Episode 3

Episode 3

Reducing Health Inequity Through Local Knowledge Production: The Case of African Health Sciences

Dr. James Tumwine, Professor of Paediatrics and Child Health who recently retired from the School of Medicine, College of Health Sciences in Makerere University at Mulago Hospital in Kampala, Uganda. Professor Tumwine is also the founder and Editor-in-Chief of African Health Sciences, an open access, free, internationally refereed, multidisciplinary journal publishing original articles on research, clinical practice, public health, policy, planning, and implementation and evaluation in health and related sciences in African countries.

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SECTION 1: Opening

You are listening to the Unsettling Knowledge Inequities podcast, presented by the Knowledge Equity Lab (housed at the University of Toronto’s Centre for Critical Development Studies) and SPARC (the Scholarly Publishing and Academic Resources Coalition). 

Section 2: Intro 

Safa

Over the past year, the COVID-19 pandemic has highlighted how global health and wellbeing goes well beyond borders and national policies. All over the world, communities have been hard hit by the economic, social, and health impacts of the pandemic.

But of course these impacts have not been equally felt.  Communities living at the intersection of multiple identities  – including gender, class, race, disability and more –  continue to face disproportionate challenges globally. 

In this context, prioritizing and addressing various aspects of health equity has taken on renewed global importance. 

Today we are in conversation with Dr. James Tumwine, Professor of Paediatrics and Child Health who recently retired from the School of Medicine, College of Health Sciences in Makerere University at Mulago Hospital in Kampala, Uganda. 

Professor Tumwine is also the founder and Editor-in-Chief of African Health Sciences – which is an open access, free, internationally refereed, multidisciplinary journal publishing original articles on research, clinical practice, public health, policy, planning, implementation and evaluation, in health and related sciences in African countries.

Section 3: Main Content 

James  

I’m James Tumwine. I’m a Professor of Pediatrics and Child Health. But more importantly, I’m the founder and Editor in Chief of African Health Sciences, which I started sometime in 2001. Currently I am moving positions from Makerere University to Kabale University, but I’m still affiliated with Makerere University quite a lot. I’ve worked initially in Uganda. And then I moved to the Great Ormond Street Hospital for Sick Children in London. And from there, one of the best hospitals in the world for children, I moved to work in a village in Zimbabwe, in Chimanimani, at the Mozambique border, where I was in charge of setting up the health services in the eastern province. 

Safa 

The launch of the journal in 2001 had a long gestation period and was motivated by various inequitable practices and systematic discrimanation that Dr Tumwine faced in trying to publish his own research in western journals. 

James

In a way, African Health Sciences has been part of my journey as a rebel in international health. Because I was tired of the status quo. And what do I mean there? I’m very much interested in clinical research, controlled, randomized trials, etc, etc. And we were doing our own work. And I wrote up some of my experiences in Zimbabwe. And I submitted this paper to one journal, which I will not name, a UK based journal, and my paper was rejected. And then when I moved to work for Oxfam, I was staying in a little village north of Oxford, called Kidlington, and I was in a place called Edinburgh Drive. So I changed the author’s address from Chimanimani  in Zimbabwe, to Edinburgh drive in Oxford, and my paper was accepted – clearly demonstrating discrimination. The same paper, when submitted in Zimbabwe, in a village, in the bush – nobody wanted to read it. When I submitted it from a posh suburb north of Oxford, it was accepted. So that really, really, really hit me hard. And I said, If I go back to Uganda, I must start my own journal – why are we relying on these foreign journals after all? The process was quite interesting. I approached the Dean then and the Dean said, you know, why are you wanting to start this journal? I said, I’d like to help my colleagues to publish their own work in our own journal. But also of course, if you do not publish, you cannot be promoted to the next level – you will not get from Senior Lecturer to Associate Professor, Associate Professor to Professor. and my Dean said, hey, young man, you are joking. Some people will never be Professors, whether you help them to publish or not, some will enter as Lecturers and exit as Lecturers. So you’re wasting a lot of your time. I was really hit by that and then I said, okay, I’m going to do a small survey and find out the interest of my colleagues. And surprise, surprise, these people who had said they were not interested in reading – 80% said they would welcome a journal. And that really helped me. And I approached one of my colleagues, Professor Nelson Sewankambo, he gave us some little money to start and we started. And what I did, I started a writing clinic in my office. That clinic was to help people studying for specialization in say, obstetrics, pediatrics or surgery – to help them in writing up their work. And I remember the first few papers were quite powerful because they were based on real life experience in Uganda.

