With history, be prepared to construct and reconstruct it from a different perspective, a Black perspective, an African perspective too. Our stories have been told to us by others for far too long that this time, the lions are ready to take the stage. The complexities and racist histories of colonialism is finally taking center stage with this global pandemic. Variants of it has been there from the beginning, though swept under the rug of globalism. It is rather a class on colonialism and this time, there are no more slaves in this version of history. No more white people selling bodies for profit. No more tantrums from leaders disguised as fit but truly unfit. Plus no more pretense as if we are all in this together. We are not. The inequities with vaccine distribution was clue number 1. Number 2, the injustice with flight bans.
With Omicron variant surging through countries both in Asia and Europe, why is a travel ban only issued for countries in Southern Africa? This is the truth about decolonizing Global Health worth spreading, plain and perfect. Powerful leaders will always be leaders with power. They will do and claim to do what is always in their best interest even if this interest serves only their needs. Anyone expecting anything less has not been open to all the travesties that is colonialism. The emperors maybe wearing new clothes but they remain emperors, powerful ones now with subtle charm that invokes globalism when the harsh realist is individualism. They may claim change but their change is more or less like distant skies out of reach rather that streams of water in plain view. Everything about their dominant treatment of others both implicit and explicit remains true, and will always remain so during and beyond this pandemic.
The solution, lions tell your story. There will be a struggle. Embrace it. Refuse to be enslaved again and tell your story of injustices however you choose. This time, the path to pandemic freedom will be different. Not because we relied on the West, but rather because we believed in each other. I spent my morning retweeting and sharing videos of people telling the story, this time from their perspective. Dr. Ayoade Alakija’s interview with the BBC stood out to me. Watch here and see how lions are roaring to tell their stories.
I presented at the 2021 AORTIC Cancer research in Africa. There was a pre-conference the past two days and I was asked to lead this morning with a discussion on why implementation science research for cancer in Africa. What many people do not know was that the invitation which came July 12, came exactly one month before my sister in law passed August 12. I took it as her parting gift. She knows I love to talk. She also knows that I do research, implementation science research in Africa. But I have never done Cancer work. Never even felt it was my place to do so until her cervical cancer came knocking at our door steps. The preparation for the presentation has been one giant healing process for me. I literally wrote poetry, yea or maybe verses on ways to disseminate cervical cancer research using her experience as an entry point. I was so tempted to do so at the presentation that I opted out last minute. Not because I don’t think they were great and I will publish them here one day, but more because ours is still a very conservative field and the idea of decolonizing how we present research or even saying anything anti racism scares people, though I am working on verses for research. But I digress. For now, here is the standard presentation I gave and yes, I gave it in her memory as stories still, to help guide those who want to fight like hell so we don’t have to tell anymore stories like Angie’s.
I know we have heard a lot about implementation science the past couple of days, with a lot of talks about what it is and how to do, but let me paint another picture if I may of why this matter for the region.
So I am an implementation researcher, interested in how you sustain evidence-based interventions in resource-limited settings.
I am also a storyteller.
I grew up in Lagos, Nigeria, with a show called Tales by moonlight which is similar to what griots do in many other African settings, and so stories are all I know, and it was refreshing to hear Dr, Eche tell his implementation story these past few days. I think we heard yesterday for example, that policymakers respond to data, I agree.
As someone who used to work in the UN, I would also add that policymakers respond to stories, especially stories about data, stories about what works or doesn’t work, even stories about the constituents they serve. So let me tell you a story If I may of why implementation science matters for cancer research in Africa
And I want to begin from with the story of Angie. Angie, a 53-year-old woman, as is typical in most African countries, presented in the clinic with stage 4 cervical cancer.
There were no warning signs, or least when she saw some, she didn’t take it seriously. She never had pap smear in her life until she presented. She didn’t even have any access to universal health care insurance.
Only reason she presented actually, was because she couldn’t eat anymore, and felt something was obstructing her ability to eat, and was seeing blood in her stool. Angie’s story is typical in many African settings, and in particular for understanding why context matters for implementation science cancer research in the sub-Saharan Africa.
