Power and allyship in the Global North and Global South

[Music] Hello and welcome to the Lancet Voice. It's January 2025, so happy new year. And I'm your host, Gowing Cleaver. Today we're going to be talking about the global north and the global south. And for that I'm joined by Catherine Chobotongi, the Executive Director of the African Population and Health Research Center, and Maducar Pai, the Chair in Epidemiology and Global Health Research at McGill University, Montreal, Canada. They recently published a comment in the Lancet on the topic, so we'll be talking about that and we'll be exploring the intricate dynamics of global health leadership, looking at the collaborations between global north and global south. We'll look into the systemic barriers that are sustained inequities, the impact of political shifts and the critical need for genuine allyship. What are some of the challenges and opportunities for the global south? And how can we reset knowledge sharing and relationships in global health? I hope you enjoy this conversation. [Music] Maducar Pai and Catherine Chobotongi, thanks so much for joining us on the podcast today to talk about your comment that was published recently in the Lancet, talking about leadership roles and collaboration between the global north and the global south. Now global north and global south is a quite a common phrase in the world of global health that we work in, but I thought for our listeners it might be interesting to get a kind of overview of what we mean generally when we say global north and global south. We used a simplistic binary framing in this comment and we also pointed out the limitations of that, but essentially when we say global north in this context, we are primarily talking about Europe, North America, Australia, New Zealand, this rich block of countries that have much of the world's wealth, well only has about 15% of the world's population. The global south, we primarily mean all of the parts of the world, what we would call low and middle income countries. It's a I think a nice way of framing it rather than developing countries or first world versus third world countries that are kind of very hierarchical and even racist in their framing. So we preferred something like global north and global south to kind of make a point as simplistic as a binary is. But it doesn't necessarily mean to make it ultra simplistic that some countries are in the north and somewhere in the south. No, we're less worried about the geographical north and south, we're more worried about what those countries have and how they behave I guess. How did that framing first come about? We wrote a piece actually, led by them, RISKAN published in BMJ Global Health a few years ago, extremely widely at least on how various terms came about including, you know, first world, third world developing high income countries, low and middle income countries. Each has a different origin and sometimes it's not quite clear where they are originated. But what we did mention was which kind of binaries to avoid, you know, because of their hierarchical or their presumed supremacy of some and lack of advancement of others. So that's why I think that piece got a lot of traction because everybody is struggling with this with this way we speak and write, especially in global wealth. Global development is no different actually. They're even worse in some ways, right? Rich versus poor donor countries versus donor dependent countries, right? Beneficiaries. It's a very, you know, top-down way of looking at the world and we are gently trying to steer the conversation towards more, you know, lack of rather than hierarchical ways of looking at the world. It does feel like the language in this sphere has moved on relatively quickly, you know what? I mean, I remember growing up, for me it was always first world and third world before I was kind of interacting with the global health world. It's one of those things, isn't it? Where you can sort of see how problematic it is to frame it like that when you look back on it. Sometimes it's hard to tell where this this technology comes from. You just read that document and there's some new terminology and you say, "Okay, I think that sounds better than the previous one." But I don't think we are at a place where the terminology is perfect. It's just that it's easy and it's very complicated to try to maybe use different terminology when the when the community uses global and global south. But I think as Madhya has said, we are still evolving from maybe more discriminatory terminology to something different, but still not perfect. Well, that's interesting actually. So, I mean, obviously, we're talking in kind of like brute terms almost, global north and the global south. It's very hard to make a kind of hard and fast distinction in that area. So what are some of the nuances that the current usage of global north and global south actually miss? Apart from geography, obviously. I think also it's the fact that you and we didn't, I mean, when you say the global north, it's easy to think, global south, it's easy to think Asia, Africa, Latin America. But even within those regions, there are nuances. They're like not every African country is the same as the other and Africa is not the same as Asia and Asia is not the same as Latin America. But we assume that this homogeneous blob that everything is the same, that they have the same problem, the same issue, the same challenges, maybe the same opportunities. It still misses the differences even within this very outside problematic, the Eccortal North and South. And what your comment kind of touches on and which a lot of the literature and global health is centered around nowadays, it's sort of the problematic relationship between the global north and the global south. Perhaps you could tell