Universities and the poorest billion

Universities do have a role to play in helping developing countries. University image from www.shutterstock.com

The following is based on the Monash Richard Larkins Oration given by Professor Sir Leszek Borysiewicz, Vice-Chancellor of Cambridge University last night in Melbourne.

You can read and listen to our In Conversation interview with Professor Borysiewicz here.

In the UK, and maybe in Australia as well Vice-Chancellors talk about core national issues surrounding education, research, policy, financing and technology transfer to enhance economic growth.

These issues are crucial for any great University and we all know that Cambridge and Monash perform very well in all these aspects. But today I will veer from these conventional themes to discuss this challenge that global Universities must address if they truly wish to consider themselves “global”.

I am driven in part by my own background as a clinician in Infectious Diseases who had frequent but short exposures to clinical practice in West Africa, which were a formative experience.

These days, outside of my role as Vice-Chancellor of Cambridge, I also Chair the UK Department for International Development Research Advisory Committee, as well as a small Foundation that seeks to deliver new drugs for the world’s neglected diseases to patients who will never be able to pay the full costs.

The challenge: reducing poverty

As is customary on these occasions let me start with a quotation from a major historical and religious authority on poverty – Jesus.

As He rebuked his disciples for accusing a woman of wasting expensive oil on his feet he stated – “Why do you trouble this woman? For she has done a good work for Me. The poor you have with you always, but Me you do not have always” [Matthew 26, 10-11].

Oh no I hear you say, “Give a Welshman a lectern and he thinks he is giving a Chapel sermon!” However, leaving aside the obvious religious connotations, He recognised that the poor wished to be recognised and that there is a moral responsibility to do so but also that poverty is a relative not an absolute condition.

His statement is as true today as it was at the time of the Romans. The good news is that historically poverty today is not as severe as then. On a further note of optimism, its prevalence is falling at a faster rate than at any time in history – in fact the Millennium Development Goal pertaining to eradication of extreme poverty and hunger (defined by the World Bank as living with an income below US$1.25 a day) is likely to reach its target of halving numbers from 1990 to 2015.

Lest we congratulate ourselves too early, that still leaves 15% of the world population (or 1.3 billion people) living at or below this level. Furthermore as poverty is relative not absolute let us remember that a further four billion people live on less than US$9 per day?

Even in biblical times the injustice and pernicious social consequences of poverty were recognised and that is no less true today. Among the consequences of poverty are poor health, poor nutrition and poor education, particularly evident in resource poor countries.

So what can leading and global Universities do about it?

A Minister’s in-tray: health, nutrition, education

Let me start by asking you to imagine yourselves as the Minister of Health in a country, say in Sub-Saharan Africa, where most of the population live well under US$9 a day and many below US$1.25.

You are daily faced with the challenge of improving health on a tiny budget. You read and keep yourself informed, so you’ve enacted the helpful directives of the WHO on vaccination policy, improved maternal mortality by simple measures and tried to introduce basic nutritional support.

However, there is limited resource to do more and that which is available comes in variable amounts and tied to specific, externally dictated goals – often well meant and charitable in origin. But introducing a programme is not your issue, it is its long-term sustainability.

But the clouds on your horizon are even darker. There are four inescapable trends that will all impact adversely on your struggling country:

  1. The ageing population. Largely because you have established good preventative care people are living longer and the health consequences are self-evident.

  2. Most important among these, is that, as the burden of infectious disease has fallen, so the rising tide of non-communicable diseases in an ageing population is going to hit you – diabetes, heart disease and cancer. Of course, you know there are effective interventions that can prevent or manage many of these conditions, but who can afford them? One example from my own field: cervical cancer. In over 90% of cases a virus, Human Papillomavirus, or HPV, is implicated and the number of cases of cervical cancer in developed countries has dropped dramatically: it is effectively screened for; there are two effective vaccines, developed in the USA and here in Australia by Ian Frazer and colleagues, and better effective treatment. However, 260,000 women still die annually. Why – because the interventions are not available where needed – in developing countries. Furthermore cervical cancer is the one found in the difficult to reach poorest communities.

  3. To deal with non-communicable diseases is going to require a wholesale realignment of your health service – more primary care, long term support and community care. All this will cost, but even worse there is a World Bank Report of 2010 sitting on your desk that tells you there is no consensus on what works or how to do it.

