Health equity, policy reform, and Africa's future: A conversation with Dr. Olusoji Adeyi

Expect an engaging and insightful dialogue between Professor Bertie Squire and Dr. Olusoji Adeyi, an LSTM alumnus and global health expert. Dr. Adeyi shares his journey from growing up in Nigeria to becoming a leader in global health policy. He reflects on pivotal moments in his career, including his time at LSTM, his work with WHO and the World Bank, and his focus on health equity and policy reform. The conversation covers topics like the influence of social determinants on health, the impact of colonial legacies on global health systems, and the future of vaccine manufacturing in Africa. Dr. Adeyi's candid take on the need for transparency, equity, and accountability in global health makes this a must-listen for anyone interested in public health, health policy, and the challenges of transforming global health systems.

Transcript

Hello, everyone. My name is Professor Bertie Squire. I'm Pro-Vice Chancellor for partnerships at the Liverpool School of Tropical Medicine, and it's a pleasure to be hosting this LSTM in Conversation podcast with our brilliant guest. Olusoji Adeyi. Soji is an LSTM alumnus, having graduated with a master's in Community Health in 1988. He's had a brilliant career spanning 25 years and is president at Resilient Health Systems in Washington.

Soji, it's wonderful to have you with us today. I want to acknowledge at the outset the pivotal role that, a colleague, who runs the podcast series Global Health Matters, have played in reconnecting you with LSTM. So Gary Aslanyan at TDR, the special program for Research and Training in Tropical Diseases hosts conversations with key people in global health.

And I'm a fan of that series and heard you speak and mentioned that you'd been a student of the LSTM when the late Professor Ken Newell was a leading figure in a movement called health by the people. And Gary then helped me to reconnect with you. So now starting our own podcast series, it's just one way in which we at LSTM are trying to reconnect with our alumni and friends.

So, if there's anyone listening to this who's an LSTM graduate and would like to join the growing network, please do get in touch with us at alumni@lstmed.ac.uk. So Soji, I know that was a bit of a long introduction, and I'm hoping I'll talk much less and hand over to you. So could we start a little bit with some insights about you?

What inspired you to work in public health? Did your LSTM time play a role and the like? Over to you. 

Thank you, Bertie, for the very kind introduction. It's a pleasure to connect with you and join you on this podcast today. So, my name is Olusoji Adeyi and I was born in Nigeria. That's where I grew up in Oyo, which is the land of Shango.

Shango is the god of thunder. That's where I went to primary school, my secondary school years where at the Federal Government College, Ilorin, that's, one of a network of unity schools in Nigeria. And it was styled after, believe it or not, British boarding school. But I should add upfront that, buildings did not look like those in Harry Potter, fortunately

Then I went to medical school in Nigeria at the University of Effect. Looking back, my choice of public health is a convergence of factors, some of which only became very clear in hindsight. The first was the influence of my father, who was a nurse. I witnessed caring for patients, when I was very young, including extracting guinea worm from a patient's leg.

That was quite a sight and somewhat traumatic for 6- or 7-year-old. I forgot how old I was at the time. The second one, which was pivotal, was the advent of the structural adjustment, program back in the mid-80s. That happened, when I was a junior physician at the Lagos University Teaching Hospital, and user fees were increased and we were compelled to discharge patients, who could not pay the fees at the time.

If there was one “a-ha!” moment, that was it for me, because I came to the realisation that far more important than individual care provided to each patient was the importance of having policies that were rational and sensitive to the average citizen, on the streets. So, I decided then that I will go into a public health and health policy.

And it's so happened that at the time, the program at the Liverpool School of Tropical Medicine was very big on primary health care and importantly, equity. So, I went to Liverpool and the program then was head the department at the time was headed by Professor Ken Newell, who wrote the book “Health by the people”. Health by the people was quite heartbreaking.

It was a compilation of experiences around the world, including country level policies and strategies, incremental gains, subnational policies and strategies, etc., etc. My time at the Liverpool School of Tropical Medicine, while it was heavily focused on global health or international health, as it was more commonly referred to at the time, also coincided with a still raging debate about the Black Report, officially titled Inequalities in Health.

