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Karoun H. Bagamian: Welcome to “The Business of Doing Science” podcast brought to you by Bagamian Scientific Consulting. On this podcast we discuss different aspects of pursuing science related careers and just how science is actually done beyond the bench. So stay tuned to find out more.

Welcome to our second "The Business of Doing Science" Science Social Hour. I'm Karoun Bagamian joined by my co-hosts Lindsey Laytner and Heidi Bolduc. In this episode we discuss a topic that has become more relevant in the context of today's political discourse: the global health renaissance. Before we dive into this critical conversation with our guests Punam Amratia and Fredros Okumu, we want to acknowledge that this episode was recorded before the current US administration's policies began to take shape in early 2025. As we release it now, we recognize that some of the views and perspectives shared may already be evolving in response to shifting political landscapes. This discussion explores the global health renaissance: a movement toward more data-driven, sustainable, and locally-led public health systems in Africa. But as history has shown us, progress in global health is deeply intertwined with policy, funding, and international collaboration. The role of foreign investment, particularly from countries like the United States, has been instrumental in shaping public health programs worldwide. And as leadership and priorities change, so does the future of these programs. 

This episode serves as both a reflection and a call to action. As we navigate new political realities, we must carefully consider how we reshape public health initiatives. Sustainable solutions require long-term commitment, strategic adaptation, and -- most importantly -- a deep understanding of the local and global impact of these decisions. We encourage you to listen to this conversation with an open mind and a forward-thinking perspective. Now more than ever, it is crucial to protect and strengthen the systems that safeguard human health. Because progress should not be undone, but built upon. 

Now, with that said, let's dive into this very topical discussion with Punam and Fredros.

Welcome to this episode of “The Business of Doing Science”. We're really excited to have two experts, Punam Amratia and Fredros Okumu with us today to join us in this conversation about global health.  

Punam Amratia: Punam, can you tell us a little bit about yourself?  

 My background is in geospatial modeling. I've been a geospatial modeler for over a decade. I started my journey,working with KEMRI Welcome Trust in Kenya, which is a government body, moved on swiftly to do a PhD at the University of Florida before landing myself at the University of Oxford, where I was a postdoctoral fellow with the Malaria Atlas Project.  

Punam Amratia: Fast forward seven years later, and now I'm the technical lead for the new Malaria Atlas Project Dar Es Salaam node that is located at Ifakara Health Institute in Dar Es Salaam, Tanzania.  

So very excited to be here, Karoun. 

Karoun H. Bagamian: We are so happy to have you. Thank you so much. [00:01:00] Fredros, can you tell us a little bit about yourself? 

Fredros Okumu: First of all, it's nice meeting all of you. And my name is Fredros. As you said, I have a related but not exactly similar background as Punam. I am a mosquito biologist, so I catch mosquitoes for a living. For a long time, I worked in Tanzania as well. I went there as a 25 year old and only recently left. 

I still work a lot with Tanzania. Between 2016 and 2023, I was also the Director of Science at Ifakara Health Institute in Tanzania. I continue my role there as a scientist, but I've since moved to the University of Glasgow in Scotland, where I'm a Professor of Vector Biology.  

And I'm very excited also to be with you guys here. 

Karoun H. Bagamian: We are so thrilled to have you here. One of the things that we're going to talk about today is this idea of , as Punam likes to call it, the "Global Health Renaissance". Punam, will you tell us a little bit of what you think about that?  

To give the audience a little bit of context here. For those who aren't aware, [00:02:00] there was a lot of noise that went around, around the 2020 time, around decolonizing of global health. Now it's a term we don't love to use, but there was a lot of limelight put onto the concept that a lot of funding normally goes to institutes that are not located where a lot of tropical diseases are. So we term that oftentimes the Global North versus the Global South. But I'll try and refrain to use those words.  

Punam Amratia: So there was a lot of debate, that came about around 2020  

about how we need to change the fundamentals of how we're doing things in global health. We need to create more leadership, look at the local level, more equity. W hen I talk about equity, for example, funding needs to go to more local institutes where tropical health research is being conducted. 

We need to build capacity in the true essence of what capacity is, so that [00:03:00] researchers like myself, can carry out the research for tropical health in the countries that need it the most. That is the context of what the change in global health was needed. 

Karoun H. Bagamian: So you mentioned this concept of Global North. What do you mean by that? 

Punam Amratia: That's a great question. The Global North is normally defined as institutes, for example, in the U. S., the U. K., Australia, basically where a lot of funding has naturally happened or institutes that have a rich history of previous research being conducted.  

The difference of the Global North versus the Global South is that oftentimes these institutes are doing research outside of their own country. So an example of this is when US researchers are working in countries such as my own like Kenya. So that is where we define the US researchers as Global North and the Kenyan researchers as the Global South. 

 The term tropical health [00:04:00] actually comes from colonialization. The concept of tropical health was because colonialists needed to understand the diseases in the territories they were expanding in. They created the field tropical health and, therefore, created institutes like the London School of Hygiene and Tropical Medicine and the Institute of Tropical Medicine in Antwerp. Because it was part of the colony expansions to understand what was killing their soldiers and their explorers, yeah. So that's actually the history of how infectious disease, tropical medicine, and tropical hygiene really came about. It comes from that essence of colonialization. 

 Now, we're, what, 70, 80 years, out of the era of the British Empire. It's interesting how there's still that sense of privilege, right? There's these institutes which are still doing great work, but there is a lot of privilege there, that these institutes have had this rich history of [00:05:00] developing in tropical medicine and global health, and there hasn't been much treacle effect where that knowledge, that capacity has been sustained in countries, that are affected by these tropical diseases. 

When we talk about the global health renaissance, we're really talking about what's happening now. There was a beautiful article, actually, that was authored by Fredros as well, talking about, for example, 30 million dollars that was provided to funding bodies and institutes all in what we would call the Global North. So they were institutes that were in the U. S., the U. K., and Australia. And it sparked a really good conversation and dialogue where that letter opened the doors to allow funders to start talking and listening to African researchers and researchers generally in the tropical belt to understand what their needs are and how to change the funding landscapes to [00:06:00] create more equity towards researchers in these landscapes.  