Safa 

In addition to challenging discriminatory practices, Dr Tumwine was also motivated to fill an evidence based practice void by publishing research articles that were relevant to “tropical” diseases in African countries and which western journals often neglected.

James

There is no doubt, and there was no doubt even then, that nobody was interested in diseases largely affecting people in Africa, in particular. And unfortunately, that seems it is still the story. For example, the first paper on HIV, which at that time was called Slim disease, came out of Uganda in 1985, a very interesting, very good paper in The Lancet by our colleagues. And that was 1985 – 35, 36 years ago. And this disease became a pandemic 35, 36 years ago. Last year, one year ago, a new disease broke out in January. And that disease now has a vaccine. But this other disease, HIV/AIDS, which has been with us for 36 years, has no vaccine. And it’s not that we don’t have the technology or the knowledge. I will leave my listeners to judge why we don’t have an HIV vaccine. But as far as other diseases are concerned, for example, the Nodding syndrome in Sudan and in Uganda, a highly neglected disease, terrible. But we were able to mobilize minimal resources from World Health Organization, from NIH and support researchers both in Sudan and Uganda to study this new disease called Nodding syndrome. And I’m using it because it’s a very neglected disease. We now think it is from onchocerciasis, but largely it’s epilepsy that is not well managed. And once we started managing it with sodium valproate, and the control measures put in place to kill the germs that cause it, it’s now almost forgotten. And people are going on and communities where it has been, they are quite happy. And I’m so proud that our journal –  African Health Sciences, and our team, used such an example to tackle a truly African problem that was irrelevant for people in Europe and North America, for example. And by the way, let me tell you one thing, in my journal, African Health Sciences, there is a disease which we would never write about, even though it is important in the world, and that disease is called frostbite. So while frostbite might be important in Canada, for us it’s not an issue. We don’t have frostbite. If anything, we have sunshine 13 months a year. So if somebody presented a paper on frostbite, I am not interested. Maybe that’s why we shouldn’t be angry with the western journals and western research institutions for not getting interested in our specific issues. But this world is a small village. When I sneeze in Uganda, you might sneeze in Canada, and if you don’t believe it, when they started sneezing in Wuhan, people started sneezing in New York. So we can no longer pretend that we are a big world – we are a tiny little village Safa.

Safa 

In stressing our global interconnections – it’s further important to acknowledge the global political economy of health inequities. In establishing African Health Sciences, Dr Tumwine rejected the financial model used by western journals.

James

You know, one major issue, which really, really, really frustrated me and my colleagues was that we would want to read a journal article, say in one of the journals in America, or one of the leading journals in UK, or Switzerland, and as you are trying to access this journal online, they asked you, please put in your credit card number. And for you in the West, credit card is how you live. But even at that time, I didn’t have a credit card. I didn’t even know what a credit card was. I was used to getting my salary in the bank. And when I go to the bank, I withdraw money and I go the market with the cash and buy things. Now I want to access an article online, somebody says put in a credit card, what does that mean? It really, really frustrated me. But even for the others who had a credit card, they didn’t have enough money. It was outrageous how much money people were charging for us to access an article. For example, for $40 to access a manuscript. And $40 dollars at that time was half my salary as a doctor. So the issue of open access for us was at the heart of our publication. And we have a model that is unique to African Health Sciences, our work is free online. And we do not charge anybody any money. In the free access world, you’re a researcher with a lot of money, your work is published, and people access it for free. But you have to pay heavily to the journal – $1,000 to publish your work. And that’s how they run their journals. For us, we have a different model, we rely on voluntarism. None of us is paid, and none of us is charged. So we do not charge anybody any money. We do not charge authors, we do not charge readers. Because we strongly believe health information is part and parcel of our DNA. We believe that the blood that flows in our veins is the same as the material that we publish. So how do you start charging people for blood that flows in their veins? So we found a lot of challenges because of that, because we have refused to be part of that movement. When we said we are open access, then people ask us: so how much do you charge authors? We don’t charge authors. So you’re not open access? No, we are very open access. Once you publish with us, there is no money that you give us –  if you donate, you can donate, but we are not in this business to make money.