Of course, the commission was headed by Lord black, as you will remember, but the UK government wanted nothing to do with the report because, it addressed some things that were very uncomfortable, about divergences in health outcomes, among subgroups of the population in, in the country and opened up a kind of warmth on social determinants of health.

So, for a 24 - 25 year old learning in depth about the effect of social determinants on health within a country and an, again, on a high income country, was fascinating to me that in many ways, it was no different from the inequities in my own native Nigeria. I was interested. The second one was that as part of the program, I had the opportunity, of doing my thesis work in Thailand.

So, I studied rural health insurance for the poor. And you can see where this is heading. That was, again, a reflection of my own keen interest in figuring out just how do you ensure that health financing policies and practices do not impoverish the poor and in fact, that they work for the poor and for their equity?

 It's really interesting to reflect back to that time.

I also remember the Black Report, and I remember it as an activist medical student, because it was published at the time when the Thatcher government came in. And as you said, it was kind of put to one side. And yet the themes that it explored were so important and I guess have really informed what you did next.

So do feel free to give us a little bit more about the end to that. That what happened after your master's dissertation in Thailand up to what you're doing now? 

Yeah. One thing led to another. I had an opportunity to work for the World Health Organization, first in Geneva, briefly, and also in Pakistan. That was the at the Aga Khan University in Karachi with the late Jack Bryant and subsequently in Ethiopia during the war, referring now to the war that ended in 1991.

So, I was in Ethiopia for a couple of years while I was there at a conference, came to for a conference in Geneva. And there I met the late Professor Ransome-Kuti, who was the Nigerian Minister of health at the time. He was an extraordinary leader and professional, and he asked me what I was doing because he saw my nametag.

So, we had to talk. And I told him, well, working on district health management systems in Ethiopia. And he said, goodness, that's what I'm trying to do in Nigeria. And I'm trying to expand the effort and he's going to break my back. Why don't you come home and help us out? I went back to Nigeria and, I worked with him on the primary health care program there.

And then subsequently I went on to Johns Hopkins University in Baltimore, where I did my, doctoral program in public health. It was from there that I went to the World Bank, joining the institution back in 1994. So, in this sense, the idea of working in a policy setting where one could inform, influence and hopefully nudge in the positive direction, those policies that will have benefits for the average citizen and the poor, landed me in the world Bank, and it was the opportunity of a lifetime.

So I when I, retired from the world Bank, some three years ago, I decided, yeah, I would now, really concentrate my energy on policy analysis. And that is what we do at Resilient Health Systems, or policy analysis focused on those things that will have what I call multiplier effects on programs on practices, and on relationships and power systems, because global health is very uncomfortable with the word power.

So that is what I do, these days. 

So, if I may continue that part of the conversation and, and think about when, when you talk about policy analysis, could you just give a little sense of how that what does that involve you doing in an average day. How does that what does that actually look like in terms of who you talk to, what research you're undertaking? That would be great.

So, my average day, if there is such a thing, is a blend of two or more of the following, one being, client engagement. So, I do a lot of video conferences and, telephone calls, with, with clients, in different kinds of institutions, different regions, mostly in Africa and Asia.

And, then I read, I like to read, I try to stay on top of the current literature and, at any time, I'm probably reading about 3 or 4 books at the same time, spanning different, different topics. But my desk now I have two books that have just had a reading, one is an “Imperfect Storm” by Chikwe Ihekweazu, who was head of Nigeria CDC during the Covid pandemic.

I also write, I love writing because that comes with a lot of learning. And this right is almost invariably in collaboration with 3 or 4 other colleagues. I saw the topics in which I'm engaging at the moment, what I will call the convergence of challenges, this global health, climate change and global health, ambient air pollution and global health.

