Unpacking Power and Knowledge in Global Health: some reflections from the Emerging Voices 2018 cohort

By , , and on September 21, 2018

Health Policy and Systems Researcher PHD Candidate & EV2018 Health Policy and Systems Division | University of Cape Town
Health Policy and Systems Researcher PHD Candidate & EV2018 Health Economics Research Unit | KEMRI Wellcome Trust Research Program
Research Associate, Department of Disease Control and Environmental Health, Makerere University School of Public Health & EV 2016.
Pharmacist MPH and Scientific coordinator in QUAMED (Quality of Medicines for All)

A distance learning phase forms part of the build-up to the face to face training of the Emerging Voices for Global Health (EV4GH) programme in Liverpool. In August, the Emerging Voice 2018 (EV2018) cohort, working with EV alumni and experts in global health, took part in thematic discussion sessions and shared ideas on “Global health in the age of anti-globalisation, anti-solidarity and anti-evidence”. This led to the question ‘When will discussions about global health truly be global?’ highlighting how these discussions still tend to centre around views and perspectives from the global north. At the heart of the discussion that followed, was the asymmetry of power and knowledge in global health, and this editorial shares some of those key ideas.

Ndlovo-Gatsheni, a professor from the global south in the field of Development Studies asks the question: “Why decoloniality in the 21st century?”.  We unpack what this question could mean for global health today.

What is decoloniality?

When a country gains independence from a colonial power, it does not mean that all the effects of colonialism automatically disappear.  Coloniality is the condition that survives beyond the period of colonialism.  Where decolonisation describes the process through which direct colonial rule was withdrawn, decoloniality is a political, epistemological and economic liberation project aimed at dislodging coloniality and its manifestations including the coloniality of power, and the coloniality of knowledge.

Global health and coloniality of power

Asymmetrical power relationships still exist between actors from the global north and global south. In global health research, control of economic resources has often meant that those who hold the funds, get to set the agenda.  This pattern was echoed in remarks made by Ghanaian President Akufo-Addo to the French President Emmanuel Macron at a press conference in December 2017 where Akufo-Addo outlines how and why African countries need to set their national health agenda (irrespective of the origins of economic resources) in order to “Build a Ghana beyond aid”.

However, it’s not all about economic power, and while this is often easiest to see (and measure), other power asymmetries (for example along gender, race, class, ethnic, age, disability, sexual orientation, and religious lines) also play out between, and within global north and global south contexts.  While patriarchy pre-dates colonialism, an example of how the power asymmetries in gender are starting to shift is demonstrated by the fact that we see far fewer ‘manels’ (all male panels) in our global health conferences.  Importantly, we need to acknowledge that patterns of asymmetrical power play out in many complex ways, and this requires us to take a more intersectional approach to understanding (and disrupting) patterns of power in global health.

Global health and coloniality of knowledge

The patterns of knowledge production, and what knowledge is seen as a legitimate way of understanding the world is key in thinking about the coloniality of knowledge.  In global health we see the manifestations of this as some forms of research are posited as more legitimate than others, for example, the idea of the randomised controlled trial being the ‘gold standard’ in hierarchy of evidence, or the failure to recognise the value of social science perspectives in a field often dominated by clinical, biomedical and epidemiological knowledge.

Another example is the authorship patterns we see in many global health partnerships dubbed as  ‘safari research’ where low- and middle-income-country researchers are recruited but have minimum involvement in studies driven by high-income-country authors. This has significant consequences and influences what research questions are prioritised and why.

A Decolonial Approach to Global Health

Reflecting on the coloniality of power and knowledge allows for a critical questioning of existing structures in global health.

Importantly, the next step should not be a fundamentalist rejection of all things modern or European or Western.  Equally, we must be wary of false binaries (between the global north and global south) that are reductionist or over-simplifications of the very complex ways in which power affects these relationships.  Rather, a more nuanced approach is needed, one that recognises that these inequalities are bad for all of us, and cannot be separated from the broader political economy of global health systems.  Importantly, there is a role for actors from both the global south and the global north to actively participate in the decolonial project to disrupt power and knowledge asymmetries.

Some may say these asymmetrical patterns of power are inevitable while the majority of the funding still comes from the global north. Could power relationships in research partnerships between the global south and north be more equal? Could research consortia be structured differently? Are more horizontal, equal partnerships with true co-production of research possible irrespective of where the research funding comes from? We would argue that the answer is yes.

This could mean, for example, that research partnerships between the global south and north address power imbalances ensuring that resources are allocated to joint sessions allowing for the co-development of research ideas.  Research partnerships should be structured to address power asymmetry moving away from models where fund holders in the global north make resource allocation decisions, and ultimately set the research agenda.  Importantly, this would also require a shift in the mindset of funders, as they would need to value (and fund) the time required to co-develop ideas. The decoloniality of knowledge requires researchers (and funders) to recognise the multiplicities of knowledge through work which moves forward the epistemologies of the south.

Finally, we are not merely theorising about a possible future here, but arguing that our generation “must mobilise itself and confront present structural agential sources of social injustices, asymmetrical power structures, patriarchal ideologies, logics of capitalist exploitation, resilient imperial/colonial reason, and racist articulations and practices”

As EVs from the global south, we intend to do just that.


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