And to illustrate that a bit, I allow me to use some analogies. In our settings, analogies are like proverbs, they are like miniature tales, building blocks if you like in simple form of ways that the field can proceed.
This recent paper by Haines in implementation science describes context as a fabric. A blue fabric in this case, and just as embroiderers must first understand the fabric they are working with, researchers and practitioners of implementation science must obtain an understanding of the context in which they work in before selecting or adapting an intervention or any implementation strategy.
The red needle in this case represents the implementation strategies and thread is the intervention you may have in mind, and all of that have to be in harmony with the context in which you find yourself in.
I really like this paper, but let me address context in another way. Enter Yucca which many of us in Africa, may know as Cassava.
But if you traveled to South America, it is called yucca and it is used to make empanada, yucca fritters or yucca chips. Now this same tuber, if you come to my home country of Nigeria, can be found in local dishes such as Abacha, or what the Igbos’s call African salad, or eba and soup, eba being a typical Yoruba dish, or quite simply garri and groundnut, something we all eat in Nigeria as a favorite meal.
I use Yucca and Cassava here to illustrate again context matters. It the same tuber, but if you went to South America, its used differently, if you come to Nigeria, even within one country, it is also used differently. Context, like all the stories we will tell with implementation science it matters.
Another reason why context matters is that, the past couple of days was spent on ideas of what works with implementations, the how to do it literature of implementation science, and to all of that I want to add one thing that was missing and is this idea of starting with Why. And So for implementation science in the region, always start with why.
And if we stayed with cervical cancer, Remember to start with why for something so preventable and treatable, Remember to start with why for something where one in four women will die, unless they have access to life saving evidence-based therapies that exisit. Remember to start with why with resolutions that exist, the historic 90-70-90 resolution last year for example which calls the 194 member states of the World Health Organization (WHO) to achieve specific targets by 2030. Resolutions like this are actually fertile grounds and justification for implementation science in the region.And when you start with Why, you will find out that implementation science is an open and inclusive field that basically means workings not only within the context you find yourself in, but also broadening your collaborators, to include working with multiple experts and non-experts that you can work with to expand the field.
And as you do, as you pick out which outcomes, or frameworks or strategies you will use, be prepared to optimize them for your context. Many of them will not fit ERIC, storytelling isn’t in ERIC as an implementation strategy and that’s ok.
I say go for what works for you, let all that was shared these past few days be a guide, so long as you remember your why and that your context matters. This is the time to begin to galvanize efforts to decolonize even all we know with implementation science and just because it has been done in the West doesn’t meant it has to be in your setting.
In addition, and if we stay with decolonizing the field, also maintain what you know works in your setting, in your context.
You live there, so you know it better than any expert that may come to your setting. So harness that knowledge, it is just as vital as whatever knowledge you will bring from IS to your context.
And finally, be prepared to evolve. Change is evitable, CoVID 19 being a great example Of the need for example to embrace disruptions. Embrace whatever struggles you come across as you evolve. That and be open to other ideas, like the idea of health or implementation science occurring beyond a Western Paradigm.
Professor Collins Airhihenbuwa, my mentor, over 30 years ago, developed a framework called the PEN-3 cultural model, which helps to situate some of the work many of us do in the region, and it asks that we begin always by interrogating what is positive about our context, what is existential or unique about where we find ourselves, and then ultimately what are the hurdles, or challenges to be mindful of along the way, and for me the past few days of listening in, has allowed me to see first-hand, that the leadership within Aortic, in fact all they have done with setting up this conference, is the right start for tackling cancer research in the region.
I wholeheartedly believe that AORTIC is going to be a great resource and leader for anyone in the region try to navigate the rugged complexity landscapes of doing implementation science research in the Africa. And the stories we will tell, for example with the Aortic implementation science special interest group will be the escort that propels the field forward in the region. It’s your story that will convey all our gains, all our failures, and all we hold dear, or should condemn or de-implement for example with implementation science in the region.
So finally as you think through context, one thing I want to emphasize is that we all get into the habit of doing is rapid cycles of what will work or not work in our setting. Some of the speakers, Donna Shelley for example, talked about rapid cycle evaluations. The response to the COVID pandemic has been one massive rapid cycle evaluation, that I believe everyone trying to do work in the region should seize upon because the tools for cancer, whether with prevention or treatment exists and have been in existence for decades yet they continue to remain out of reach to the people who need it the most.