 That's why I call it the global health renaissance, because, that letter came out around 2020 and that sparked these conversations, and now you're starting to see this change, I believe, in the funding essence and the funding bodies. You're starting to see private foundations, such as the Bill and Melinda Gates Foundation, changing their statements, making funding more readily available to local scientists and local institutes like the Ifakara Health Institute, where I'm hosted, making available more opportunities for collaborations. You're starting to see in government bodies like the WHO, more recommendations of south-to-south collaborations. So , learning from each other.  

I've been working with a couple of projects. My field of specialty is malaria, and I work a lot with malaria programs. We recently did the Roll Back Malaria and Exchange Program, where the malaria program of Senegal went to visit the malaria [00:07:00] program of Cambodia to learn how are they running elimination programs. What is their strategies for the prevention of reestablishment? And then they're learning from each other and taking that back to impose better strategies for eliminating malaria. 

Punam Amratia: That's beautiful to see. You're seeing that because of this renaissance that people are now pushing for south-to-south collaborations. They're pushing for more ownership locally, decision makers to take charge within the countries rather than from outside countries. 

Fredros Okumu: I'm 100 percent in agreement with Punam. My thoughts have evolved quite a bit around this though since our initial letter documenting some of these problems. And I think the key aspect here is that, first of all, there's got to be this realization that this is a very complex problem.  

It's complex in the sense that there is the blame that we can apportion to the "Global North". I believe what Punam means by the Global North here [00:08:00] is really on an economic scale. Those north of the economic scale are the northerners in this sense.  

Karoun H. Bagamian: Thank you for clarifying that but that makes sense. Definitely. 

Fredros Okumu: So there's a portion of the blame that can go to people who benefit from systems built in those countries that somehow have internalized the privileges associated with those systems and find it difficult to live otherwise. But there is also a significant portion of the blame that would go to the governments of the disease endemic countries in "The Tropics" or the low and middle income countries. 

So much so that for people like Punam and myself, when we begin a war like this, it's almost as if it's the war of the elite. Because back in my village, my mother's medication will still arrive only if the Global North puts money in there, to a large extent. If you think about, let's say, HIV control, in many African [00:09:00] countries, it's almost entirely financed by the United States.  

We can blame the United States scientists for taking advantage of this system, but we must also blame the countries for neglecting this public health crisis. And in fact, for the low income communities in these countries, they really have no alternative. When I was growing up, there was no Global Fund, which is today the main financier of HIV, malaria, and TB control in Africa. There was no USAID President's Malaria Initiative, which is now the main financier of malaria control in Africa. There was no Bill and Melinda Gates Foundation. These are very recent developments. 

But there are also governments where the parliament will refuse to allocate financing to the Ministry of Health with the argument that the Ministry of Health has already received money from Global Fund. And so they do not deserve any additional allocation. 

So actually, for me, it becomes even a more messy [00:10:00] conversation. And it's a conversation that requires the understanding from the North, but also the understanding from the leaders of the South. And that is where the concept of the Renaissance comes in. Because it's got to be a Renaissance that includes the self reflection of the people like Punam and myself.  

What do we do? What can we do?  

And how do we continue without alienating the people from the North, but instead making them realize that some of the structures within which we currently work are not sustainable, are not moral, are not ethical? 

We appreciate that their universities might have been built up on these structures, but as individuals, maybe there's something they can do to improve things, for example. They can build capacity in these countries, so that by the time they finish with their research project, there is also someone like Punam or someone like Fredros who can do the next research. 

This is how I was [00:11:00] trained, and I think that's a good process. That you're not just going to do your research, getting the data, going back to your university, getting all these accolades. Et cetera, et cetera. But in the process, you're also helping that country, creating some jobs, training some local people who can continue this process. 

So this is where I think we should emphasize a little bit and continue the conversation from there. But yes, I completely agree that we are at a time when a lot of conversations are happening here. And I think it's an opportunity for us to actually implement the so called renaissance, as Punam describes it. 

Karoun H. Bagamian: Yeah, that sounds like a tall order for you guys, but it's amazing that you're actively living this and doing this. That's actually something that I'd like to hear more about. I'm sure others would too, about your personal experiences and how that has tied into this, your journey and how that's tied into what we're talking about. 

Lindsey Laytner: So I think that the [00:12:00] important point to raise here is that for countries that are overburdened by infectious diseases, they need not just the supply of medicines or instruments and money. In addition, they also need a good supply of technical capacity. And actually, it might even be that having technical capacity is a better start than having the medicines and the equipment. For people like myself, we have benefited from systems where the financing came from the North to do small amounts of research in these countries. But the people who led this research saw that it was necessary to also build the technical capacity there. And so we are products of those. 

Fredros Okumu: This is how I got to train, initially at local universities, and eventually at the London School of Hygiene and Tropical Medicine, where I received my PhD. And I think [00:13:00] for most countries, you need this technical capacity regardless. People don't have to be sent abroad to train, they could train locally, but that's a good starting point, having that technical capability. 

Once you have this, it then becomes the responsibility of those people to decide on what exactly their strategy should be on how to deal with these diseases. Where do they want to put their resources? And I think what unfortunately continued to happen was that the " Global North" not only provided money, but also enforced their own desires in terms of where the strategy should go. So much so that for diseases such as malaria, Punam and myself work on malaria control, we know from historical times the best approaches to control the disease based on the basic biology of the mosquito. Approaches that have been used in the United States very successfully, have been used in Europe very successfully. 

You cannot [00:14:00] find those approaches in a malaria control strategy in a malaria endemic country in Africa today. So, you open the strategy of Ghana, Kenya, Tanzania, you will not see the things that actually worked. Instead, what you will see are the things that are agreed upon at meetings in Geneva or Washington, D. C. or Western capitals, usually in meetings led by the Global North with participation of the African elite, like myself, who essentially are just gatekeepers.  

This is why I said in the beginning that when we try to tackle this global health structure, we have to, first of all, protect the lives of the low income people in these countries, so that our fight for recognition does not deny them the products that they need and that when we put pressure on the international community to [00:15:00] do right, we also put pressure on the leadership of the countries for accountability. For taking space--because if you leave that space, someone else will come. 

But you see, instead, we are ending up in this battle where some people are I've even heard people say, we don't want to see old white men. And I'm like, oh man, I was trained by old white men. And a lot of them mean very well. So if we make this about the battle of the sexes, or the battle of the races, or nationalism, it just will not work. 

Karoun H. Bagamian: Global health is global health. What we need to do is to tackle all the sides. Ensure that the Global North is doing the right thing. But at the same time, ensure that the endemic countries are doing the right thing. And that's a difficult one to do.  

