Decolonizing Global Health: A UNC Experiment That Shows the Way

Simon standing in front of two paintings
Simon Aseno at the Lusaka National Museum

Last summer was an immersive period of learning and discovery. I had been grappling with a lot of questions around decolonization and localization of global health.

The scars of colonialism in Africa can be found in the profound inequities in healthcare across the African continent. But much has been achieved. And much yet more is desired. To deny the progress made thus far in transforming healthcare across the African continent is shortsighted. But that does not absolve global health policy makers and industry leaders of responsibility to do even more to bridge the inequities.

For context, I would like to highlight the gravity of the issue confronting global health and why decolonization should be reprioritized. As recently as 2020, 85% of global health organizations were headquartered in High-Income Countries (HICs). In these organizations, Diversity, Equity and Inclusion remain elusive as the data show that about 70% of board representations are mostly men (not Black men!), and of the 70% board representation, 80% of them are citizens of HICs and mostly educated in these countries. It doesn’t end there. The real cause of the inequity is in the money and who decides how much should be spent, and where, and at what time, and for which population. Let me give you an example: the funding that goes to local organizations for humanitarian work is less than 2%. USAID awards about 80% of its contracts and grants directly to US organizations. The US and HICs enjoy on average 70% of NIH Fogarty funding grants. Ultimately, this translates to agenda setting by these organizations and micromanagement of global health work even if local institutions have their own expressed health needs and priorities.

Gender parity is critical to global health for the lack of it is a continued symptom of colonization and all the vestiges of privilege. On the gender score, the situation is even more grim with projections that gender parity in global health would remain a mirage until 2074. That is unconscionable. See, while 80% of global health work is in Low and Middle-Income Countries (LMICs), only 5% of women in these settings are represented in global health work. Meanwhile, women and children constitute the largest population who bear the health burden in this group of countries. Doesn’t it make sense that the people who suffer the inequity most should be given the opportunity to set the agenda and policies regards their own wellbeing?

Doing it the UNC way…

Are there institutions that are championing the change we desire to see in the global health space?

During my summer internship, I worked on an upcoming clinical trial called INSIGHT in Zambia. The Institution—UNC Global Projects Zambia (otherwise called Zambia Hub)— characterized a classic example of how decolonization looks like in some fronts. First, Zambia Hub was established by UNC in Zambia as one of a few centers for global health research in the world. This proofs a point. That global health institutions can also succeed where their services are needed the most. I witnessed how local capacity was strengthened using technology to facilitate inter-institutional learning and capacity development of local staff.

More to it, and even more impressive is the fact that the leadership of Zambia Hub including my own immediate supervisor, research assistants and other support staff were women who constituted the majority of the organization’s workforce. That affirmed something: that women too can run organizations and do so even better if given the opportunity.

I did not do a management audit, nor did I formally interview staff to learn about how the institution was funded and whether locals managed funds, or whether funds were micromanaged from the UNC at Chapel Hill. I am reporting my personal observations about how the setting up of the Zambia Hub and the empowerment of women to run the organization refutes fears I have often heard about mistrust from development partners about the capacity of locals to manage institutions and funds. Zambia Hub, like the rest of the hubs set up by UNC is self-evident and should be sustained.

Going by the hypothesis that decolonization is not an endeavor to take and that it is one that would not yield good returns for donors and funding partners, the success of the Zambia Hub partnership with UNC presents compelling evidence to reject the null for the alternative.

Researchers sitting at desks
Simon Aseno leading an ICT Capacity Development Seminar for Research Assistants at the Kamwala Health Center in Lusaka

From a global health security standpoint, we all live in thatch houses. And so, when you don’t support your neighbor to put a fire belt around his house, when his house catches fire, your house is next. In other words, I am saying that if we continue to ignore the clarion call to meaningfully decolonize global health, the next bat bite in Africa will cause an outbreak of nose bleeding in the West. Think about it.

While you are thinking about it, I would like to thank Dr. Margaret Kasaro, my preceptor, for her leadership that sees the Zambia Hub grow from strength to strength and proving to the world that yes, locals and women, when given the opportunity can be equal partners in the global health leadership structures and boardrooms. My supervisor, Manze Chinyama, was sterling in her tutelage and experience in all phases of clinical trials and I would like to thank her for her mentorship. To Modesta, the community engagement nonpareil, Laston Zulu, Harold Banda, Chileshe Kasonda, Elizabeth Mubanga and all the Research Assistants I worked with, I want to say thank you for all the support I received during my stay in Zambia.

– Simon

From IMPOWER 022 to INSIGHT: HIV PrEP Still in Focus

Simon at the INSIGHT study site at the Kamwala Health Center in Kamwala, Lusaka, Zambia.
Simon at the INSIGHT study site at the Kamwala Health Center in Kamwala, Lusaka, Zambia.

It isn’t sheer happenstance. No. I don’t believe it. Doing my practicum with UNC’s Global Projects Zambia (UNC GPZ) comes to me like a déjà vu. When I was researching UNC, I learned about the summer practicum placements which are compulsory. I knew that I did not want to do my practicum in the US or Europe. It had to be Africa. I started eyeing opportunities that would bring me back to Africa right from the time I got accepted into UNC. I fixed my gaze on Lilongwe and Lusaka. I even started reaching out to professors about possible opportunities in South Africa. Later, other exciting opportunities came up – Uganda and Tanzania. For some reasons, I had to give up all other opportunities and head South of Africa.

Initially, I was going to work with IMPOWER 022 which is a third phase clinical trial project. This project assessed a promising once-monthly Pre-Exposure Prophylaxis (PrEP) drug against HIV as a substitute for the current daily regimen which presents adherence challenges due to the frequency of intake required for efficacy. An ideal PrEP should work like a contraceptive – offering choice–thus allowing for a single jab or swallow to last effectively for a longer period.  For some reasons, IMPOWER 022 is currently on hold in the Zambia study site even though it is continuing in other sites.

So, INSIGHT, another study which is just starting off is the one I got involved in. Led by researchers from the University of Washington and the University of North Carolina at Chapel Hill and funded by the Bill & Melinda Gates Foundation, INSIGHT aims to advance PrEP discovery and delivery for African women. It will be a multi-site study based in eSwatini, Kenya, Malawi, South Africa, Uganda, Zambia, and Zimbabwe.

I will be fortunate to participate in and learn more about the regulatory process since this project is just starting out with preparatory work being done to meet various IRB requirements here in the United States and in Zambia. My second objective is to understand the community engagement process in Zambia which yields high enrollment rates for various studies in the past. I am interested in understanding the strategies adopted and implemented by the Zambian research team in achieving low attrition and high retention of study participants.

Localization and decolonization of Global Health is an area that interests me most. The UNC Global Projects Zambia hub is a classic example of how global health can be decolonized, and I am excited to be part of this network at this juncture of my career and studies.

I am thankful to my faculty advisor Prof. Suzanne Maman, the Director of UNC GPZ, Dr. Margaret Kasaro, and the Vice Chair of Research and Innovation at the UNC Department of Obstetrics and Gynecology, Dr. Ben Chi, for the opportunity and mentorship before and at the commencement of my internship. I have learned so many valuable lessons thus far and find this opportunity as one that would open many doors for my public health career in the foreseeable future.