Suchita Shah: The lost brigade—why diasporas matter to global health


Reflections on the second UK-East African Healthcare Summit, London 2017

Talk of nations, national borders, and national identities has become a part of the ideological foreplay that inevitably leads up to big political events. As the UK general election looms, there couldn’t be a more apt time to consider what “homeland” means to us in the context of global health.

Diaspora, from the Greek “diaspeirein” (to disperse), refers to people dispersed from their original homeland. According to World Bank data, more than 247 million people, or 3.4% of the world population, live outside their countries of birth.

The people who make up these global diasporas send around $601 billion in remittances to all corners of the globe, and a report by the Migration Policy Institute argues that they also contribute significantly to “foreign direct investment (FDI), market development, technology transfer, philanthropy, tourism, political contributions, and the more intangible flows of knowledge, new attitudes, and cultural influence.” Yet, from Chinese immigrants blamed for transmitting the plague in 19th century San Francisco to refugees being seen as a burden on European health systems, diasporas are often regarded as a threat to health—the harbingers of disease, violence, and cultural decay.

So how can we rethink the role that diaspora communities play in global health? In April I attended the second UK-East African Healthcare Summit, organised by the Uganda Diaspora Health Foundation in partnership with the BMA and BMJ, which brought together key stakeholders to address this question. As a doctor, born in Britain but the daughter of Kenyan Indians, I have a personal as well as professional interest in reflecting on the issues raised that day.

Approximately 32.6 million people worldwide belong to the African diaspora. They are “pivotal developmental actors” in global health, said Dr Terry John of the BMA. Speakers from Kenya, Tanzania, and Uganda identified a range of country health priorities, two of which are further discussed below as areas for potential diaspora involvement:

Economic investment and public-private partnerships

There are major foreign investment and public-private partnership (PPP) opportunities in East African healthcare. A PPP is, loosely, where a public authority has a contract with a private company to build or run a service. As an NHS doctor who has, over the past decade plus, seen the likes of shiny PFI hospitals crumbling under toxic debts, I have personally regarded PPP as somewhat of a cautionary tale—one of complicated financing, fluid fiscal rules, and creative accounting. But at this meeting, the idea of PPPs was met with much enthusiasm.

Mark Fletcher, representing Lord Popat, the UK prime minister’s trade envoy to Uganda and Rwanda, said that innovative private sector organisations must be “part of the story,” especially because they can “reach where others can’t.” He spoke of the positive impact of UK private investment on maternal and child health services at Busolwe Hospital in rural Uganda.

There are genuine opportunities here for diaspora and local business communities to work with each other and local governments to address health and some of its broadest determinants, such as infrastructure, energy, and poverty. But global PPPs should not turn into neocolonialist free for alls, whereby the most influential private players scramble for lucrative public contracts without ensuring value for money, accountability, or equitable access.

Professor Nelson Sewankambo of Makerere University, Uganda, argued that the conditions needed for successful PPPs in the health sector (and its natural bedfellows, education and research) include: clarity of purpose, an enabling institutional environment, and appropriate regulatory frameworks, such as Uganda’s Public-Private Partnership Act 2015. In short, partnerships between high income countries and low and middle income countries (LMICs) must be reciprocal and mutually beneficial.

Workforce development, knowledge exchange, and closing the stable door

Humans with skills and knowledge are just as important a resource as money, and Lord Nigel Crisp wasn’t putting too fine a point on it when he said that the current global health worker crisis “may hold back or accelerate development.”

There are 51 000 East African healthcare workers in the United States alone. Not only do these workers’ skills become lost to a home country, but also, often, to science itself—to which the number of PhD taxi drivers attest.

As a way to address the brain drain problem, an organisation called MedinAfrica is compiling a database of East African diaspora health workers, with a view to connecting them with African scientists and medical professionals as “global knowledge communities,” and perhaps even inviting them to return home. Although Dr Jane Kengeya-Kayondo of the Africa Research Excellence Fund pointed out that LMICs need to limit the exodus in the first place, rather than waiting until the horse has bolted.

Various speakers discussed how diaspora communities can help improve quality and safety in healthcare and medical research—for example, through funding, knowledge exchange, mentorship, innovation (e.g. digital health), influencing policy, and disseminating cultural norms such as safe driving.