The vexing challenge of ensuring end to end manufacturing capacity in low and lower middle-income countries, especially on the African continent. The unending quest for universal access, to basic health services and, crucially, the promotion and sustainability of what I will call a compact between the government and the governed in terms of accountability for health improvement and health systems in low and lower middle income countries.

I also do, teach at the Johns Hopkins Bloomberg School of Public Health, which is in Baltimore. So that's just one, from where I live in Washington. 

Brilliant. Soji, so I, I'm hearing a very full day, actually, full of reading, writing, mentoring, teaching and, very inspirational. Could I, could I take you back to the writing piece?

I'm struck by a couple of pieces of writing. One. One is the book you've written and Global Health in Practice investing amidst pandemics, denial of evidence and neo dependency. And the second is just the piece that you wrote recently and, plus global public health on market access. And you mentioned it already, this, this issue around vaccine manufacturing, maybe we could look at those two, one after the other.

I think I've written in my mind or in my head, I've written variants of that book since the day I left the Liverpool school. I've written that book over and over in my own mind, of my head, but I never really had the time to. I didn't have the opportunity to just have space around my head, to put it down in the form of a book.

 So, as I as my career progressed and I had this wonderful opportunity of working in practically every region of the developing world, I kept experiencing the consequences of what I call the congenital defects of global health, which arose from colonial expeditions. I kept experiencing the sensuality of power. I kept experiencing, the fact that humans, let's face it, are not rational animals.

They are psychological animals. They are not logical entities. And I also kept experiencing the tragic fact that there is a contrast between the morality of an individual. On the one hand and the immorality or immorality, sometimes of institutions on the other hand. So along the way, as I worked in Asia and in Africa and Latin America, Eastern Europe and Central Asia, some of these themes kept cutting across and I could not shake the fact that there was, let's face it, the fact that the global health system, it was not that it wasn't working well is that it was working.

It was achieving what it was designed to achieve in terms of those regional and subregion that inequalities and inequities. And so those power imbalances. Then one day I came across a quote, attributed to Toni Morrison, and it went like this, that if there is a book you'll, you wish to read and you cannot find it, then it's your duty to write the book.

So, I locked myself up, for one year, and I wrote the book, went from I believe was November 2020 to November 2021. Yeah, that was from initiation to submission. That was the period, I wrote the book, and the idea is to distill the genesis again, the congenital defect of global health benefit to warts and all, to really unpack with examples, some of it's highs and lows and to dive into what I believe it would take to positively transform global health without holding much back.

Some of the feed that I've received included “my-oh-my”, we have haven't really read something with this degree of candour in a long time. But more importantly, the feedback that said, thank you for not only identifying problems, but for proposing potential solutions. So, that was the book for me. Some of the most energising feedback I've received, has come from the younger generation, folks who write and say, thanks for opening my eyes, or from middle-aged or senior professionals in very large, influential institutions who say, your book gave us.

It opened the space, thereby making it possible for us to have a conversation that none of us dared to start in those institutions, before your book came out. But the learning continues. So, the recent paper, I think you were referring to the one, that several colleagues and I wrote on the R21 malaria vaccine policy.

Yes. Before you dive into that, I want to just to pause and reflect on the book. I, unlike you and I'm not as good at keeping up with my reading. And I have a teetering pile of books by my bedside. One of which on my aspiration list is yours? And also, just to mention check, Chikwe’s book as well.

And also to mention to our, our, listeners that we awarded Chikwe an honorary Doctorate of science, LSTM in 2022. And again, another inspiring book worth flagging for people. So, with that in mind, and I hope maybe we can return to some of the themes you talked about, especially the phrase you used, which I think is really it's really stuck with me, this idea of congenital defects, of global health.

And maybe when we come to wrap up, you could think a little bit or return to that idea in the broad scheme of global health and what it means for us to, as you work in this space, to work together and what it means for how we move forward from here, bearing in mind some of the candid recommendations you make.

