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Digital bridges cannot cross analog gates

Reda SadkiGlobal health, Thinking aloud

I’ve been doing a lot of thinking recently about an interesting question, as I’ve observed myself and colleagues starting to travel again: “Why are we again funding high-cost, low-volume face-to-face conferences that yield, at best, uncertain outcomes?”

I am surprised to have to ask this question. I was hoping for a different outcome, in which the experience of the COVID-19 pandemic led to a lasting change in how we bridge physical and digital spaces for a better future. We were brutally forced to work differently due to the COVID-19 pandemic’s restrictions on freedom of movement. Nevertheless, we discovered that it is possible to connect, meet, collaborate, and learn without sinking budgets into air travel and accommodation. At least some of work-related travel was due to habit and convention, not necessity. Yes, there were limitations, especially due to the emergency nature of the pivot to online. But the debate is open whether the limitations we experienced being forced to work online are more or less severe than those of the offline medium.

In global health, traditional face-to-face meetings, workshops, and conferences have been part and parcel of professional life for decades. They served their intended purpose, helping staff connect formally and informally, providing the connective tissue to learn, share, and coordinate. They have been – and remain – deeply ingrained in the culture of global health. Why should this modus operandi be reconsidered?

As someone who is often required to attend face-to-face conferences, despite being a vocal advocate for more efficient, inclusive models, here is how I understand both sides of the dichotomy that this scenario presents.

Traditional face-to-face meetings, workshops, and conferences offer a unique charm. They allow the select few to reconnect with colleagues, stay updated on institutional developments, and keep fingers on the pulse of the latest changes in our fields. Information can be shared informally, which is far more difficult to do online. (This is not inherent to the online medium, but due to the technologies we have developed that assume, support, and structure formal communication.) If you were invited or selected to be at the meeting, that indicates to those in the room that you are a valid stakeholder.

There is a considerable downside. These events are exclusionary by definition. Not everyone’s costs can be covered. Selection is often based on hierarchy. Often, only the most senior get to go. When less senior practitioners are included, tokenism is difficult to avoid. Then, there is the high cost. It is primarily expenditure on travel and hotels, not event quality. There is also the cost to the environment. Think of the carbon footprint. They are disruptive to everyday work, as attendance requires absence. Strangely, their impact is seldom measured, evaluated, or questioned.

The same donor who will unquestionably plunk down $150,000 for the plane tickets and hotels rooms of 100 people might require the evidence of a randomized controlled trial (RCT) before investing in a new digital learning approach that might include 1,000 or 10,000 people for the same cost and produce far more significant outcomes than a meeting report.

So why are face-to-face events still being funded, at high cost and questionable return, when global health is supposed to be evidence-based and focused on impact?

Ironically, as Girija Sankar made the case recently in The Lancet, the very conferences designed to push the boundaries of research and collaboration in global health often act as “gates,” creating a divide between insiders and those on the outside. These gatherings are often arranged by the gatekeepers of global health, the credentialed leaders who control funding and policy. Their decisions shape the future of health at a global level, conferring agency upon a select few while inadvertently excluding many others.

It is undeniably satisfying – and deeply so – to connect with colleagues over the course of several days, sharing conversation, meals, coffees. It is not only about listening and learning. It is about being human together, despite the constraints and urgencies of the work. So, if you are in a position to fund such an event for yourself or for your colleagues, why would you say no, given the obvious benefits and zero incentive to deny your colleagues what they are used to getting?

The value of such events is in part premised on their exclusivity. Letting everyone in could dilute their value. Furthermore, digital experience remains awful: a Zoom call is undeniably inferior to the experiential richness and pleasure of a meeting in a shared physical space.

Unfortunately, as long as such wonderful moments are reserved for the few – due to the nature of the medium, despite the best intents –, such communion stops at the conference walls – and excludes everyone outside them.

The Geneva Learning Foundation’s Teach to Reach program presents a stark contrast to this traditional model. Our online, digital, and networked peer learning events are dynamic, inclusive, connecting local practitioners from everywhere. With no upper limit on participants, these digital events rally thousands from all corners of the globe, providing an unparalleled platform for shared learning and action.

