Assembling a global health image: Ethical and pragmatic tensions through the lenses of photographers.

BACKGROUND: Recently, global health has been confronting its visual culture, historically modulated by colonialism, racism and abusive representation. There have been international calls to promote ethicality of visual practices. However, despite this focus on the history and the institutional use of global health images, little is known about how in practice contemporary images are created in communities, and how consent to be in photographs is obtained. METHODS: We conducted semi-structured interviews with 29 global health photographers about the ethical and practical challenges they experience in creating global health images, and thematically analysed the findings. FINDINGS: The following themes were identified: (1) global health photography is undergoing a marketing transformation and images are being increasingly moderated; (2) photographers routinely negotiate stereotypical and abusive tropes purposefully sought by organisations; (3) local scenes are modified, enhanced and staged to achieve a desired marketing effect; (4) 'empowerment' is becoming an increasingly prominent dehumanising visual trope; (5) consent to be photographed can be jeopardised by power imbalances, illiteracy, fears and trust; (6) organisations sometimes problematically recycle images. INTERPRETATION/DISCUSSION: This research has identified practical and ethical issues experienced by global health photographers, suggesting that the production cycle of global health images can be easily abused. The detected themes raise questions of responsibility and accountability, and require further transdisciplinary discussion, especially if promoting ethical photojournalism is the goal for 21st century global health.

Scholarly Publishing, Boundary Processes, and the Problem of Fake Peer Reviews.

Over the past decade, the phenomenon of "fake" peer reviews has caused growing consternation among scholarly publishers. Yet despite the significant behind-the-scenes impact that anxieties about fakery have had on peer review processes within scholarly journals, the phenomenon itself has been subject to little scholarly analysis. Rather than treating fake reviews as a straightforward descriptive category, in this article, we explore how the discourse on fake reviews emerged and why, and what it tells us about its seeming antithesis, "genuine" peer review. Our primary source of data are two influential adjudicators of scholarly publishing integrity that have been critical to the emergence of the concept of the fake review: Retraction Watch and the Committee on Publication Ethics. Via an analysis of their respective blog posts, Forum cases, presentations, and best practice guidance, we build a genealogy of the fake review discourse and highlight the variety of players involved in staking out the fake. We conclude that constant work is required to maintain clear lines of separation between genuine and fake reviews and highlight how the concept has served to reassert the boundaries between science and society in a context where they have increasingly been questioned.

Online on the frontline: A longitudinal social media analysis of UK healthcare workers' attitudes to COVID-19 vaccines using the 5C framework.

This paper explores vaccine hesitancy among healthcare workers (HCWs) in the UK, where different COVID-19 vaccines were being rolled out through a national vaccination campaign from 2020 to 2022, consisting of a first and second dose programme. Through a mixed-method approach using qualitative discourse analysis and network analysis of Twitter data, we assessed HCW perceptions and views about the administration and delivery of COVID-19 vaccines in the United Kingdom (UK). We were also interested in exploring HCWs' personal experiences and attitudes towards taking COVID-19 vaccines themselves. We drew upon sociology, ethics, communication studies and used research methods concentrating on social media and media analysis. By employing the '5C framework' of 'confidence, complacency, constraints, calculation, and collective responsibility' we evaluated a longitudinal selection of tweets to capture relevant factors driving vaccination views and behaviours among HCWs. We found differing positions expressed about COVID-19 vaccines and policy during the first dose compared with the second, through a drop in confidence compounded by supply and access issues, as well the news of a vaccine mandate for HCWs by the UK government in 2021. HCWs asked calculation questions to the community or brought forward competing pieces of information about vaccine policy and guidelines. Constraint levels in access issues were noted, especially for those with work and caregiving responsibilities, and student nurses found they did not have equal vaccination access. HCWs also displayed collective responsibility on social platforms to both encourage vaccination and express concerns through the organisation of social action against vaccine mandates.

Navigating uncertainties of death: Minimally Invasive Autopsy Technology in global health.

Global health practitioners and policymakers have become increasingly vocal about the complex challenges of identifying and quantifying the causes of death of the world's poorest people. To address this cause-of-death uncertainty and to minimise longstanding sensitivities about full autopsies, the Bill and Melinda Gates Foundation have been one of the foremost advocates of minimally invasive autopsy technology (MIA). MIA involves using biopsy needles to collect samples from key organs and body fluids; as such, it is touted as potentially more acceptable and less invasive than a complete autopsy, which requires opening the cadaver. In addition, MIA is considered a good means of collecting accurate bodily samples and can provide the crucial information needed to address cause-of-death uncertainty. In this paper, we employ qualitative data to demonstrate that while MIA technology has been introduced as a solution to the enduring cause-of-death uncertainty, the development and deployment of technologies such as these always constitute interventions in complex social and moral worlds; in this respect, they are both the solutions to and the causes of new kinds of uncertainties. We deconstruct the ways in which those new dimensions of uncertainty operate at different levels in the global health context.