Safa 

Over the past 20 years, the open access model used by African Health Sciences has been successful and has removed the cost barrier for researchers and readers globally. 

James

How have we been managing as part of the open access movement? We’ve been managing very well and for example, I have been an Editor at PLOS Medicine. And because of that, we’ve had a lot of our students and our scientists, the fees were waived, because none of our candidates, none of our students, they were using their own money to do the research, they didn’t have any funding. So we’ve made friends with journals abroad.

We’ve formed the Africa Journals Partnership Project, in which we have a number of African journals with western journals, and they’ve been assisting us to train our editors, our authors, etc, and to make African work to be pushed and to be published. So that’s one area that we’ve really worked very hard. It was one of our objectives. 

We did not start this project, this journal to become British Medical Journal. I’m trained in the British Medical Journal. But it was very clear from the beginning that I did not want to become the British Medical Journal. My aim was to get trained to the BMJ, and they were so kind and they helped us gain the skills, and it was clear that we were talking from different angles. For example, when I visited the British Medical Association house in London, their building was bigger than the Parliament of Uganda. So it was clear that my little journal could not be BMJ. But we, I think, have made quite a big mark, particularly on open access. People are cognizant of the fact that even if you don’t have money to pay as an author, it can be waived, or it can be negotiated downwards. So I think we’ve influenced this. And we formed a lot of friends – Bioline, through Leslie and others, have helped us a lot. And we’re extremely appreciative of the value of making work free online. You can imagine, if you go on Bioline, and you put in African Health Sciences, we have over 2 million eyes looking at our journal. This is incredible, Leslie we thank you so much.

Safa

Another way in African Health Sciences has rejected western knowledge practices is through its commitment to publishing multidisciplinary articles across the fields of health, policy, research and development and promoting a holistic analytical approach. 

James  

There is a movement in the world for super specialization. The super specialization might be good where the health service and the health sector is over developed, very well developed. But when you have a health system that is in intensive care, then you need to be strategic and see whether it is really necessary to super specialize. Let me give you an example. One day I went to visit a friend of mine whose son had features of cancer of the small intestines. And this patient was sharing a room with a retired veterinary officer. And this retired veterinary officer was going to the bathroom like 40 times a day to pass water. And the father of my friend asked me when we had just left the hospital, why are they not testing this man for diabetes? I said no, no for me, I just visit you, I cannot interfere with the management of this patient. So the guy, he was working in one of our broadcasting stations here. And he said, I’m going to be brave. So it was the ward round, there were doctors from the US and I think from Canada wearing white coats and the Ugandan doctors, so this guy asked them: excuse me Sir, for me, I’m a journalist, but that patient you are discussing, whom you think has HIV, I think he has diabetes – he goes to the bathroom 40 times a day, have you tested him for sugar? And of course, somebody shouted at him: who are you, you are not a doctor. But quietly, they went and tested for sugar, and indeed, the person had diabetes. And the reason is that the patient was being treated by a super specialist. So, to me, that’s why we need a multidisciplinary journal, the one that takes one person as a person, not one that takes one person as a pancreas, or one person as bones. So we are totally committed to this multidisciplinary approach. We publish from every angle, but sometimes we forecast, for example, on non communicable diseases or infection. And we also have training for our potential authors on how to write policy documents, policy briefs, very short 700 word briefs, a summary of their work, and how to write it for the Minister of Health, or how to write it for the Minister of Finance, or the Member of Parliament. And that is part of the work of our agenda, making sure that we make our work understood by the general population, but particularly by the policymakers who allocate the money or control the budget.