That's really insightful.  

Karoun H. Bagamian: You mentioned original strategies that aren't used anymore to control mosquitoes. I'm just curious, what do you mean about that?  

Fredros Okumu: I'm a mosquito biologist, and a lot of my work revolves around methods [00:16:00] to control malaria. Malaria is a disease transmitted by mosquitoes, so usually you get bitten by a female mosquito of a species we call Anopheles, and it can carry the parasite into you from someone else. 

It can also pick the parasite from you to someone else. This mosquito breeds in surface water, and it's more likely to be found in houses that have openings. In the past, people studied this basic biology and just made sure that surface water was nonexistent except in very few places that people had good housing. 

In addition, they carefully sprayed very effectively inside people's houses. This worked very well. In fact, in many places, it just finished the disease. Then, of course, you gradually improve the economies of this household, so if someone gets sick, they're not having to choose to either buy food or go to the hospital. And this gives you long term sustainability. And you continue to ensure that the houses are increasingly better and better. These are not things you do within the Ministry of Health. These are [00:17:00] things you bring in your Ministry of Environment, your Ministry of Housing, your Ministry of Finance, and we say, this is a societal problem, how do we solve it? This is how you deal with the problems on a sustainable basis. 

Today, instead, what is happening is that there is a commercial aspect to things such as insecticide treated mosquito nets. And so people in the decision making committees believe that the best way to control malaria is to distribute commodities. And yes, of course, these nets, when you sleep under them, they will give you some protection today and tomorrow and for the next one year or two. And then you have to distribute them again. And again. And again, and every time you distribute it, a country is asking for 20 million dollars to do a single round of distribution. In two years, they're looking for another 20-30-40-50 million dollars to do another round of distribution. And year in, year out, populations are increasing in these countries. The prices are going up.  

So you are [00:18:00] essentially just chasing wind. You're doing nothing sustainable. But this seems to be the only thing that makes sense to decision makers. Because they can say we distributed 2 million nets. They can go to Congress and say we need money for another 1 billion nets. Today as we speak, 3. 3 billion bed nets have been distributed in Africa since 2000. What has happened to malaria cases? They've continued to go up. A few times you see a reduction for one or two years, and then it continues to go up. 

Punam spent a lot of time mapping the risk of malaria. It never changes! And yet, this is not cancer. This is not some autoimmune disorder that is difficult to know. This is a disease for which we have known its etiology more than 150 years. It can be controlled with simple methods.  

The people driving the agenda are interested in new technologies, which I agree with. We need to continue looking for vaccines, for new drugs, but while we are doing that... there are [00:19:00] traditional things that I would like to see in our strategies. And why are these things not in the strategies? Because countries are afraid that WHO has not approved this, and if WHO does not approve it, the people with the money will not pay. They go to their strategy, they put the things that WHO has approved, because then they can go to Global Fund and say, "Can you give us money to buy 2 million nets, 200, 000 nets or six million nets." And then Global Fund can pay because WHO has approved. This is how it works, and it puts these countries in this quagmire where they know the right thing to do, but they cannot do it because the money man will not pay. 

We are saying, in the global health renaissance, can we build the capacity in the country for people to make the right decision, and in addition, can we change the international financing system, so the countries are free to spend the money whichever way they want. [00:20:00] These are difficult problems because, as low income countries like Ethiopia or Kenya or Tanzania, they cannot go to the international market and borrow loans, pick up money. 

They will be told you don't have credit worthy rating. So you have to spend your own money and it's very difficult. So it's a situation where you have to ask the West for the money. And you have to spend it in the way you want. And the West is saying, "We will give you the money, but we will also give you the experts." 

And we are saying, "No, can you please continue to give us the money, but let us make the decision how to use it." And that is not an easy thing to do. And so, I think the Renaissance will be a long lasting battle, but I think it's a battle worth fighting.  

Karoun H. Bagamian: I think that's really, unfortunately more common than not. Society always wants a faster, in their eyes, stronger solution that they think is more efficient, but then they ignore things that have worked before. 

And especially in this case, it sounds like what worked before would require a lot more [00:21:00] investment, investing in better homes or better construction and these kind of things. But in public health, there's this idea of one health that everything's connected, basically your environment, your people, your socioeconomics. 

And this is a great illustration of that.  

Punam Amratia: I really agree with what Fredros is saying. The entire concept of global health is the global part. It's to work together. It comes with challenges. There is nothing that comes without a caveat to say, right? There have been very good things that have also come out in the last decade. 

 My space is all about data. I'm a geospatial modeler. As a modeler, that means that data is my best friend. I'm a bit of a data nerd. Because there has been this presence of we need to understand the disease, we need to understand where it is, there's been a lot of infrastructure built into health systems to start [00:22:00] collecting information about just public health in general in the population, right?  

These systems are called health information systems. They're digital platforms like the DHIS-2 that many countries have been progressively setting up, as well as starting to collect a lot of general data about what is their disease burden in their countries. That has really come out of a system of, because the funding has been relatively global, and yes, the Global Fund is a pretty new scheme in the grand scheme of things. It's been there since my time in global health. So, thanks, Fredros, because I don't know the previous, before global health times. But part of global health funding is also to fund health systems and strengthen health systems. For example, Global Fund specializes in the three major ones of HIV, TB, and malaria. And so they recognize that if you want to fight these three major diseases in countries, you need a strong healthcare system [00:23:00] in place. And so they build an infrastructure to collect data to understand what is going on in these diseases. 

It's why people like me, who are modelers, can now go in and start exploring and looking at this data and looking at, well, you've decided to put lots of bed nets in your country. I can now look and explore what the impact of that is. I can explore what the distribution and coverages are. I can explore what the gap is. 

And that's part of this renaissance. That global health has always been something that has been done heavily in the Global North. It was heavily based on projects, but now you're starting to see systems being built up-- that infrastructure and the system itself being built up. That data is now becoming more and more usable to start helping people make decisions. 

So that's been really nice to see, and I think one of the really nice examples of this is also during [00:24:00] COVID. Yes, not every country in Africa had the systems in place for diagnostics and testing, but because they have data collection infrastructures in place because of tropical diseases, they collected information on registries, digitalizing that information on registries and then exploring with more simplistic analytics, what is the number of cases of COVID in their countries. There are methods that I apply in my day-to-day basis in modeling that can take that kind of information and fill in the gaps.  

