1 Travel Bans, Vaccine Exclusion, and Political Theater
As has been the case outside of Africa, African countries have experienced multiple consequences from the COVID-19 pandemic that extend beyond its immediate impact on human health. In Africa, much like elsewhere in the world, the pandemic has had a significant economic impact, leading to profound global economic distress. African countries have also experienced consequences that are unlike those of much of the rest of the world. For example, the pandemic has contributed to a sovereign debt crisis that led to sovereign defaults by Zambia in late 2020, Mali in early 2022, and Ghana in late 2022, and that might lead to additional defaults.Footnote 1 Travel bans and COVID-19 vaccine exclusion are key COVID-19 policies that have also had a particular impact in Africa. These and other COVID-19 policies in African contexts reflect patterns of exclusion that are at least in part a consequence of continuing colonial hangover.
In late November 2021, scientists in South Africa and Botswana discovered a new variant of the COVID-19 virus.Footnote 2 This new variant was subsequently designated Omicron.Footnote 3 Just a year earlier, in late December 2020, amid concern about an earlier COVID-19 surge, the United Kingdom had announced an immediate travel ban on flights to South Africa; this ban was lifted in October 2021.Footnote 4 Shortly after the lifting of the 2020 travel ban, a new travel ban was imposed within two days of the identification of the Omicron variant. In a December 2021 comment in the medical journal The Lancet, a group of South African scientists labeled the UK travel ban a form of “political theater.”Footnote 5 UN Secretary General António Guterres referred to the travel bans as a form of “travel apartheid.”Footnote 6
Patterns of COVID-19-era exclusion also extended beyond travel bans to access to COVID-19 vaccines. In the earliest days of the distribution of COVID-19 vaccines, many African countries did not receive adequate access to them. As Gavi, the Vaccine Alliance, noted,Footnote 7 “early access was inadequate; by the end of 2021, a number of low-income countries, particularly in Africa, had barely been able to vaccinate 10% of their populations … In contrast, many high-income countries had already achieved vaccination rates of 75–80% by this time.”
Vaccine exclusion was due in part to hoarding by wealthier countries,Footnote 8 as well as the policies of some vaccine manufacturers that sought to wring maximum profit from their vaccines: “Moderna, whose coronavirus vaccine appears to be the world’s best defense against Covid-19, has been supplying its shots almost exclusively to wealthy nations, keeping poorer countries waiting and earning billions in profit.”Footnote 9 Vaccine exclusion was also likely exacerbated because poorer countries were in some instances charged more for vaccines than wealthier ones.Footnote 10
The experiences of African countries during the COVID-19 pandemic highlight key consequences of colonial hangover and fundamental structural impediments and inequalities evident in global and local contexts. As Oumar Seydi, the Gates Foundation Africa Director, noted in December 2021:
To many here [in southern Africa], the travel bans feel like punishment. Why is it, people here want to know, that when it comes to vaccines, Africans are last in the queue, but when it comes to travel sanctions, we’re first? Why do travel bans target the countries that can least afford it, while people in higher-income countries can travel freely?Footnote 11
2 Policy Contagion and the Costs of COVID-19 Exclusion
African countries were not the only countries to have experienced COVID-19 travel bans. However, the manner in which bans were imposed on countries in Africa reflects such countries’ disparate and likely discriminatory treatment.Footnote 12 The travel bans imposed against African countries after the South African announcement of the detection of the Omicron variant reflect a pattern of policy contagion.Footnote 13 The spread of COVID-19 policies highlights uncertainties about the nature of policy diffusion during times of crisis,Footnote 14 as well as ways that public health and other policies and institutions reflect continuing patterns of colonial overhang.