This idea of making a plan, then doing, then studying, then acting, or making another plan will do the field well and help save lives now. If you choose to move in this direction, let me stay in the issue of just planning and tie it squarely to the issue of sustainability. I believe that it is unethical for people to implement interventions in regions with limited resources without even a simple plan on how you last.
Most of the research you will come across implemented in the region, are never sustained. This paper for example by Johnson et al on NIH R01 grants in general with an implementation science focus found that none had plans to last.
We found the same thing in a systematic review I led, about 5 years ago about the sustainability of research in the region. We also noted that if you are going to come do any implementation science work in the region, the least you can do is plan to last.
It should not be done in the end, not even in the begin, but throughout the lifecycle of whatever interventions you have in mind. Having a plan, can be as simple as gathering the right stakeholders to work with, learning from them, be willing to change or adapt along the way, while nurturing what truly matters in within the context in which you find yourself.
And so in recap, I loudly and enthusiastically appeal to the group to come do implementation science work in the region particularly with cancer, and as you do, with whatever frameworks or strategies you use, plan, plan, plan to last.
Thank you to the organizers of this conference for allowing me to speak, Drs. Odedina, Alaro, Bello, I thank you for the invitation. Your invitation came at a time when my family was dealing with the stage 4 cervical cancer burden of Angie my Sister in-law. We lost her to cervical cancer this past August 12th. But I give this presentation in her memory for the many other Angies we all have to fight like hell for, so they live, in a region where context matters. Implementation science needs more storytellers and I hope that AORTIC works to cultivate the next generation of storytellers truly making a difference in word and deed for cancer research in the region.
‘Currently the scientific process is doing a major disservice to patients and society.’ That was the conclusion of a paper that popped on my Twitter field today. It’s like the entire universe is conspiring to say something to all of us in this field and I am so here for it. The authors led by Calster et al. (2021) basically stated that ours is an enterprise where the quality of the work we do remains poor. The criticisms remain longstanding. Business as usual is the backbone of the enterprise where most initiatives to address this issue are top-down. I guess I am not alone is all I can say. That and we all need to do better. COVID19 made it painfully clear. According to Calster and colleagues (2021) ‘the focus remains more on the destination (research claims and metrics) than on the journey. And so the problem of poor research persists. The problem is deteriorating further.’
‘Notwithstanding, research should serve society more than the reputation of those involved. Science should not be a game in which we collect credits to reach the next level of our career.’ Which made me decided to keep this today. With research, even with the publications you write, keep being in service to people.
Be in service to people as you study disease prevention, disease management and disease treatment. Be in service to people without focusing on disease too. Be in service to people as you reduce poor quality research, reduce poor design, reduce poor research conduct, or reduce poor reporting. Be in service to people to simply reduce ‘research waste’. Be in service to people with research that has value for patients, research that has value to society. Be in service with research that is simply of value and not harmful.
But of all this, know that research waste remains a persistent problem. Research waste is structural injustice. Research waste is costly and truly harmful to society. Research waste is a function of all of us in academia. We are the problem with research waste. We can also be the solution. And I want to be counted in the number of those working towards a solution.
In 1968, Dr. Morris Schaefer, a Professor and Head of Department of Public Health at UNC, Chapel Hill wrote a striking paper about the current issues in delivering better health services. He presented it at the 95th annual meeting of the American Public Health Association and many of what he shared then resonates with the state of public health today. In it he shared ‘how our incapacity to appreciate the character of the problems we face, may render us helpless when we encounter future challenges. Our field is not only confronted by new challenges, but also an increased urgency attached to old problems, new responsibilities, new functions, all at an increasingly rapid rates. Also with each new challenge, comes the need to respond to continuing changes, all while maintaining the stability necessary for effective Public Health Service.’
