© World Health Summit

An expert panel discusses power and partnerships in global health.

When a disease outbreak is detected inside a country, what is the appropriate role for outside support? Rapid Response Teams, often comprising experts from high-income countries, have become a standard feature of outbreak response efforts in low- and middle-income countries. But to what extent do they perpetuate neo-colonial attitudes and practices through imbalances in power and resources, and assumptions about where expertise resides? 

A group of international experts from the ‘Global North’ and the ‘Global South’ had a frank exchange on this important topic during a session organised by Germany’s Federal Ministry of Economic Cooperation and Development (BMZ) at the 2023 World Health Summit in Berlin.

Health systems are a global public good. We have a shared interest in making them work.

The session was moderated by Andreas Gilsdorf, the chief of staff to the president of the Robert Koch Institute and the former head of the German Epidemic Preparedness Team (SEEG). SEEG is a multi-sectoral, multi-disciplinary Rapid Response Team that the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH coordinates on behalf of BMZ, the German Federal Ministry of Health (BMG) and the German Federal Ministry of Agriculture (BMEL). Since its creation in late 2015, SEEG has undertaken 60 deployments to countries in Africa, Asia and Latin America to strengthen systems for detecting and containing infectious disease outbreaks. 

What are the political motivations behind such initiatives? And why, for example, is the German parliament willing to finance the work of German experts in other countries? For Jochen Flasbarth, State Secretary at BMZ, there is a shared interest in ensuring that health systems everywhere have the capacity to respond to threats.

With COVID-19 the world understood that when we talk about global health systems, we are talking about a global public good. No one is safe until we are all safe.

Jochen Flasbarth, BMZ

An outbreak situation is the time to look and see if there is something that can be done to support partner countries, he continued. ‘To provide expertise where there might be a lack of expertise is, in my view, an appropriate approach.’   

Global health should be global

Ngozi Erondu, the Co-Chair of O’Neill-Lancet Commission on Racism, Structural Discrimination and Global Health, agreed that there can be a place for international Rapid Response Teams, but that their use needs to be ‘informed and specific.’ In her view there is an urgent need for a set of overarching principles and standards to govern the way such teams prepare for their missions and then operate in countries. This would help to guard against neo-colonial tendencies, including outbreak teams arriving in countries with little understanding of existing health system capacities; failure to integrate into local systems; lack of relevant language skills; ignorance of local cultural or religious practices; and taking data and specimens out of the country at the end of an assignment.

Ngozi Erondu also pushed back against a ‘hierarchy of intelligence’ which presumes that all good ideas come from the Global North. ‘Global health should be global,’ she said:

It seems so one-directional – as if only low- and middle-income countries need help. We know from COVID that this is not true. Everybody needs help.

Ngozi Erondu, O’Neill-Lancet Commission

She noted that many African countries have significant experience in responding to outbreaks. The failure to consult Nigerian experts regarding the re-emergence of mpox (monkeypox), for example, is a recent example of a major missed opportunity to draw on expertise from the Global South.

Before stepping in, question the premise of your support

Prior to entering a country, it is imperative that Rapid Response Teams take the time to understand what the local capacities actually are, said John Amuasi, the Co-Chair of the Lancet One Health Commission, and then ask themselves, ‘Why are we doing what we’re doing?’ 

He described the different premises which can be at play when outsiders ‘step in.’ A common premise is that ‘help is needed’ (ask yourself: is it really?). Another is that outside teams can ‘do something better than those who are there’ (sometimes this is true, but it is in this case?). There can be other premises, too: adding on to what is already there, ‘so that we win together.’ Or: ‘learning with you and from you, so that when we are in a similar situation we will be better together.’

If we question why, it will lead us down different pathways which will give us better results, including understanding what is already there.

John Amuasi, Lancet One Health Commission

Noting that ‘rapid is inherently temporary,’ John Amuasi asserted that it is unethical to deploy Rapid Response Teams without attention to the sustainability of their impacts. A positive example is Guinea, where a smaller Ebola outbreak in 2021 was readily managed thanks to the capacities which local health workers gained during the major 2014-2016 outbreak. 