I listen a little bit about sort of what forms that problematic relationship takes before we get on to talking about your comment. This this framing is within the context of global health. And at first value, global health seems like this good thing, like this thing that is maybe accepted and understood and practiced sort of with some kind of common understanding about what it's about. But now when you start digging deep about the actual practice of global health, that's where maybe this problem start imagining about the manifestation between north and south. And how it is accepted that there's a north and south even when geographically doesn't make sense, economically doesn't make sense, culturally doesn't make sense. But it's accepted. And the question is who accepts it, who defines these terminologies, who uses them, and then how do they get accepted globally. So it's still reflects those hierarchies in power that of course have a long history, colonialism and all that. And so as I say that first value global health looks like this inocuous good thing. But then when you start peeling off the layers, then you actually recognize that global health has been sort of accepted as that thing that people from the north do to people in the south. So it's like northern scientists and practitioners practice global health on global south people. And somehow I don't think we have a question that like how well did we get here? How is this normal? That this is something he sort of accepted as a norm. And so as again as I said, these they are the normal historical practices and reasons and how we got here. But I think we at the point where we have to question this acceptance of people from one side of the world doing things for and on people from another side of the world. And then frame these as something that is aimed at achieving equity. And maybe without questioning do they people in the south find this equitable? Do they find it okay? But the such the such a system is so entrenched that it's hard to even imagine a different system. So so again, yeah, long historical reasons, but really I think it's the time is right to question, you know, this acceptance of what global health is for instance. Yeah, it makes me think actually of all the kind of departments institutions that for example, still have the words tropical medicine in the name. Institution in the global north that are actually based around going to the global south and then doing research on people there and on places that it's it really shows, I think, here I have historically based the whole the whole situation is. So as much as we think global health is this very equitable neutral field, it continues to be extremely balanced in terms of power. At every level actually doesn't matter whether it's money in terms of wealth, who holds the wealth, in terms of who sets the agenda of what needs to get done, who is funding who, where does all the money flowing, who gets to publish, you know, whether it's launch set or whether it's our general plus global public health, who gets to, you know, go to conferences even, who has the right to present on behalf of who, and it's to global health simply put neither global nor diverse nor inclusive and yes, We're talking about this in 2025, almost. So it's shocking that a field that is born out of colonialism continues to be disembalanced, even more so, I think, during the pandemic, where we saw rich nations pretty much holding vaccines and allowing millions of people to suffer and die in under-vaccinated countries without any access. So it's a sad reality. It's very clear from the data actually, none of this is our opinion. It's all factually born out. Question is, what do we do about it? Which is what the comment really was focused on? Yes, I've been following you on social media for a long time now, Madu, on Blue Sky, of course, these days. And the conference's point is one that's always incredible to me. I think, you know, obviously, in my privilege growing up in the UK and having the sort of passport that is kind of waved through a passport control, it never really occurred to me until I started following you on social media and saw your campaign against putting conferences in places that are difficult for people to access around the world. But it's still, now, armed with that knowledge, it's incredible to me that conferences are still organized in places that it can actually require people, months of work, and thousands of dollars to access in the first place. And it actually perpetuates inequality massively, doesn't it? Because it's simply access to these conferences where knowledge is shared. Absolutely right. It's actually quite devastating these days. You know, Canada where I am, it's extremely difficult. And UK is extraordinarily difficult in the US. And of course, with all of this, our new governments, which are like extremely right wing, you know, a rollback of democracy in many parts of the world. The anti-immigrant, anti-refugee sentiment is sky high. And the visa issues are tied to this whole notion of, we need to control our borders, that all these other people are coming and taking over our land, our jobs and whatever. And it impacts global health more than many other fields. Because how do you have a quote and quote tropical medicine conference in Canada or the US and not have people from the so-called tropics who are suffering the most and have the most knowledge to share on it, can't even get a chance to come. So it's like really lopsided and almost unquestioned as Catherine said, right? None of those conferences even think it's a bizarre to have an AIDS meeting in Montreal where many Africans couldn't even make it. Nobody felt that that was really absolutely bonkers bizarre. Right? That the continent that is most impacted by AIDS somehow is not there to share