If only our field heeded his advice in 1968. That and the idea that Public Health for better or worse is deeply enmeshed in political activity, despite the fact than antipolitical ideology persists. The handling of the pandemic is a glaring example of this. One section though that I choose to keep today is his focus on how ‘the past is still present.’ He was so thorough with the significance of the past and why we all need to have a reorientation in our attitudes about public health that it only makes sense to render it in verse for the present.
Without no further ado, read my keep below inspired totally by Dr. Schaefer entitled the ‘keep knowing that the past is present in public health:’
Public health faces a new day. While a hangover still remains.
Unsolved longstanding problems remain. Unfamiliar areas of services too.
Shortage of personnel remain. Solutions for the future too.
Conditions of uncertainty remain. Clamor for demands too.
Varied programs and goals remain. Complicated disciplines too.
Target populations remain unknown. The public we serve too.
Useful but limited textbooks remain. Old, standard associations too.
Struggles between agencies remain. Tensions across disciplines too.
Uneasy frontiers for public health remain. Uneasy boundaries between agencies and governments too.
Delusions of a old and well-propagated myth of the non-political character of public health remains. The persistence of the non politics myth too.
Lost opportunities remain. Lack of clarity of vision too.
Unsolved current problems still remain. An extension and intensification of past problems too.
Social problems significantly remain. The hands of the past on the future too.
Discerning local interests remain. Harmonizing initiatives too.
The need for imaginative and highly capable actions remain. Increased competency with information technology too.
Enormous strains on coordination remains. Responsibilities and resources too.
Long standing tensions among professional groups remain. Equal status of groups too.
The need for greater visibility with public health remains. Shortening lines of communications too.
Loss of potentially fruitful research remains. Duplicating research and services too.
Existing fragmentation of agencies remain. Business as usual too.
The urgency of problems affecting particular groups remain. Disruptive and limited responses too.
Struggles for allocations remain. Visibility and authorizations of those allocations too.
And so the continuing problems of the past remain. In the midst of new problems too.
Limited understanding of the persistence of these problems remain. So too our inability to solve them still (whether in 1968 or 2021).
Maybe we should have talked more often. I should have asked more questions too. Not just hello, or how are you or Ke maka Di gi, or Chekwube? But have you checked your cervix lately? When was the last time you checked? Did you collect the sample by your self? What did the results say? Why are you still bleeding then? Fibroids will not cause you to bleed this long. Treatments are deficient, I know, but what did the doctor say? It’s a developing country and cancer is a death sentence. Maybe, just maybe if I had asked these questions always, all the time, then maybe Angie would still be here. We would have found out early. Angie, would still be calling me, my name, Osodieme. Check your cervix, for Angie. For me.
Henrietta Lacks is like all of us to the scientific landscape. Nameless, faceless, voiceless, with no power to make decisions with how we are viewed to the field. She didn’t have a say with her own unique cells. No wonder people distrust a paradigm that continues to treat people as if they have no name, no face, no voice, not even power. Until now. The past week has been surreal.
To give a quick background and this is from Yasmin Amer for NPR news: ‘In 1951, a Black woman named Henrietta Lacks walked into Johns Hopkins Hospital in agonizing pain. Doctors diagnosed her with cervical cancer. She died just months later. But what this mother of five never knew was that her cells would outlive her and be used to develop new drugs and vaccines…Her cells were the first known immortal cells. Whereas other cells died in the lab, hers thrived. They multiplied. They gave doctors the ability to do new, innovative research. Names and fortunes were built on them, nicknamed HeLa cells for Henrietta Lacks.’
Watching the Lacks family do their part to put a name, a face, a voice to cells used without permission is soul gratifying. To see the highest health organization in the world, the World Health Organization acknowledge that some injustice occurred in a field that preys on people for what what just is and not for their overall being, is also soul gratifying. Henrietta Lacks is no longer nameless, or faceless or even without voice because some voices, came together to say in harmony together, enough is enough. Enough is enough with treating people as if they were commodities in science. Treating them as if they were indispensable. Enough is enough with being faceless in science too. Enough is also enough with being voices with science. She matters just as everyone else matters as well. Science can no longer pretend as if it’s not in the business of people who have names or faces or voice. They do.
