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#DecolonizeGlobalHealth: Rewriting the narrative of global health

By Renzo Guinto
on February 11, 2019

The history of the field of global health is always traced back to tropical medicine, an earlier discipline started by former Western empires. Generally, the focus of tropical medicine was the study of infectious diseases prevalent in colonies in the tropics. The purpose was to find measures to protect the colonizers from acquiring these diseases and bringing them back to their home countries. Today, while almost all colonies have already been emancipated and the study of such diseases has evolved into ‘international health’ and later ‘global health,’ tropical medicine remains embedded in some academic institutions in the Global North (ex. London School of Hygiene and Tropical Medicine, Institute of Tropical Medicine-Antwerp) and the term is still widely used in former colonies (ex. The University of the Philippines College of Public Health is a SEAMEO-‘TropMed’ Collaborating Center).

Nevertheless, while global health’s mission has already expanded from protecting colonizers from disease to improving health equity worldwide, it can be argued that there are still some signs of colonialism lingering in the field. Old colonial powers still very much control the restricted space of global health policy and decision-making – though the rise of China’s Silk and Belt Road and the backlash against globalization as shown by Brexit and Trumpism may also be initial signs of (global health) crumbling empires. Recent decades have seen the birth of neocolonizers – from non-state actors without legitimacy to emerging economies demanding a seat at the table – that rather than offer a new narrative, end up helping perpetuate the status quo. Meanwhile, dissidents and emerging voices from the Global South still largely assume token positions in global health discussions instead of playing meaningful roles in global health operations – though I would be remiss to ignore programs such as the Emerging Voices for Global Health from which I greatly benefited and that are attempting to, borrowing this blog’s tagline, switch the poles in international health policy.

The past months have seen a surge of interest in the idea to decolonize global health. Late last year, I started a hashtag #DecolonizeGlobalHealth on Twitter which generated some initial feedback and suggestions, especially from fellow young Global South voices. Some even reiterated that the growing movement towards advancing women leadership in global health is deeply intertwined with progress in global health decolonization. Last week, my fellow students at Harvard organized a conference on the decolonization of global health, whose slots were not just immediately filled but which was also widely anticipated in livestream worldwide. (I missed the conference because I’m currently based in the Philippines finishing my doctoral thesis. As part of my decolonization project, it was my intentional choice to focus on a community-based action project in my home country rather than write a global health policy paper for an international organization.) In the past weeks, I was approached by some colleagues asking what can be done to move this conversation from Twitter to the real world.

But what do we really mean by #DecolonizeGlobalHealth? In order to prevent this new concept to end up becoming a buzzword that will later fade away, it is vital that the global health community of scholars and practitioners unpack, examine, and reflect upon this idea. From my view, there are at least three areas of inquiry where researchers and policy-makers can ask questions, debate ideas, and find answers.

1) The analysis of global health. All global health action emanates from a certain understanding of the world. There are values, assumptions and premises on which decisions and relational arrangements are based, and frameworks for analysis define the boundaries and dictate who is included and who is not. Just a few years ago, developing countries were still generally seen as mere recipients of charity and generosity, bereft of good ideas and innovation, and possessing limited potential for leadership. Along the same lines, ‘capacity-building’ of poor countries was (is?) a ‘white man’s burden’ of the ‘developed world’. Today, arguably, new narratives are evolving, moving away from the traditional donor-recipient relationship towards country ownership and partnership – though some may feel that this is more rhetoric than practice.

Territorial colonialism may be long over, but the colonization of the mind, of culture, of domestic politics and of the economy continues and reparations are yet to be realized. Meanwhile, colonial powers did not just dominate over foreign lands – the Western mindset of progress and capitalist ‘development’ (copied pretty much everywhere in the world now) also exerted enormous pressures on the very Earth that sustains our health and wellbeing, leading to the climate crisis that puts our future health at great risk in return. The new frame of planetary health offers the best form of hope – but it will require a deep expression of humility from planetary colonizers of all forms – countries and corporations alike.

2) The institutions of global health. Who are the agents of modern-day colonialism in global health? This question requires scrutiny of a wide range of actors – from formal institutions such as the WHO and World Bank, to non-state players such as the Gates Foundation and the pharmaceutical industry, to influential personalities that control what Richard Horton once called (on Twitter) the ‘old boys’ club’ of global health – whether they are in Lancet Commissions, Twitter feeds, or conference organizing committees. One time, I saw an academic tweeting a photo of an all-white global health meeting – I thought ‘global’ was more colorful than that!

Promoting diversity and inclusion in boards and staff of global health organizations is a good first step. For instance, apart from UN agencies and philanthropic foundations, I have always wondered about the composition of global health departments in elite schools of public health. A quick count of faculty members in my alma mater, Harvard Chan School, shows that out of 35 primary faculty at the Department of Global Health and Population, only 13 have non-Western-sounding names and 14 are non-white or white Latin Americans. Only 1 professor worked in a developing country immediately prior to joining the faculty, which may indicate that almost everyone from the Global South stayed in the US or Europe either prior or shortly after graduate school. One piece of good news is that a Brazilian professor just got appointed as department chair, replacing a Sudanese who served for seven years.