But maybe we could return to those and maybe not at this point. And I suspect there's overlap with some of what you're thinking about. And then look at this paper that that you have just came out in July, the R 21 malaria vaccine The Spotlight on Policy Goals and Pathways to African vaccine manufacturing. I guess one of the conclusions you draw there is about the importance of transparency and rigor in health regulations.

Can you say a bit more about that and what you see as the steps to achieving that?

I should, but I'll give a shout out, thanking, the wonderful colleagues with whom I wrote this paper, from whom I learned a lot in the process. That's Prashanth Yadav, that's Raj Panjabi, and that's Wilfred Sharma.

It was a very enriching experience, writing this paper with them, the advent of the Rs 21 malaria vaccine concentrated, minds on a central problem, which was when you have a promising technology such as this, what should one optimise for? We found that explicit or implicitly, or some combination of the two current global health policy was optimised for only one thing getting the vaccines to people and that's a noble thing.

After all, vaccines don't save lives. Vaccination stays alive. So that's it and it's sensible. When you go one step further, you'll find that that is necessary. It is insufficient. And it is there, I see potentially counterproductive. How so? The continent most severely affected by a force of malaria is Africa. And given what was experienced during Covid, one might have expected, a more robust, shall we say, aggressive efforts to ensure that those vaccines will be manufactured on the continent, not manufactured elsewhere.

And then imported. But inside the current construct is, simply put, the when the vaccines will be manufactured by the Serum Institute of India and then sent to Africa. Now, in all fairness, the Serum Institute of India has entered into some distribution agreements with some firms in, Nigeria and Ghana, at least, with some promise to progress, to, fill and finish somewhere down the road.

Well, that's the problem. That's part of the construct is too timid, and that part of the construct is too opaque. And that part of the construct is to couched in what I call the razzmatazz and PR of global health, which is one of the worst dimensions of global health. So, we proposed that a policy around the R 21 malaria vaccine optimise for two things.

One is getting these vaccines, to those who are at risk of malaria. So, we're not against that intent? No, we're fully supportive of it. And concurrently, a full-scale effort to achieve in the shortest time possible, end to end manufacturing of that vaccine on the African continent. And we would like to see the key agencies and institutions and foundations who are engaged in this, as well as the African Union and its, and its agencies.

And its organs put under a microscope. And we, we propose, the development of a basket of, about six, six indicators to transparently assess the extent to which any proposition is of ultimate benefit to the continent. So, does it how well does it align, for example, with the African Union's own goals or seeking to manufacture a certain percentage of vaccines on the continent by 2040?

And is there a rigorous, demonstrable plan to progress, to end to end manufacturing, not just fill and finish. And that is that is no longer acceptable. Also, what kind of commitments do the African countries themselves have, and do the international financing institutions have to procure those vaccines from Africa based manufacturers even before they achieve economies of scale? And finally, we think it's important that no entity outside the African continent be it's a well fund, a well funded foundation, be it, some international, multilateral or bilateral agency should have a veto over what Africans do.

On their own continent with a vaccine. So that's where we're coming out. And again, this was about the R 21 malaria vaccine policy. But it's emblematic of a whole array of challenges and potential solutions in global health. 

Absolutely. I think it's a very rigorous framework. When I've read through this, and it feels like a really helpful set of signposting.

And, and I wonder if you could just say a little bit more about how you how do you envisage, that kind of what I imagine are key players coming together. What I'm thinking a little bit about governments, private sector, civil society. What does it take to get to the point where those criteria can be hit and also be monitored, I guess.

If it were easy, it probably will have been done already. Hey. Yeah, sure. And what does it take? I think it takes explicit recognition that send to what we are discussing is a legacy of power imbalances in global health. Which, at the risk of oversimplifying, it's under this global by simplifying it is actually minimal, consists of highly equipped technical institutions in the Global north, combining with wealthy entities, be they individuals or institutions or foundations or philanthropists in the Global North.

To tell people in the Global South what to do, how to do it, and on what on those terms. That really is the core of the matter. That's what is going on. And that is why it is challenging to do, because making progress requires stripping those entities of a measure of the power they have had for generations, and rewriting the narrative in which they have marinated for generations.