their knowledge is just purely shameful. But yet happening every day in global health. And I think it speaks to what I said earlier about what is global health really. Because if you do all this practice where people from the North do things on and for people in the South, either in Macchars at all, why are you doing research that you're sharing with people from the same geography that are a lot affected by this problem? And you have all these amazing scientific papers and discoveries that you're sharing amongst yourselves. It doesn't seem like somebody doesn't even question why are you sitting in a conference, where you collected data on an illness, on a problem, on a health issue, on a challenge that affects people that none of them is in the room and you're talking amongst yourselves. What is the point? Only if you ask yourself, what's the point? What's the point of this conference? And so again, it goes back to like we never sat down to question for who and for what is global health. And it's become, I think somebody said that it's something like a career. So you can decide to be a comedian and now you decide to do global health. And global health, you never even stop to think that a comedian's role is to do something in society, maybe to entertain the people happy. Global health at the heart of it is equity in health, in the world. And you never stop to question that you're engaging in practices like these big conferences that cost thousands of dollars in a space where you're not actually solving any problem, other than sharing the latest information amongst yourselves as academics and practitioners. So for me, that's, I think that's at the heart of where we have a problem that global's practitioners, global health has is dipped into careerism. It's a career just like any other. And I don't think global should be a career like football or, you know, commit comedy. It should be a career that is grounded in the need to see equity in the world. And these practices don't advance equity at all. I think you're mentioned of equity there. And it kind of goes to the heart of what you are talking about in your paper. And it brings me very nicely onto my next question, which is, I wanted to ask you both how academic institutions in the global North contribute to this sort of perpetuation of inequity through their sort of research and education priorities. You know, as an academic was based in the global not academia, I can see how we perpetuate many of the inequities that global health are first on. First of all, our academic institutions are merely a reflection or a mirror of our global not societies and governments. For example, let's say I am an academic in Canada and I am inviting Catherine to come here, to be my guest faculty, you know, from Kenya, Uganda. And if she can't get a visa, then, then, you know, I am part of the problem because it's my government in Canada that's denying her a visa. So this is just the society that we are part of. And if our governments are holding vaccines, or where holding vaccines, our academic institutions are silent and not able to really say much or do much about it. And then our own academic institutions are very hungry for money in terms of grant monies. We don't like grant monies directly going to Catherine's institutions. We would rather have it go through our institutions because that is how we get big overheads out of these global health grants. And we would like to control the money as PIs. So we have a say on what gets done or not. We get to decide because we hold the purse strings, who will get to be the first author or senior author, and where research gets done and how. So it's enormous power in the hands of global not institutions. And many global not academics as well intentioned as they need to be. We are all part of this system where we are rewarded on the basis of the wrong incentives. The incentives for our progression here in a global not are things like how many first author papers do we have, how many grants do we hold as PIs, how many million dollars did we bring in, now much overheads did we bring to our institution. It is not to do things like have we really been a good ally to Catherine's institution, have we actually helped solve the HIV problem and is it really led by African solving their HIV crisis and we are being good allies to them. There's no place in the CV to even talk about trust building and allyship work. It's all about me, how much did I get, how many awards did I win. And that's what I am incentivized at my institution and that's how most global not institutions are. That's partly why everything in global not health is dominated by global not academics. And many global not academics are also very leading very precarious lives in the sense that they have to bring a huge chunk of their own salaries through grants. They are on what we call soft money and that soft money existence makes them extremely precarious but also extremely aggressive in terms of looking for the next grant, pushing their careers ahead of the work that needs to get done because they are really pushed to the back by their institution. So lack of security and precariousness is a very deadly mix and it really pushes global not academics to be very self centered at the cost of equity I would think. That's an interesting framing really isn't it because it makes it such a kind of structural issue for literally how all these institutions structure, how knowledge is researched and put out in the first place which is a very deep rooted problem isn't it? Extremely structural which is why we call them institutional barriers. A single good person in a global not at university will struggle as well intention they are. We know lots of good intention really solid people in a global not and I'm sure Catherine will fully endorse that but we