Prof. Agnes Binagwaho

The global health enterprise has contributed to improving the wellbeing of people and increasing access to health services. However, deep structural inequities persist between institutions from high-income countries (HICs) and those in low and middle-income countries (LMICs) in access to resources, training, and knowledge. This results in significant health inequities, lack of ownership, lost opportunities, misguided priorities, and wholly insufficient attempts at achieving the Sustainable Development Goals. Power imbalances are embedded across funding opportunities, research management and coordination, knowledge production and transfer, access to training resources and most technical and political aspects of global health.1 The current pandemic, which has further highlighted these inequities, is an opportunity to acknowledge and rectify these gaps.2 The changes needed include ensuring that partnerships between HIC and LMIC institutions are equitable and that benefits from those arrangements accrue equally to all parties. Collaborations rooted in respect, honesty, equity, as well as commitment to mutual capacity building and health outcomes aligned with the needs of the LMIC partners are essential to reforming global health. Previous attempts have been made to address this imbalance, but there is a lack of accountability. The following reforms are concrete suggestions, particularly for the academic community, to achieve this objective. Overcoming the research to policy gap is critical to addressing health challenges.3 However, knowledge generated and reported in scientific publications is largely inaccessible to LMIC researchers even when they play a significant role in the research process.4 HIC research institutions should provide free access to their academic libraries to their LMIC partners. Moreover, research findings must be shared with equity, fairness, and respect for the work of LMIC and HIC collaborators. Results of global health research should be translated into local languages, with plans drawn at the start to ensure dissemination to all stakeholders including communities which are the subject of the research.

Patterns of marginalization and exclusion of the vulnerable in medicine and public health have become the norm. The vulnerable, especially on the African continent, have been left out of the distribution of life-saving medical and public health interventions. When included, they have always been last in line to receive such interventions. This inequity prevents Africa from stopping the spread of diseases, resulting in preventable deaths. The repercussions of this inequitable distribution are magnified in countries whose health systems have been weakened by centuries of colonization and unfair international policies such as the structural adjustment programs that hollowed out public investment in health systems.1 A prime example that illustrates the historical marginalization of the vulner- able is the distribution of antiretroviral therapy (ART). In the 1990s, powerful administrations such as the U.S. government strongly pushed for ART to be denied to HIV/ AIDS patients in developing countries as it was considered too expensive, too complicated, and not cost-effective.2 Instead, leaders around the world called for prevention as a cheaper means of reducing the spread of the virus, leaving the 40 million infected in Sub-Saharan Africa in 2002 with no treatment options at a time when treatment was available.3 This is just one example of the countless manifestations of injustice that have pervaded our society, leaving Africa to contend with diseases that have become an afterthought on other continents.

Background Africa is undergoing both an environmental and an epidemiological transition. Household air pollution is the predominant form of air pollution, but it is declining, whereas ambient air pollution is increasing. We aimed to quantify how air pollution is affecting health, human capital, and the economy across Africa, with a particular focus on Ethiopia, Ghana, and Rwanda. Methods Data on household and ambient air pollution were from WHO Global Health Observatory, and data on morbidity and mortality were from the 2019 Global Burden of Disease Study. We estimated economic output lost due to air pollution-related disease by country, with use of labour income per worker, adjusted by the probability that a person (of a given age) was working. Losses were expressed in 2019 international dollars and as a proportion of gross domestic product (GDP). We also quantified the contribution of particulate matter (PM)2·5 pollution to intelligence quotient (IQ) loss in children younger than 10 years, with use of an exposure–response coefficient based on previously published data. Findings Air pollution was responsible for 1·1 million deaths across Africa in 2019. Household air pollution accounted for 697000 deaths and ambient air pollution for 394000. Ambient air pollution-related deaths increased from 361000 in 2015, to 383000 in 2019, with the greatest increases in the most highly developed countries. The majority of deaths due to ambient air pollution are caused by non-communicable diseases. The loss in economic output in 2019 due to air pollution-related morbidity and mortality was $3·02 billion in Ethiopia (1·16% of GDP), $1·63 billion in Ghana (0·95% of GDP), and $349 million in Rwanda (1·19% of GDP). PM2·5 pollution was estimated to be responsible for 1·96 billion lost IQ points in African children in 2019. Interpretation Ambient air pollution is increasing across Africa. In the absence of deliberate intervention, it will increase morbidity and mortality, diminish economic productivity, impair human capital formation, and undercut development. Because most African countries are still early in development, they have opportunities to transition rapidly to wind and solar energy, avoiding a reliance on fossil fuel-based economies and minimising pollution.