Every single person that interacts with the field has power even beyond science. We in the field are not the only ones that get to decide what has impact or who counts. They public had a critical say to advancing the field. They have a critical say with dictating how we best use our tools to serve them. And if and when we deviate from what is permissible, the public has a say with putting us right back in order. That is what Henrietta Lacks Family did for her this past couple of days. She may be long gone, but forever and ever we will say her name, see her face and know her voice. She was powerful beyond her wildest dreams and will remain so for as long as time permits.
Zora Neale Hurston described research as a ‘formalized curiosity.’ One that involves poking and prying with a purpose. I have been blessed to call research my job. To engage in this formalized curiosity full time is the best gift I have ever given to myself. Many take it for granted, but I know what I am capable of. Whether it is about remote ischemic conditioning or crowdsourcing youth interventions, if it requires poking and prying with a purpose, I’m all in. Which is why of late, I have been wondering what else can I use my research skills with. Clearly, it has taken me to the world of literature, black literary scholars to be precise, from the eyes according to Zora, to light according to Audre. There are some books on becoming dreamers, books on why my future depends on me remaining curious and of course books about tracks along dust roads or the fire in my head. I see this phase of my research as intentionally trying to uncover all that I can about the world in which I dwell in. Research now has taken me to places I never imagined, reading words, I never expected. In some instances, I have been carried away, whether is with a list focused on dreams that never end, or a list of why chasing butterflies matter. In other cases, I found myself writing things that seem harmonious in my head, to the point where I recite them to myself, as if on a stage for spoken words only. These dances in my head, unleashed through words in this blog is my attempt at surrendering to chance, surrendering to what I intend to do for me. To research things I want to for my own pleasure. To think I have been on this journey for 13 months seems surreal. The future also seems very uncertain. But for today, I’ll rather remain curious, remain compelled to do this formalized curiosity work Ms Hurston described as research.
Last week the U.S Surgeon General issued an advisory that declared ‘misinformation as a public health threat.’ In a blue document with massive bold letters in white, he argued that we need to begin the process of confronting misinformation by ‘building a healthy information environment.’ I was intrigued and kept scrolling down the document to understand for myself what he meant by the terms ‘a healthy information environment.’
I also welcomed the invitation to ‘limit the spread of health information as a moral and civic imperative that will require a whole-of society effort.’ His words. The table of contents seemed easy to follow with suggestions on the ‘what’ people can do whether as individuals or educators or journalists or even funders and of course the government. There was even a ‘where do we go from here’ section that increased my curiosity with the report. But from the first page, the background, the report lost me and I am sure the public. None of this centered the ‘public’ in public health.
There is a reason why health misinformation is so rampart these days and it has nothing to do with long backgrounds, even those focused on correct health information. We fail and continue to fail the ‘public’ if the words we use to speak to ‘public’ doesn’t include language or even tools that makes sense to the ‘public.’ I wanted to root for this document because of the seriousness of the topic, because this is literally a life and death matter and people, black and brown lives are dying everyday because of health misinformation.
Then it dawned on me, if I took a camera and walked down the streets of Harlem or Newark, or Augusta, or Pittsburgh, or even went to stores like Sam’s Club or Costco, would people be able to tell me what if anything they remembered from the Surgeon General’s advisory. Would they even know it exists?
There in lies the dilemma with health misinformation. While the public health experts are so focused on what it is or what it is not, the ‘public’ is focused on the why in the forms of stories they pass on to each other, through words and languages and other mediums that make sense to the ‘public.’ There is a reason why social media is widespread and content is viewed as powerful. People are expecting from public health, serious comments about their lives using tools and language that make sense to the ‘public,’ that speak to the ‘why.’ They are not expecting the ‘what.’ They are expecting connections, truths, even art and spoken words that say things important to help them with life, their health. The sooner we understand the ‘why’ of health information, the quicker we can begin to center the ‘public’ in public health. This is what is meant by public health to me these days, a deliberate focus on the public’s health, not by us the experts but by the public first.