So we have a really nice saying when it comes to modeling. It's by George Fox: " All models are wrong, but some are useful." And I'm sure many people have heard that saying before. It just goes to show that you can collect lots of data, but then you know that the data might not be perfect. And, so, a model can maybe help you with understanding that little component that you might not be able to see. It won't give you the ultimate answer to [00:25:00] anything, but it will help fill in a gap. I think that's a big part of the global health renaissance-- that now we have this strong ability to build in data analytics into our kind of work streams.  

And as you mentioned, my personal story, I'm born in Kenya, grew up in Kenya. Like Fredros, I also went to institutes in the UK and the US. I did my Master's at Imperial College, I did my PhD at the University of Florida, where I met you, Karoun, actually. I got to get trained by some of the world's best in the space of modeling. And now I get to take that back with me and build a team that's local in Tanzania that can support a really important scheme, which is trying to understand why are we stalling in malaria. What are the best strategies? Where should we be deploying the right things like Fredros is saying, in order to try and change the curve for malaria overall? 

Karoun H. Bagamian: [00:26:00] So it sounds like there's been a real growth of data use culture that you're talking about. What I find interesting is you mentioned that data collection is not perfect. I think surveillance data collection of any disease anywhere is usually difficult and let's say, for example, COVID, right? 

Of course, at the beginning, when it was easier to document what was happening, we have better data on that. But then, over time, we don't know how many cases are going on or things like that. I think it's really common. I think that's a challenge in general, but it's a big deal to be able to recognize the importance of that and then figure out how to integrate that into your systems. 

 In those countries too, there's a lot of local experience with dealing with emerging infectious diseases. Is that right? 

Punam Amratia: Exactly. 

Karoun H. Bagamian: That's knowledge that is already there. So capitalizing on some of that, becausea lot of diseases emerge in the tropics because of different environmental factors and things like that.[00:27:00]  

Punam Amratia: But that knowledge probably also comes into play, when you're facing, let's say, the pandemic, correct?  

Exactly. We have schemes. So I live in the city, Nairobi. Nairobi is an incredibly dynamic city. If you ever are in Kenya, please come visit.  

Punam Amratia: But when COVID hit, it wasn't as shocking as you would think. So yes, it was shocking to see what was going on in countries like the UK, the US, how things are shutting down. 

Yes, our country shut down, but there was a lot of sensibility in the rules that applied. The way our population structure is in Kenya is that a lot of elderly people live in more rural parts and a lot of young people tend to live in urban centers like the capital, Nairobi.  

Because this was a disease you were starting to identify was affecting elderly people, instead of locking everybody down, they said, "Hey, we're going to restrict movement from cities to rural parts. So if [00:28:00] you live in the city, stay in the city." We will impose a curfew to minimize interaction instead of completely saying, "Hey, stay indoors and only indoors." And you saw that life continued as is. it wasn't as scary here. Yes, there was still some level of death and some level of morbidity. Hospitals were definitely overwhelmed, but it was not as scary as what you were seeing in the UK, for example. The systems in place kicked in and worked pretty well in order to support the populations. It did help that the population was generally young in the city as well. So that means that less people dying, more people who are just-- if you got sick, you stay home.  

But what was very fascinating again, I'm going to ping it back to the malaria space here. When COVID started rising up, especially in 2020, we were really concerned in the malaria space that, oh, no, that is going to hinder a lot of the [00:29:00] strategies, like how Fredros was mentioning, when a country decides to deploy a mass campaign of bed nets and distribute them to the whole population. And we were really concerned that was going to get hindered. And, it was impressive to see how health systems were so resilient that, yes, there was a little bit of delays in the process, but it still happened. So they found ways and mechanisms to continue the important public health work, especially in these major diseases to carry forward. 

So the systems themselves did not halt, which was pretty impressive. 

Karoun H. Bagamian: And what do you attribute to their success? What do you think helped them?  

Punam Amratia: I think every country had a different story in that instance. Some countries decentralize their systems, meaning that they put supplies outside and then they just manage local people to start doing distributions. For example, if you are in the northern part of Kenya, there are distribution centers [00:30:00] that already have the supplies that you need, the commodities like tests and drugs and nets when it comes to malaria, that instead of trying to centralize it, they just said, "No, it's decentralized. Your county, your village. Find local people to distribute it."  

Distribution continues on regardless of what's going on elsewhere. And that's really what made sure that things continued on. Yeah, that's interesting. Instead of it just getting stuck in one warehouse somewhere, basically. Yeah. It's like adapting and figuring out what's the best way to help more people. Having a more flexible response.  

Exactly. We were so worried that everything is going to turn to this massive pandemic, meaning people are going to come in and... Fever is the number one symptom for many diseases, not just malaria. So how do you distinguish a fever that is coming into facility and say that it's malaria or it's COVID or it's something else entirely? 

Punam Amratia: , [00:31:00] Doctors were pretty good at being able to distinguish this because they know the telltale signs clinically of the differences between a fever of malaria versus a fever of something else entirely. So you didn't actually see many dips also in malaria cases going on in the surveillance systems. 

Karoun H. Bagamian: Yeah, that's great.  

So one of the things that I believe both of you touched upon when you were talking a little bit earlier was this idea of true capacity building. I think it'd be nice to learn a little bit more about that. What we mean by that, and maybe what it was like and what it's like now. 

Fredros Okumu: Punam, before we go to the capacity building side, there's something that you raised which I think adds to the global health renaissance idea here, in the sense that there are a lot of lessons from how African countries dealt with COVID that should be and could be borrowed by the West. I think at the moment [00:32:00] there is this general idea that good practices flow from the West to Africa. 

But I think that there are many cases where there are actually a lot of good practices that can flow from Africa to the rest of the world and COVID was a fantastic example. In cases where countries chose not to treat COVID as a single disease, but instead look at it as a societal problem. The realization that if you close schools, there's going to be a lot of trouble with teen pregnancies and mental health and multiple other challenges. We don't have a laptop class in Africa, so you can't implement work from home effectively. And so you just have to find other ways of keeping the economy going and relying more on travel restrictions as opposed to stay indoors. And I think that in the future events, Western countries can learn a lot if they are open to that. And I think this is an important [00:33:00] aspect of the so called global health renaissance here. 

Karoun H. Bagamian: No, I think that's a really good point to point out that ideas should flow both ways, right? That is definitely a really good point and I'd love to hear more about that.  

