Inequality and International Partnerships in Global Health: The Case of Ebola Vaccine Trials

The Rise of International Partnerships in Global Health

International collaborations have become a cornerstone of global health efforts. These partnerships typically involve well-funded, scientifically advanced institutions from the global North working with partners in the global South, including governments, universities, and NGOs, which often require research, funding, and technical expertise.

International collaborations in global health gained prominence in the 1990s [1]. This shift came after two decades of neoliberal policies, increased influence of multilateral organisations and multinational corporations, and a decline in state capacities to serve their populations effectively [2, 3]. Global health (and later international partnerships) were part of a larger developmental model that emerged after World War II and coincided with former colonies gaining independence [3, 4]. After World War II, Europe was rebuilding, and the US began to emerge as the new global superpower [5]. Attention increasingly turned to the inequalities between wealthy countries (usually in the global North) and poorer countries (usually in the global South) [5]. Western countries often fail to locate global inequality histories of colonialism and ongoing relations of extraction and exploitation [6]. Instead, researchers from these countries suggest that poor nations can develop with the assistance of wealthy nations. Whereas anti-colonial and dependency scholars explain inequality in terms of resource extraction, the exploitation of labour and environment, and the silencing or appropriation of indigenous knowledge, Western logic often insisted on a stadial approach to development and inequality [7].

Partnerships And Equity

It is in this context and logic that global health partnerships emerged. By the 1970s, as the neoliberal logic took hold globally, population health was seen as a critical development area for poor countries. Better health outcomes could be achieved with the aid of wealthy countries ahead of the development curve [8], so partnerships were put to work to alleviate inequality. For example, the Council on Health Research for Development published a report in the 1990s noting that most health spending had little impact in areas with high disease burdens. Research partnerships were framed as the solution to this equity gap [9].

Importantly, partnerships signify critical sources of value for partners in the global North and South. For those in the North, partnerships often provide opportunities to study diseases and other challenges in real-world contexts, access to populations they would otherwise not have access to, grant funding opportunities, and training opportunities [10-12]. For partners in the global South, partnerships represent access to funding, upskilling, and resources such as infrastructure and networks and the potential for research to make a meaningful difference in the communities they work with and are often a part of [13-15].

Yet, partnerships have been accused of reproducing inequalities rather than remedying them. Various accounts, ranging from network analysis to tracing financial flows and bibliometric and qualitative accounts, have pointed to partnerships' unevenness [16-18]. In response to these claims, scholars have advanced various normative, empirical, and practical approaches for several years to develop more equitable partnerships [19-21]. Yet, it is not clear how and if more equitable partnerships may change anything significantly.         

Ebola Vaccine Trials and Internation Partnerships

My research involved vaccine trials in two West African countries. In both cases, international partnerships enabled these trials. I interviewed West African researchers, clinicians, and trial administrators involved in trials.

The value trials brought to host countries, research and communities was evident in both cases. For example, trials directly or indirectly ensured the training of researchers, clinicians and administrators. This involved informal training to lead and manage the clinical trials and formal graduate training programmes abroad. In many instances, trials also paid staff (especially those working in the public sector) significantly more money than their public sector jobs. Trials built state-of-the-art laboratories, research units, buildings and other infrastructure. Trials also paid for the care of research participants directly or indirectly. Moreover, trials also paid for certain public functions in hospitals or other public health facilities, as explained in the next section.

Trials and inequality

To understand how value accrues, we must consider the context in which this occurs. I will illustrate this point by drawing on examples from funding and healthcare.

While interviewees praised partnerships for the work of trials, it is clear that they valued these trials precisely because of inequality between partners (and the countries they represented), their resources, opportunities and power, and the contexts of host countries. For example, one of the trials collaborated with a local hospital in one of the host communities. It employed ten doctors, while the hospital only had one doctor. The trial also employed a paediatrician (as it later also enrolled children) and refurbished the hospital’s paediatric wing. The paediatric services were available to the general community, not only those who enrolled in the trial. Those who enrolled in the trial also got free healthcare, including consultation with a doctor and medication, regardless of whether their illness was related to the investigational product. For many, this was the first time they had a consultation with a medical doctor.  

Funding for the trials was generous in both countries where I conducted this research. For example, trials funded all research activities, including employing staff, recruiting participants (including “inconvenience allowances”), and renting space, etc. Trial funding also built sophisticated labs with the newest technology available. Trials also paid for the maintenance of these facilities, such as flying down technicians or buying reagents. Moreover, trial funding also covered additional costs. For example, the electricity supply is erratic and unreliable in many parts of the countries that hosted these trials. Trial sites, including laboratories, often had dedicated power supplies, and in some instances, they also provided power to certain public facilities (albeit in a more limited capacity). In other cases, trials also funded certain functions of public facilities, such as paying for specific functions in public labs or hospitals. In both cases, it was clear that spending on trials far surpassed what governments of host countries could spend and surpassed what governments were spending on entire sectors. In other words, spending on specific trials eclipsed what governments could spend on research and, in some instances, public services.

While conducting my research, I observed that Ebola trials had either ended or had recently ended. In both cases, researchers were clear that the only way to continue was through more international partnerships, research, and, specifically, clinical trials. What is at stake in these contexts is not only research but also employment, public services, and care, amongst other things.

Inequality Underwriting the Value of Trials

That transnational research occurs in unequal contexts is not new. What the above examples point out is that trials occur not just in unequal contexts but also that trials are valuable because of their unequal contexts. This is an important distinction. My findings suggest that instead of seeing inequality as an incidental or contextual feature of research, inequality underwrites the value of these trials. Inequality is constitutive of the value of the trials. Joanna Crane, in her work on international partnerships and HIV research in Uganda, reflected “valuable inequalities”, especially amongst US researchers and intuitions who benefit from these unequal partnerships [12]. In my work, I shift the emphasis to reflect on how trials are valuable for host countries and what creates the value for these trials and partnerships which rely on inequality.

Framing inequality as central rather than incidental to the functioning of the trials presents a fundamental challenge to how international partnerships are framed and operationalised – that is, as a response to unequal development. If international partnerships are to make a meaningful difference, broader inequalities must be considered and addressed.