Invisibility in global health: A case for disturbing bioethical frameworks.

In recent years, the global health community has increasingly reported the problem of 'invisibility': aspects of health and wellbeing, particularly amongst the world's most marginalized and impoverished people, that are systematically overlooked and ignored by people and institutions in relative positions of power. It is unclear how to realistically manage global health invisibility within bioethics and other social science disciplines and move forward. In this letter, we reflect on several case studies of invisibility experienced by people in Brazil, Malaysia, West Africa and other transnational contexts. Highlighting the complex nature of invisibility and its interconnectedness with social, political and economic issues and trends, we argue that while local and targeted interventions might provide relief and comfort locally, they will not be able to solve the underlying causes of invisibility. Building from the shared lessons of case study presentations at an Oxford-Johns Hopkins Global Infectious Disease Ethics Collaborative (GLIDE), we argue that in dealing with an intersectional issue such as invisibility, twenty-first century global health bioethics could pursue a more 'disturbing' framework, challenging the narrow comforting solutions which take as a given the sociomaterial inequalities of the status quo. We highlight that comforting and disturbing bioethical frameworks should not be considered as opposing sides, but as two approaches working in tandem in order to achieve the internationally set global health milestones of providing better health and wellbeing for everyone. Insights from sociology, anthropology, postcolonial studies, history, feminist studies and other styles of critical reasoning have long been disturbing to grand narratives of people and their conditions. To rediscover the ethos of the WHO Alma Ata Declaration-a vision of "health for all by the year 2000"-these thinking tools will be necessary aids in developing cooperation and support beyond the narrow market logic that dominates the landscape of contemporary global health.

GLIDE Wellcome Open Research Gateway.

The Global Infectious Disease Ethics (GLIDE) Collaborative is launching a new Wellcome Open Research (WOR) Gateway, and we as the leaders of GLIDE hope to encourage submissions to this timely and necessary new platform for publishing open access peer-reviewed articles focusing on this area.

Making global health 'work': Frontline workers' labour in research and interventions.

This Special Issue of Global Public Health draws on the concept of 'body work' among those employed to support operationalising, researching, and implementing global health while in direct contact with the bodies of others. This collection brings into sharp focus the specific forms of labour of those occupying positions as frontline workers - those who make global health work. Making Global Health Work includes authors from diverse backgrounds, disciplines, and geographies. Through compelling ethnographies, qualitative interviews, and focus group discussions, they explore 'body work' globally, including: Afghanistan, Bangladesh, Ethiopia, India, Indonesia, Kenya, Malawi, Myanmar, Nigeria, Nepal, Pakistan, Sierra Leone, South Sudan, Tanzania, Thailand, The Democratic Republic of the Congo (DRC), The Gambia, Vietnam, and Zimbabwe. These papers demonstrate that proximity to, and work on, the bodies of others engenders specific forms of (physical, emotional, mental, social, ethical, and political) labour, which occur not only in emergencies and pandemics, but also throughout the quotidian practice of global health. Making Global Health Work provides insights into the provision of maternal healthcare, treatment of multidrug resistant tuberculosis, rapid HIV testing programmes, sleeping sickness and polio eradication campaigns, mass drug administration clinical trials, epidemic preparedness and response, and the management and care of dead bodies. These papers argue for greater attention by global health actors on frontline workers in management of the complexities involved in making global health work.

Doing 'reciprocity work': The role of fieldworkers in a mass drug administration trial in the Gambia.

In their roles as nurses, data collectors, or other, fieldworkers undertake myriad tasks working intimately with and on the bodies of others - a type of work called 'body work'. This work further includes the micro-political relations shaping these interactions, and studies have shown the importance of these relationships in the success of clinical trials, particularly in the Gambia. This study seeks to expand the concept of body work to understand the roles and interactions of fieldworkers within the trial community, and the effect on a mass drug administration (MDA) clinical trial. We conducted a mixed-methods social science study alongside the MDA in 2018-2019, including in-depth interviews, focus group discussions, and semi-structured observations with the population involved (and not) in the MDA, as well as the MRC fieldworkers. We found that fieldworkers participated in what we call 'reciprocity work'. Through their regular tasks and interactions, they necessarily showed respect and established trust in a way that formed and contributed to reciprocal relationships, the results of which impacted the trial and individuals' autonomy in the decision-making process. Understanding the role of fieldworkers and their reciprocity work is a vital component in comprehending how research ethics are made and conducted in global health research.

Power and Powerlessness in a Group Based Digital Story Telling Project-An Exploration of Community Perceptions of Health Concerns in Urban Malawi.