are often helpless when our own institutions have set different incentives and targets for us rather than doing the right thing. So it takes that's why I think it's it's even possible to decolonize quote unquote one's own practice in global health but decolonizing our institutions is an absolute nightmare. It's it's virtually impossible the way the institutions are structured in the global not are governments being the single biggest barrier I would think to general inequity. Yeah so I was going to ask with the shorts of kind of deconstructing modes of knowledge in in the global north. What are some of the changes that might be necessary to better promote an equitable collaboration with Global South. I think as we framed in our paper, two things need to happen almost simultaneously. It isn't like there is one right way to do it. I think the Global South generally needs to own the space of Global Health. If it's anything to do with them, they need to be in charge, which is exactly what Catherine has been talking about. If it's Malaria and Uganda, then Ugandans will have to lead that agenda. They will be the ones to solve it, not for me in Canada or anyone else in the US or UK to solve that problem. They need to claim the space that is rightfully theirs. We, people like me and the Global North, need to rethink what we've been thinking of as ourselfers leaders in this space. We're not leaders. We're not going to be the ones solving the problem. We're far away from the problem, to be honest. And we can make disastrous mistakes because the further you are from the problem, the less and less you have lived experience, the less and less you have contextual experience, the less and less we are likely to get it right. So we need to be a lot more humble about our role. And as we said in the comment, our role changes from being a leader in Global Health to being a good ally or a good co-librator if you wish to folks who are really truly at the front lines, struggling with the issues and solving the issues. So, allyship is a very complex idea and it's a very rich loaded term. But I think we've given concrete examples of what allyship could look like in our article. Yeah, so perhaps we could talk about some of those concrete examples. Like how has this looked in practice so far, this notion of allyship? Let's take something concrete. We lived through this extraordinary pandemic where Global North Nations hooded vaccines refused to back their intellectual property waiver that was requested and endorsed by hundreds of countries. Even today, rich nations combined together and colluded with Big Pharma to scuttle the pandemic a court, which was meant to avoid this kind of holding and lack of access and equity in future pandemics. So I think the right thing we could have done should have done is to not only share vaccines very quickly, also helped other countries manufacture their own vaccines by sharing the vaccine technology. And certainly we should have all backed the pandemic a court or treaty to make sure this kind of egregious inequities don't occur in the future. So allyship for me is to genuinely show up when there is a need and center others rather than ourselves. Look at the impact crisis in Africa right now. Again, vaccines are being donated at a slow trickle when Africa needs way more than that. And Africa needs to manufacture their own vaccines so that they are not left high and dry every time there's a pandemic or there's a crisis. And I think global not allyship means supporting Africa in their efforts to manufacture their own medicines, drugs and vaccines. So these would all be concrete examples by which global not can be better allies when we have been all these years I would think. And then in the in a comment, we've also given examples of what global not allyship among journals could look like. So journals like Lancet journals like ours, plus global public health, what can we do to make our journals much more safer for colleagues from the global south who rarely get an opportunity to publish with us. How diverse are our editorial boards. And all of them are examples by which I think global not based institutions, governments, academia journals, we could all make a difference even global not based conferences. At the minimum, we should rotate the conference between the global not venue and the global south venue. That would I think be the lowest bar for any meeting that considers its our global health in the year 2025. If we continuously hold these meetings in hostile visa hostile countries, I'm afraid we have completely lost the plot on what global health is or should mean. So lots of work to do. It's not like I have a thousand great examples of allyship by global not. Power does not like to shift power or share power. So there is nothing in the way global not institutions or governments behave that gives me any reason for hope. Yes, there are a few institutions that are trying to do the right thing. But in general, global not has accumulated power over centuries by taking power from others, taking wealth from others through colonialism, settler colonialism. So we have a horrible track record behind us. That is why it's extremely hard for us to even understand what shifting power or sharing power even means let alone enacted. It even doesn't even occur to us. We can have a zoom that we were bond rich and wealthy. We are not bond rich and wealthy. We were accumulated wealth by extraction and ongoing extraction and neocolonialistic capitalistic practices that harms the global south immensely. So it will take a huge amount of self-reflexivity to even come close to knowing what the problem is, let alone doing the right thing. A spectacular example is climate crisis. So the global north is the reason why we are in this catastrophic climate crisis. And yet how many global