One of my most vivid memories from my experience as a Peace Corps volunteer in rural Senegal occurred soon after I moved to my assigned village. A group of NGO and government workers arrived to immunize children. Village elites enthusiastically told them to leave, even though children were routinely infected with tetanus, measles, and polio. The elites shunned this government-supported, well-funded international effort. Overtime I came to discover some of their reasons: distrust of the state, bad experiences with NGOs, and cultural views on biomedicine. But the incident illustrated to this naïve volunteer a powerful lesson: Lofty aspirations and action plans that come from the top may mean little in local communities.
I discuss this incident almost every semester when I teach about development or global health governance. While the event raises numerous questions, I tackle two in my new book Africa and Global Health Governance. The first is “What factors affect the implementation of global health policies?” The book uses case studies of AIDS, the Ebola outbreak in West Africa, and non-communicable diseases (NCDs) to explore this question. It builds on country case studies and incorporates explanations from the international, state and local levels of analysis. For example, in the Ebola case I illustrate how religious and traditional leaders pushed the Liberian state to act quickly but in ways that could both challenge and incorporate a crisis narrative that resonated in donor countries like the United States.
A second question is “Who shapes decisions in global health governance?” We often assume that donor states like the United States and international organizations like the WHO or the World Bank are the crucial voices in the design of global health policies and programs. While it is true that these actors have significant resources, power, and capacity, the picture is more complicated. African states and civil society play a role, though their activities have received little attention in the scholarship. For example, African leaders made influential and dramatic pleas for AIDS resources at the United Nations in 2001, and they used behind-the-scenes diplomacy to affect donor AIDS programs. The book explores how the actions (or inactions) of some African states shape global health governance.
In addressing these two questions, I emphasize the agency of African states and civil society. These actors are often portrayed as victims of economic and power structures and thus, highly dependent on foreign aid, NGOs, and humanitarian do-goodism. But the reality is that conditions of dependency and agency lie on a continuum, as Emma-Louise Anderson and I illustrate in our study of AIDS support groups in Zambia and Malawi*. In Africa and Global Health Governance, I show how some African leaders used extraversion—the practice of emphasizing their weakness—to gain donor resources. I demonstrate how state elites designed donor-required AIDS institutions to consolidate their ruling coalitions. In the Ebola case, I argue that the very weakness of the International Health Regulations enabled African states without Ebola cases to place restrictions on travelers from affected countries, despite WHO statements against such actions. In these agentic processes, domestic and global politics are closely intertwined. It is this tangled knot that creates dynamism in global health governance.
One of my goals in the book is to highlight the views to African actors involved with global health issues—advocates, local community health workers, government officials, NGO representatives, people living with or affected by disease. I engaged in fieldwork that spanned several years in Liberia, Zambia, Tanzania, Ghana, Uganda, and the United States. Observations in South Africa and Senegal also inform the work. Ultimately, the book provides a complex picture of the health policies and programs that affect millions across the continent. In the process it calls for deeper analysis of the agentic behavior like I observed in that Senegalese village many years ago.
* Emma-Louise Anderson and Amy S. Patterson, Dependent Agency in the Global Health Regime: Local African Responses to Donor AIDS Efforts. London: Palgrave Macmillan, 2017.