Safa

As Dr Tumwine alludes to, Uganda has a public health system – although it is complimented by both private, community based and traditional health service providers. In his own medical practice, Dr Tumwine reflects on some of the systemic resource challenges that exist. 

James

I think I need to write 10 books.  Fortunately, we don’t concentrate on the challenges, we always find our way around them. But I call them SOS. So it is “shortage of” –  shortage of, shortage of staff, shortage of shillings, shortage of equipment, shortage of medicine, etc. So really, the biggest challenge in our practice is shortage, shortage, shortage. And it’s very difficult for you who work in high income countries to appreciate this, to know that I can run a hematology ward, when I cannot do the hemoglobin. It is madness. You specialize in blood diseases, but you cannot measure the diseases. And this is everyday life. And I’m so glad that these lockdowns in America, in your country have brought some of your populations to that level. You know, not long ago, I think President Barack Obama was president, people in Canada, my friend in Toronto, said, we are having a credit crunch. I didn’t know what the credit crunch  means until this person explained. So I said, Oh, welcome! For us, we live with credit crunch – we have grown up in a credit crunch. So we have challenges of shortages. And basically the shortage starts with inadequate budget. We don’t have the resources that we would have wanted in the budget. And it’s because the country doesn’t have those resources, we raise the resources from taxation and the tax base is very small. So we make sure that, for example, in the pediatric ward, a lot of the nursing care is carried out by the mothers themselves. Because I don’t have the money to employ all the people I want. So the shortage, shortage, shortage, shortage is really the number one in the health sector as a challenge. Secondly, the inequities are obvious – in that the majority, for example, 90% of the pediatricians in Uganda, I’d say 70 – 90% of the pediatricians in Uganda are in the capital city, in Kampala, which has a population of 2 million out of 40 million – the population of Uganda is 40 million plus. So you have 70% of the pediatricians looking after 2 million children, or 2 million people – but the 40 million have probably like 10 pediatricians left. So this urban rural inequity is really heavy. And that’s why I’m planning to relocate completely to the rural areas, so that I can continue being part of this revolution of trying to change the health inequities. 

Safa

In addition to urban-rural disparities – another way in which inequitable and differential access to health services manifests is through the phenomenon of medical tourism. 

James

We used to have a lot of middle class people going to India for their treatment. Let me give you an example. My daughter, she’s a lawyer, and she had friends from India, who were going to buy a ticket to go back to India for treatment of their child. And my daughter asked them: why don’t you try and see doctors locally? But anyway, the patients came to our hospital and their problem was urinary infection. And all we needed to do was to look at the urine and start treatment for this fever, which had been there for several weeks. And yet, this family wanted to go for their treatment in India – they were going to buy air tickets – those air tickets could pay my doctors for about six months. So the middle class, the upper class, they don’t have confidence in the Ugandan health system. They want to go abroad for their  treatment, even for the most simple thing. Let me give you another example. I have a friend who works in Nairobi, which is one hour flight from Entebbe here. And my friend had come for a weekend in Kampala. And he went on the plane. And he was chatting with people on the plane. And when he went to Nairobi Hospital and was going to enter his office, he was seeing this line of people, half of them from Uganda, half had been on the aeroplane. And he said what do you want here guys? They said no, we have come for treatment. And who was going to treat them? That same Ugandan doctor who had traveled from Entebbe with them. So they could have been seen by this doctor in Kampala, but they like to go and be treated in a foreign country, even though it’s the same doctor who is treating them there.  I think in the west you call it medical tourism. It’s a terrible thing. 

Safa 

Part of the process of mobilizing for greater investment in public health services is advocating with and holding governments to account. 