not countries are willing to even admit that? Let alone compensate and do reparations for the global south through the last loss and damage fund that has been created. Reparations is something we don't even talk about anymore. How do we address the colonial damages that have caused immense harm even to just African continent? How do you even account for the damages done to them and the ongoing damages done to them? So that's why somebody rightfully critiqued our comment. We're saying you have given terrific examples of why nothing will change in global health. And I'm like, yeah, I know, I know, I'm sorry, but we were just being honest in the state of affairs. The first half of the commentry is very depressing because it really lays out down to its bone why global health is so messed up. It's the second half where I think our editor, Janna, wanted us to bring some hope by sharing some positive examples of what's possible or what others are actually doing in a meaningful way to shift power. Yeah, I was going to say a lot to do doesn't even begin to cover it. I was a Catherine of the House. We can come to you and talk a little bit about what the challenges are for global south leadership in this situation. Well, we wait for the global north to address these points, which could take a while. What is it that the global south can be doing and is doing where the kind of opportunities and challenges for the global south countries? I think maybe I'll start from what would global south leadership look like? And I think leadership would come at different levels. The beginning point is how are problems identified? What is a problem for instance in Uganda? What is a health problem in Kenya? What is the biggest challenge that the Kenya Kenya faces? The beginning point of how we identify problems, I think, would need to change and the leadership would come in from the global south, scholars, academics, researchers, communities to define their own problems. And that would mean dismantling the current practice of relying on this knowledge system, which depends on literature. So you deal a systematic review and it tells you there's a big problem. But there are biases that have been beauty to that into the papers which gives the systematic review. And what is known as lived experiences and passes knowledge is shunted aside. As a scientist somewhere in the global north, we'll sit down, basis, systematic review and decide that malaria is a very big problem in one district in Uganda. And then they'll find common do more research about this big problem. If you asked anybody in that district and say what's your biggest problem, they never said malaria is a problem. Not to minimize the impact of malaria, but if you asked them to prioritize the biggest problems, maybe malaria would end feature. And so the fact that we have this knowledge system which has been accepted as the best way to define problems means that in many instances we're addressing the wrong problems. So leadership would come from how do we define problems, who defines problems. And a different way of acknowledging that perhaps the people that you're trying to help, maybe no better what their problems are than us using a system to define what their problems and what of course what solutions are. Which is such a basic level isn't that but it kind of shows how deep rooted the issues are that we're still talking about allowing the global south to define what a problem is. And it may not be malaria. It doesn't matter how much we think malaria is a problem as a group has community. If your community says it's not our problem, then you should listen to that community and say it's okay, so what's your problem. And let's deal with that. And you might find that by dealing with a community problem over time you actually deal with malaria indirectly. That's the beginning point of who defines the problem, how we define problems. And then of course at the end of the day what gets done and who gets to do that. So that is that's where familiar leadership comes in and in a way to do some required dismantling our own. You know wild view because we are trained in the global system. So yorealista pero perturblat ―chepntiaio se Covid se hexet ―….kimi tutaka hidik Nana ―revalimita ―— ― buna Юn Sakura ―…kimi tutaka hidik ―…kimi tutaka hidik ―…kimi tutaka hidik ―…kimi tutaka hidik are decides that they're going to manufacture HIV medicines, their vaccines, their epochs vaccines, so that they become less and less and less reliant on global North and all the hegemony and power differential that comes with. So I think this is a beautiful real world illustration of where leadership should come from. And in the meantime, what global North, well intentioned individuals and an organization should fight hard to continue to do what is right until the time when Africa is self reliant and no longer needs any support for HIV or anything else for that matter. I think it's hard to be optimistic, it's got to be honest. I'm looking at where the world is going, but actually my bigger concern is that what you observe politically, I think is a result of other things. And so and those other things to me are things like the growth of misinformation and disinformation as an industry that pedals not just in you know, scientific, work and truth or falsehoods, but now goes into political falsehoods and creates narratives and really drives narratives in society. And so there's like a like as San this, I think there's something we are not fully prepared for around the information, I think the attention economy it's called in some ways. The attention economy and how that has grown by lips and bounds and we are fully unprepared on how to deal with it. So it's driving political shifts. So that's one thing like these changes are happening within a bigger context and whether it's