Soumyadeep Bhaumik: International public health specialist from India on shortfalls in decolonizing global health and pathways ahead

The Spotlight series is an interview-based profile series by McGill Global Health Perspectives. The series focuses on researchers and practitioners in global health outside of high-income country settings (and) or representing marginalized groups. For our fifth spotlight profile, we are featuring Soumyadeep Bhaumik, who is a medical doctor, and an international public health specialist. He is the co-head of Meta-research and Evidence Synthesis Unit of George Institute for Global Health. He is also a doctoral student in University of New South Wales, Sydney, an Associate Editor, Evidence Synthesis, BMJ Global Health and a Fellow in the Royal Society of Arts.

Can you tell us about how you became interested and your journey in global health?

I am a medical doctor by training, and I studied in Bankura Sammilani Medical College, in West Bengal, India. This was founded as part of the Swaraj movement – a call for greater self-reliance during the movement to free India from colonisers. The catchment area of my medical college included the economically poorest districts of West Bengal, at that time had Naxalist (left wing extremism) insurgency. The government hospital that I trained in was the only tertiary health care most people from these districts could access.

This environment and history influenced a lot of my thinking as I studied and practised medicine. Because, at least where I come from, you do not generally become a doctor thinking of going into public health. You go into medicine to treat patients, become a clinical sub-specialist. However, when you go to a school like this which has a rich history of caring for communities and in a context of social-political upheaval, you realise things – on your day-to-day activities - you see how the brute force of clinical medicine alone is not sufficient for improving health of people.

And as you decided to seek opportunities within public health research - which is not always a linear pathway - could you speak to your journey as a researcher?

After medical college, I was not sure on what career options in research was there. So I decided to look for a job and based on my limited prior experience of research, I applied and got one in the South Asian Cochrane Center in Christian Medical College, Vellore. That was in 2013! This pushed me to want to gain a master’s in public health and I went to Liverpool School of Tropical Medicine (LSTM) in 2015-2016. Following my master’s, I worked on evaluating a monitoring and evaluation programs focused on Bihar, India for LSTM, health promotion division at the Public Health Foundation of India, and currently I am at the George Institute for Global Health, India.

So, can you speak to the current work that you do within George Institute for Global Health, India?

Currently, 50 percent of my time is dedicated for George Institute for Global Health, India. There I work on two portfolios: as co-head of the meta research and evidence synthesis unit (MRES)and the other focus is on injury division. My injury work intersects with my doctoral work where my research focuses on policies and systems to address snakebite. At MRES there is a team of 5 brilliant young scientists with whom I share this journey.

As you are managing multiple priorities, can I ask you to dive a bit deeper into your MRES work at George Institute for Global Health, India?

We formally set up the MRES Unit in 2021. The roots of the unit are in an earlier project supported by the Alliance for Health Policy and Systems Research of the WHO. It started as rapid evidence synthesis unit with a simple idea: to support policy makers and public health officials make evidence informed decisions.

To expand, public health officials and policy makers need evidence to inform their policies - but a key challenge is time and focused expertise. Rapid evidence synthesis fills that gap- unlike traditional systematic reviews which takes months we did evidence synthesis on-demand in a matter for weeks. Our most notable work came in March 2020 due to the pandemic. We had a three-day timeline to examine the role the community health workers (known as frontline health workers in India) can play in the COVID-19 response. We completed what you might call an ultra rapid synthesis analysis since we only had three days. The results not only helped the government of India but also helped support thinking around the response including informing WHO guidelines at the time.

Since many stakeholders including national and international partners valued the practical utility of these efforts (beyond academic concepts), we at the George Institute of Global Health decided to establish this unit. However, the unit in its current shape does not focus on rapid evidence synthesis alone, we also do high quality systematic reviews (including individual participant data meta-analysis, qualitative evidence synthesis and the like) on topics that are important to current discussions on global health and their applications like guideline development, policy briefs etc. We also added a section for meta-research – research on research – to understand the methodologies, reporting and application of research itself. The few organizations that work in evidence synthesis/meta-research space are mostly based in high income countries. So, especially as meta-research help guide research and their application, to be able to make such efforts more contextually sound, we need to have voices from low- and middle-income countries. So, entering that space and pushing for higher quality work is a big picture goal for us. This is also important to break the methodological hegemonies and the philosophical capture of research space by few high-income countries and organisations. They set the narrative on what is acceptable not acceptable conduct of science, often ignoring the realities in which scientists work, are not in alignment for work at the intersections of academia-government or academia-industry and not based on philosophical principles of communities in Africa and Asia. The colonial nature of doing research is outdated.

So, as you have journeyed through both clinical and public health research realms in India, I first want to ask what do you see as challenges for public health and conducting public health research in India?

Essentially, being under-resourced and not being a political priority means it is very difficult to improve health systems. Contrasting the allocation of around 1 percent of the Gross Domestic Production (GDP) for health with defense expenditure paints the picture of political interest that is detrimental to people – health wise and economically. Instead of universal health coverage the needle has moved to “universal health insurance”. The two are not the same. The Ayushman Bharat health insurance scheme does not cover preventive, promotive care, or outpatient care, which I feel are essential for a healthy population. It also does not cover the entire population, and has a cost limit so its not really even “universal health insurance”. In contrast, if you look at progressive states like West Bengal, the Swasthya Swathi scheme is truly universal in terms of population coverage, but outpatient care and spend limits remains a gap. There is no UHC anywhere in India, and in fact the ability to seek care, without any limits in government health facilities is slowly being dismantled as our tax monies are being very routed to private players with no noticeable effect on health or well-being of people. India requires a stronger primary healthcare system but the progress towards that is slow. From the funding allocated for health from the GDP, most of it goes to tertiary healthcare systems. As a result, the pool of money or resources allocated for public health is quite small. This has an impact on research as well. So, for public health research, you are already trying to look for funding from a very small pool of funding.

