Madhu Pai Profile picture
13 Sep, 34 tweets, 12 min read
Thread on racism in #tuberculosis & global health.

I have been writing about power imbalance in global health.

Every aspect of global health is dominated by individuals, institutions and funders in HICs. Global health is neither global nor diverse.

forbes.com/sites/madhukar…
This NYT piece by @apoorva_nyc brought this discussion home to my own field of tuberculosis. It hits me hard because I know the people, and I served on the Board of @StopTB. I care about the agency & have given my time/expertise.

nytimes.com/2020/09/12/hea…
I respect the Board's independent investigation and look forward to the findings.

Whatever the outcome, it is critical to use this moment to reflect on the structural issues that make tuberculosis problematic. Otherwise, nothing will change.
First, tuberculosis has a very old colonial, exploitative history. This article by Paula Akugizibwe is powerful and worth reading:

howwegettonext.com/the-exploitati…
Second, although TB did kill millions in Europe and North America, the disease today mostly affects Black, Indigenous and People of Color (BIPOC) people in low and middle-income countries. In Canada, it primarily affects Indigenous communities where the incidence is 300X higher.
Although TB mostly affects BIPOC folks, the agenda today is still set by agencies and individuals in high-income countries, and mostly led by White folks from privileged backgrounds. I am aware that I am privileged, working on TB in a Center located in Canada.
Who controls TB funding & who has influence?

USAID, Global Fund, BMGF, Unitaid, DFID, Global Affairs Canada, etc (all led by White folks in HICs)

Yes, TB affected countries do spend money, but donors have a huge influence on the global agenda.
Where are major TB agencies headquartered & who leads them?

WHO, Stop TB, USAID, Global Fund, FIND, Aeras/IAVI, TB Alliance, Unitaid, Union, KNCV, BMGF,

All are based in HICs, all led by white folks.
Who dominates tuberculosis research productivity?

Our own bibliometric analysis shows that America dominates TB research (despite the low incidence). USA is also the biggest funder of TB researcher and R&D.

journals.plos.org/plosone/articl…
Where are big decisions made about TB?

Geneva, Washington DC, London, Seattle, NYC
So, this is why TB, like all of global health, is structurally problematic. Even well-intentioned people cannot overcome this deep power imbalance.
So, at some level, it is not surprising that TB has been included in a long and growing list of agencies which have structural racism and lack of diversity:

UNAIDS, UN, MSF, Women Deliver, USAID, Planned Parenthood, London School, IWHC, etc.
The structural issues have been bothering me for some years. In 2018, I wrote this piece @PLOSMedicine

Time for high-burden countries to lead the tuberculosis research agenda

journals.plos.org/plosmedicine/a…
I had written: The world cannot depend on a few wealthy countries with very low TB incidence to support all the research that is required to tackle TB. High-burden, middle-income countries with high TB rates must step up.
What we see in TB, we see in every global health organization & international aid agency.

-BIPOC folks are not in leadership roles
-Decisions are made far away from where the problems are
-Funding is tightly controlled by groups in HICs
-HIC researchers dominate
All of this creates toxic work environments and incredible levels of stress in global health and aid agencies.

My piece on burnout in global health digs deeper:

forbes.com/sites/madhukar…
Since global health leadership is dominated by White men from HICs, it cannot be easy for women and BIPOC. Concerns about sexual harassment, racism, White supremacy and abuse of power have been raised in many settings.

Here are some recent articles on this:
White Supremacy in Global Health by @AnuKumarIpas

thinkglobalhealth.org/article/white-…
From Dependency to Decolonization in Global Health by Paula Akugizibwe:

republic.com.ng/august-septemb…
We must translate anti-racism statements into action by Dorothy Peprah:

devex.com/news/opinion-w…
Let’s equalise our antiracist language by @Dr2NisreenAlwan

blogs.bmj.com/bmj/2020/07/03…
Real Talk on Racism in the Global Health Sector by @globalgamechngr

globalhealth.org/letter-from-lo…
How Gender Parity Improves Global Health by @DrTedros @DrSenait

project-syndicate.org/commentary/gen…
Challenging international development to get out of its comfort zone on gender equality by Rachel Firth & @RoopaDhatt

devex.com/news/opinion-c…
It is not enough to be quietly anti-racist by @ColleenDaniels8

medium.com/@colleen.danie…
Can schools of global public health dismantle colonial legacies? @DrMishalK @udnore & Dorothy Peprah

nature.com/articles/s4159…
On equity in the international development sector — we need more intravists, by @BlessingOmakwu

devex.com/news/opinion-o…
How (not) to write about global health

@desmondtanko

gh.bmj.com/content/5/7/e0…
It’s time to put an end to supremacy language in international development by Ann Hendrix-Jenkins

opendemocracy.net/en/transformat…
Each of us approaches the above issues through our own lens:
- Some of us are advocating for women in global health
- Some of us are advocating for LMIC representation
- Others focus on racism against BIPOC
- Others point our White supremacy
- Some focus on improving diversity
- Some of us are focused on "decolonizing global health"
- Some focus on neoliberalism
- Some on the White gaze

They are all connected and result in the inequities we see.