Fredros Okumu: This is why we call it global health, right? There are many people who work in these settings. If you work in the Congo, if you're doing health systems in the Congo, it's a difficult thing. The country is so big. One village to the next is like one city to the next in the United States. You don't have highways, you don't have train lines, but somehow they still manage to do it. How do those community networks operate? And I think there are lessons that can be learned from there to support infectious disease control in the U. S. So that's that.  

But you asked a question about capacity. I think there's another aspect. When Punam was talking about data use and using local data to inform local decisions. For a long [00:34:00] time, we had this situation where best place to obtain country data was in some Western database.  

I remember having a conversation many years ago with the people at the Institute of Health Metrics and Evaluation, IHME, based out of Seattle. I was telling their director that actually the best place to obtain data for some of these countries is in your website, not in their own country databases. I don't know if that's a good thing or not.  

But at least one thing that is now increasingly happening is that the capacity to analyze this data is also now localized. So you do not have as many people as you would wish to, but you have an increasing number of scientists, locally, that can actually use this data and inform the countries on the ground what to do. And so if you have a global pandemic where everybody is busy in their own country, you are not alone. You still can rely on your own people. 

Sometimes they are not trained to deal with that specific disease. They were trained to deal with malaria or to deal with tuberculosis or deal [00:35:00] with flu. But then you have a veterinary condition to deal with this, you can still repurpose these same people. And I think that, too, is part of global health renaissance. And we should encourage it more, train more people locally, get more people involved, and allow them the opportunity to get engaged.  

There are times when I would go to the Ministry of Health and say, "May I have a meeting with you?" And if at the same time there was a Western agency that arrived, they would give the meeting to the Western agency and not me. These countries themselves didn't necessarily listen to their own scientists, in part because we didn't have the financing to organize a meeting and pay per diems, but some Western agency had the money. That is changing a lot, because once the local scientists have the credibility and the expertise that they need, and they've demonstrated that they can do this, their own countries are starting to listen to them. And I think that is a much more scalable way of doing things, a much more impactful and also much more sustainable way of doing [00:36:00] things, than continuously relying on experts from the North. 

Punam Amratia: You make a fantastic point. When it comes to capacity building, there have been many programs in the past where you would say that you're going to capacitate a country, and it turns into a more fly in, fly out situation. People come in, they do the work that they do, they maybe get a couple of people trained in collecting data, doing field science. They get their information and then they go back to their institute and build their careers based off all this hard work that was done on the ground. Claiming that the capacity that they built was that they did field research, right?  

That was pretty common, at least during my time at KEMRI-Wellcome Trust. That there were a lot of these scientists that would come in and, as I was very young, I was a research assistant at this time, I'd be watching them, and I'd see all this cool stuff, but I'd always wonder to myself-- I [00:37:00] collected that information. I did the hard work to go out into the field and sit with my hands there and let a mosquito land, which mind you, is not that easy, I'm sure Fredros can attest to that. And then that hard work, that sitting out there in the hut for two days turns into one data point. And that data point went to the University of Oxford for someone else to put in a model.  

And that really is what sparked why I wanted to do what I wanted to do as a career. I saw there was a lot to be done, and there wasn't someone who looked like me that was a modeler. There were people who were coming from abroad, coming and saying all these fancy mathematic terms and statistics and putting up fancy maps. And I was like, I want to do that one day. And so I spent a decade trying to train myself with the best. So I went to learn from the best to find out how to do that. And now I'm coming back.  

So when I talk about capacity building in this true essence, [00:38:00] I'm going to bring it back to what my team is doing. MAP, the Malaria Atlas Project, it's a 20 year running project that originally started at the University of Oxford in collaboration with KEMRI and then eventually moved to Australia. Now we're in our third tier, where we've taken the concept of We work on malaria. We can't be living in a country like Australia that has no malaria and then working on making maps for countries elsewhere. So we decided, Let's decentralize ourselves: let's actually take the knowledge that we have and build a critical mass of geospatial modelers in country and build that capacity to do all this technical analytic work. And so that's really what the charge of the Malaria Atlas Project Dar es Salaam node is. That's what drives me today. That's what I want to do.  

So now I have an amazing team behind me. It's still growing. So if [00:39:00] anyone is interested, please come by if you want to collaborate. Just a nice shout out there.  

But I have a great team behind me. I have a team of people who are in Senegal working with the Senegal government to try and make risk maps to help support Senegal to understand how do we move towards elimination. I have Tanzanian folks who are working with the government to figure out, Well, how do we survey school children? Because they're an easy access group that we can then start understanding burden. I'm working with scientists in Mozambique that are looking at, Hey, let's collect some genomic data because we don't understand what's happening with drug resistance. And how do we use that in a model now?  

So I'm working with all these amazing local scientists, and then I'm identifying, I've got a skill, and I'm sure you've got someone who could learn from that skill. So let's build that critical mass of people that can work everywhere and build this skill and then move [00:40:00] on to build a more localized network of modelers instead.  

That's what I mean by capacity building in its true essence. It's taking that learned knowledge that people like myself and Fredros have had and helping to build that new generation now. That's not to say that we do it alone. Malaria Atlas Project is located both in Perth, Australia and in Tanzania, and we work really closely together. We have teams that are constantly crossing paths. So the Australians are coming over to learn the local context of what they're doing because they think global, and my local modelers are going to Australia to learn from other scientists to think of how do I build this architecture? How do I work with cloud computing? How do I do something else or think of another different kind of model? So there is an exchange that is going on that makes the whole capacity building a lot richer.  

Karoun H. Bagamian: That's amazing. Regular interaction, regular [00:41:00] travel in both directions and truly learning from each other. That's what would really build the capacity. Like you guys were saying, it's global. It has to be everybody working together and figuring out good ways of building teams around these questions. 

Punam Amratia: Exactly, but you can't think short term either, right? Capacity doesn't happen overnight.  

Karoun H. Bagamian: That's right.  

Punam Amratia: And so this is not a two year project. This is something that's going to happen over a really long period of time. And there are projects in place. So recently in 2022, the Bill & Melinda Gates set up a Grand Challenges event where they put out funding to build PhD programs to support modeling in Africa.  

This is just the start, right? It's a great scheme. It's set up five different groups that helped in building capacity for modeling. Yes, it's specific to malaria, but I think over time, you're going to see more and more of this happen and more and more longer [00:42:00] term events happening.  