COVID-19 policy contagion, which has been particularly evident in travel bans, may not be grounded in science or even public health best practices:
Rapidly imposed travel restrictions make sense in the early stages of an outbreak, when infections of a variant are few and test-and-trace systems are still able to follow the paths of contagion. When imported cases account for more than 10% of infections, bans can have a big impact on the growth of the epidemic. They can thus buy time to find out about a new variant, prepare hospitals or roll out vaccinations … But travel bans have a habit of sticking around even though, once a virus or variant is circulating freely in a country, they are largely pointless.Footnote 15
Travel bans may be counterproductive in a number of ways. The South Africa Omicron travel ban potentially limited access to important sequencing reagents for South Africa’s critically important COVID-19 genomic surveillance activities.Footnote 16
After its initial South Africa travel ban, the United Kingdom soon extended the ban to other countries in Africa, including Angola, Malawi, Mozambique, Nigeria, and Zambia. Notably, Nigeria, which is more than 2,000 miles away from South Africa, is not even in the Southern African region where Omicron was first identified. This travel ban would be akin to imposing a ban on travelers from the United Kingdom as a result of cases in Cyprus. Further, at the time the United Kingdom travel ban was imposed on Nigeria, the percentage of travelers from Nigeria testing positive for COVID-19 after arriving in England between October 14 and November 3 was “similar to the proportion among those arriving from several European countries” and was less than percentages of travelers testing positive from both Spain and Italy, neither of which became subject to a travel ban.Footnote 17 This reflects a broader pattern of imposition of Omicron travel bans against countries in Africa when bans were not imposed against countries outside of Africa with much higher levels of COVID-19 cases:
Nearly two weeks after South Africa raised the flag over the new omicron variant, African leaders have called the newly imposed travel bans on African countries discriminatory and unjust … Despite the omicron variant being detected in over 40 countries, including the US and across Europe, similar travel bans are yet to be imposed against non-African countries … Yet covid-19 numbers remain far higher in Europe than across southern Africa. On 7 Dec., the UK registered over 50,000 new cases, whereas South Africa registered 6,400 and Malawi 16. This has led to several African leaders calling the bans discriminatory.Footnote 18
The Omicron travel bans targeted at African countries soon spread across the globe: “Though scientists have little information about the new variant and aren’t certain where it originated, several countries, including the United States, Canada, the United Kingdom and the European Union announced immediate travel bans from South Africa and other southern African nations.”Footnote 19 In late November 2021, Canada banned nationals of several African countries, including those such as Egypt and Nigeria that are far away from the Southern Africa region where Omicron was first detected.Footnote 20 Notably, Cairo, the capital of Egypt, is farther away from Pretoria, the executive capital of South Africa, than Canada’s capital Ottawa is from London, United Kingdom.Footnote 21 Canada also created an innovative policy of imposing a third-party testing requirement on Canadian citizens traveling from the African countries on the banned list, requiring such travelers to stop in a third country and take a COVID-19 test in the third country “before continuing their journey to Canada.”Footnote 22
Inequity in access to COVID-19 vaccines and travel bans, particularly the Omicron travel bans, mirror and likely intensify existing patterns of global inequality. Lack of access to vaccines led to a widening poverty gap for countries excluded.Footnote 23
Whereas many wealthier countries were able to not only leverage domestic production capacity (and repurpose existing capacity to manufacture COVID-19 vaccines) but also take huge gambles on the advance purchase of a spread of vaccines, most African nations were not and were left behind in the race to protect their populations. The impact was increased mortality, greater fragility of health systems and weaker economies.Footnote 24
Lack of vaccine equity can also contribute to the emergence of new variants and increase stress for countries that may already be fragile, which could exacerbate political unrest.Footnote 25 Vaccine exclusion might also contribute to precarity, evident in increased poverty, food insecurity, and unemployment.Footnote 26
Exclusion from access to vaccines may boost the likelihood of migration, which is an increasingly contested issue in relationships between countries in Africa and Europe.Footnote 27 The economic impact of travel bans for countries in Africa has been significant. An estimate in early 2022 suggested that South Africa had lost more than 2 billion Rand (more than US$123 million) in tourism spending because of the Omicron travel ban.Footnote 28
3 COVID-19, Exclusion, and International Institutions
Travel bans and vaccine exclusion are a continuation of patterns of exclusion of African countries from international institutions. This exclusion reflects a pervasive colonial hangover that has had a continuing impact locally within Africa, as well as globally. As UN Secretary General António Guterres noted in July 2020:
The legacy of colonialism still reverberates … We see this in the global trade system. Economies that were colonized are at greater risk of getting locked into the production of raw materials and low-tech goods – a new form of colonialism. And we see this in global power relations. Africa has been a double victim. First, as a target of the colonial project. Second, African countries are under-represented in the international institutions that were created after the Second World War, before most of them had won independence. The nations that came out on top more than seven decades ago have refused to contemplate the reforms needed to change power relations in international institutions.Footnote 29
Colonial hangover is evident in African representation in varied global policymaking contexts. Dominant legal, regulatory, and policy frameworks, within many countries in Africa and globally, can be traced directly back to colonial-era lawmaking and postcolonial legal and policy approaches that have replicated colonial-era patterns.Footnote 30 This means that many today operate under assumptions and use of policies and laws that were created and deployed during and even prior to the colonial era.