Nanyini mufu yakwata awawunya

It is the close relative of the dead who must touch the part that smells the most. This old Buganda saying means that as the owner of a problem you are expected to manage the worst part. East Africa needs to take the lead in improving its own healthcare.

This can be helped through regionalisation and South-South cooperation. For example, Grace Cerere, deputy head of mission at the Kenya High Commission, talked about the possibility of free customs unions, monetary unions, and regional medical centres of excellence.

When I visited Nairobi earlier this year I could smell enterprise in the air. We should be celebrating East Africa’s immense richness and not just focusing on its deficiencies. However, as Dr Mbololwa Mbikusita-Lewanika, health adviser at the Commonwealth Secretariat, said, there is a danger of emphasising Africa’s economic successes too strongly while ignoring inequalities and the lack of inclusive growth. No one spoke of corruption and bureaucracy and how they impede health system development. I’m not just talking about LMICs—we all need to clean up our backyards—but this and other elephants in the room that day compelled me to consider more deeply the relationship between diasporas and the homeland.

For while the summit highlighted several ways in which diaspora communities can help improve health in their home countries, the link between a diaspora and their homeland is not a simple one.

Diaspora engagement in global health is not simply an intellectual exercise. Each dispersed person, however business-like in their interactions, will feel at some level within their emotional core the umbilical tug of the motherland. This may generate a passion to “give something back” but, like any parent-child relationship, it may also be fraught with complexity.

Forever wanderers and reluctant returners

There are those, like my family, for whom migration has not been singular or unidirectional. Multiple cartographies flow through their veins. Furthermore, for those who are part of second generation diaspora communities (and beyond), but who themselves have never migrated, “home” may still be problematic to define. In short, a diaspora may never identify with a single geographical “home”; and if you are struggling to work out your own identity, the push-pull of personal ties to different lands may lead to internal confusion and disconnect in terms of professional engagement with a “home” country.

Secondly, not everyone has left home voluntarily, not everyone is part of the educated brain drain, and not everyone has emigrated to the rich North. What of the persecuted, enslaved, displaced, and expelled; where do the narratives of these diaspora communities fit in the global health picture? What about their own health needs? Can they reasonably be expected to engage with their home countries in the same way as their more privileged counterparts?

The reality of home

Even for those people whose dispersion has not been complicated, forced, or painful, the rose tinted memories of forsaken homes may not match current realities. Life moves on in ways that can sometimes be disappointing to those who have held on to the past. How people returning home will be regarded and treated by locals, and vice versa, is a delicate question. Changemakers might be seduced by the notion of a global tribe of citizens with aligned supranational values, but this can unravel if in reality such concordance does not exist, particularly when it comes to collaborative projects—for example, differences in values, ways of working, priorities, and communication.

The promise of the future: from talk to action

Despite the very real complexities outlined above—which cannot sufficiently be covered here, but which should nonetheless be considered—I genuinely think that engaged diaspora communities are essential, invaluable, and often overlooked players in the global health arena. Many are highly educated with the financial resources, skills, and knowledge to fill or strengthen vital capacity gaps. I also think that the shared universal experience of human health and disease—along with mutual respect, clearly outlined goals, regulatory frameworks, defined processes, and strong institutional backing—can overcome many obstacles to diasporas and home countries working together to improve healthcare.

The goals of the Uganda Diaspora Health Foundation, and its umbrella organisation the Uganda-UK Health Alliance, are to promote such partnerships, to develop internationally recognised standards of healthcare delivery and international development, and to assure value for money. And it was clear from the summit that they have the energy and enthusiasm to channel the social capital of diasporas towards better health for East Africa.

Acknowledgements: With thanks to Mr Moses Mulimira of the organising committee for the kind invitation to attend and for assistance with points of fact. Thanks also to Dr Aparna Nair for her invaluable comments. All the views expressed here, other than those quoted, are my own.

Suchita Shah (@SuchitaShahUK) is a portfolio GP in Oxford, UK. She also holds degrees in public health and international relations. Her professional interests include primary care, public health, global health, medical education, writing, photography, and the arts.

Competing interests: Nothing further to declare.