Digital Story Telling (DST) is an art-based research method used to explore embodied experience of health and initiate dialogue with under-represented groups on issues affecting them. It involves engaging participants to create and share their stories using photos, drawings, and audio recordings in short videos. Benefits of DST include enhancing co-creation of knowledge, empowering participants to confront dominant narratives and revise inaccurate representations. We report our experiences and reflections of using DST to explore community perceptions of health concerns in urban Malawi. Community leaders were briefed about the project before and after study related activities. Three participatory workshops were organized to train community members in DST, support them to develop videos and discuss their experiences of DST. Twenty-six participants from two high density urban communities consented to be part of the workshops. They were all new to DST. All the 26 participants were invited together to the three workshops and their DSTs were developed in smaller groups (n = 7), based on their geographical location. Although we engaged residents from selected communities to share priority health concerns, all the seven groups presented challenges pertaining to Water, Sanitation and Hygiene (WASH), and their powerlessness to address the complex challenges. The collective focus on WASH showed that DST effectively empowered communities to present priority health concerns. The inability of community members to address the challenges without external assistance or failure to use findings from DST to generate social change however raise questions on the ideals of empowerment and social justice. In addition, lack of financial resources or technical know-how to produce digital stories and unequal power relationships between service providers and community, may affect the use of DST for community activism among socio-economically disadvantaged groups. We conclude that DST empowered participants to articulate genuine health challenges that they felt powerless to address. We question the realization of "empowerment" and social justice of vulnerable participants in cases where structural challenges present obstacles to effectively address social inequalities.

Kenya's "Fake Essay" Writers and the Light they Shine on Assumptions of Shadows in Knowledge Production.

In this contribution to the special issue on Fakery in Africa, I examine the booming "fake essay" industry and draw on the role and perspectives increasingly occupied by of tens of thousands of young and highly-educated Kenyans. These so-called "Shadow Scholars" are part of a vast global online marketplace, an invisible knowledge production economy, where students and academics in the global North solicit and pay for their services in exchange for confidential and plagiarism-free essays, theses, dissertations, qualifications and publications. This article centres on descriptions of these writers as "shadows" as a means of complicating not only the most popular description of Africa in the global imagination - as existing in the shadow of an infinite number of different entities - but to challenge the notion of the shadow in relation to African knowledge production as being fake. It pays attention to the Kenyan writers' protestations that their knowledge, experiences and labour are all real and that analogies with shadows reduce them and the impact of their work to something that is non-existent and not alive. From their perspective the term shadow is pejorative because it further reduces the intellectual contribution of Africans, presenting them as derivative.

Katika mchango huu kwa suala maalum kuhusu Udanganyifu barani Afrika, mimi huchunguza tasnia ya "insha bandia" na haswa jukumu na msimamo wa makumi ya maelfu ya vijana wakenya na wenye elimu ya kiwango cha juu. Hawa wanaoitwa "Vivuli vya Wasomi" ni sehemu ya soko kubwa la mkondoni ulimwenguni, uchumi wa maarifa usiojulikana, ambapo wanafunzi na wasomi katika kaskazini mwa Ulimwengu wanaomba na kulipia huduma zao kwa malipo ya insha za wizi na usiri, tasnifu, ujuzi wa kitaaluma na machapisho. Utafiti huu unaangazia ufafanuzi wa waandishi hawa kama "Vivuli" kama njia ya kutatanisha sio tu maelezo maarufu zaidi ya Afrika pia katika fikra za ulimwengu, kama ilivyo katika kivuli cha idadi isiyo na mwisho ya vyombo tofauti, lakini kupinga wazo la kivuli kuhusiana na uzao wa maarifa ya Kiafrika kama bandia. Inatilia maanani maandamano ya waandishi wa Kenya kwamba maarifa, uzoefu na kazi zao zote ni za kweli na kwamba mlinganisho na vivuli hupunguza na athari ya kazi yao kwa kitu ambacho hakipo na sio hai. Kulingana na maoni yao, neno kivuli ni la kudharaulisha kwa sababu linapunguza zaidi mchango wa kiakili wa Waafrika, kuwaonyesha kama waigaji.

Ethical and sociocultural challenges in managing dead bodies during epidemics and natural disasters.

BACKGROUND: Catastrophic natural disasters and epidemics claim thousands of lives and have severe and lasting consequences, accompanied by human suffering. The Ebola epidemic of 2014-2016 and the current COVID-19 pandemic have revealed some of the practical and ethical complexities relating to the management of dead bodies. While frontline staff are tasked with saving lives, managing the bodies of those who die remains an under-resourced and overlooked issue, with numerous ethical and practical problems globally. METHODS: This scoping review of literature examines the management of dead bodies during epidemics and natural disasters. 82 articles were reviewed, of which only a small number were empirical studies focusing on ethical or sociocultural issues that emerge in the management of dead bodies. RESULTS: We have identified a wide range of ethical and sociocultural challenges, such as ensuring dignity for the deceased while protecting the living, honouring the cultural and religious rituals surrounding death, alleviating the suffering that accompanies grieving for the survivors and mitigating inequalities of resource allocation. It was revealed that several ethical and sociocultural issues arise at all stages of body management: notification, retrieving, identification, storage and burial of dead bodies. CONCLUSION: While practical issues with managing dead bodies have been discussed in the global health literature and the ethical and sociocultural facets of handling the dead have been recognised, they are nonetheless not given adequate attention. Further research is needed to ensure care for the dead in epidemics and that natural disasters are informed by ethical best practice.