International institutions exemplify continuing consequences of colonial hangover and African exclusion. Institutions created in 1944 as part of the Bretton Woods system continue to play a key role in global economic and financial matters today. The International Monetary Fund (IMF) and International Bank for Reconstruction and Development (World Bank) were created at Bretton Woods, New Hampshire at a meeting of forty-four nations.Footnote 31
The IMF and World Bank have had notable successes, including facilitation of the rapid post-World War II reconstruction of Western Europe and Japan, “which led to the period of the fastest economic growth and, particularly, the fastest growth of international trade in world history.”Footnote 32 The collapse of the original Bretton Woods arrangements in the 1970s led to what economist José Antonio Ocampo describes as “the de facto rise of the current ‘non-system’.”Footnote 33
Organizations created at Bretton Woods remain a strong institutional force, particularly in African contexts. In the 1990s, during a debt crisis, the IMF and World Bank were described as “institutions, founded half a century ago at the Bretton Woods Conference to serve the needs of the industrialized world, [that] have become the overlords of Africa in the 1990’s.”Footnote 34 The governance structure of the system established at Bretton Woods continues to embody colonial-era power dynamics:Footnote 35
[T]he rules embedded in the Bretton Woods institutions are protectionist, asymmetrical and impede balanced economic development … The governance structure of the Bretton Woods system constitutes mostly industrialised countries which make vital decisions and form policies that are implemented by all as they represent the largest donors. Sometimes these decisions are made without adequate consultation with the developing countries.
The ad hoc framework that followed the collapse of the original Bretton Woods system has contributed to significant asymmetries between developed and developing countries. Ocampo has noted that such asymmetries have led emerging and developing countries to have a limited share in the creation of international liquidity and greater economic vulnerability.Footnote 36 Ocampo also points out that such countries have an “inadequate voice and representation in international economic decision-making and in the International Monetary Fund (IMF) in particular.”Footnote 37
International public health institutions were created during the same era as international financial institutions, and the United Nations’ “key global health agencies, such as the UNICEF [United Nations Children’s Fund] and the World Health Organization were born in the post-World War II era of 1946–48, in the waning years of colonialism.”Footnote 38
Colonial hangover in COVID-19 contexts mirrors key elements of colonial hangover in the financial and economic sphere and exemplifies specific aspects of such hangover in the intellectual property (IP) and public health arenas: “exclusionary colonialist patterns that centre Euro-Western knowledge systems have also shaped the language and response to the pandemic – which, in turn, can have adverse health outcomes.”Footnote 39
As COVID-19 exclusion thus highlights, colonial hangover has long been evident in the public health arena and is apparent in patterns of knowledge production, as well as policy and funding approaches. External public health donor funding in Africa may be driven by external needs and often external funding institutions. On April 15, 2021, an open letter to the editor in Nature Medicine noted continuing patterns of external donor funding for malaria largely being used to fund institutions outside of Africa:
In 2017, the USA, UK and Canada collectively spent US$1.1 billion on malaria development aid, which includes research funding … 81% of funding was used to support institutions in the funding country and 18% went to non-governmental organizations (probably based in high-income countries) – that leaves just 1% of malaria funding available to local in-country research institutions. We recognize that the current funding structures create an imbalance of power and a monopoly that favors Western institutions and is derived in part from the perpetuation of inequities in access to funding with policies that lock out African institutions. These structural inequities must be examined, and they must end.Footnote 40
Public health reflects an “epidemic of illusions … propagated by the coloniality of knowledge production,” which involves questions about the “mechanisms in public health science,” particularly epidemiology, “that enable groups to sanction one account of disease causation over another.”Footnote 41 COVID-19 vaccine exclusion has been facilitated by structures of global knowledge production that continue to exclude African countries. Few African countries have local capacity to produce COVID-19 vaccines, which both reflects and exacerbates colonial hangover. Less than 1 percent of all vaccines used in Africa are locally produced, which “reveals the region’s intense vulnerability and overdependence on foreign supplies.”Footnote 42
