In a recent series, The Lancet Global Health published a collection of responses to the question ‘What is wrong with global health?’ Commentaries identified numerous challenges and inequalities that have long plagued the field. The story of the Uganda Cancer Institute (UCI) chronicled in Marissa Mika’s Africanizing Oncology takes a different angle on the problems (and promises) of ‘global health’. While the inequities that trouble partnerships generally and oncology specifically are an important thread woven through the book, the focus overall is on the persistence, resilience and productivity of the Ugandan professionals who manage to keep the UCI going in the face of crisis after crisis.

Mika’s book lyrically chronicles the creativity of the UCI in the face of diverse crises, from its remarkable stability during the Amin era to the years of struggle during Obote II, the war with Tanzania, structural adjustment, the HIV and AIDS pandemic, and Museveni’s first decades in power. Although Mika states at the outset that the book is explicitly not a story of the failed state, the Ugandan state is a presence that hovers over the story – often glimpsed through the comparative fate of Mulago, the neighbouring national referral hospital. The UCI does best when allowed administrative independence from Mulago, as was the case during the Amin years, when it remained relatively well stocked and functioning even as Mulago went without running water for nearly a decade. When the UCI is subsumed under Mulago’s administration during the austerity years of structural adjustment, it must make do with a month’s supply of chemotherapy drugs per year and rare access to morphine – barely enough to provide any treatment or even palliation, and certainly not enough to continue the chemotherapy trials that had been so fruitful in past decades.

The book concludes with the UCI’s transition back to administrative independence from Mulago and a promising new American partnership, this time with Seattle’s Fred Hutchinson Cancer Research Center (‘the Hutch’). It is a venture informed by the shortcomings of partnerships past. Mika recounts how the UCI’s Edward Katongole-Mbidde brings the Hutch’s Corey Casper on a tour of the ‘mausoleum’ of collaborations past – a room filled with defunct freezers and research equipment, each with the name of a now-dissolved partnership hand-carved into its surface. He then asks the hopeful collaborator if he, too, will be leaving another abandoned freezer.

The UCI–Hutch partnership hopes to avoid some of the pitfalls of these past partnerships by creating ‘durable experimental infrastructure’ in the form of a new building. Opened in 2015, the new UCI–Fred Hutch Cancer Centre is a 25,000-square-foot, air-conditioned, state-of-the-art research, training and care facility described on the Hutch’s website as having a ‘three-color brick exterior … designed to match the buildings on the Fred Hutch Seattle campus’. As the UCI’s motto proclaims, ‘research is our resource’, and the Hutch partnership is indeed a tremendous resource for Ugandan physician-researchers, oncologists and patients. The number of Ugandan oncologists, while still small, has increased from one to twenty in the past two decades. The Ugandan state recently invested in an adjacent five-storey inpatient cancer hospital. Mika notes that ‘there are few other sites on the continent with the depth or breadth of publicly available cancer services’ (p. 8). From this angle, the UCI is an example of what’s right with global health – a durable investment in infrastructure that benefits the host nation in terms of both research and care.

And yet, Mika understandably tempers her praise for the effort with notes of ambivalence over what might be lost in the transformation. The new cancer centre is built on the site of the UCI’s original incarnation – the Lymphoma Treatment Center (LTC), established in 1967 through a research partnership with the US National Cancer Institute. Families from all over the country brought their children there to be treated for Burkitt lymphoma, and they often lived at the facility for many months. The fledgling collaboration (which grew into the UCI) quickly realized that in order to treat patients, they would need to care for entire families. The LTC provided meals, bus vouchers, a full-time schoolteacher, and even a tailor on site to serve the families staying there. This ‘experimental infrastructure’, Mika shows, demonstrates a humanization of the research endeavour and an awareness that research cannot and should not proceed separately from care.

The new centre, by contrast, represents a very different experimental infrastructure. It is decidedly not a residential facility. Unlike most buildings in the Mulago complex, it is fully enclosed and does not utilize outdoor space. As Ugandan oncologist Dr K notes: ‘When you are in the building you feel like you are in Seattle.’ There is no physical space for the kind of family care and caregiving that defined the now-bulldozed LTC. Perhaps that kind of care will endure at the neighbouring state-funded inpatient cancer hospital, but quite separate from the research practices into which it was once integrated. What does this growing division between ‘doing research’ and ‘government medicine’ mean for oncology in Uganda?

In a November 2021 opinion piece in Stat News titled ‘Isolated in Uganda’, three Ugandan researchers decried the rapid evacuation of foreign research ‘partners’ in the face of Covid-19, just when international expertise might have been most helpful. In global health partnerships, the authors note, equity ‘almost always feels like a moving target’. Given her intimate attention to the UCI’s partnerships over time, I am curious to hear Mika’s take on what a ‘good’ partnership might look like in the age of Covid-19. In The Lancet Global Health series and elsewhere, writers have called for the ‘decolonization’ of global health, but there is little consensus on what this means. Given the title of this book, I wonder whether thinking about the ‘Africanization’ of global health might open up a historically informed space to envision more equitable futures for international partnerships.