We spend too much time focused on the ‘what’ of health that we forget the ‘why’ in public. There is a reason why stories live on long after the storyteller has ended the story. We can start there by bringing back stories to public health. Poetry too. As a tool, whether spoken or listened too, poetry can humanize us, make us whole, both emotionally and intellectually. Art can do the same. Art for and by the public can be intentional and life-sustaining with centering the public in public health. While letters to the public, like a ‘Dear Public Health’ can help the public confront the worst so as to be free to experience the best that is unshakable in public health, the ‘public.’
It is always about the ‘public’ after all. Our future depends on listening, seeing, feeling, daring even to center the ‘public’ in public health. We are all amplified when we center the ‘public’ in public health. That should have been the main crux of the advisory, a foundation through which to dismantle the public health threat that is health misinformation. We have miles to go but if we want to end this war, as it’s a war to, with casualties increasing everyday, the ongoing pandemic being a clear example, then we have got to bring back the ‘public’ in public health.
I am in the business of light making. It is messy, very complex with turns that keep winding.
When rich countries get 40-60 percent of Covid vaccines and others, especially countries in Africa, get only 3%, you will understand why I choose light.
When racism, especially structural racism is at the heart of why we consider some youth to be deficit rather than as asset, then you will get why I fight for light.
When people are denied deep sleep for centuries, due to trauma inflicted generations ago from the sins of enslavement, then you will understand why deep healing through light becomes the only way.
What would it be like to live in light, to live in a space where the pursuit of our healing is not defined by others but us.
Audre Lorde once noted that ‘our battle is to define survival in ways that are acceptable and nourishing to us, matching it with meaning, substance and style.’
This is my attempt at a doing so, by being a burst of light for public health.
Though the road ahead is rough, I remain committed to this business. It is forcing me to reach out to unlikely partners. The public demands that we do. The public also demands that we listen as we reflect and act on this long-overdue renaissance necessary for public health.
We are convinced that the only way forward is to intentionally put the public back in health. Not in a way that oppresses them or consider them to to be the problem only, but in ways that build, ways that uplift, with every single thing we publish.
I am in the business now of doing what Petteway and Bowleg asked that those of us committed to the public’s health should purse. Not with using the master’s language only, but with using and finding tools that serve the every day realities of all the people we want to serve.
The process is messy, complex too. But I am committed to dismantling the ways we disseminate information on health to the public.
Who needs impact factor when the factor we seek to impact is more important than words that never connect to daily realities.
I am in the business of distributing light instead, not as p values greater than .05, but as people values that allow people to thrive.
I keep wanting to run away from it, to ignore it, hoping that the itch would go away. But I am drawn to it.
To become one with light is bravery undefined, love unfiltered, for possibilities unquestionably misunderstood.
So I follow the paths it illuminates along this way for the course of being different. Everything in my mind says we are on the right course. This feels right too and if I’m not sharing much yet, know that the time has not come for me to unveil all that is happening behind the scenes. But in due time, we will tell the story. Of how brave folks fought for light, with all their might in-spite of the all the fear that held them in a grip so tight.
We pushed through.
For when you are in the business of light making, the only way forward is light making, no matter how long it takes to make the light you seek to inspire.
I am in the business of becoming that leader that will work to ignite the healing and transformation necessary for the public’s health. I don’t have an answer or solution yet. But I want to keep this here for me as a reminder to keep being in this messy, complex business of making light. We just may become the burst or pacemakers for this renaissance.
We were surrounded by trees yesterday at Forest Park. Cherry blossoms trees as majestic as can be. Cherry blossoms signal the return of Spring. Like raindrops on a sunny day, they bring awe, and continuity for life’s many mysteries. They also bring joy. The mere sighting of a tree full of cherry blossoms evokes feelings of silence. Not because words fail me, but because they won’t do. The beauty of a cherry blossom tree is endless so silence is not needless. To see these trees blossom at once is to know the hidden message of trees. Life can be full of joy, full of silence, full of ease, if only we appease our deeper desire for continuity. For as sure as there will be another Spring weather, season after season, there will be cherry blossom trees too, season after season. This certainty, continuity as a certain thing, is why we should keep cherry blossoms in mind. For if we want our research to last, if we want there to be findings, season after season, for as long as the public health issues remain, then we must first begin like cherry blossoms. Keep continuity (i.e sustainability for those of us in implementation science) like cherry blossoms in mind.