Dr Ebere Okereke, Lead Consultant in the International Health Regulations Strengthening Programme, Public Health England

CV IN BRIEF

EDUCATION Bachelor of Surgery and Medicine at the University of Nigeria. Postgraduate Diploma in Tropical Medicine at the Liverpool School of Tropical Medicine. MSc in Public Health at Newcastle University. Postgraduate Professional Course in International Health Consultancy at the Liverpool School of Tropical Medicine and Executive Programme for Global Health Leadership at the London School of Hygiene and Tropical Medicine. 

 CAREER SO FAR Consultant in Communicable Disease Control at the Health Protection Agency. Consultant in Global Health Strategy at the International Rescue Committee. Former Trustee and Chair of the UK Advisory Committee at TB Alert. FormerTrustee at the Nigeria Healthcare Project. 

 CAREER WITHIN PUBLIC HEALTH ENGLAND Consultant in Communicable Disease Control Yorkshire & Humber region, Epidemiologist Emerging Infections and Zoonoses. Consultant in Global Public Health. Lead Consultant in Global Public Health on the IHR Strengthening Programme.

 LANGUAGES SPOKEN English, Igbo, Kiswahili

DATE OF INTERVIEW 22.10.2020

 AUTHOR Martha Bowler

Three pieces of advice: 

1. Check your reasons. Global health is a broad church which requires the experiences, skills and perspectives of many, but the world is not waiting for you to come along and fix it or save it. The idea is to bring your skills to work alongside people living the experiences you wish to address, wherever they are. Before deciding that you need to go 'do global health' or 'do international development', look around you and check what you can do where you are. You may make more of a difference and use your skills more meaningfully in your neighbourhood or community. This doesn't require flying across the world to try to address issues you may not fully understand. 

2. Listen, listen again, and listen and understand. Check your biases, your assumptions. Listen. Do not go in with a solution you assume is right and will work in the given context. It is crucial to go in with knowledge and skills and a willingness to learn and to contribute but recognise that you may not be the solution needed, and that requires listening. 

3. You need to love what you do. That is not just relevant to global health, that is the advice I give everybody who asks me for career advice. We are all going to have to work most days of our lives. With the current trajectory of increases in the pension age, probably until our 70s. So, you have to love what you do. Doctor Ngozi Okonjo-Iweala, who is in the running for the WTO presidency, said at a conference the other day that you need to be happy to go to work 70% of mornings. You can live with the other 30%. You will not love your job every day, but there has to be enough balance between the days that are “oh gosh, no I have to do this”, and the days you feel you are making a difference.

You currently lead the UK aid-funded International Health Regulations (IHR) strengthening project at Public Health England. Could you talk me through the IHR and your day to day role?

The International Health Regulations have existed since 1969; they are one of only two legally enforceable instruments that the World Health Organization has. The first version addressed defined diseases, such as smallpox. In 2007, a new version of IHR (2005) came into effect. The greatest change was its move away from being disease-specific to acknowledging the need to respond to unknown pathogens and non-infectious hazards, thus taking an all-hazards approach. In this way, IHR focuses on public health events with the potential to become international threats. 

The project I lead is a component of the UK Government commitment to Global Health Security; it is funded through the Department of Health but delivered through Public Health England. We work with several countries (Nigeria, Sierra Leone, Ethiopia, Zambia, Pakistan and Myanmar) and international bodies, to build their capacity to comply with these regulations. These capacities include having the capability to prevent, detect, respond to public health events, predominantly but not exclusively infectious disease-focused. The countries we work in have been selected based on the capacity to absorb the support we offer, as well as their vulnerability, needs and relationship to the UK, amongst other factors. 

We work predominantly with National Public Health Institutes in those countries. We want to avoid flying in, giving some training and certificates and leaving; we aim to work as a partnership, alongside those countries to improve their systems. We do the training but, then we work alongside them to ensure that the actual improvements in systems and structures are embedded. 

Do you deal with conflicts?

We are not engaged in conflict zones. Our programme focuses on capacity building to strengthen the existing public health infrastructure. We are not currently involved in any countries in active conflict.

What made you specialise in public health rather than pursue what is deemed to be a 'regular medical career'? 

I was born in the UK, but I spent most of my formative years in Nigeria and went to medical school in Nigeria. I started medical school wanting to be a brain surgeon (don’t we all) but very quickly realised that surgery was out of the question for me. I left Nigeria after medical school and pursued my other passion, travel. I ended up working as a junior doctor in Trinidad and Tobago, after that, I returned to the UK and started my residence in clinical medicine.