An example I can give is the President's Malaria Initiative have a strategy where they're now getting local agencies to start taking over some of their work. This is programs like CHISU. CHISU is a local entity that is now starting to use a transition phase to phase out what the President's Malaria Initiative is doing and hand over a lot of the technical capacity to local agencies. So they have a 40 to 50 year plan on transition because they know it's not going to happen overnight. 

Karoun H. Bagamian: That's truly thinking ahead-- that's a long period of time. I know from working in this space, a lot of things are so in and out or this short period of time where you really wouldn't be able to see that. That's really great that they're thinking that far ahead. I'm a little bit surprised, and that's great. 

Punam Amratia: I know. I was surprised, too.  

Karoun H. Bagamian: So what do you guys see happening or where do you think we're going with all this? 

Fredros Okumu: [00:43:00] Multiplication, expansion, acceptance, and many of this kind of stuff. So I want to see 200 Punams. But I also want to see them being accepted by the countries. You don't want your own country telling you that, I would rather listen to a scientist from Johns Hopkins than listen to my own scientist, yeah? Which, unfortunately, might still happen in some settings. So you want acceptance.  

And I think we also want scale and adoption of simpler ways of doing things, not necessarily reinventing. There are cases where we have to learn the methods of the West because those really are the only methods. But the world is transforming a lot, and so there are cases where we could actually skip some of those processes and learn the easier ways. Punam's begun a career with basic coding, I presume. And I'm wondering whether countries can scale up much more by natural language coding. And just do the same thing at [00:44:00] scale. 

From our research group, we graduated six PhDs and two of them worked on AI powered systems for disease diagnostics. One of them worked on AI powered systems for disease diagnostics, another worked on AI powered systems for surveillance. But I remember that when we were beginning, we didn't have any local capacity in Tanzania to do that, so I had to send students abroad to go and do that. 

So for me, when you see for the first time an entirely homegrown PhD program with a very strong basis on AI based diagnostics, you feel it may not be the end, but I think it's a very good start. And so you want to see the multiplication of these processes. You want to see many more of these people. 

Obviously, we realize that not all of them will go into local practice as public [00:45:00] health. But by scaling up these processes, you have a lot more pathways. Some of them will go into academia, some will go into industry, some will go into policy, decisionmaking . And this is really, then, when it becomes transformational. Because, as always, with public health, you don't achieve value solely from the efficacy of a product, how good that product is. Often you achieve a lot of this value from the scalability of the product. So sometime, when you have something that is imperfect, but you are able to do it in millions, then you can get a lot of scale. 

And that requires training more people. At the moment, the best training is available in very small number of institutions. There was a time when this was the best way to do things because then you can concentrate your resources in that single institution to provide scale. I think we are now at the stage where you can also scale the institutions themselves. You can have many more institutions performing these functions. [00:46:00] So when we have an organization in Tanzania having to support Senegal, can we actually have organizations in West Africa doing that kind of support as well? Can we do this in many more institutions? And then you're starting to complete the cycle of renaissance , and then you're really going with it.  

 This is really what I would love to see in the next decade. It's probably a very big ask. You have to balance the quality as well, obviously, when you start having many more people. 

So you really need those three things. You've got to scale, you've got to multiply, you have to have the local countries also accept these people and make use of them. 

Punam Amratia: I might add, when you talk about scaling up the institute, it's also building, I'm guessing you mean universities. We've started with the Malaria Atlas project we're collaborating with the University of Dar es Salaam, for example, to start a master's program in geospatial modeling, because we need that critical [00:47:00] capacity, right? We need to start younger. And in fact, I don't even think a master's level is enough. 

We're going to start looking even lower down to bachelor's level and even considering high school. How do we build that excitement to go into this world of data science and modeling and geoscience and things like that. So it really does start down from the foundations itself of education. 

Karoun H. Bagamian: Yeah, building a stronger pipeline throughout all the levels. I feel like that's been happening with public health, in general, too. Just starting earlier, people being more aware of the importance of that.  

Punam Amratia: Building the relevant infrastructure as well. And what I mean by that, and I'll take it a little personally. A lot of the type of things that I do require high processing compute power, which means that I'm oftentimes working on cloud computing. It was a very big eye opener when I moved back to East Africa to realize that there's not a single [00:48:00] server on the African continent that can support cloud computing. Which means that for me to do any cloud computing, I connect to my closest server, which is Belgium.  

Fredros Okumu: For me personally, I would love to see that kind of infrastructure to help support these new technologies a lot more come into Africa. And I'm hoping that, with the opening of offices like Microsoft and Google on the continent, that this will become more and more readily available.  

I agree. Punam, do you think that someone else should be deciding this for the countries, or do you think there should be some pool where the countries are actually attracting this as a strategic issue rather than waiting until they're approached? 

Punam Amratia: Yeah, I think the countries should be strategic and pooled together. It is something that I would consider a shared resource that would benefit everybody in the grand scheme of things. So coming together as a group would probably have more strength than trying to do it on your own.  

Fredros Okumu: Yeah. In the Africa Union, I've had discussions about [00:49:00] highways, for example, building new dams, building a road from Cairo to Cape Town. But I would be super happy if I could hear them saying, "Oh, we're going to set up two data centers in the continent." I think that would be really cool.  

But I think that global health systems rely a lot on external infrastructure that also support other things. And I think that integration requires multi sectoral conversation led by the governments. As scientists, we operate a lot on, you know, one to one. I talk to global health scientists in the north and we start a collaboration. But to make these things work sustainably, it's going to require our government to begin putting in the time and the resources to strategically put these things together. Because then they will be supporting not just global health, but also other service industries, right? They will be supporting education sector, they will be supporting the agriculture sector, and unfortunately, without such systems, there's only so far you can [00:50:00] go.  

Growing areas such as genomics, data sciences, AI, stuff like this is going to be very difficult to do without some background investment in number one, the people and number two, the infrastructure. 

And these are things that only the governments can lead. They're not going to be a university based projects, they have to be led by the government.  

Karoun H. Bagamian: How do you guys feel when you think about the future? 

Punam Amratia: I'm always sunshine and rainbows. So I feel very hopeful.  

I think that we're starting in a good direction now. Yes, there are a lot of roadblocks along the way. There's dwindling funding. There's challenges of conflicts that are happening. There's lack of infrastructure. But I think we're always moving in the right direction. 

