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‘Labouring’ on the frontlines of global health research: mapping challenges experienced by frontline workers in Africa and Asia

‘Labouring’ on the frontlines of global health research: mapping challenges experienced by frontline workers in Africa and Asia

ABSTRACT

Drawing on the reflections and discussions from a special session at the 2021 Global Health Bioethics Network summer school, this paper has summarised the key challenges faced by Frontline Workers (FWs) across research sites in Africa and Asia in performing the everyday ‘body work’ entailed in operationalising global health research. Using a ‘body work’ lens, we specifically explore and map key challenges that FWs face in Africa and Asia and the physical, social, ethical, emotional, and political labour involved in operationalising global health in these settings. The research encounter links with wider social and economic structures, and spatial dimensions and impacts on the FWs’ performance and well-being. Yet, FWs’ ‘body-work’ and the embedded emotions during the research encounter remain hidden and undervalued.

Busisiwe Nkosi, Jennifer Ilo Van Nuil, Deborah Nyirenda, Primus Che Chi & Mira Leonie Schneiders (2022) ‘Labouring’ on the frontlines of global health research: mapping challenges experienced by frontline workers in Africa and Asia, Global Public Health, DOI: 10.1080/17441692.2022.2124300

Image credit: Image by Matteo Guedia is licensed by iStock

Whose voices should shape global health education? Curriculum codesign and codelivery by people with direct expertise and lived experience

There are contrasting opinions of what global health (GH) curricula should contain and limited discussion on whose voices should shape it. In GH education, those with first-hand expertise of living and working in the contexts discussed in GH classrooms are often absent when designing curricula. To address this, we developed a new model of curriculum codesign called Virtual Roundtable for Collaborative Education Design (ViRCoED). This paper describes the rationale and outputs of the ViRCoED approach in designing a new section of the Global Health Bachelor of Science (BSc) curriculum at Imperial College London, with a focus on healthcare in the Syrian conflict. The team, importantly, involved partners with lived and/or professional experience of the conflict as well as alumni of the course and educators in all stages of design and delivery through to marking and project evaluation. The project experimented with disrupting power dynamics and extending ownership of the curriculum beyond traditional faculty by codesigning and codelivering module contents together with colleagues with direct expertise and experience of the Syrian context. An authentic approach was applied to assessment design using real-time syndromic healthcare data from the Aleppo and Idlib Governorates. We discuss the challenges involved in our collaborative partnership and describe how it may have enhanced the validity of our curriculum with students engaging in a richer representation of key health issues in the conflict. We observed an enhanced self-reflexivity in the students’ approach to quantitative data and its complex interpretation. The dialogic nature of this collaborative design was also a formative process for partners and an opportunity for GH educators to reflect on their own positionality. The project aims to challenge current standards and structures in GH curriculum development and gesture towards a GH education sector eventually led by those with lived experience and expertise to significantly enhance the validity of GH education.

Sbaiti M, Streule MJ, Alhaffar M, et al Whose voices should shape global health education? Curriculum codesign and codelivery by people with direct expertise and lived experience, BMJ Global Health 2021;6:e006262.

‘I’m Not that Kind of Doctor’ On Being In-Between in a Global Health Intervention

Within multi-disciplinary global health interventions, anthropologists find themselves navigating complex relationships of power. In this article, I off er a critical reflection on this negotiated terrain, drawing on my experience as an embedded ethnographer in a four-year adolescent sexual and reproductive health research intervention in Latin America. I critique the notion that the transformative potential of ethnographic work in global health remains unfulfilled. I then go on to argue that an anthropological practice grounded in iterative, inter-subjective and self-reflexive work has the potential to create ‘disturbances’ in the status quo of day-to-day global health practice, which can in turn destabilise some of the problematic hubristic assumptions of health reforms.