  4. Not only is the population growing and ageing it is also moving. The trend of urbanisation in low-income countries is such that >50% of the population in these states will live in cities by 2020. Of itself this will not reduce poverty in the short term. But it could make matters worse as the migration is unplanned and shantytowns created - with no sanitation, energy supply nor rudimentary town planning; a health nightmare.

Not much of a job description for a minister, I’m sure you will agree.

Issues of poverty are not restricted to health but health inter-relates with other problems of poverty. In 2011, an estimated 165 million children under five years of age worldwide showed stunted growth, and 101 million were underweight. But the cause of under nutrition is not poor health – it is poverty and consequent lack of food in quantity and quality.

Finally, education. About 72 million children worldwide remain unable to access primary education despite progress under the Millennium Development Goals. Millions more drop out, and for many the experience is of large class sizes; poor teacher training and a lack of basic resources such as textbooks reduce the likelihood of a full and effective primary education.

Poor health, poor nutrition, and poor education all derive from poverty and are inter-related by poverty.

Poverty is indeed pernicious.

What is the role of universities?

This is common ground: global poverty is tragic, its consequences a blight on individuals, society and the planet. But the role of universities in reducing poverty and its impacts is a matter of debate.

My contention is that global research universities like Cambridge and Monash have a key role to play.

In fact, universities’ contribution to the alleviation of poverty, disease and malnutrition is seriously undervalued and misunderstood, including by universities themselves.

I argue that the advancement of health, wealth and nutrition in low income countries is, firstly, a wholly legitimate target, as well as a major academic challenge, for the world’s top universities, and secondly that we are in fact uniquely well placed to make a difference.

Let’s take those two points in turn.

A proper pursuit for universities

The continuous genealogy of universities begins in medieval Europe, in Bologna, Paris, Cambridge and Oxford, and preparation of leaders for the Church and for public life were a primary purpose.

The philosophy changed in the 19th century with Wilhelm von Humboldt in Germany and Cardinal John Henry Newman in England and Ireland setting out competing and overlapping Ideas of what universities should be for, building on, rather than demolishing, the medieval idea.

In the 20th century, the unification of teaching and research in universities, following Humboldt, became a common paradigm in the West, and universities began operating on a global stage.

My point is simply that in every historical and geographical incarnation of a university, “making a difference in the world” has been a recognizable aim.

Academics do not withdraw into universities, despite their monastic roots, to think deep thoughts - they deepen those thoughts by constant engagement with others and the challenge of real world problems such as poverty.

On Monash University’s website I see the following sentiments:

“Monash is a university of transformation.

The desire to make a difference informs everything we do.

We see a brighter future as more than just possible - it is something for which we are directly responsible; something we can help create.”

The mission statement of the University of Cambridge meanwhile is “to serve society through the pursuit of education, learning and research at the highest international levels of excellence”.

Both seek to serve society.

Monash and Cambridge are neither alone nor unusual in this respect. Large research-intensive universities have global reach, ambitions that stretch far beyond the short term, and an acute understanding that they are there to tackle the big questions on behalf of society.

And “society” in the globalised world of the 21st century, is not restricted to the medieval or Victorian world view of local, regional or national entities but society encompasses the whole world.

But what exactly do we bring to the table?

The effectiveness of universities in overseas development

For me, three characteristics of Universities are prominent: firstly, we are multidisciplinary in our approach to research and education; secondly, we network to support local universities; and thirdly, we can broker relationships with others, including with the private sector.

Let’s explore these three in turn.

Multi-disciplinarity

We employ hundreds if not thousands of extremely bright people, with skill sets of exceptional breadth and depth. No other agency can match their track record nor scope and scale in research and education. Because we have the capacity to bring these together, for example: Arts and Humanities with basic science. Universities are the last great integrators of knowledge and can address the real world, grand challenge problems, such as those in low income countries, in the round. This matters because putting technological solutions to work is nearly always a multi-faceted problem worthy of universities’ attention.

The reason polio is not yet globally eradicated is not because we don’t understand how the disease nor vaccine works – the biomedical solution exists. However, there are three countries in the world – only three – where it is still endemic: Nigeria, Afghanistan, and Pakistan. Addressing this problem requires every academic discipline from religious studies to supply chain dynamics and sociology to health services research and therefore needs our academic staff to engage.

Just as vaccine implementation is a complex system problem, poverty itself can be thought of as a system. This approach exposes the unhelpful mind-set that “every little helps” – that lots of small interventions are sufficient, because they can add up to a huge transformation.

Of course lots of small interventions are of course effective on their own terms, particularly locally such as microfinance initiatives. They have an important place but if they add up at all, they add up to precisely the sum of their parts, and no more.