The upcoming Teach to Reach 8 event on 16 June 2023 is a testament to this, with over 16,000 anglophones and francophones already registered to join. Most notably, the majority of participants are government health workers working on the frontlines in Africa and Asia. Teach to Reach is led by an “organizing committee” composed of 282 Teach to Reach Alumni from 35 countries who are founding Members of the Global Council of Learning Leaders for Immunization in November 2020.

Some global-level colleagues who have rejoined the mission travel, conference, and workshop circuit share that they struggle to understand Teach to Reach. It is just too different from what they are used to. They have to painstakingly listen to staff with lousy connectivity who share local experiences, problems, and challenges that seem quaint, compared to the abstract global-level strategies they usually engage peers who are almost exactly like themselves. Such sameness is reassuring. Comparatively, Teach to Reach is too chaotic and noisy. So many voices, speaking from so many different pespectives. Too time-consuming. Too confusing. Too different from what “we” are used to. Too messy. 

Yet, the real world is messy. We know that the probability of finding a solution locally increases with the number and diversity of inputs available. At Teach to Reach, thousands share their experience, using a robust, proven peer learning model. The global experts who do attend do so as “guides on the side” rather than “sages on the stage”.

The unstated, underlying assumption of many so-called capacity-building initiatives is that the locals do not know. Therefore, “we” must teach them. There is no way to call this anything other than a colonial assumption. Recognizing the value and significance of local expertise and experience may have been less important in the past, when countries successfully carried out effective top-down strategies that moved the needle of vaccination coverage across the world. Today’s more complex immunization challenges require problem-solving approaches that recognize that context is central. What you know, because you are there every day, side-by-side with families and communities that you serve, turns out to be more important than generalities.

For example, the Foundation’s research has shown that reaching zero-dose or underimmunized children calls for local creativity to tailor and adapt strategies, rather than apply a cookie-cutter guideline. Should we be searching for generalizations that can be turned into norms and standards, when every zero-dose context is different? What if the opportunity were to hone in on the ‘how’ of local action, to better understand what makes the difference at the last mile of service delivery?

Should we assume that it is local staff who need to develop their capacity and change, when behavior change is probably necessary for everyone, at all levels?

Change is hard, but it is definitely happening. The last two editions of Teach to Reach have been in partnership with UNICEF and since 2022 with support from Wellcome. Ephrem T. Lemango and Kate O’Brien, who lead immunization at UNICEF and WHO respectively, prefaced the latest Teach to Reach report, writing: “Uniquely, the Geneva Learning Foundation’s platform and its Teach to Reach events provide a way to link such people together, so that they can share experiences about what works and equally important, what doesn’t work, while learning from each other. Learning happens best when people seek answers to their specific daily challenges. Teach to Reach is proof that immunization professionals are hungry to learn, and hungry to share.”

Furthermore, they note that “it is humbling to hear how committed people are to sharing experiences in the hope that they will benefit someone else, how the inadequacies of internet connections fail to deter people participating, and how so many are using precious digital data to take part. The digital space allows everyone to participate, irrespective of national boundaries or positions in an immunization hierarchy.”

Girija Sankar also reminds us that gatekeeping is not only for the leaders. It is also an opportunity for each of us to consider our roles and responsibilities. When deciding on invites, we should ask ourselves, “Is the limitation due to budget constraints or based on our perception of who has the most valuable input or the most funding to contribute?” It is also a call to action for those of us who have access to closed-door meetings or sit on advisory boards. We must pause and reflect on our roles and use our authority to pave the way for those who might not traditionally have a voice in these important discussions.

So, while I, and many others, have to travel to face-to-face conferences to stay “in the loop”, it is essential to recognize the limitations of these gatherings and work towards more inclusive and efficient models. The need to shift our mindset is more pressing than ever in the field of global health. In our quest for a healthier world, let’s ensure that the gates of knowledge and decision-making are open to all. Let’s embrace models like Teach to Reach, breaking down barriers and creating an inclusive platform for dialogue, learning, and action.

Imagine if the World Health Organization’s unspent mission travel budget in 2020 – around $400 million – had been invested in digital infrastructure to support continuous learning to explore and support new kinds of collaboration between different levels of the health system.