That's one dimension of it. The second aspect is holding to account the leaders on the African continent itself. Many, in fairness, not all, many of whom have become comfortable with perhaps indulge in what I call a culture of dependency. So there need to be a greater emphasis on let's focus on the African region. Just for specificity, there needs to be a greater emphasis on what the African Union itself is accountable for as a regional forum.

And at the county level, there needs to be a greater emphasis on is a compact, a sociopolitical compact between the government and the governed, which in many places simply does not exist. Some years ago, when the government of the UK announced or indicated that it was going to slash funding for, neglected tropical diseases, there was a lot of weeping and wailing and gnashing of teeth, by a group of former African heads of state and government and basically, sought to plead for the continuation of that funding.

And I thought, look, you folks who are leaders of countries in the tropics, so if anybody neglected tropical diseases, you neglected tropical diseases. But the narrative has been built over decades and centuries that when a problem arises, you don't look within, you look outside, and you beg for solutions. That's where this is challenging. So there need to be concrete targets with dates.

And I think the heads of state, heads of government and regional entities on the continent, need to have the fortitude to tell some of the most prominent philanthropists, some of the most prominent heads in certain health institutions, to just take a back seat for a change, because speaking frankly, it is my observation that some of those, prominent external actors have gotten used to using the continent as what I call a sounding board for self-flagellation in the name of philanthropy.

And that is ultimately a disservice to people on the continent because it's infantilized these their leaders. It gives the leaders an excuse to abdicate their own responsibilities to their own people. I, I'm hearing two great pieces of great strands of responsibility. I guess one is one is, as you say, to African leaders and the other strand of responsibility is to institutions and organisations in the Global North.

And for a sort of reflection on where we've reached and how do we how do we move forward from here, which, if I may ask for some thoughts that you may have, we at LSTM, we recognise our roots in, the colonial era. We're particularly conscious of those roots in this, 125th anniversary year. I think we should recognise that in some senses, we're part of those congenital defects of global health.

I think I shared with you some of the work we've in, I hope, a humble way try to give some leadership to our colleagues in developing some principles for the way in which academic partnerships between organisations like ours and those that that go ahead in low and middle income countries might be informed. And I wonder whether you've had a chance to look at those seven principles and, and any reflections you have on that on then the way we've approached them.

Any advice, whether you think that is at least a part of what you've just outlined, that kind of bigger responsibility that the global northern institutions and organisations have. 

Before I, I zoom in on, my response to your question. Let me just also, say about Liverpool, the city, that it's a positive experience living there.

During my time at the, at the Liverpool School, partly because of the Liverpool Football Club and Anfield, I so, I feel I retain my, my affiliation, as, as a diehard fan of, of the club. 

And if I have to interrupt you there and just say Hallelujah! As a fellow supporter, I can’t confess to be a fan properly, but definitely a supporter.

Sorry, Soji, I've interrupted your thought process there. And of course, the city, this city gave the world, the Beatles among, among quite a few other things. So yeah, a shout out to, to the city, but yes, indirectly response to your question. The School of Tropical Medicine occupies a very interesting and frankly unique place as, the first among, those types of institutions which you know very well, of course, because Liverpool as a port city benefited, more than many others, from the shipment of goods and the shipment of people, across the Atlantic, folks who were who, enslaved from Africa, to the Americas.

And we all know, of course, that the advent of the Liverpool school was, substantially out of a concern for how, shipping magnates would protect their investments. So let's figure out a way to try to treat these exotic diseases, exotic to people in England at the time, that sailors were coming back with. And here's Alfred Jones, who then the princely sum of 350 pounds still found the school.

 So fast forward to 125 years later. Yes, I have read that paper. Thanks for letting me do it. I think it is very thoughtful. I think the authors pulled no punches at all in, putting forward the 6 or 7 recommendations for what would enable equitable partnerships. I'm not going to go over all of them, but I want to zero in on 2 or 3 that especially resonate with me.