But decolonizing global health actors is more than having additional Global South seats in still-colonial organizations. Colorful composition does not automatically mean transformed structures and changed values. To decolonize institutions, there is a need to retell the story, rewrite the rules, and even redesign the system.

3) The processes of global health. Finally, apart from critiquing the starting framework and the cast of characters, it is also important to investigate the processes that animate the global health space. The management of organizations, shaping of rules, making of decisions, generation of knowledge, and allocation of resources are just some examples.

Let me describe two processes that receive little attention. Part of the decolonization of processes is to level the playing field so that emerging scholars and practitioners from the Global South can have a chance. The first are the procedures and requirements governing journal publications. I once had my Global South-perspective commentary about a novel emerging issue rejected not because of it being not well-written but because of ‘oversubscription’ and ‘lack of space.’ Meanwhile, a colleague from the Global North who has clearly penetrated the ‘old boys’ club’ published six commentaries within a six-month period in that same journal – or at a rate of one article per month!

Another area that needs to be examined is the recruitment of global health professionals and how their work is recognized. To illustrate, a year-long stint done in a developing country by a colleague from a rich country will be counted as ‘global health experience.’ Meanwhile, coming from a developing country in the process of health reform, my decade-long contributions at home will be considered only ‘domestic work.’ This means there is a high chance that the development bank, which counts the number of countries an applicant has worked in, will hire the other and not me.

Some initial steps: write, mobilize, reflect

To start global health’s decolonization and rewrite its narrative, more Global South scholars and practitioners must begin writing and talking about global health – its analysis, institutions, and processes – as they see it. There is nothing to fear about sounding politically incorrect – after all, there is nothing politically correct about colonialism. But there is always room for a respectful conversation.

As an indication of the need for alternative global health stories, only seven of the global health books included in a list recently generated from a Twitter survey are written by a Global South author (plus Global Health Watch by the People’s Health Movement, and not counting Harvard-based Amartya Sen). Meanwhile, Paul Farmer – the white Harvard doctor who would cure the world – has six books out of 100 – five written by him, and one about him. (Don’t get me wrong – I admire him and his work.)

Another essential step is to ensure that the decolonization discourse does not only occur in Twitter-verse and global health reunions. Decolonization begins at home, and so movement-building at the country level is crucial. A Global South expert sitting comfortably at a desk in Geneva is not decolonization. #DecolonizeGlobalHealth must inspire a new generation of global health leaders to question the status quo and take bold action at home and elsewhere.

Finally, for us who were educated in schools of public health that are based in former colonizers or were agents of colonialism themselves, we need to be constantly reflexive about our position of privilege. We might not be noticing it, but in our pursuit to decolonize global health, we could very well end up becoming neocolonizers ourselves.

About Renzo Guinto

Renzo R. Guinto, MD DrPH is the Associate Professor of the Practice of Global Public Health and Inaugural Director of the Planetary and Global Health Program of the St. Luke’s Medical Center College of Medicine in the Philippines. He is also a member of the Scientific Committee of the One Sustainable Health for All Forum and the co-chair of the International Working Group 3 on Human-Nature Interactions.
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Sunanda Agarwal says:

Well written. Nice to see bare facts, simply stated.

Jeff Barnes says:

You failed to mentioned the most insidious aspects of the “colonial” system of global health and focused on the superficial aspects. The most colonial tendency is the extreme top-down approach of global health initiatives that originate in the western donor countries which set goals for the rest of the world and then spend their funds and divert the attention of national governments to track each country’s achievement of those goals. Look at the way the global fund, FP2020, the Presidentials Malaria Initiative and especially PEPFAR operate. There is a fig leaf of buy in from countries who only do so to get access to the funds and then they have to put up with all sorts of targets, processes and systems changes that are imposed on them in the name of accountability.

Nyuydzedze Stanley says:

The top down approach as articulated by Barnes is one of the key issues in neocolonisation which fuels inequity in global health. Countries in the global south for example Africa while there are clear health concerns related to communicable diseases and an increase in the NCD’s have to redefine their priorities to access funds and equally to align to the ”global” indicators leaving a vicious cycle and never achieving reasonable health goals while wasting resources which would better fund local/regional health goals to eliminate pertinent health concerns.

I fully agree on Mr. Barnes top-down appraoch and accountability. It creates a vicious circle

Ddungu Charles says:

Nice piece and a good building block for decolonising of global health. While all the three areas mentioned are important, I miss a fundamental one to all processes of decolonisation: the knowledge gap. Will it be possible to decolonised global health using colonised knowledge? Contray to other discplines, (mainly in the human and social sciences), global health is a descipline where the lingering legacy of colonised knowledge and a Eurocentric epistemology leaves much to be desired. Decolonising knowledge should and must be at the heart the process.