Nelson E (2019) ‘I’m Not that Kind of Doctor’ On Being In-Between in a Global Health Intervention, Anthropology in Action, Vol 6, Issue 21

Navigating ‘ethics in practice’: An ethnographic case study with young women living with HIV in Zambia

While ‘procedural ethics’ provides essential frameworks for governing global health research, reflecting on ‘ethics in practice’ offers important insights into addressing ethically important moments that arise in everyday research. Particularly for ethnographic research, renowned for it’s fluid and spontaneous nature, engaging with ‘ethics in practice’ has the potential to enhance research practice within global health. We provide a case study for such reflexivity, exploring ‘ethics in practice’ of ethnographic research with middle-income young women living with HIV in Lusaka, Zambia. We explore the ethical issues arising from the layered interaction of the population (young women), the disease under investigation (HIV), the method of study (ethnographic), and the setting (Zambia, a lower middle income country). We describe how we navigated five key practical ethical tensions that arose, namely the psycho-emotional benefits of the research, the negotiated researcher-participant relationship, protecting participants’ HIV status, confidentiality and data ownership, and researcher obligations after the end of the research. We exemplify reflexive engagement with ‘ethics in practice’ and suggest that engaging with ethics in this way can make important contributions towards developing more adequate ethical guidelines and research practice in global public health.

Constance R. S. Mackworth-Young, Virginia Bond, Anne L. Stangl, Mutale Chonta, Alison Wringe. (2020) Coming of age with HIV: a temporal understanding of young women’s experiences in Zambia. AIDS Care 0:0, pages 1-8.

The Ghost Is the Machine: How Can We Visibilize the Unseen Norms and Power of Global Health?

In his recent commentary, Gorik Ooms argues that “denying that researchers, like all humans, have personal opinions … drives researchers’ personal opinion underground, turning global health science into unconscious dogmatism or stealth advocacy, avoiding the crucial debate about the politics and underlying normative premises of global health.” These ‘unconscious’ dimensions of global health are as Ooms and others suggest, rooted in its unacknowledged normative, political and power aspects. But why would these aspects be either unconscious or unacknowledged? In this commentary, I argue that the ‘unconscious’ and ‘unacknowledged’ nature of the norms, politics and power that drive global health is a direct byproduct of the processes through which power operates, and a primary mechanism by which power sustains and reinforces itself. To identify what is unconscious and unacknowledged requires more than broadening the disciplinary base of global health research to those social sciences with deep traditions of thought in the domains of power, politics and norms, albeit that doing so is a fundamental first step. I argue that it also requires individual and institutional commitments to adopt reflexive, humble and above all else, equitable practices within global health research.

Forman, L. (2016) The Ghost Is the Machine: How Can We Visibilize the Unseen Norms and Power of Global Health? Int J Health Policy Manag. 2016 Mar; 5(3): 197–199

Navigating Between Stealth Advocacy and Unconscious Dogmatism: The Challenge of Researching the Norms, Politics and Power of Global Health

Global health research is essentially a normative undertaking: we use it to propose policies that ought to be implemented. To arrive at a normative conclusion in a logical way requires at least one normative premise, one that cannot be derived from empirical evidence alone. But there is no widely accepted normative premise for global health, and the actors with the power to set policies may use a different normative premise than the scholars that propose policies – which may explain the ‘implementation gap’ in global health. If global health scholars shy away from the normative debate – because it requires normative premises that cannot be derived from empirical evidence alone – they not only mislead each other, they also prevent and stymie debate on the role of the powerhouses of global health, their normative premises, and the rights and wrongs of these premises. The humanities and social sciences are better equipped – and less reluctant – to approach the normative debate in a scientifically valid manner, and ought to be better integrated in the interdisciplinary research that global health research is, or should be.

Ooms G. (2015) Navigating Between Stealth Advocacy and Unconscious Dogmatism: The Challenge of Researching the Norms, Politics and Power of Global Health, Int J Health Policy Manag. 2015 Oct; 4(10): 641–644

‘Doing’ health policy analysis: methodological and conceptual reflections and challenges

The case for undertaking policy analysis has been made by a number of scholars and practitioners. However, there has been much less attention given to how to do policy analysis, what research designs, theories or methods best inform policy analysis. This paper begins by looking at the health policy environment, and some of the challenges to researching this highly complex phenomenon. It focuses on research in middle and low income countries, drawing on some of the frameworks and theories, methodologies and designs that can be used in health policy analysis, giving examples from recent studies. The implications of case studies and of temporality in research design are explored. Attention is drawn to the roles of the policy researcher and the importance of reflexivity and researcher positionality in the research process. The final section explores ways of advancing the field of health policy analysis with recommendations on theory, methodology and researcher reflexivity.