James

So the hard fact is that decisions, economic decisions are made at different levels. But for us at the national level, the economic decisions are made in Parliament, but they are also made in the Cabinet. So it’s very important that whatever policy decisions, whatever influence we want to have, has to be at the ministerial level, but also at the parliamentary level. That’s why we form partnerships and we make sure we have allies in the Ministry of Health, the highest level in the Ministry of Health, and allies in Parliament. And we have, with the help of the National Library of Medicine, formed the Uganda Health Communication Network, and the journal is part of that partnership, so that we can influence the budget, the priorities, the health priorities of the country. And I must say, we to a large extent have been successful – influencing the relocation of large chunks of the budget to the preventive sector, for example, prevention of malaria, continuing immunization coverage, etc, etc. So to that extent, I think we are in the right direction. I think globally, we have a big challenge. And the challenge is that big pharma, in my view, is dominating the health sector right now and also in the last 10 years. But the stark shame that we are facing today, as I’m talking, is the vaccine apartheid, where your own country where you’re talking to me from, has stocked COVID-19 vaccines seven times the amount that you need. So when everybody has received the vaccines, where are you going to put these others now? They will expire on you and it will be a big shame on you. How can you hoard  vaccines 2,3,4,5, 6 times, 7 times the amount that you need? In English, it’s not my mother tongue, that word is hoarding: h o a r d i n g. And for us in Uganda, hoarding is a big shame. Because it was a phenomenon brought by Idi Amin. People would hide the food, while others are starving because of money. But it’s really a big shame for me and I’m talking about it openly –  how can people who are civilized engage in hoarding? The other part of the world is starving and for you are keeping the food: where is the humanity? We are trying to work on climate change and all that, you know, and yet people are hoarding vaccines? I can tell you Safa, we are very angry. It means that we in Uganda, we in India, are second class citizens. And yet we have to buy Canadian goods, we have to buy American goods. What if we don’t buy your goods? Will you eat your cows? Will you eat your ventilators? I don’t know – you manufacture them, I don’t know we’ll buy them.

Safa 

One initiative that is trying to facilitate a more equitable global rollout of vaccines is the COVAX coalition, co- initiated by GAVI – the Vaccine Alliance,  the Coalition for Epidemic Preparedness Innovations (CEPI) and WHO. It is bringing together governments, global health organisations, manufacturers, scientists, private sector, civil society and philanthropy, with the aim of negotiating to provide innovative and equitable access to COVID-19 diagnostics, treatments and vaccines. 

James

You see, a year ago we knew and we learned that we are all living in the small village. You know, you are in Wuhan, you start sneezing. When you sneeze, Toronto sneezes. Now you want to prevent the sneezing in Toronto, so that people in Uganda do not sneeze, people in New York do not sneeze, that people in New Delhi do not sneeze. And somebody says no, that’s not our business, let them sneeze. Okay, you can have your vaccine, you can hoard your vaccine. When we get a mutation, when we have COVID-19 mutating – and there is every evidence that is mutating, you will get it in Canada and it will come back and it will be square one, your vaccine will not work on it. So I don’t know why people are so blind, why they cannot see clearly that we are in the same village and when you are in the same village, when your neighour has no food, you say okay, come and share supper with us. You do not just throw away that supper. So we need to have a movement of international, modern, global people who know that if it is vaccine, it is for the world. If it is global warming, it is for the world. When Canada starts flooding, Uganda will start having a similar problem. When children in Uganda suffer, children in Canada suffer. So we need to mobilize, we need to work with the community, with the people, to pressurize our governments to become  a part of this global village and we have no choice – that is what we have to do. 

Safa 

That very spirit of mobilizing and taking action is what has motivated Dr Tumwine over the past 20 years. Now, on the 20 year anniversary of African Health Sciences, he reflects on some of the achievements he is most proud of. 