Colonial hangover is evident in a broad range of knowledge production infrastructures, including in relation to research and development (R&D). The lack of local vaccine production capacity mirrors gaps in research capacity more generally and African countries’ tremendous deficit in scientific and technological infrastructure: “[Sub-Saharan Africa] accounts for less than 1 percent of the world’s research output while being home to 13.5 percent of the global population … In 2008, [countries in Africa] produced the same number [of research papers] as the Netherlands,”Footnote 43 which in 2021 had a population of 17.53 million as compared to a population of some 1.391 billion in Africa and some 1.181 billion in Sub-Saharan Africa.Footnote 44
Research activities within Africa reflect externalized networks, evident in international collaborations.Footnote 45 Current internal research capacity within Africa reflects low levels of local R&D investment, which has led to research being “highly dependent on external funding support, often through intermediary institutions, and thus not optimal for effectively addressing research problems in the region.”Footnote 46 Not surprisingly given past patterns, Sub-Saharan Africa significantly lags most of the world in key knowledge production metrics, including R&D expenditures as a percentage of gross domestic product (GDP) and the number of R&D scientists per million people.Footnote 47
The exclusion of African countries evident in varied settings reflects both external and internal constraints. External constraints largely emanate from hangovers from colonial-era power arrangements, while internal decisions have too often not sufficiently disrupted such hangovers and may have even exacerbated the negative impact of external constraints:
Globalization has brought many opportunities to African countries, but African economies have not transformed enough away from dependence on raw materials, and thus many remain on the bottom rungs of global supply chains. This is not only the fault of the global superstructure; it also has to do with the policy choices that many African countries have made, especially in the last thirty years. But attempts over the last two decades to regulate some of the worst excesses of globalization have paid scant attention to the needs and constraints of developing countries. The rise of new challenges, such as climate change and the digital economy, and of frameworks to regulate them sharpens further the difficulties faced by African states.Footnote 48
Colonial hangover is particularly visible in the IP realm: “The international rules governing intellectual property have been framed to protect companies’ investment in research and development. However, intellectual property rights as they are currently designed place developing countries at a constant disadvantage, especially in areas such as public health.”Footnote 49 African countries have long criticized current IP arrangements in relation to a number of things, including the World Trade Organization (WTO) Dispute Settlement Mechanism.Footnote 50 In the digital era more generally, notwithstanding the potential promise of new technologies, African countries have increasingly been left behind or disadvantaged by various infrastructures, including in relation to digital economy governance, digital economy infrastructure, and the international tax regime.Footnote 51
Patent protection and access to medicines have long been contested in global IP discussions and became a critical and continuing point of dispute during the HIV/AIDS pandemic. The importance of access to medicines became apparent with the HIV/AIDS pandemic, which has had its greatest impact in Africa.Footnote 52 Patents for antiretroviral therapies (ART)Footnote 53 have long been a contested issue.Footnote 54 ART helps people with HIV live longer and healthier lives and profoundly reduces risk of HIV transmission.Footnote 55 Debates surrounding access to medicines, particularly ART, underscore the interaction of law, policy, and issues related to human well-being that continue to reflect the impact of colonial hangover.Footnote 56 The COVID-19 pandemic, which also raises critical patent-related issues for African and other developing countries,Footnote 57 may intersect with and worsen HIV/AIDS outcomes.Footnote 58
4 Colonial Hangover and Double Marginalization
Vaccine exclusion and travel bans reflect patterns of exclusion of African countries that are not new. Although formal colonialism ended more than half a century ago in much of the world, a pervasive colonial hangover continues to shape relationships within and among countries. Colonial hangovers evident during the COVID-19 pandemic represent one of many colonial hangovers evident in economic relations, global business and finance, international relations, and public health.
