. They end up setting up parallel administrative infrastructures to avoid that.  And I think with this doctor was arguing, and what some others argue, this can actually reduce the capacity of African universities to administer these kinds of programs.

The study that I shadowed set up what was essentially an NGO to be their fiscal agent.  And that is very common.  They set up this parallel NGO and routed their money through that, and for a variety of reasons, it ended up imploding.  One of the reasons, which was out of the researchers hands, is the way that NIH grants and other large grants work. They only allow 8% of any grants to go towards indirect costs and overhead for a foreign grant recipient, versus if you were at, say, Johns Hopkins, say, where they get a much higher percentage for indirect costs.  A common response is for Western researchers to set up parallel infrastructures, which do not build capacity in African institutions, and those parallel administrations may not really work either.

This is one of the most difficult things in these partnerships—the part that tends to be boring and bureaucratic.  But it’s very meaningful on the ground, because this is how people get paid, and this is where the money is.  There’s an issue there around power, and it’s complicated. There are no simple answers. The researcher I worked with actually decided to set up a system with the local university to track grants within the Ugandan university. So maybe that’s a way forward.

 

Do you think, in general, researchers from wealthier donor countries are aware of how the research projects are creating tensions at the local level?

I think certainly the researcher that I profile in the book was certainly aware of it. People are aware that international money, whether it be through research partnerships or NGOs or PEPFAR, creates an uneven pay scale in a lot of these countries.  If the average public-sector health physician’s salary tends to be low, it can create an incentive for doctors to leave the public sector, because they can actually make a decent living working for foreign research project or NGO—although they don’t have the same kind of job security. That gets called the internal brain drain.

I’m not sure that there’s much awareness of how it affects people who are not at the high professional level of a physician. There are folks who work as research assistants, or laboratory assistants, who might say, for example, “Harvard is funding our research, but I can’t access any benefits from Harvard. What good is it for me? I just suffer. I’m working for this very powerful American university, but I’m not seeing really any benefits from that affiliation, and in fact, in some cases, it may be frustrating, because my paycheck has to get routed through very complex international bureaucracy, and sometimes it doesn’t show up on time.”  There are some lower level impacts that really interesting, which I haven’t studied extensively, and I don’t think there’s as much awareness of that level.

 

As Western scientists and researchers continue to seek out partnerships, what kind of advice would you offer about how to maintain as equal of a footing as possible with a research partner?

I have a couple pieces of advice.  One of the Ugandan physician-researchers said to me that if a collaborator is coming to him from abroad, what he doesn’t like is when the foreign researcher comes over and says, “Here’s my research proposal. Who wants to work on this project with me?”  That puts the foreigner in the position of having already designed the research and just looking for someone to facilitate access to patients and help with the IRB process.  It’s not really a partnership.  The Ugandan researcher expressed appreciation for people who came over and said, “I’m interested in this topic, I’d like to write a research proposal.  Can we write it together? Let’s write this collaboratively.”  That’s one very simple thing that people can do, is to really write their proposals collaboratively.

Another piece of advice is about long-term commitment.  This is based on watching my key informant start working in Uganda, by his own admission, not really knowing anything about it. And now, 10 years later, he is still working there and going back there very frequently.  You need to really have a long-term view, show your commitment over time, and be willing to learn from your mistakes.  Listen to your collaborators and stick around over time.

In my key informant’s case, some of the mistakes that were made early on in that project were addressed over time, because there was a commitment to a long-term presence there. So there was time for some of the harder stuff to get talked about and actually get addressed. For example, they made a data sharing agreement and figured out how to make the clinical data from standardized forms useful to the clinicians. There was time for that to get sorted out. So I think time is actually big component in terms of building an equitable partnership. It takes time. It’s maybe not the most surprising answer, but I see it more and more as I continue to watch opportunities for partnerships come from afar.

Lastly, these boring bureaucratic issues around administering funds and around fiscal agents are actually very political.  I think we could pay more attention to the ways in which those are negotiated in ways that impact people on the ground.  At least from the American side, from my observations, there tends to be a very practical approach.  It’s logistically difficult to have a global health program and to get the funding through to another country.  From the American perspective, we ask, “How can we streamline this to make it as easy as possible for our fiscal people back in, say, Seattle to administer this project in Uganda?”  Rather than having the priority be streamlining and efficiency, I would like to see attention paid to the power dynamics inherent in setting up those kinds of administrative structures. I think that’s a bit under-examined.

 

Here’s a similar question. You talk in the book about the explosion of global health education.  More and more universities are sending students abroad to do internships in developing countries.  How can students remain aware of the power inequalities we’ve been discussing, and think about addressing them at a more personal level?

That’s a really important question. I’ve talked a lot with colleagues and faculty who work in this area.  In global health, we have this feeling somehow that going to Africa, in particular, has become almost like a rite of passage for undergraduate students—especially for premedical students.  There are a lot of ethical issues involved in that.

I really talk to students about this.  Some students are quite aware of power dynamics and want to think critically. Other students have a more naïve mentality of just wanting to do good, wanting to save the world, wanting to help the poor—all of which are excellent motivations, but I try to encourage those students to get out of the mindset of “I’m helping.”  Good intentions only get you so far, and it’s important to think about how you’re actually probably not helping.  You’re actually here to learn, this is actually benefiting you.  You are maybe not going to benefit anyone in the country you are going to, and you actually may burden them in some ways, because you’re not a trained medical provider.  And people are going to have to figure out things for you to do.  There may be ways in which you are actually not helping. That’s hard thing to say. I don’t want to discourage people from trying to do good things in the world, but I also don’t want them to not think critically about it.

I would also say that the problem isn’t so much with individuals. I do want individuals to think more critically about what they’re doing, and what they’re not doing when they go on these kinds of global health training programs. But I also think there’s a way in which global health itself needs to be rethought. We tend to think of global health as something that happens far away, over there, and I would argue that the US is a part of global health, and that you can do global health in the US in a lot of ways. I would love to see more of a discussion around that as well.

 

That brings up another interesting idea from your book about what constitutes global health for people who are actually working in the Global South.  Are they inherently doing global health just by working there?

Right, or do they have to go someplace even poorer, as one person said, for it to count as global health? There needs to be a way for us to talk about global health and to do global health that isn’t just about, to put it crassly, people from wealthy countries working in poor countries.  Global health shouldn’t mean that physicians working in poor countries are just doing public health, not global health, and it shouldn’t mean that you can’t do global health in the US. There needs to be a discussion of what global health really means.

I have found a fairly receptive audience among a lot of graduate students and medical students in global health, who really are striving to deal with some of these inequalities and approach them critically.  It’s quite inspiring to see.  This is a conversation that people actually want to have and are having.  There’s a very receptive audience, a very engaged audience, for this kind of critical discussion, and that’s really exciting.

 

 

Johanna Tayloe Crane’s suggested readings:

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