James

So the first one is the open access. When we started open access was like just a talk. So now we’ve, we’ve really moved, we’re having an open access reality. And we wish to believe that we’ve contributed something to that. Secondly, we believe that we’ve earned respect for African researchers and authors, and our right to research – to develop our own research agenda that addresses local problems, maybe with a global touch. To me that is very important to have earned that respect, and have the confidence that when I do my research, I can bring it to the world without a struggle. I have the audience, I have the platform with which to disseminate my research findings that are credible, that are respected by my university, but also by international universities. So for example, we have received over 2,000 manuscripts a year now, ranging from people in Africa to those in the diaspora, and if they didn’t have confidence in their own journals, they wouldn’t be doing that. So for me, that has really been very important. And the fact that the National Library of Medicine has assisted our organization, this African Journals Project, to get our journals in to Medline, PubMed – but also into The World of Science, The ISI, Impact Factor, etc. That has been a really big, big, big achievement for us – to be publishing work that is internationally recognized, so that we are equals among equals. We are not beggars any more.

Safa 

In mainstream western media, there is often a problematic, discriminatory and false narrative that assumes that African countries do not have the health systems necessary to adequately respond to or cope with a health crisis  – a narrative which was replayed at the start of the COVID-19 pandemic. 

James

You see, I told you that for us we live in a credit crunch. While for you, when you get a credit crunch, it affects you. For us, it doesn’t affect us, because for us, we’re in the chronic credit crunch. What you had 10, 20 years ago – for us, that is normal. So we know how to survive on the little that we have. When people come to Uganda and talk of recycling, I start laughing at them. Because we don’t throw away anything here – we recycle everything. Our health sector is resilient. For example, if you look at Uganda, we’ve had several outbreaks of Ebola in the last two decades. And how did we cope with Ebola? We did not need people to come from Canada or America to come and help us control our Ebola –  we controlled it ourselves. So we have the skills, we have the capacity to control epidemics. Right now we have Ebola not very far from where I am right now talking from, in Congo, and because there is Ebola in the Congo, Uganda is very alert. So when the COVID-19 came, we had people with that experience, we had the system that had experience in handling these epidemics. We may not have had enough ventilators, etc. And that means we didn’t treat so many people with ventilators, but our mortality is extremely low compared to the mortality elsewhere. And the people, the way we live communily, also helped. So while people can sit somewhere in Switzerland or in Mexico, or in Canada, or someplace and predict the doom for our health system, we know how to handle our sick people. A lot of communities have been struggling, but managing how to control and tackle these issues. And at the end of the day, it is the Ugandans, it’s the Africans themselves, who are going to control COVID-19. And where we don’t have the resources, yeah, the world can help, like in COVAX. But if they don’t help – that is a challenge for the whole world, because if you don’t help Africa, the disease will eventually end up in the western capitals as well. So let me try and summarize it and say, we’ve got our own health systems, they are weak, but they are not on their knees, they are not dead, they are operational – particularly the preventive aspects of our health sector is quite strong. And it is based on a government health system that is weak, but is functional. 

We still await the results of the COVAX initiative. And my hope is that it will be successful, because now we have the commitment of the US government within the new president there – I think that the CDC is doing some very good work in terms of coordinating these activities, and their role, I think, is largely to coordinate how countries respond, but also to be part of the International lobby, to mobilize the resources for us to handle this epidemic. And the African Union, which is like the European Union, have been quite active in mobilizing resources, in coordinating policy, in conjunction with the World Health Organization.

Safa  

Over the past 20 years, African Health Sciences has also initiated and participated in numerous regional partnerships and knowledge exchanges that have helped promote a collaborative research culture. 