External economic relations of African countries have too often been based on a model of plunder and extraction of raw materials that today increasingly extends to data and information. These extractive models have contributed to the economic and political exclusion of African countries in varied global contexts. Extractive models have also reflected significant external determination through which decisions about internal needs are too often based on the needs and interests of external actors. These externally oriented and often extractive models reflect top-down approaches that have contributed to double marginalization in African and other contexts. At the first level of marginalization, African countries are marginalized and to a significant degree excluded from global power relations.
In many African contexts, a second level of marginalization has long been apparent in the exclusion of a significant portion of the population from access to opportunities and resources, including healthcare. Many in Africa are poor, and global poverty is increasingly a Sub-Saharan African phenomenon: “Extreme poverty will become a predominantly Sub-Saharan African phenomenon in the coming decade and the continent will be home to the lion’s share of the global poor by 2030.”Footnote 59
High levels of poverty within Africa are a testament to high levels of internal exclusion. In 2018, the World Bank estimated a 40 percent regional poverty rate for Sub-Saharan Africa, which contained 13 percent of the world’s population in 2017,Footnote 60 with countries in Sub-Saharan Africa accounting for close to two-thirds of the global population of extremely poor people. While the poverty rate in Sub-Saharan Africa decreased from 56 percent in 1990 to 40 percent in 2018, the number of poor people continues to rise. This means that the poverty rate in Sub-Saharan Africa has not fallen fast enough to keep up with population growth in the region. In 2018, 433 million Africans were estimated to live in extreme poverty, an increase from 284 million in 1990.Footnote 61 This second level of internal marginalization, which is a key element of the significant double marginalization confronting many countries in Africa, requires targeted locally facing policy interventions.
The impact of internal marginalization soon became apparent during the COVID-19 pandemic. In COVID-19 contexts, vaccines eventually became more widely available in Africa despite continuing external supply limitations. In early 2022, as the supply of COVID-19 vaccines increased in many African countries, the need for policies to promote vaccine uptake became apparent: “Although COVID-19 vaccine supplies to Africa have risen significantly, the continent is struggling to expand rollout, with only 11% of the population fully vaccinated. The vaccination rate needs to increase six times if the continent is to meet the 70% target set for the middle of [2022].”Footnote 62
The 70 percent target was not met in 2022. As of December 31, 2022, the Africa Centres for Disease Control and Prevention (Africa CDC) estimated a 25.6 percent rate of fully vaccinated people in Africa, with utilization of 77.4 percent or 801 million of the 1.0345 billion vaccine doses received.Footnote 63 Despite greater availability of vaccines, existing policies in many countries may not have sufficiently facilitated widespread vaccination efforts or effectively countered vaccine hesitancy. Existing policies have also in some instances contributed to expiration of unused doses of vaccines: “In African countries, public confusion over whether to get inoculated, and if so when and where to do so, has contributed to the expiration of doses. Like Malawi[, which threw away 16,000 expired vaccine doses in early 2021], South Sudan saw 59,000 unused doses expire this month.”Footnote 64
Poverty in Africa underscores patterns of exclusion and marginalization that may exist internally within many countries in Africa. Internal exclusion and marginalization draw attention to the continuing internal impact of colonialism and colonial governance, particularly in relation to elite intermediaries. During colonialism, elite intermediaries in former British colonies, for example, were selected, validated, and kept in power by British colonial policies that primarily attended to the needs of external actors and interests.Footnote 65
Elite intermediaries were an important aspect of governance structures in varied colonial contexts. The incentives that shaped the behaviors of internal intermediaries during colonialism continue to play an important role in the policy arena that has not fundamentally disrupted the most deleterious aspects of colonial governance. Rather, colonial and postcolonial governance may offer such internal elites opportunities to profit from differences between internal and external legal and governance arrangements through practices such as jurisdictional arbitrage and other forms of elite extraction that may have exacerbated internal contestation.Footnote 66
Anthropologist Elizabeth Colson noted how internal contestation played out in the development of customary land law. Contestation was particularly evident in contexts of scarcity when people became aware of “the conflict between the old political obligation to maintain general access to adequate resources for all citizens, and the possibility of extracting an individual profit from areas preempted under the rule that a man might enjoy the fruits of his labor.”Footnote 67
The contestation noted by Colson remains fundamentally unresolved, largely because institutional structures were for the most part not put in place during or after colonialism to check internal patterns of extraction. This has led to questionable incentives that may be baked in institutionally and that may continue to the present day in too many African contexts. The combination of internal and external factors and constraints have led to widespread poverty and pervasive scarcity of opportunity, particularly for many young people. This combination has also contributed to a policy environment that would benefit from a focus on the development of sustained strategies and policies for the benefit of the majority of the population in contexts shaped by colonial hangover.