So I'm hopeful for the future. And I see this as something that's not going to change in 1 to even 10 years. This is something that is going to take at leastdecades, if not a century to change, but I'm hopeful [00:51:00] that it will change. If not in my generation, the generation that comes after me. 

Fredros Okumu: I'm hopeful too. The speed of change is unpredictable. I would still wish to see a lot more accountability and responsibility. Actually, when we wrote our 2021 paper, we wrote a second letter also to the African research leaders, which didn't get any headway. 

Punam Amratia: Oh, I remember that paper. It was great. 

Fredros Okumu: We were basically asking them to take responsibility. If you don't, someone else will and then we shouldn't blame those people for doing so. 

So I want to see a lot more responsibility from the African leadership. I appreciate the fact that a lot of financing is still coming from the Global North. But I think while that is happening, we should be building more resilient structures with our own domestic funding, even if it is small. 

But we need to be putting in gradually long term systems. And an example I like to give is, you help us buy bed [00:52:00] nets this year and next year and for the next 10 years. But while that is happening, we should make sure that our health systems are very strong. Gradually improve people's houses with basic things like, have a simple house regulation that says: you need a metal roof instead of a thatch roof, and the government will give you a subsidy. We can have this program planning in the background essentially making sure that when those commodities go down, we are not having a rise in cases, in disease.  

Things like tuberculosis, a lot of it is caused by the environment. People living in crowded areas. Countries can do a lot by just teaching people and helping improve the environment, educational systems. HIV, there's a lot that we can do on the background. And I think that if we don't have governments taking responsibility, global health will remain basically a playground for Westerners. 

Fredros Okumu: And we can't blame them because, at least for the locals, that is their only way to getting [00:53:00] antiretroviral drugs. It's the only way to getting malaria medicines. The only way for them. If Global Fund pulled out, if the United States was not financing HIV control in Africa, there will be a lot of deaths. A lot of deaths, I'm telling you.  

But whatever we get from it, can we use it with the knowledge that one day it will run out? And so in the process, can our countries put in resources? And so I would love to see more of that responsibility as well. And obviously the people with the power right now, whatever they can do to help sustain, 

Punam Amratia: I just wanted to add something for the future as well. And then talking about this ownership by the countries is something on my wish list is also ownership for being able to manufacture a lot of these products locally.  

Yes, we live in a era of free and global trade. And I won't dive into that too much because I don't know enough about it. But we saw this in COVID, right? When there aren't enough vaccines to go around. Something I would really [00:54:00] wish for in the future is to be able to see the local ability to manufacture some of these vaccines to support vaccine preventable diseases. 

I know that this is a big agenda in the WHO AFRO region. And I hope that as part of the agenda for the African Union and the African CDC that this is going to be something that is going to really happen.  

And you're starting to slowly see that with the BRICS, with Brazil, India, South Africa and China, that they're taking more leadership into developing and manufacturing a lot of these products that go into public health systems. Meaning that there's more local ownership or regional ownership to help support their regions. So, fingers crossed that will continue in the right direction. 

Fredros Okumu: Yeah, that's right. I am aware of these issues, especially I know there was vaccine shortages during COVID that could have been prevented if there was more local producing. And I know that there's a lot of efforts in different countries in [00:55:00] Africa to have facilities for that. And then sometimes things get derailed. So, I hope that will work out.  

This is one of the most frustrating things for me. Vaccine manufacturing is much more complicated one. There are simpler things. Bed nets is a good example. We need millions of it every year across Africa, but it's very hard to find a local manufacturer. 

Fredros Okumu: So if you think about it, the fabric or apparel industry is very vibrant in Africa. In Kenya, they manufacture a lot of clothes that they then export to the United States. So a lot of the clothes you wear are probably manufactured in these African countries through the EPZ systems, but somehow we don't manufacture the one global health tool that we need most. We don't manufacture bed nets. We don't manufacture the basic stuff, and that I don't understand.  

And I really do hope that, I mean, Nigeria has 25 percent of all the malaria in the world. That's why for me, [00:56:00] when you talk about global health renaissance, I find it a very complicated conversation because there's a very big accountability issue, a very big local leadership issue that must be addressed before we even start complaining about Global North.  

Fredros Okumu: And some of it is just many of these countries, they would rather import a product from India than buy it locally. And in fact, I know many times in Tanzania, when I go to a drugstore and say, "I want to buy Tylenol or paracetamol," the guy will say, "Do you want the one from Germany or you want the one from Kenya or you want the one from India?" And so if you ask them the reverse, "Which one do people buy most," they'll say, "The locals would rather buy the one from Germany or India than the one from Zimbabwe." 

We don't even trust the products built locally. So it becomes a very complicated thing. That is why I think, in the long run, we will need [00:57:00] acceptability by our own countries. Because then you can manufacture stuff in Ethiopia, but the Kenyans will still rather import it from India than buy it from Ethiopia. But in the end, sub local manufacturing really has to be done at scale. 

Punam Amratia: I mean, you've put a very beautiful African Kitengi Nigerian net in my head, and I think that would look way more fabulous on my bed than anything that the US or Europe would make. Just the colors alone. 

Fredros Okumu: Kitanga net would be a nice one. 

Punam Amratia: Right? Think we better patent that, Fedros! 

Fredros Okumu: Agreed. Agreed.  

Karoun H. Bagamian: Function and fashion. What more could you want? 

Punam Amratia: Exactly. 

Fredros Okumu: You know, I wrote about this a while back. One of the papers that I found very difficult writing is a paper I call the Fabric of Life. I think I wrote this in 2020, where I asked the question, what if bed nets didn't have insecticides but were manufactured locally? 

Karoun H. Bagamian: Interesting. 

Fredros Okumu: The argument at the time was that one of the main reasons that African [00:58:00] countries don't manufacture bed nets is because they don't have the technology to put the insecticide in the net. This is technology that they have to borrow from Western companies and because they don't have the technology to put the insecticide inside the fabric, which is the most difficult part of that process, they can't participate in this pool procurement process. 