There is an analogy in energy sustainability: the Cambridge physicist David MacKay has argued that when a well-meaning citizen obeys directives to unplug his mobile phone from its charger, he is following good practice and the best advice – but by doing so he will save one quarter of one per cent of his household’s energy consumption. But if everyone in the world does it, won’t that add up to a huge difference? No, it won’t, says MacKay: they will save one quarter of one per cent of their energy consumption.

So in a systems problem, “every little” does not in fact help very much at all. To make a significant impact, yes you need local interventions, but we also need either large-scale, complex solutions or we need to create conditions in which the whole of local interventions can genuinely be much, much greater than the sum of the parts. The latter is sometimes possible - but it’s rarer than we think, and it requires “systems thinking”.

One of the best interventions in world poverty would tackle the triad of interlocking priorities – Food Security, Health and Education - as a system. They are co-dependent on many levels affecting communities as well as individuals: a poor harvest means a village can’t afford medicines or education; poor health means workers can’t plough the fields or look after the livestock, or go to school as pupils or as teachers; and poor education means that healthcare and hygiene are not prioritised.

This is the sort of problem that universities excel at, and university research contributes strongly to the work of the International Food Policy Research Institute, IFPRI, which champions this approach, as a healthy, well-nourished and well-educated population can contribute to its own development.

Supporting universities in low-income countries through partnership

These human systems problems cannot be solved by applying Western solutions unthinkingly. Cultural relevance, context and local sustainability must be taken into account enabling low-income countries to define development on their own terms. Therefore local integrators, i.e. local Universities, are required.

As the head of one East African state has remarked: “my country has little money, most of the people cannot read or write, most of the children are not in school. I must invest in primary education – and yet how can we be a proper nation without a university?”

Such an enlightened vision recognises the additional value of tertiary education even in a low-income setting. It develops civic leadership, scrutiny of secondary education, the retention of talent and intellectual property, international partnership and much more. How better to build this sort of university capacity than through North-South partnerships between universities?

A partnership programme between Cambridge, the University of Ghana and Makerere University in Uganda, supported by the Carnegie and other philanthropists, seeks to strengthen capacity for a sustainable research and mentoring culture, by cultivating the talented individuals who will make this long-term goal a reality in our African partners. This programme and other similar ones in Cambridge are part of a broader Cambridge in Africa programme strategically orientated towards strengthening their tertiary education.

Shortage of PhD-level staff, research-active mentors and internationally competitive research groups is a serious limitation on training the next generation of African researchers, to an extent that is not true of India or China.

The long-term goal must be to build capacity to a point that the University in a low income country is strong enough to exercise choice of partner based on its own reputation and excellence.

Gone for me are the days of exploitative partnership or a neo-colonial model, which merely seeks access to populations or resources – we must seek engagement on the basis of equality, and partnerships, where we are clear about how and where we add value.

Universities as brokers

The last of the three characteristics I want to explore is our role as a broker. Universities work all the time with governments, charitable funders, the private sector and NGOs to get innovations quickly into service in developing countries.

We can do this because universities are rightly seen to be independent, autonomous, honest brokers – and unlike NGOs we’re not mission-specific. We avoid the difficulty of the “solution looking for a problem” – academics have some defence against this owing to their training in evidence-based conclusions, and with antennae primed to detect what I would call “policy-based evidence-making”.

Our record of engaging only with a funder who allows freedom to publish outcomes is perhaps the characteristic that could make us a partner of choice in the investigation of interventions that may carry significant financial or individual reward. Therefore Universities must guard this privileged position as a vital component of institutional autonomy.

The power of private sector, for-profit investment is colossal and its’ potential for benefit to low-income countries huge. Nowhere is this more evident than mobile phone usage.

In Africa there is 60% penetration, in India 70%. This can be readily turned to health and education benefit, but as the customers are among the four billion any application has to be simple and affordable or free, working to a mass market business model.

Developing these applications linked to telemedicine or education and their field evaluation is precisely the type of programme at which our academic staff excels. A win-win possibility for all concerned with the independent University based development and evaluation at its core has to be a good.

University-based spinout companies can play a significant role in this sector. Two Cambridge examples are Eight19, which makes low-cost flexible photovoltaic cells, allowing sunlight (which is plentiful) to take the place of mains cables (which are not); and CamFridge – which is developing low-cost magnetic refrigeration.

University developed technology applied by these private companies, addresses aspects of poverty: cheap fridges help nutrition and cold-chain supply; cheap lighting means students can study after dark.

