Opinion: Avoiding the colonization of 'health equity'

Early in my career, I served as a medical officer at a small health clinic in one of the poorest areas of Punjab, India — an expanse of corrugated tin siding, cardboard, and plastic intersected by open drains and heaps of garbage. One day, a local woman in tattered clothes walked into the clinic holding her naked infant. I thoroughly examined her and wrote a prescription.

Confused, she asked for the medicine instead. I explained that she could have the prescription filled by the local pharmacist. She tore the paper to pieces and threw it at me, asking: If there is no medicine, what are you doing here?

Ever since, that question has informed my advocacy for health equity as I seek to answer it.

According to the World Health Organization, health equity requires an “absence of unfair and avoidable or remediable differences in health.” Considering how we can ensure that everyone is able to attain full health and well-being — irrespective of race, ethnicity, religion, gender, socioeconomic status, and other social determinants — is at the heart of the health equity debate.

Interest in health equity has exploded in recent years. But while the increased focus is a welcome change, the agenda to advance health equity is seemingly being hijacked by the very same powerful forces that perpetuate disparities. Is the megaphone of large global health entities drowning out the voices of the affected people who should be at the center of this conversation? The crucial questions of who is driving the health equity agenda, who is visible, and who is being left out should be addressed.

1966 saw the first publication on health equity, but the concept started to gain traction in the 1990s. Around the same time, the corporatization of health — on the pretext of improving the performance of publicly run health systems — started to be pushed in middle-income countries. This transition, directed by powerful Western forces, perpetuated health disparities.

For example, corporatization of the Punjab health system changed the structure for user fees under a World Bank project. Health services that had previously been free began to require identification cards for fee exemptions, thereby excluding many of the poorest who lacked a home address needed for an ID.

Corporatization also led to a surge in private hospitals. The state health sector became the only option for the poor, even though it was riddled with corruption, inefficiency, and inadequacy, thus widening class disparities and creating additional barriers to health services for those already the most vulnerable to illness and disease.

When I was working as the head of the postpartum unit in a district public hospital, I vividly recall raising the concern of corporatization’s impact on the “health for all” agenda. Ultimately, local protests and voices were dampened under the weight of financing controlled by multilateral entities such as the World Bank.

The message was clear: To get monetary aid, local priorities would have to shift to match the Western world's “solutions,” even though they rarely consider the needs and asks of the affected communities. While global health investments, science, and medicine have come a long way, health equity has not gone far enough. Over decades of bending to prescriptive benchmarks, we accomplished nothing more than a Potemkin village of health equity gains, looking good from afar but hollow on the inside.

Even more troublingly, the same entities that espouse health equity values — governments, corporate America, foundations, elite medical voices — are seemingly the ones perpetuating barriers.

The United States is a prime example of government-propagated policies that are antithetical to health equity. For example, the U.S. is the only high-income nation that lacks a national guarantee of paid leave for parents, even though large bodies of evidence show that paid time to care for newborns or newly adopted children creates an environment for healthy development, boosts maternal health, supports fathers' involvement, and improves families' economic security.

Furthermore, in tying insurance and paid leave to employment — something not accessible or ensured to everyone — the U.S. has turned health into a privilege.

The medical community struggles to put action behind the health equity ethos as well. Recently, The Lancet’s editor-in-chief wrote about the “real meaning of decolonisation.” Yet featured journal articles show a who’s who of Ivy League graduates, many raised in affluent societies.

Organizations like The Lancet might ponder how to democratize ideas around health — rather than co-opt them, rewriting the meanings of “equity” and “colonialism” in their own voice. They should proactively seek out content from marginalized voices and consider creating a support mechanism to feature global south perspectives that goes beyond tokenism.

The medical community would do well to take stock of its shortcomings and work toward equity within its own ranks, facilitating a seat at the table for those who have been marginalized. After all, if well-respected mediums within the health equity space don’t lead this effort, how can we expect the donor class to follow suit?

Whatever the latest buzzword or phrase — “health for all,” “health as a human right,” “health equity” — those of us in the global health and advocacy community have an obligation to see the nuance and complexity of inequities from governments, intergovernmental and nonprofit organizations, the broader health care arena, and, yes, even ourselves.

To truly make strides in advancing health equity, we should begin by putting people before profits and reorienting health care to prioritize well-being as the bottom line rather than dollars. From there, we might guarantee universal health coverage, pass legislation that decreases or puts caps on the cost of prescription drugs, improve the quality and accessibility of public health services, and privilege the needs of those in marginalized communities.

Advancing health equity globally necessitates a paradigm shift in the way we view the relationship between donors and implementing countries. The way forward requires a removal of narrow self-interests so that we can call out our shortcomings. Only then can we begin to take accountability and reframe our practices to more intentionally include all people and experiences.

Power dynamics between the global north and global south need to shift away from a colonization paradigm to a true partnership based on the interconnectedness of everyone’s health. Otherwise, our commitment to health equity is nothing more than rhetoric.