Critically, existing governance approaches have left many governments with insufficient tools to address crises such as COVID-19. Internal and external constraints and governance structures make navigation of difficult external and internal challenges potentially perilous for many within African contexts. This became particularly evident during COVID-19, when many countries in Africa lacked the internal capacity to produce vaccines, were too often last in line to gain access to critically needed vaccines but became first in line for travel bans and other products of policy contagion that had a significantly negative impact across the African continent.
5 Learning from COVID-19 Exclusion: Strategies and Policies to Disrupt Colonial Hangover
Policy approaches to COVID-19 should not be limited to dealing with COVID alone but should be the start of robust processes that disrupt knowledge production structural impediments and inequalities. Lack of local vaccine production capacity in Africa highlights continuing patterns of external dependence that are a hallmark of colonial hangover. This lack of capacity underscores the need for knowledge production and innovation infrastructures that disrupt colonial hangover. External actors and sources of authority continue to be given primacy in too many African contexts with insufficient scrutiny of whether such primacy is merited and ways in which modification of external policies might lead to better outcomes.
Colonial hangover is evident in models of governance, policies and laws, and institutions developed during colonialism. These models, laws, policies, and institutions were created to a large extent by external powers with an external orientation. During colonialism, verbatim copying of laws and policies was a norm. Patterns of external determination underscore potential problems that come from indiscriminate borrowing from external sources. Borrowing from other contexts comes with histories, contexts, assumptions, disputes, and accommodations. External determination reflects persistent patterns of policymaking and lawmaking that fail to sufficiently consider the local. A clear need exists today for strategies that better incorporate the local. As a 2021 Policy Brief from the African Policy Research Institute notes, in crafting a digital economy agenda, African countries must “ensure that policies and strategies are not indiscriminately copied from other contexts. National and regional policymakers should exercise creativity and judgement that reflect the specificities of African contexts in formulating their digital policies.”Footnote 68 This suggested approach should extend beyond just digital economy policies.
Intellectual property laws are key mechanisms that govern knowledge production and innovation. In African contexts, IP frameworks have been implemented with insufficient consideration of the local. Colonial hangover has led to fractured and highly fragmented IP frameworks in Africa “comprising an array of partially overlapping and sometimes conflicting agreements, laws, policies and sub-regional organisations.”Footnote 69 As many commentators have noted, the COVID-19 pandemic underscores the need for local patent reform within African countries and globally to give greater attention to the critical need for local vaccine manufacturing and other types of capacity in Africa and other developing countries.
The COVID-19 pandemic draws attention to a persistent lack of consideration of the local impact of knowledge production frameworks. This inattention has hampered policy, planning, and local vaccine production. As a result, much of the population in Africa remained unvaccinated well after widespread dissemination of vaccines in developed countries. Even if vaccines were to have flowed in greater quantities to countries in Africa at an earlier point in time, other potential limitations might have impeded vaccination efforts. In late October 2021, UNICEF projections suggested that “to reach the new COVID-19 vaccination targets, and assuming an unhindered vaccine supply next year, there could be a shortfall of up to 2.2 billion auto-disable syringes.”Footnote 70
The ability to accurately measure infections and death rates remains a persistent problem in many countries in Africa.Footnote 71 The COVID-19 pandemic illustrates the high costs of insufficient measurement because reported numbers of infections and deaths may not be accurate. This is certainly not an exclusively African problem. The COVID-19 pandemic has highlighted pervasive underestimates of COVID-19 deaths within and outside of Africa. For example, according to official South African data, by mid-2021, 90,000 people had died from COVID-19.Footnote 72 An analysis in South Africa found excess deaths during the pandemic of more than 190,000 between May 2020 and July 2021.Footnote 73
Healthcare inequities in African contexts highlight the increasing number of poor people in Africa. The COVID-19 pandemic also exposes patterns of double marginalization that combine pervasive external marginalization of African countries with significant levels of internal marginalization within such countries. Responses by external actors to COVID-19 in African countries reflect the inability of such actors to overcome their tendency to recreate persistent patterns of exclusion.