A graphic elicitation technique to represent patient rights.

BACKGROUND: A patient charter is an explicit declaration of the rights of patients within a particular health care setting. In early 2020 the Save the Children Emergency Health Unit deployed to Cox's Bazar Bangladesh to support the establishment of a severe acute respiratory infection isolation and treatment centre as part of the COVID-19 response. We developed a charter of patient rights and had it translated into Bangla and Burmese; however, the charter remained inaccessible to Rohingya and members of the host community with low literacy. METHODS: To both visualise and contextualise the patient charter we undertook a graphic elicitation method involving both the Rohingya and host communities. We carried out two focus group discussions during which we discussed the charter and agreed how best to illustrate the individual rights contained therein. RESULTS: Logistical constraints and infection prevention and control procedures limited our ability to follow up with the original focus group participants and to engage in back-translation as we had planned; however, we were able to elicit rich descriptions of each right. Reflecting on our method we were able to identify several key learnings relating to: 1) our technique for eliciting feedback on the charter verbatim versus a broader discussion of concepts referenced within each right, 2) our decision to include both men and women in the same focus group, 3) our decision to ask focus group participants to describe specific features of each illustration and how this benefited the inclusivity of our illustrations, and 4) the potential of the focus groups to act as a means to introduce the charter to communities. CONCLUSIONS: Though executing our method was operationally challenging we were able to create culturally appropriate illustrations to accompany our patient charter. In contexts of limited literacy it is possible to enable access to critical clinical governance and accountability tools.

Structural coercion in the context of community engagement in global health research conducted in a low resource setting in Africa.

BACKGROUND: While community engagement is increasingly promoted in global health research to improve ethical research practice, it can sometimes coerce participation and thereby compromise ethical research. This paper seeks to discuss some of the ethical issues arising from community engagement in a low resource setting. METHODS: A qualitative study design focusing on the engagement activities of three biomedical research projects as ethnographic case studies was used to gain in-depth understanding of community engagement as experienced by multiple stakeholders in Malawi. Data was collected through participant observation, 43 In-depth interviews and 17 focus group discussions with community leaders, research staff, community members and research participants. Thematic analysis was used to analyse and interpret the findings. RESULTS: The results showed that structural coercion arose due to an interplay of factors pertaining to social-economic context, study design and power relations among research stakeholders. The involvement of community leaders, government stakeholders, and power inequalities among research stakeholders affected some participants' ability to make autonomous decisions about research participation. These results have been presented under the themes of perception of research as development, research participants' motivation to access individual benefits, the power of vernacular translations to influence research participation, and coercive power of leaders. CONCLUSION: The study identified ethical issues in community engagement practices pertaining to structural coercion. We conclude that community engagement alone did not address underlying structural inequalities to ensure adequate protection of communities. These results raise important questions on how to balance between engaging communities to improve research participation and ensure that informed consent is voluntarily given.

The masking and making of fieldworkers and data in postcolonial Global Health research contexts.

This paper centres on the roles and contributions of fieldworkers-local data-collectors in Global Health research in postcolonial contexts. It is informed by two separate ethnographies, conducted in two different East African biomedical research institutions. It discusses how common characterisations of fieldworkers as 'low-skilled' and 'local' make them attractive to research institutions in two important ways - as community-embedded data-collectors thus facilitating community participation and as being unlikely to fabricate data because they lack the skills to avoid detection. This paper questions these assumptions. It draws on Daston's idea of the 'scientific persona' and Fanon's concepts of mask-making to explore how fieldworkers construct identities and data within their liminal roles. Fieldworkers create particular pseudo-personae or masks for getting and staying employed. They dumb-down CVs and emphasise their similarities with community members in ways which are partially 'real' but also 'fake'. These constructed identities provide fieldworkers with a persona that allows them to fabricate or modify data without raising suspicions. They frequently engage in practices known as 'genuine fake' data fabrication which is data perceived as factually correct and verifiable yet methodologically incorrect, hence it is real and fake in varying degrees. We understand the 'pseudo' as the blurry space between real and fake where fieldworkers construct their identities and data. Given the seemingly laudable aims of Global Health, we argue that fieldworkers' masking and making up data signal the need for greater attention by those designing its research, to better understand and address why and how these practices unfold.