Due to the impact of the pandemic the awareness on the importance of public health in India has improved but this has not necessarily translated to political prioritization or policy action for public health nationally and in most states. Thus, resource constraint settings are a primary challenge for public health and public health research in India.

Re-circling back to the colonial nature of global health, which you earlier alluded to what do you think about decolonizing global health movement and so on. In the context of India, what impacts do you see from these movements?

For decolonizing global health, I see four main challenges.

First, is the control of narrative and the agenda on decolonisation. My initial interest in the movement has decreased because I feel the narrative is increasingly controlled by high income country actors – I call them high priests of global health. In my view, decolonizing efforts (including the anti-colonial movement) efforts that are happening outside of high-income country settings, that do not get much attention, holds more value. I do understand though that both these movements have some similarity in goals, but the power differentials are noticeable.

Second, a key part of decolonizing for me is that it essentially means strengthening your own national health and research systems. This include gaining funding for the places and countries that you want to support. If your larger goal is getting work done on behalf of high-income country institutes and trying to build your expertise elsewhere, I feel that it mirrors some of the colonial structures. I understand the limitations of trying to change this overnight and that these structures are prevalent. As individuals, there is little we can do. However, we need to shift our thinking to working in places that need our support and we care about.

Third, is the lack of movement in efforts towards structural change in global governance. Even the UN systems, still operate from a post World War 2 perspective, with veto powers and not necessarily in a democratic manner. A key tenet of democracy is proportionate representation and without it we really cannot hope for any change in the current global governance system. Even the WHO has a representation problem where it is full of those from high income countries.

Fourth, is the capital flow. This is dictated by the global economic system. The reality is most of the funding is concentrated in high income countries. So, I do not see how global health can get decolonized without also efforts towards decolonizing economic systems, funding structures, the UN and multilateral systems that are in place.

So, realistically I feel the role of global health professionals making these changes within these larger systems is quite limited. We can have some wins, like representation which I feel are small changes following an ill-defined change trajectory. However, meaningful change, I feel comes from these structural changes.

Bringing the conversation back to movements, given the current structures and the limitations you mentioned earlier, do you see a hopeful future for global health?

First, from my understanding, I think different social movements have different roles to play. The way I am framing decolonizing global health has a different role to play and appeals to a certain audience. On the other hand, the other movements that stem from high income countries also have a role to play and appeals to a different audience. I do not see these movements as mutually exclusive. These movements complement and supplement but there can also be friction. And this friction is very important for change to happen.

However, I do think it is quite important to push for working and being based in regions that you are focusing on and strengthening those systems. Also, framing of what decolonizing is should also happen largely from non-colonial actors, as they are the ones most adversely affected from neo-colonial models. Because even if you set agendas, have big players, and pour resources into it, you need to have buy-in from those living in the relevant locales. To achieve this, we need to focus on structural changes and more concerted effort is needed on that front, because currently we are focussing on inconsequential things.

For me an ideal outcome of decolonization would be to have stronger national health systems. Ideally, these systems would be learning health systems - from global and local context. So, it would still be global in nature, reflecting, learning from and reacting to the changes that are occurring globally but are led by and controlled by nationals.

Finally, for global health research what recommendations do you have for us as individuals and organizations?

First, as individuals and organizations we should strive for equity , equality and justice - start within our own teams. Our good intentions need to translate to fair wages, enabling work environment and equitable and transparent processes in your own teams.

Second, creating jobs is important, especially in low- and middle-income countries. It is important to not to act as a conduit for volunteer work for high income country institutes. These are some of the to do steps we can take to strengthen our teams and institutions.

Third, we need to be methodologically rigorous. This is a global challenge. Researchers, practitioners, and educational institutes need to invest time and effort on learning and teaching methodology and their applications. Those who are not methodologically rigorous pushes the field back even if their research gets published. Without this we cannot be reflective of the limitations of the current way we conduct research. It might seem slow but there is no replacement to reading a methodological textbook cover-to-cover.

Finally, I think communicating science is important for making our societies rational. I understand it is a resource intensive effort - so it needs to be balanced. But it is important to dedicate effort by communicating through public interactions, in our daily conversations and other platforms such as social media. We need to create a culture of evidence-informed decision making by communicating more effectively and that is very valuable to the society. The pathway for this is not talking within our own global health bubble, but to have a life and to communicate outside of it!

Soumyadeep Bhaumik Tweets at @DrSoumyadeepB

Recent Relevant Publications:

About the Author(s):

This is a collective effort of the McGill Global Health Perspectives Team. Shashika Bandara led the interviewing and the writing for this conversation with Soumyadeep Bhaumik.

SpotlightMcGill Perspectives on Global HealthApril 22, 2022covid19, globalhealth, india, decolonize