The general trend for women in medicine in Nigeria at the time I trained was to become a paediatrician, which I found to be too emotionally draining. So, I was in general medicine for a while. Following my love for bugs and parasitology, I moved from general medicine into infectious diseases. In this role, I gained more interest in prevention. I decided to do a Diploma in Tropical Medicine in Liverpool, as a means of exploring wider interests. While on the course, I attended a lecture on communicable disease control by Professor Adetokunbo Lucas, a professor of community medicine, working at the World Health Organization at the time. At the end of the lecture, I went to the faculty of public health, asking “how do I do that?” This is how I ended up on the Public Health training programme, and subsequently in communicable disease control. 

Do you think public health has become a more popular career? 

It is difficult to make a general statement about that. There are still, rightfully, far more doctors in clinical practice than in public health. Public health is a broad category which does not only involve doctors, there are also many other specialists with a variety of skill sets.

As health systems, not only in the UK but globally, we are moving away from a model based purely on healthcare and biomedicine, into understanding and responding to wider determinants of health. With this move, public health has become a broader specialist area, attracting more people from diverse academic and professional backgrounds; this is most welcome.

Global Health is often criticised for its colonial legacy in wanting to impose western views on less developed countries. How do you and PHE avoid this when working with low- and middle-income countries?

I can only speak for the project I lead, not for everyone involved in Global Health. I had the privilege to work with others to design the programme based on a proposal which had been approved for funding. We adamantly focus on building partnerships, working with the countries and our public health colleagues, not doing things for them. This meant jointly defining and identifying the priorities within the IHR capacity arena and then working alongside them to improve them. 

This is a constant challenge as the traditional method involves having experts from the global north flying in and telling people what to do. This may result in bringing a model which works in their own country and trying to squeeze it into other systems when it may not be applicable. We try and avoid that by working alongside our partners to define the problem together and to jointly develop solutions. 

It is interesting to reflect on the current pandemic and to further understand the two-way process of learning. In a way, the nature of our project makes it - we do not bring money, we are not a funding programme, we come and say: we are public health specialists in this domain, how can we work with you? What are your priorities? How can we work jointly to improve your systems and make it easier for you to comply with IHR? After the project, we reflect on what we learn from the process. 

So, rather than identifying the needs of specific countries, it is about gaining an understanding of who has the infrastructure and what current policies exist in the country that you can work with?  

For our current project, we spent about six months scoping the needs. We looked at their existing strategies, their compliance with the regulations, identified their public health leaders are and enquired about their priorities. 

 In this way, we attempt to find common grounds on what we can work on together. In Ethiopia and Nigeria, we tried to improve the quality of cholera diagnostics as they experience outbreaks of cholera every year. The argument is that improving laboratory standards for the diagnosis of diseases, you will then have a foundation which will facilitate disease preparedness in case of an epidemic or pandemic. When our programmes are not based on the country's needs, we risk imposing Western ideologies without effectively embedding changes into the system. We try to avoid this.

80% of Global Health Leadership is dominated by the West, and 70% by men, so, mostly white men. As a black woman, do you often feel undermined in your work and, how do you think this is changing? Are you personally advocating for a change? 

One remit of our project, which I am passionate about, is enhancing leadership with a specific focus on gender. In addition to enhancing technical skills, such as improving a surveillance system, improving laboratory processes and emergency operations systems, we also look at the broader organisation. We believe competent and qualified people stay if the organisations value them. If you do not use and enable the women in your workforce to bring their A-game, you are already working with one hand tied behind your back. As human capacity is a limitation in public health, and especially in our partnering countries, we cannot afford to undermine half of the population. So, we do a lot around gender, gender advocacy, and making sure to work off reliable data. For example, when we are offering training, we ensure women can access it and that we engage with them. We are developing a lot of mentoring partnerships as we built good relationships. We do this across the board, for technical and system leadership, with a particular focus on women.

Women's health-focused work in the countries you work in is often unpaid. Do you do anything to address this disparity or, is your focus on leadership? 

We do not address it directly, because the remit of a project is specific to global health security which we address through training and capacity building. But what we do have is a voice - a significant part of public health is advocacy. We use every forum that we have to raise the issue of gender equity in all its spheres. I spoke about gender equity at the Africa Centre for Disease Control Conference and in meetings with national public health institutions across the continent. I am very honoured to connect with the groundswell of women and men who are committed to gender equity across the globe. 

I see that you are working on COVID-19. How does this work compare to your work on other diseases in the past?