Walt et al (2008) ‘Doing’ health policy analysis: methodological and conceptual reflections and challenges, Health Policy Plan (2008) 23 (5)

Reflections on Researcher Identity and Power: The Impact of Positionality on Community Based Participatory Research (CBPR) Processes and Outcomes

The practice of community based participatory research (CBPR) has evolved over the past 20 years with the recognition that health equity is best achieved when academic researchers form collaborative partnerships with communities. This article theorizes the possibility that core principles of CBPR cannot be realistically applied unless unequal power relations are identified and addressed. It provides theoretical and empirical perspectives for understanding power, privilege, researcher identity and academic research team composition, and their effects on partnering processes and health disparity outcomes. The team’s processes of conducting seven case studies of diverse partnerships in a national cross-site CBPR study are analyzed; the multi-disciplinary research team’s self-reflections on identity and positionality are analyzed, privileging its combined racial, ethnic, and gendered life experiences, and integrating feminist and post-colonial theory into these reflections. Findings from the inquiry are shared, and incorporating academic researcher team identity is recommended as a core component of equalizing power distribution within CBPR.

Muhammad M. et al (2014) Reflections on Researcher Identity and Power: The Impact of Positionality on Community Based Participatory Research (CBPR) Processes and Outcomes, Critical Sociology 1–20

Getting personal: Ethics and identity in global health research

‘Researcher identity’ affects global health research in profound and complex ways. Anthropologists in particular have led the way in portraying the multiple, and sometimes tension-generating, identities that researchers ascribe to themselves, or have ascribed to them, in their places of research. However, the central importance of researcher identity in the ethical conduct of global health research has yet to be fully appreciated. The capacity of researchers to respond effectively to the ethical tensions surrounding their identities is hampered by lack of conceptual clarity, as to the nature and scope of the issues involved. This paper strives to provide some clarification of these ethical tensions by considering researcher identity from the perspective of (1) Guillemin and Heggen’s (2009) key distinction between procedural ethics and ethics in practice, and (2) our own distinction between perceptions of identity that are either symmetrical or asymmetrical, with the potential to shift research relationships toward greater or lesser ethical harmony. Discussion of these concepts is supported with ethnographic examples from relevant literature and from our own (United States (US) Government-funded) research in South Africa. A preliminary set of recommendations is provided in an effort to equip researchers with a greater sense of organization and control over the ethics of researcher identity. The paper concludes that the complex construction of researcher identity needs to be central among the ethical concerns of global health researchers, and that the conceptual tools discussed in the paper are a useful starting point for better organizing and acting on these ethical concerns.

Simon C. and Mosavel M. (2011) Getting personal: Ethics and identity in global health research, Dev World Bioeth. 2011 Aug; 11(2): 82–92

Health Systems Research in a Complex and Rapidly Changing Context: Ethical Implications of Major Health Systems Change at Scale

This paper discusses health policy and systems research in complex and rapidly changing contexts. It focuses on ethical issues at stake for researchers working with government policy makers to provide evidence to inform major health systems change at scale, particularly when the dynamic nature of the context and ongoing challenges to the health system can result in unpredictable outcomes. We focus on situations where ‘country ownership’ of health systems research is relatively well established and where there is significant involvement of local researchers and close ties and relationships with policy makers are often present. We frame our discussion around two country case studies with which we are familiar, namely China and South Africa and discuss the implications for conducting ‘embedded’ research. We suggest that reflexivity is an important concept for health system researchers who need to think carefully about positionality and their normative stance and to use such reflection to ensure that they can negotiate to retain autonomy, whilst also contributing evidence for health system change. A research process informed by the notion of reflexive practice and iterative learning will require a longitudinal review at key points in the research timeline. Such review should include the convening of a deliberative process and should involve a range of stakeholders, including those most likely to be affected by the intended and unintended consequences of change.

MacGregor, H. and Bloom, G. (2016) Health Systems Research in a Complex and Rapidly Changing Context: Ethical Implications of Major Health Systems Change at Scale, Dev World Bioeth. 2016 Dec; 16(3)