The first one is that they were explicit in recognising power asymmetries. I said this because, again, this is not something with which folks in global health comes to discuss it. Because we like to say it's all about universal brotherhood and sisterhood and, let's just get services to people. So I think that's a very positive side of the, of the paper.

They talk about early inclusion. I think that's good to know, bringing people, into partnerships as afterthoughts and transparency. They talk about contextually embedded knowledge. I, I clapped when I go to that part of the paper because it enables the, the researcher to make sense from numbers. One that especially stood out to me was this concept of multi-centric partnership models.

I think this is essential. I also think it's probably going to be one of the most challenging institutionally, not for individual researchers at the Liverpool School of Tropical Medicine, but institutionally. How so? It's a tremendous shift, potentially because the model on which the school developed and others like it. So this was not unique to the Liverpool school. The model on which the school developed implicitly, not, in fact, explicitly saw the school as the fountain of knowledge, as the fountain of wisdom that will then be dispensed to others.

So those other satellites or moons. And the school was the sun. Again, this was not unique to the Liverpool school, but the school is the granddaddy or the grandmother of them all. It bears additional responsibility, and I think shift shifting from that unipolar or uni centric model to a multipolar or multi centric model will involve or require solving multiple problems along the way, and success in solving those multiple problems along the way will have multiplier effect on the quality of research.

Questions posed will have multiplier effect on the quality and capacity of research teams that can be deployed. Will have multiplier effect on the credibility of research products, and therefore will have multiplier effect on the potential of those research findings. To effectively inform policy discussions and to effectively enable change within and across countries, I think the paper is, is a tour de force.

I have to say, when you talked earlier about your ability to be candid, I was a little nervous about your stance to the to the work we've done. But I, I'm humbled by the way you've the way you've laid that out. And I completely agree that this idea of a shift to a multi centric approach is so, so important.

Before I wrap up, just to ask you, I can't I'm, I'm inspired to ask you, given what you've been describing, what would it take for you to physically relocate back to Africa, given that you're now in one of those the Global North countries and have a long history of engagement with many of the global northern, if you like, organisations, two paths to that.

One is never say never. Oh, good. One is never say never. The second part, is that, much of the work that I, that I now do is actually, in Africa, as I said earlier, my work is mostly in Africa and Asia. Yeah. I think particular joy in, working with and advising African institutions and, often informally, informally advising different leaders on the continent and also advising, different institutions on the continent as they seek to add, chart new paths or to improve their current, their current practices on the continent.

And I'm, of course, looking forward to my next visit to my native country of Nigeria to go and, indulge myself in my mother's cuisine. So I'm, I'm counting day. I'm counting the weeks until I got fabulous. Soji I'm going to wrap up with, a massive thank you to you for taking part. I, struggling to pull out 2 or 3 key takeaways from the very rich conversation we've had, but let me give it a go.

I feel like we've been very privileged to explore a whole lifetime of experience, really inspired at the outset by this thorny issue of equity. Really, throughout what you've been discussing, right from those early days, the issue of equity, the importance of having a having a focus on equity, not just in terms of health outcomes, but in the way we proceed in global health.

I think it's really key. And you provide some inspiring insights into that, which I hope will guide many of our listeners and certainly will make me think. The other thing that I'm struck by is, is that this idea of a multi centric partnership model is really important, and I think it causes us to think about if I now bring us back to the UK and health disadvantages in the UK, we are acutely conscious in Liverpool of divided health outcomes on socioeconomic grounds.

We have some of the most socially deprived wards in the UK in our own backyard, and we are learning actually from colleagues in the Global South about community engagement and I think thinking about our mutual value. You've really pointed a lot about how we can mutually think about contributions to global health and health in general and, and equity.

So, thank you very much indeed. I'm going to sign off by a huge thank you to everybody who listened and hoping that we can return. Perhaps so when you come to Liverpool, which I know is coming in September, but big thanks to everyone involved in the podcast, everyone who's listened and most of all suggest to you thanks ever so much.

 Thank you very much.