one president today, I think for me, those are bigger concern because one president is you know four years, five years, but the next president actually might be you know, shaped by these things that we're not dealing with adequately. So for me, the bigger context is a problem and the bigger context has the misinformation, the disinformation, but also an underlying anti-science movement. So for me, the anti-science movement actually is a greater concern, maybe than PEPFA, PEPFA you know, can before years and then you know, the president comes and PEPFA is reinstated. Of course, there are big issues which are going to happen in the four years, but the anti-science movement may even have greater implications whether this PEPFA or not. So the context in which this change is happening for me is called is a huge concern. And then beyond of course, the change is in funding. You know, if PEPFA was pulled, it would be catastrophic. I don't think there's any African government prepared for this test to step up and do what PEPFA was doing. But the other issue which is again part of the context, I think is the narratives. I think we admit some progress around, you know, humanity, you know, this humanity, solidarity, where human beings equity. And now all this is like, oh no, D, I his nonsense. Let's like forget D, I like all this. Why do we have to talk about this? Racism is now the norm. It's okay to be racist, it's okay to be semitic, it's okay to be things which were society could not tolerate. Now we're tolerated at the highest level of political power. So it changes the narrative completely. So even don't know where do we start talking about localization. Like localization maybe is the last thing on anybody's mind because even the narratives within the people who've been power is like, what are you talking about? Why do we need to be smart of this power? There's no need to dismantle it. It should be as it is. So it's the narratives that are going to set us back many many many centuries. And then of course, the funding is now a much bigger short term problem. But the narratives I think are going to be much more enduring. And then they'll make it even harder with time to recover the ground. That's maybe the momentum that we started making when it comes to decolonization and all these other things. So then now of course now it comes to us the global south people and the leaders. I had hoped that COVID would be a wake up call to our political class. It wasn't. We're still sort of stuck in this fantasy about how the world works. And maybe this is going to be another wake up call. Maybe the real one. But ultimately, African so African governments have to step up. Whether it is today, whether it's in five years from now, the seniors from now, they have to step up because you can't keep like in this state where you're dependent on the goodwill and the mercy of others. And you're dependent on an election cycle every four years. There's anxiety. If this happens, then you know, I don't I don't think that's sustainable. So African governments need to step up. How they step up? It's of course, it's a long term thing. And it goes back to those things about a lie ship and how things can work differently. But I think the political class needs to recognize that we live in very dangerous times. And it is dangerous to be from a poor country or from a region of the world that is deemed to be a bit certain kind. And he's put in this big black box of of the furiority. So I don't think our political lessons are working up to that fact. Things are things are quint about gets worse before they get better. I think you're so right. And what's kind of struck me recently about the political situation in the US is that even if you say in four years time, we get a quite left wing government in that wants to put in programs all over the world. For example, you still, as you mentioned, got that danger of four further years down the line. And even further right wing government coming in in the US. So it actually sort of hopefully could pull away the veil. If that makes sense, that actually the US is not a reliable long-term partner for these programs by this point. The polarization there has got so bad that it can no longer be relied on as a stable because global health needs to work in decades. If a program can get removed every four years and then brought back every four years, but we've lost the four years there, we're just trying to rebuild. It makes an understandable situation, doesn't it? And hopefully people will read and listen and engage and think harder. As Katzin said, the coming years are going to be even more harder, I think, for equity and global health. We already seeing signs of it very clearly. So everything we said in our comment is even more relevant. I think in the coming years, in terms of the changing political context and the worsening of even basic human rights these days are not guaranteed for anyone. I think the conflicts around the world, including Kazaar, tells us there are people who are still not deemed worthy of humans and human rights. And that's the sad reality we are faced with. And it's a pleasure to collaborate with Katyn on this. She inspires me and I hope we can platform more such people in both in the journal and in the podcast as well, Kevin. Because that's what we need to be hearing, I think. Well, and Madu Pai, Katherine, Shobaton Ghee, thank you both so much for joining me on the podcast. It's been a real pleasure to talk with you and I wish you all the best for 2025 and beyond. Thanks, Kevin. Thank you. Thanks so much for listening to this episode of The Lancet Voice. If you're interested in other podcasts offered by The Lancet, as well as all of our videos and graphics, you can head to the Lancet.com/multimedia. Thanks again and we'll see you next time. [Music]