At the moment, it is all hands on deck, though it is not my core job. For the first six months of the pandemic, I was supporting as a past consultant in communicable disease control alongside other public health colleagues. My time was spent developing some of the early guidance. I am not doing that full time anymore; we now have formal structures in response to the pandemic.

I am focusing on positive engagement, working with country partners through the opportunities stemming from COVID-19 to embed system changes long-term. In public health, we never let an emergency go to waste. I believe this is an opportunity to concentrate and focus attention on making significant and positive changes that will outlast this emergency. This public health crisis allows us to test whether our work to improve emergency operating centres translates to real-life contexts. On a downside, COVID-19 has coincided with a period of political nationalism. This has led to less than admirable decisions and approaches to the pandemic across the world. Interestingly, it has also shown that the most efficient solutions do not sit with the usual suspects. We are now shifting from looking at the West for solutions to South Korea and Singapore. Every public health emergency starts with the language: “this is a leveller, this will impact everybody”. We now see that this is not true: COVID-19 is exploiting existing inequalities in society, exaggerating and exacerbating them.

How have the local international responses and restrictions to the pandemic affected your work? 

Firstly, travel is significantly reduced, we cannot just go to Ethiopia, Zambia, Pakistan. So, we have had to adapt quickly and move to virtual platforms. We have learnt to use remote learning effectively, making it a viable and effective option for some system development changes we wish to support in the future. I believe we have learned a lot about how we adapt and respond during emergencies. 

And what do you think everyone can learn from the pandemic?

The pandemic has been a reminder about how important it is for the public to trust decision-makers. Public health requires trust, where trust is lacking, for whatever reason, it inhibits our ability to effect change. 

It has also shown that we can learn a little bit from everyone. For me, it is about that equality of contribution - one of the main aspects of that has been the increased openness and accessibility to science and research. Most of the major journals moved to open source and allowed free access to key publications on COVID-19. There are still multiple problems. Papers that are written from a low-income country take much longer to be published than in the global West, due to more rigorous scrutiny. However, there have been some very positive changes, for example in accessing vaccines, COVAX and the international commitment of governments – well not all governments at the moment, but an increasing number of governments – to a pooled approach to access new vaccines. Hopefully, we will not set this aside after COVID-19 and, it will extend to wider pharmaceutical products and medicines. 

Finally, this has shown the importance of old school contact tracing. It is great to have the apps, it is great to have the diagnostics, the sequencing, all of this is phenomenal. The ability to move from new pathogen to diagnostic tests to a vaccine at such pace, in such a compressed time is phenomenal and, evidences hard work behind the scenes. Yet, this pandemic has also shown the crucial need to value some of those old school skills.

Do you think COVID-19 has the potential to change the field of global health for the better in the long term? 

I am generally an optimist, but I am also pragmatic. In public health, we are doing our job right if the world does not know we exist. When the world knows about us, it is because things have not gone as we would have hoped, such as with COVID-19. When I am feeling more optimistic, I would like to think that public health will be more front and centre globally though I am not entirely convinced. There will be some improvement, but I would not say things are going to be good from here on. That is not how society evolves. 

Data disaggregation based on sex and gender is not a mainstream practice. This disfavours women globally. Do you think that the clear clinical difference between women and men in COVID illness has been accounted for changed in epidemiological data? Or is it kind of following the same trend as before? 

The lack of gender disaggregation in the analysis of health data is not new, and I have not seen a significant difference with COVID-19. Women continue to be underrepresented in science, as participants, in the design and delivery of research and as recipients of research funding. Until we change the representation through genuine diversity and inclusion at all tiers of the health system (especially in leadership), and until we have representative decision-makers, this will remain the norm. Equal representation in decision-making will help drive research questions and funding towards addressing a wider spectrum of issues relevant to health and wellbeing for men and women. In the past, and now, still, we are unaware of the implications of health policy decisions and scientific breakthroughs for women. This is because we do not ask the right questions at the beginning.

The pandemic has put public health professionals in the limelight. What do you think are the effects of this new visibility?

I cannot make a universal statement on that; it varies based on location, on perceptions of the profession and how it is relayed to the public. I am being a bit tongue in cheek but, everybody is an epidemiologist now. There are lots of people who are speaking on social platforms who pre-pandemic would not have described themselves as public health specialists. Conversely, many public health specialists are not getting this visibility in response to the pandemic. 

When the actions needed to improve public health have significant impacts on the ways that society functions, everything becomes political very quickly. With increased popular interest and surge in visibility comes the propensity to be accused of creating problems, rather than solutions, or both. I would say that, although necessary for effective public health, visibility is not entirely always a good thing, and we have to manage it, during the pandemic and afterwards.