South Africa has experienced significant external marginalization evident in vaccine exclusion and travel bans. The country has the largest and most integrated local vaccine production capacity in Africa.Footnote 74 However, it also faces continuing challenges in internal marginalization. For example, it has excellent private healthcare in a highly unequal health system, particularly for the 70 percent of the population that relies on the public healthcare system.Footnote 75
South Africa is not alone in having unequal internal access to healthcare. Many countries both inside and outside of Africa have significant internal exclusion and marginalization. In African contexts, double marginalization must be considered in crafting innovative and hybrid policies that take sufficient account of local contexts and needs. Increasing local R&D funding and local science, technology, engineering, and math (STEM) capacity are of critical importance in establishing the groundwork for greater local ability to manage digital economy strategies and address COVID-19, healthcare more generally, and other local needs in African contexts.
COVID-19 highlights consequences of ineffective strategies for dealing with the internal and external. The pandemic also draws attention to the need for greater targeted internal funding and strategies to promote development of sustainable innovation ecosystems. Public and private funding, including from venture capitalists, have been important sources for financing STEM innovation globally.Footnote 76 Internal STEM funding in African contexts is far too often insufficient and may continue to be shaped by colonial hangover. Inadequate internal funding of R&D and other elements of scientific and technological capacity have made external funding even more important.
However, as malaria funding patterns discussed in the Nature Medicine letter to the editor suggest, funding by external donors can be governed by external needs and priorities that may leave little funding for or room for input from local organizations. External private funding in African contexts can be driven by biases imported with investors that may replicate racial patterns and funding biases evident in Silicon Valley and other contexts that some have described as a form of neocolonialism. These funding patterns were highlighted in a July 2020 article in The Guardian, with the title “Silicon Valley has Deep Pockets for African Startups – If You’re Not African.”Footnote 77 This article noted that of seventeen companies that raised $1 million or more from venture capital in Kenya in 2019, only one was founded by locals, four by a mix of expatriates and locals, and eleven by expatriates only.
COVID-19 has revealed critical shortcomings in local enabling environments and capacity in African countries, including in relation to public health. Policy approaches to the COVID-19 pandemic should disrupt structural impediments and inequalities that reflect colonial hangover. These approaches can also be a part of broader strategies intended to facilitate local capacity and diminish continuing patterns of exclusion for many countries in Africa.
Disrupting colonial hangover and double marginalization will require attention to the external and internal. Approaches to COVID-19 vaccine exclusion may be crucial in the emerging recognition of the critical importance of attention to both the internal and external. For example, in April 2021, the Africa CDC and the African Union (AU) Commission held the virtual summit “Expanding Africa’s Vaccine Manufacturing for Health Security.”Footnote 78 This summit and the New Health Policy announced by the Africa CDC and AU Commission in September 2022 reflect approaches that combine scrutiny of the internal and external.
The New Health Policy calls on governments, multilateral organizations, nongovernmental organizations, the private sector, and civil society organizations to support implementation of Africa’s New Public Health Order, which is seen as a “roadmap to sustainable health outcomes and health security.”Footnote 79 Critically, in addition to calling for new partnerships to advance vaccine manufacturing within Africa, the New Public Health Order emphasizes the importance of internal investments in capacity building, including domestic health infrastructure, manufacturing capacity, institutional and governance structures, and public health workforce and leadership development.Footnote 80
The New Public Health Order presents a potential model that could be applied in other contexts to address internal and external conditions that have exacerbated colonial hangover and double marginalization. Alternative and hybrid models have the potential to provide a basis for greater inclusion of African countries within global policy frameworks and institutions. Such models may also play an important role in ameliorating internal conditions that reflect colonial hangover and in fostering internal inclusion. Reducing internal and external exclusion will be a key element in truly disrupting the shadows of colonial hangover in Africa.
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