Yet efforts to strengthen long-term outbreak response capacity are being systematically undermined by the active recruitment of experienced health personnel from the Global South by countries in the Global North – yet another manifestation of a neocolonial approach. ‘AlI of this has to be brought into the discussion,’ he said. ‘If we want the impact from Rapid Response Teams to be there, and for it to be ethical, we have to think much, much wider than the immediate problem.’

‘Mutualising efforts’ through regional Rapid Response Teams       

Virgil Lokossou, who works with the ECOWAS Regional Centre for Disease Surveillance and Control, advocated for the institutionalisation of regional Rapid Response Teams to shift the locus of outbreak response expertise closer to the places where outbreaks happen and to counter the default narrative that international expertise should be the first point of call.   

Regional Rapid Response Teams tap into local solidarity and help to strengthen regional collaboration through peer learning and benchmarking. ‘It can be hard for one country to have all the needed capacity in place,’ he explained. ‘We offer an opportunity to come together and “mutualise” efforts.’

For this to succeed, acceptability and trust must be built between countries prior to an outbreak occurring. Towards this end, ECOWAS brings public health authorities from different countries together to identify capacities and professional profiles which can be moved from one country to another. Protocols, standard operating procedures and official agreements help to ease deployments, said Virgil Lokossou. Joint training activities, simulation exercises and agreements around logistics support also strengthen trust. Experience has shown that deployments tend to be more successful when they are framed as an opportunity for joint learning around a common challenge, and not as one country arriving – ‘with its flags’ – to help and support a neighbour, he added.

According to Virgil Lokossou, for Regional Rapid Response Teams to be sustainable, they should be built upon the basis of national Rapid Response Teams which are embedded within public health systems. A key principle is that regional teams should supplement existing national capacities, not replace them.

What we are giving to a country is what they are missing to improve their response, because we trust that there are local capacities to be leveraged.

Virgil Lokossou, ECOWAS

New GOARN strategy puts country needs, sovereignty and ownership at the center

The transition currently underway at the Global Outbreak Alert and Response Network (GOARN), the largest multidisciplinary network of its kind in the world, is in part a response to many of the abovementioned challenges and considerations.

According to Gail Carson, Chair of the GOARN Steering Committee, the network has come out of a nine-month consultation process and has adopted a new strategy which will shift the focus more to the local level, with the aim of putting country needs, sovereignty, leadership and ownership center stage. During this period GOARN will continue to provide assistance when called upon, to offer training opportunities, and to play a catalytic role in bringing together relevant actors – both GOARN members and non-members – at the country level as attention increasingly turns to building national rapid response capacity.

She noted that positive changes are already underway within GOARN. For example, there is a greater emphasis on regionalisation, as well as on ‘strategic groupings’ – collaboration between clusters of countries linked by geographical, historical or linguistic factors (e.g. Portuguese-speaking countries). 

While endorsing these shifts as a ‘correct and righteous transition,’ Gail Carson also noted that GOARN’s membership continues to grow and that the role it plays is still needed, at least for now. In order to move this complex situation forward, she proposed that thinking differently about the challenge – ‘managing the polarities’ – might open up space for improved solutions.

Maybe it’s less about: ‘Do we have Rapid Response Teams or not?’ Maybe it’s more about: ‘How do we have the international or the regional with the national? How do we move that forward to invest in Rapid Response Teams, but at the same time deal with the struggles that many of our countries are seeing?’

Gail Carson, GOARN

Towards partnerships with respect

The panelists agreed that discussions about the role of Rapid Response Teams are both necessary and demand nuance. It is not a matter of ‘yes or no,’ ‘good or bad’, but rather one of how such teams work to ensure that they embody partnerships with respect. 

‘At the end, it is desirable that each and every country has capacity to rapidly respond,’ said Jochen Flasbarth, of BMZ, summing up his main takeaway from the discussion. ‘That does not mean that we exclude the support by specialised rapid response teams from other countries, but these teams should not come from one region of the world alone.’

October 2023