The term “decolonization” has been increasingly used to refer to the elimination of the colonial experience and its legacy. However, the use of this overarching term masks the real root of the problem. European countries, whose populations are majority white, used their assumed supremacy as justification for the colonization of current low- and middle-income countries (LMICs) where the majority of non-white people live. This clear overlap between geographic and skin color differences explains how the white supremacy ideology triggered European colonization. Therefore, calls to decolonize global health education must focus on the roots of colonization and fight for the elimination of white supremacy ideology that is one of the pillars of the current ills of our global health architecture. A step in this process acknowledging the expertise that emerges from LMICs, alongside challenging the traditional high-income country (HIC) hegemony over knowledge and strengthening universities in LMICs to provide quality medical and global health education. Additionally, we also need to reevaluate curricula, research selection, and design as well as partnerships. Students need to be equipped with the skills to question norms and contribute to the creation of equitable, mutually beneficial partnerships. This needs to accompanied by the adoption of transdisciplinary education to address critical societal challenges. By challenging the white supremacy ideology, we can shift the center of gravity in global health to respect the right to equal say in education and research according to the disease burden and the distribution of the world population.

There is increasing evidence that elimination strategies have resulted in better outcomes for public health, the economy, and civil liberties than have mitigation strategies throughout the first year of the COVID-19 pandemic. With vaccines that offer high protection against severe forms of COVID-19, and increasing vaccination coverage, policy makers have had to reassess the trade-offs between different options. The desirability and feasibility of eliminating SARS-CoV-2 compared with other strategies should also be re-evaluated from the perspective of different fields, including epidemiology, public health, and economics. To end the pandemic as soon as possible—be it through elimination or reaching an acceptable endemic level—several key topics have emerged centring around coordination, both locally and internationally, and vaccine distribution. Without coordination it is difficult if not impossible to sustain elimination, which is particularly relevant in highly connected regions, such as Europe. Regarding vaccination, concerns remain with respect to equitable distribution, and the risk of the emergence of new variants of concern. Looking forward, it is crucial to overcome the dichotomy between elimination and mitigation, and to jointly define a long-term objective that can accommodate different political and societal realities.

Children are exquisitely vulnerable to environmental hazards.1 This sensitivity reflects children's unique exposures, their immaturity, and the great complexity of early human development. Exposures during prenatal windows of susceptibility can increase risk for disease in childhood and impair health across the lifespan. WHO estimates that one death in four among children worldwide could be averted by reducing hazardous environmental exposures.2 Three hazards of particular concern today are air pollution, toxic chemicals, and climate change. Air pollution harms children's health by increasing risks of premature birth, low birthweight, stillbirth, and asthma.3 Air pollution is linked also to IQ loss and increased risks of autism and attention deficit hyperactivity disorder.4 More than 90% of air-pollution-related deaths occur in low-income and middle-income countries (LMICs).5 Chemical pollution is a growing threat.5 The health hazards of chemical pollution have been recognised since the publication of Rachel Carson's Silent Spring in 1962,6 but the problem has worsened since then. Children today are surrounded by an estimated 350 000 manufactured chemicals,7 many of which pollute the planet and harm human health. Polychlorinated biphenyls (PCBs), methyl mercury, lead, brominated flame retardants, and organophosphate insecticides impair cognitive function and increase risks of neurodevelopmental disorders.4 Phthalates are linked to male reproductive birth defects and neurodevelopmental delays.8 In-utero exposure to bis(4-chlorophenyl)-1,1,1-trichloroethane (DDT) increases risk of adult breast cancer.6 Prenatal exposures to perfluorinated substances (PFAS) are linked to immune dysfunction and impaired fetal growth.9 Climate change increases risks of adverse pregnancy outcomes, heat-related illness, allergic diseases, famine, and migration.10 The burden of these climate-related hazards is only beginning to be measured.

The growing awareness of colonialism’s role in global health partnerships between HICs and LMICs and the associated calls for decolonization in global health has led to discussion for a paradigm shift that would lead to new ways of engagement and partnerships, as well as an acknowledgement that colonialism, racism, sexism, and capitalism contribute to inequity. While there is general agreement among those involved in global health partnerships that the current system needs to be made more equitable, suggestions for how to address the issue of decolonization vary greatly, and moving from rhetoric to reform is complicated. Based on a comprehensive (but not exhaustive) review of the literature, there are several recurring themes that should be addressed in order for the inequities in the current system to be changed. The degree to which decolonization of global health will be successful depends on how the global health community in both the HICs and LMICs move forward to discuss these issues. Specifically, as part of a paradigm shift, attention needs to be paid to creating a more equal and equitable representation of researchers in LMICs in decision-making, leadership roles, authorship, and funding allocations. There needs to be agreement in defining basic principles of best practices for global partnership, including a universal definition of ‘decolonization of global health’; the extent to which current policies allow the perpetuation of power imbalance between HICs and LMICs; a set of principles, best practices, and models for equitable sharing of funds and institutional costs among partners; a mechanism to monitor progress prospectively the equitable sharing of credits (e.g., leadership, authorship), including a set of principles, best practices, and models; and, a mechanism to monitor progress prospectively the extent to which decolonialization will contribute to strengthening institutional capacity in the LMIC institutions.