Rethinking prestige and dependency in global oncology

Abstract

Global oncology has made substantial progress over the past two decades. Childhood cancer survival has improved in many low- and middle-income countries (LMICs), diagnostic and treatment infrastructure has expanded, and cancer has become a global health priority alongside infectious diseases.¹ These gains reflect the efforts of LMIC health systems, often supported by international partnerships.

Despite these improvements, a gap persists between global oncology’s potential and its reality, which are maintained by persistent structural and cultural patterns. Global health still operates in a hierarchical manner where institutions in high-income countries (HICs) retain control over funding, recognition, and agenda setting, whereas LMIC actors remain constrained by externally imposed standards and power dynamics.² Although this structure may sometimes have led to improvements in measured outcomes, it also sustains dependency across research, training, and health financing. In countries like Uganda, disruptions in foreign aid have jeopardized access to essential treatments, revealing the fragility of donor-reliant systems.³ Recent US funding cuts to the Global Alliance for Vaccine and Immunization and to the World Health Organization further illustrate how political shifts in donor countries can destabilize LMIC programs.^{4, 5} Addressing these legacies requires not only resources and technology but fidelity to patients and systems: a foundation that endures beyond shifting agendas and political turns. When survival depends on visibility rather than durability, institutions adapt in ways that subvert priorities. These imbalances foster a form of structural corruption, propelled by the universal impulse to seek prestige and influence.

Ambition and prestige can be productive, and desirable, when aligned with equal opportunities for patients. In global health, these opportunities become problematic when they dictate priorities according to misaligned, external definitions of success. International partnerships offer resources and visibility, and at their best, can build capacity that endures beyond the partnership itself. However, when partnerships are designed to impress external audiences, they risk privileging symbolic achievement over local relevance. They impose foreign agendas, encourage unhealthy competition within LMICs for resources and recognition, and rely on unprepared HIC visiting delegations at the expense of long-term needs.^{6, 7}

Several years ago during my first job at Bhaktapur Cancer Hospital in Nepal, a donor from New Zealand gifted a radiotherapy machine to replace a 50-year-old cobalt unit. A large celebration followed. The donor was revered, the hospital leadership celebrated for securing a legacy, and a costly bunker was built at local expense. The machine itself never operated, presumably already unusable when it arrived. This is not unique to Nepal: across LMICs, prestige-driven donations of equipment for symbolic value rather than functional need often end up abandoned for lack of infrastructure or maintenance.⁸ The trend extends to training programs and drug supplies, and international partnerships frequently favor already privileged institutions which deepens urban–rural disparities.⁹

High-quality foreign training is indeed valuable, but its indiscriminate elevation above local expertise marginalizes professionals educated within their own contexts.¹⁰ Short-term training programs often reinforce these imbalances, with visiting clinicians from HICs granted greater trust than experienced LMIC counterparts.^{6, 11} In parts of South Asia and sub-Saharan Africa, lighter skin and foreign accents are still conflated with higher competence.

International fellowships, high-impact publications, and advanced technologies bring benefits, but when external benchmarks define success, institutions may prioritize symbolic alignment over durable care.^{7, 11} Partnerships built on uneven terms can perpetuate hierarchies, where foreign ties outweigh local experience in determining whose voice carries weight.⁷

I discuss these distortions not to discourage partnerships but to strengthen their design.

First, they can fragment systems. Institutions competing for recognition often prioritize exclusive partnerships over shared strategy or national coherence.¹² In Haiti, pursuit of external funding has led to siloed programs, duplicated services, and parallel infrastructures that weaken overall system function.¹³

Second, they can distort investment priorities. Donor funding frequently concentrates on urban centers or high-profile institutions with established external ties and better recognition leaving rural services underdeveloped.¹⁴ Emphasis can shift to donor-friendly metrics over integrated care or sustainable governance.¹⁵ When unmodified HIC guidelines are implemented wholesale in LMICs, they may divert resources toward interventions unsuited to local infrastructure, bypassing feasible, high-impact alternatives.¹⁶

Third, they can misalign education, workforce development, and evaluation. International collaborations often prioritize research output, subspecialty training, and alignment with Western accreditation systems while neglecting core skills such as early diagnosis and preventative education, palliative care, and multidisciplinary coordination.^{15, 17} Without adapting guidelines to local epidemiology and resources, even well-trained clinicians may be constrained by standards that are clinically inappropriate or financially unsustainable. The result is a façade of progress: visible, misaligned, and unaccountable to local needs.^{7, 10, 15}

Addressing these patterns requires redefining what counts as progress (Table 1).

Saroj Niraula: Conceptualization; methodology; software; data curation; supervision; resources; project administration; formal analysis; validation; visualization; writing—original draft; investigation; funding acquisition; writing—review & editing.

The author declares no conflicts of interest.