Contributor: Adam Leonard

“Imperialism leaves behind germs of rot which we must clinically detect and remove from our land but from our minds as well.”

Franz Fanon

I have been reflecting on this quote since I returned from a summer research residency in South Africa as a part of my first-year Ph.D. program in nursing. The quote, written by the Afro-Caribbean psychiatrist, philosopher, and anti-colonial activist Frantz Fanon in his classic 1961 book The Wretched of the Earth, has left me questioning the ethics of my own role in global health research and what, if any, ethical path forward exists for me in the field as an emerging scientist from the United States of America.

 I spent six weeks at a drug-resistant TB (DRTB) hospital ward in South Africa “supporting” (insomuch as a novice scholar can) the launch of a multiyear National Institutes of Health (NIH) grant implementing and evaluating nurse-initiated DRTB treatment in community public health centers as compared to physician-delivered care in tertiary regional hospitals, which is the current standard of care in the country. As one might imagine, situating a several-month course of treatment that requires frequent in-person visits at a regional center many miles from most patients’ homes presents a significant challenge to treatment initiation and completion for many South Africans with TB who are living in poverty.

TB, especially DRTB, is a significant public health problem in South Africa: in 2022, an estimated 280,000 people were infected with TB, and a sobering 54,000 died from the disease. Fortunately, pharmacological advances have led to shorter course treatment with high cure rates. Despite this, nearly one-quarter of South Africans with TB in 2021 could not complete treatment because of structural barriers or, unfortunately, death. This is to say nothing of the fact that all of this is occurring against the backdrop of the largest HIV epidemic in the world, further complicating the public health response. This research trial can potentially improve cure rates through increased care retention and reduce catastrophic costs due to treatment by limiting travel time and missed work. This effort builds from the previous successes of South African nurses’ role in delivering primary healthcare; South Africa has the largest public HIV treatment program in the world, and it is largely delivered by nurses.

My concern is about my own ethical involvement as an outsider coming into the study and potentially nesting my doctoral research within this trial. The development and design of the project itself grew out of a more than 10-year relationship between a U.S.-based nurse researcher, South African academics, government health officials, and professional nurses within the country’s public health sector. The NIH grant includes three principal investigators, one U.S. researcher, one South African faculty, and a top official in the country’s Department of Health (DoH). The intervention is training South African nurses, including those who are not directly involved in the study, to treat DRTB in outpatient, local settings as part of a long-term capacity-building initiative to shift treatment closer to communities most impacted by the disease. This effort directly aligns with the nation’s DOH Strategic Development Plan. My trepidation is not with the overall project but rather how I ethically fit into it.

The history of global health itself stems directly from European (later American) imperialism and colonialism, the Atlantic slave trade, industrialization, and the subsequent rise of global capitalism and corporatocracy. Epidemic control was born from a colonial drive to maintain labor supply, subjugate indigenous peoples through a “civilizing” process, protect imperial settlers and military forces from depletion, and create environments conducive to corporate exploitation. The emerging field of “tropical medicine” was used as a tool to create a distinction between Europe and its colonies and to form a biological basis for racialized medicine and dehumanization. Along with the emergence of the corpo-state in the early 20th century came scientific philanthropy with its own capitalist agenda, and no entity was more influential in the birth of international health than the Rockefeller Foundation. This history demonstrates that global health work is not just a technical pursuit but also an exercise in power and authority, and as such, requires constant self-reflection and reasoned analysis if one intends to engage in the field ethically and morally.

Inspired by Fanon and Critical Social Theory (CST), I am intentionally evaluating if and how I can, as a Ph.D. student, meaningfully conduct global health research in an decolonial way. Nursology outlines key questions to address when using an emancipatory framework, like CST and Fanon: Who benefits? What is wrong with this picture? What are the barriers to freedom? What changes are needed? I will briefly share my own reflections on these questions but do not intend to answer these questions decisively and for all readers. Rather, I hope my reflections and the following resources will inspire emerging scholars in a similar position to critically reflect on their own global health endeavors.

Considering who benefits from my potential doctoral research in South Africa has an obvious answer: me. Pursuing a global health dissertation will ideally (in the opinion of the academy at least) lead to predoctoral funding opportunities (such as an NIH National Research Service Award Predoctoral Fellowship aka F31 award), publications in prestigious US / UK-based journals, and a competitive postdoctoral fellowship (such as a Fogarty Award)—all culminating in a faculty appointment with a “promising research agenda.” I would like to think that my dissertation research will make a difference in people’s lives, but that is not what dissertation research is designed to accomplish. The problem with this scenario is that it is inherently self-serving in the short term, regardless of any long-term research goals. It is difficult to build equitable international partnerships within the constraints of a doctoral program. The academy values publications in “high impact” journals or presentations at “elite” conferences rather than periodicals and meetings more likely to reach health professionals in the communities from which the data were derived.

There are many barriers to engaging in more equitable, emancipatory doctoral research. Any goal of changing the academic system from within requires entry into the academy in the first place. This requires “playing the game” as it is currently set. Though many faculty members are leading the way in transforming global health research and eagerly provide mentorship, the larger structures determining a “fundable score” on a grant or “merit and promotion” for early carrier faculty are far behind such a transformation. Similarly, government funders and donor agencies largely prioritize “scientifically sound” (aka randomized controlled trials) that can be completed within a five-year period, none of which are conducive to the extensive unfunded work and time needed to co-define problems and co-create solutions across national borders. The changes needed to create a more equitable global health environment are nothing short of revolutionary. Save a collapse of the current global political economy, I will focus on resources that can help me—and hopefully others—consider if one can and how one might engage in equitable global health work.

To start, the Global Nursing Caucus has curated educational courses and curricula for ethical global health work. Specifically, they link to a case-based course on ethical issues that may arise in short-term global health research experiences. I intend to engage with this content before doing any doctoral research in South Africa. Second, both the University of Washington and the Research Fairness Initiative have developed a toolkit and extensive guidelines for decolonial frameworks for global health work. If I do pursue a global health dissertation, I intend to utilize these tools before, during, and after designing, implementing, and reporting my findings. Finally, the International Council of Nurses has recently launched a Certified Global Nurse Consultant certification in recognition of the need for nursing voices in the global health dialogue that uplifts equity and justice in global health policy and research.

I am fortunate to have had the global experience and educational mentorship to be considering these essential ethical questions now, in the first semester of my Ph.D. program. Global health work is indeed wrought with ethical and moral dilemmas. But in this moment of late-stage global capitalism, engaging in the work as justly as possible seems essential to respond to the human suffering brought about by this filthy-rotten system. While I hope and work for the complete transformation of the imperial global paradigm, I hope to find a way to ethically contribute to knowledge that improves people’s health in South Africa. I guess I will let you know how that goes in four (or five) years.

About Adam Leonard

I am a white, queer, gender-expansive individual who is a survivor of an invisible disability. I am part of the global Irish diaspora and a white settler colonialist living in the so-called United States. I work to integrate my own ancestral experience of imperialism and forced migration with the fact that I have been an occupier of unceded indigenous lands throughout my lifetime: Mdewakanton Lakota, Seminole, Ramaytush Ohlone, and most currently, Piscataway and Susquehannock. I come from a working-class family in the service industry and am the first generation in my family to attend college. I continuously benefit from unearned privilege as a white person in a white supremacist society. I work to upend my implicit biases and work for justice and liberation through antiracist and decolonial praxis: continuous learning, critical self-reflection, and reparatory political and civic engagement. As a health care provider, I am in a position of power in relation to patients, and I strive to operate from a foundation of emancipatory practice. I am currently a PhD student at the Johns Hopkins School of Nursing.