James  

So we have this African Journal Partnership Project, where we have collaborated with journals in Ethiopia, in Kenya, in Uganda here, in Rwanda, Zambia, Mali, and Ghana. We have also several projects supported by the Swedish government, and the Norwegian government, in which we have worked closely with South Africa, University of Cape Town, Stellenbosch, Tanzania, South Sudan, where we still have some collaboration and the Congo, Eastern Congo here, to try and support the health systems through training and publication. And also to stimulate research using very, very small amounts of money. For example, in all those collaborations we’ve been raising like $4,000 for research for a student. And $4,000 might look like little money for research, but because we’re working in teams, we then support the young researchers to do some work,  answer a research question which might be related to policy development, and eventually the candidate is able to publish their work and eventually get, for example, PhD support and start on a wider study for their PhD. So with those small grants, we’ve really worked really hard. Let me give you an example. We would work with district teams, that means the health workers at the district level, we worked with them, give them skills, identify the challenges, and then they discuss with the communities to design solutions to those challenges. And then they would go and implement and sort out the challenge, and then write papers on that. And also disseminate the information. I look forward to trying to do similar work here in Kabale University, trying to work with the district members to do that type of work so that the knowledge that we generate, we share it with the communities. And once we share it with the communities, it can impact the way our communities respond to challenges of health.

Safa 

In looking to the future, Dr Tumwine has a vision for better addressing health inequities in Uganda and the next steps for the African Health Sciences journal. 

James  

It is so important that the whole political economic health becomes a household issue. That people in schools, people in universities and colleges, they start to talk about the political economy of health, so that we do not delegate this responsibility of conscientizing – that’s probably the correct word, conscientizing our communities about the link between equity, health and development. And what I’m glad of, what I’m really, really very proud of is that the last 3 Ministers of Health in Uganda, were all mentored by me in their master’s program, including that current Minister of Health, and I’m so glad she has just won herself a Member of Parliament seat again, and I hope that she remains as the Minister of Health. So if we can influence political decisions, the issues of equity at the highest level in the country, my hope, and my work, and the way I want to spend my last energy is to influence, to try and influence that at household level, that at school level. And right now, I am privileged, I’m Chair of National Teachers College Kabale, which is one of the college’s training teachers for primary and secondary school level. And we’re working very hard to make sure that the question of health and the politics goes on top of the agenda. And I think actually COVID-19 is a blessing because it has put health on top of the Uganda development agenda. So in the next 20 years or 40 years, we hope that people become conscious about their health and the way they link that health with equity or inequity, so that health is not taken to the market. Health becomes a right. We cannot take health to the marketplace, where they put health to the marketplace, even though they have a lot of money, it has been disastrous. Where we put the health at home, where we put health in our villages as a right, we have not had as much catastrophe as those who have put in health at the marketplace. So that’s where I would like to move. I’d like us to have this knowledge and conscientization movement, where we really campaign for health as an equity issue.

So our journal, we’ve sustained it on a voluntary basis, and we hope to continue that way. But I have some ideas, I’ve had them for some time. We want to start what I call baby journals. So we have African Health Sciences – this African Health Sciences is now 20 years. And in our culture, when a man or a woman becomes 20, they start looking somewhere to form their own home. So they start their own home and they start having their own babies. So we hope that African Health Sciences, we are going to plan to have baby African Health Sciences, in which we take one critical issue and make a journal for it. Although we are a general journal, then we can have a baby that can be a sub-general journal – political economy, etc, etc. We have done a lot of thinking and consultation. But watch this space –  I think in the next 10 years, we shall have probably three or four more journals, baby  journals out of this African Health Sciences. But finally, I really want to thank everybody who has supported African Health Sciences, ranging from the Africa Journals project, to Leslie and Bioline, and the other journals, BMJ, New England Journal, The Lancet, JAMA, etc. It’s never easy to start a project and make it succeed. It is because members of that village have supported us and we are truly international. Thank you so much.

Safa 

Thank you Dr Tumwine and all your colleagues at African Health Sciences for your pioneering work over the last 20 years. We congratulate you, we celebrate you and thank you for sharing your reflections with us. 

And thank you also to our listeners. To learn more about African Health Sciences, please visit the link to their website provided in the show summary.

SECTION 3: Outro

We invite you to join us in fundamentally reimagining knowledge systems and building healthier relationships and communities of care that promote and enact equity at all levels. 

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