So I said, what if you didn't have to put the insecticide on the net? Maybe the countries could just be encouraged to manufacture fashionable nets that are very durable and that protect you and protect the next person and so on and so forth, they don't have to have the insecticide. And I think that there are viable opportunities in these cases, but you need to have local support, generally speaking, for local manufacturing of the things that we need or the commodities that we need in global health. Without that, we will continue to rely on price differences from the West. When the first malaria vaccine was approved in 2021, I believe, the [00:59:00] WHO recommended it for places where malaria is moderate to high. This was a four dose vaccine. An estimation at the time suggested that every year, 25 million children are born in those areas. So for a four dose vaccine, you needed 100 million doses of this vaccine every year. The company producing it could not guarantee even 18 million doses. And so they say, "Okay, we'll give you 18 million." And then WHO starts this process. "Okay, we have this 12 countries that have applied. How do we distribute 18 million doses of the vaccine?"  

A disease that is killing 600, 000 people yearly has 250 million cases. You are dangling 12 million doses of the vaccine and saying, please go share this one. It's a very sad situation. And the reason is none of these local countries can manufacture. So I think that local manufacturing would solve a lot of these things. And other than that, we just won't go anywhere. 

Lindsey Laytner: I think this is all so fascinating and also so complicated, right? But I think it's [01:00:00] all very doable as I believe everyone here feels that way. 

Especially with the fact that we have the data. We have countries collecting data, so that's going to go back to funding agencies, to show things are actually working. And I actually feel like in the future, we're going to see a lot more cost effectiveness because it seems to me there's also a lot of money that's being wasted on things that don't necessarily work, right? 

So as you're building capacity on the ground, and you're having more accountability and you're, hopefully, developing a better infrastructure to be able to do these things, really at the local level, like how they make sense, we'll be able to save a lot of money long term, which I think will keep the money circulating. And the North and the South, if we want to look at it that way will continue to be working together and then the South to South and maybe South to North-- we'll all just be able to put money into the pot and make sure that we're all [01:01:00] healthy.  

Cause it's going to go back to the dollar, and we need to be able to show all these institutes, all these funders that, the money is being used appropriately, and we're seeing these changes and this is gonna really benefit us, so keep pushing more money through. And I just keep thinking with this global health renaissance that we'll see this money being put to better use and possibly even saving money, which would be huge for all of these global donors that are always looking how are we going to cut costs here and put more money towards this thing. It's just gonna be better for everyone. So I think it's the direction to go in, it's just logically makes a lot of sense. 

Punam Amratia: Yeah, no, I agree with you. And you already start seeing that. And again, I'll talk about the malaria aspect. At least a decade ago, maybe more, there was a lot of blanket approaches of let's just put bed nets everywhere. Let's just have one strategy for an entire country and you're like, hang [01:02:00] on, if we've got 40 million people living in this country, we don't necessarily have to give 40 million people a bed net. 

Because there's some places that have malaria, and there's some places that don't. And so we started, with WHO. WHO put out a global technical strategy that highlighted that a one size fits all approach is not necessarily the right mechanism. That we need to start thinking of the geography of what is cost effective, as you said. What will work, what won't work in certain places because of biological threats like resistance. Pulling that all together, then, to build a strategy that's cost effective and is going to get the best bang for buck. So the highest impact. And through that came the birth of initiative called a High Burden, High Impact initiative, which I have actually been working on for the last six years supporting with risk maps. And you are starting to see a little bit of that change.  

But you mentioned something else [01:03:00] about cost effectiveness is yes, it's about being cost effective, and Fredros mentioned that the money is not always going to be there, right? We have to find sustainable mechanisms where governments are taking responsibility.  

But at the same time, we also need empowered leadership. We live in a world where we need to show evidence for everything. And that's where the data comes in, generating the right evidence to show the impact of something. If bed nets are not the most ideal, we need to show that through data and evidence, so that countries have the capability to go to these larger bodies and say, "Hey, this is not working. We need to change our strategies overall." And we really would love to see that bottom up approach of the government or the countries leading the global health agenda for these type of diseases. 

Lindsey Laytner: I [01:04:00] completely agree. Yeah.  

Fredros Okumu: Obviously you also need the data to show the people giving you the money that their contribution is saving lives. And I think for fundraising, this is particularly important. If we can go back to, donors and say: We were at place A. With your financing, we are place B. It provides the motivation to continue doing that. And I think it's important to, to feel both ways. So we need the data to decide how to use the resources, but we also need data to provide feedback on how this resource made progress.  

Lindsey Laytner: And I think that part of the capacity that we are building, that should be built, is also this global health diplomacy. Because you are scientific leaders or your technical leads at country level must have an understanding of how to manage these conversations with the private sector. You must encourage the private sector, but you must also regulate them, as you said. In [01:05:00] mosquito control, we rely a lot on the agriculture industry, because that is where the pesticides come from. 

Fredros Okumu: So it's easier that way because they don't see a big threat from the public health industry into the agriculture industry. But we still have to convince them that you have so much money, why can't you put a little bit in public health because then we can rely on it. Now if you don't encourage them to do that, they just will not. 

All the new pesticides we now have for public health came from agricultural side. And they can do that if they're encouraged. If at the same time I am parroting to their board about genetically modified mosquitoes, they're like, "Oh, so you want me to invest in that new pesticide? And on the other hand, you're bringing a vaccine. Where's the market for me there?"  

So, it's got to be a mix of carrot and stick here. But there's room for everybody. The thing is that many of the global health challenges we are tackling are so big that even if everybody got involved, they'll still have enough income to do that. So part of [01:06:00] it really is just activating the market and making sure it's vibrant, that the countries are willing to do that. 

SoI think that If you're American, you say the pie is big enough. So I think everybody can be satisfied, but yes, we need the private sector, but we've got, the capitalist systems, the private sector will take advantage of you very easily if you don't regulate it. And it's their right to do it. 

Punam Amratia: Thank you so much, both of you for joining us. This has been such an informative and enlightening conversation.  

Karoun H. Bagamian: Thank you for having us on the podcast of "The Business of Doing Science". It's been such a pleasure having this discussion with you and having a little tete-a-tete with my colleague Fredros here, talking about the global health renaissance.  

We've definitely enjoyed it. 

Fredros Okumu: No, thank you so much as well from my end. As we said in the beginning, it's difficult but important conversation, so it was nice to listen in and also participate and I wish you guys all the best. 

Karoun H. Bagamian: Thank you.  

Lindsey Laytner: Thank you. 

Karoun H. Bagamian: Thank you for joining us and listening to "The Business of Doing Science" podcast. For more information on our guests and access to career development resources, please click on the link to our website below. And remember, you can also visit the website to learn more about how Bagamian Sci can help you do science.