Could we take this further in partnership with SMEs in low-income countries brought into partnerships? Difficult - but a worthwhile challenge.

The contrary view: why not do this?

Although I believe that universities can and should transform the landscape of international development for the better, I would like to consider for a moment the opposite position: that this is not a primary role for universities.

There are two threads to that position: first that universities have other more important roles; and secondly that others can do it better.

The first argument asserts that countries task their universities with multiple objectives: to educate, research and deliver national benefit. Universities are primarily national assets and taxpayer investments and additional activity is a distraction.

I refute this, on two grounds. Firstly, our millennium-long missions to serve society, and our unique relationship with the long-term future beyond the electoral cycle of a parliament. Secondly, as our students see the institution and our staff as role models if we reject such engagement in the “real global world” what example are we setting them?

The second argument runs as follows: universities do not have the structure or skill sets to contribute effectively to the alleviation of poverty, disease and malnourishment, and with limited resources for such activity that role should be ceded to other organisations better placed to make a difference.

I would argue that there would be substance to that argument if I was trying to argue a sole role for Universities, but I am not. We can only contribute alongside others and we must each bring our skills to bear on the problem.

There are no universal panaceas to the issues of poverty and inequality, or water supply or food security, but we have essential skills among our staff that can impact significantly.

Furthermore, our track record of partnership is something other agencies can engage with and our staff can make a contribution. And we know that Universities, as honest brokers, can knock on doors that are not opened to governments. Countries that might find it politically unacceptable to deal with some governments or the private sector are perfectly happy to deal with universities and with most NGOs, and in my experience are anxious to do so.

Another angle on this same argument is that academics are independent and can’t be told what to do or won’t engage or will lose interest; but that’s OK, they want to do this. As academics that cannot see a knowledge gap without wanting to fill it, we are fascinated by the intractability of the problem of poverty, and want to understand it.

No amount of coercion could nor indeed should be brought to bear on any academic not wishing to participate – the reason being that the outcomes sought are long-term and need engagement in the timeframe.

But our academics need structural support and they must believe that the University is itself committed such that it recognises their activity as core to the mission.

Academics worry whether exercises such as the Research Assessment Exercise in Australia or REF in the UK would be unsympathetic – which inherently they are not. However, putting it bluntly, if saving lives interferes with research assessment models, then which one needs to compromise?

The matter boils down to two questions: should we, the world’s universities, do this? And can we do this? ….

And my answer is yes we should – and yes we can.

Conclusion

The whole notion of the complex interdependence of the problems of development and of poverty alleviation would not be so centrally present on the world stage if it had not been for the role of university research in putting it there.

I began with the question whether universities had much to contribute.

I end by concluding that there is in fact no other sort of organisation that can contribute nearly as effectively as we universities can.

• Because we are independent, honest brokers

• Because we have been around a long time, and rely on society’s trust

• Because we find partnership natural

• Because we integrate knowledge, and are the last institutions that can do so

• Because we have idealistic students, committed to changing the world, and bringing the energy and creativity of youth

• And because we have idealistic academics, committed equally to changing the world, and bringing networks of contacts and profound expertise.

If governments and taxpayers are worried that a day spent on helping a low income country is a day not spent on addressing austerity at home, then they can console themselves that in the long term, the increased trade with a healthy, prosperous and more developed country will be worth more in pounds and dollars than the lost day’s productivity.

So to return to our hypothetical Minister of Health, what can we offer that would make a difference to her burgeoning problems?

First, I suspect she would just like to know that there is someone interested enough to engage. She would be wise enough to know that we cannot wave a magic wand, send billions of dollars and make the problems disappear. But we can help her gain a greater understanding and detailed analysis of local impact.

We could bring her problems to the attention of our academics – often that is all it would take, they will often do the rest.

We could support a local team of experts, perhaps from her local University, to include our staff and students to study, the nature of the problems and potential solutions.

That University may need capacity in key areas to help mitigate or resolve the practical issue at hand – we could help their needs.

We could engage with key academics to support required local research and share access to wider networks to engage her problems “as a system”. Students from both the local and our University will benefit by the interaction.

We can use our influence to help make the compelling arguments to policy-makers, local and international, as well as with funders and other agencies, including the private sector to support evidence-based implementation plans.

Therefore Ladies and Gentlemen I could dwell further on the moral and academic values that draw me to my conclusions but maybe I will close with a simple question to you - does the Vice-Chancellor make that call to the Minister of Health?

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