We are trying to touch/fix different parts of the same elephant.

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More from @paimadhu

6 Aug
Thread on 'global health degrees:

Ever wondered what a "Master's degree in Global Health" might cost you?

In our @GlobalHealthBMJ paper, by @svadzianita @av_Nathaly & @seyeabimbola, we identified 41 degree programs & estimated total tuition costs.

gh.bmj.com/content/bmjgh/…
Vast majority of such degree programs are in Europe & North America.

Across all 41 degree programs, the mean tuition fee was US $41,790 for international students and US $33,603 for domestic students.

This does NOT include living expenses, travel, healthcare or other costs.
Tuition was higher for international students, on-campus degrees, and in private schools. Even online degrees cost US $19353.

For US schools, the average tuition fee for all students was US $68,093. There was little difference between domestic and international student fees.
Read 18 tweets
18 Jul
A thread on burn-out in global health.

Having been engaged in global health for nearly 2 decades, I suspect high rates of burn out was a big issue before this pandemic.

Rarely discussed and most people suffer silently.
Global health (pre-Covid, at least) involved a lot of travel, and a crazy lifestyle (living off suitcases, meetings, conference calls at crazy hours, need to attend social events). This is initially exciting for young people, but not ideal for stable relationships & families.
The next big issue is global health work is inherently political - dealing with the constant politics, putting out fires, endless negotiations, competition, inter-agency rivalry etc. comes at a personal cost.
Read 12 tweets
15 Jul
This worries me a lot. Nobody has any experience in giving the live BCG vaccine to elderly people! Without proving safety, no program should be vaccinating elderly people.

There is no direct evidence proving that BCG will reduce #Covid19 mortality.

Please wait for RCT results!!
Let me clarify further:

1. Millions of infants get BCG every year. It is quite safe in this group.
2. But the number of elderly people given BCG is close to ZERO.
3. BCG is a live vaccine. It should not be given to elderly (who might have comorbidities) without safety data.
4. All we have now are ecologic correlation studies showing a link between BCG & #COVID19

5. These studies have serious limitations (see Forbes piece below).

forbes.com/sites/madhukar…
Read 5 tweets
9 Jul
So, I was born & raised in a town called Vellore in South India. Here is a pic of one of the schools I attended.

Growing up, I did not see anything that was unusual or exceptional about Vellore, save for the hospital I was born (Christian Medical College) which was amazing.
Fast forward to present, it is incredible to see Bill Gates highlight Vellore district as an exemplar - a positive outlier - in terms of its progress towards SDGs!

Right now, India is not on track to achieve to SDGs, but Vellore has achieved them a decade before the deadline!

Incredible! Makes me so happy!

So, what can other districts in India learn from Vellore?
Read 5 tweets
5 Jun
Global health poses many dilemmas & conflicts.

I was born & raised in India, but now live in Canada. Can I still speak for India?

I am a male. Can I advocate for gender equity?

I am not a TB survivor. Can I advocate for greater civil society representation in TB?
No matter what I do, it never seems enough. I know others like me with their own struggles.

At a minimum, I can transparently acknowledge my privileges.

I can use my privilege to serve as an ally in the quest for a more diverse and equitable global health.
This piece with @KatriBertram & @udnore (who are dealing with their own versions of my struggles) is all about exploring this complex territory of who can speak for whom about what.

We don't have answers, but do care to reflect & raise these issues.

thinkglobalhealth.org/article/silenc…
Read 6 tweets
10 May
As lockdown starts easing up across India, what is the plan to deal with the massive surge of people who have been deferring care for all sorts of conditions? Undiagnosed TB, severe diabetes, cancer, mental health, you name it.

A plan for the "big surge" must be in place.
When people begin seeking care, there several big challenges for them to get adequate care:

1. There will be fewer private facilities operating, given the impact of COVID

2. Public systems will still be dealing with COVID-19, as cases will occur even after lockdown lifts
3. Private facilities that come back online might charge more to make up for revenue losses over the past 2 months; supplies will cost more

4. Both public and private sectors will take several weeks to recover and resume regular services
Read 8 tweets

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